Cent. Eur. J. Med. • 3(4) • 2008 • 482-486 DOI: 10.2478/s11536-008-0074-2

Central European Journal of Medicine

Effect of and/or on pulmonary arterial pressure in adults

Research Article Saeed Abdelwhab1*, Khaled. M. Dessoukey2, Gamal Lotfy3, Ashraf Alsaeed4, Hesham M. Anwar5

1 Faculty of Medicine, Ain Shams University, 2322 Cairo, Egypt

2 Faculty of Medicine, Alazhar University, 2322 Cairo, Egypt

3 Faculty of Medicine, Zagazeg University, 2311 Zagazeg, Egypt

4 Faculty of Medicine, Zagazeg University, 23115 Zagazeg, Egypt

5 Faculty of Medicine, Alexandria University, 23110 Alexandria, Egypt

Received 18 May 2008; Accepted 10 September 2008

Abstract: The aim of the study was to determine the mean pulmonary pressure in adult with hypertrophic tonsils and and to clarify whether tonsillectomy and adenoidectomy has any effect on mean pulmonary arterial pressure of these adult. The study was carried out on 50 patients with diagnosis of upper resulting from hypertrophied tonsils and adenoids (group1). 25 adults were assigned as control with similar age and sex distribution (group2). For study subjects Routine general Examinations, BMI, ECG, Chest X ray, Arterial blood gases and Echocardiography were done. Mean pulmonary arterial pressure was measured by using Doppler Echocardiography preoperatively and mean 3-4 months postoperatively in all subjects. Elevated PAP (pulmonary artery pressure) was found in 15 patients (30%) in group 1 preoperatively. Mean PAP was 28.34 ±5.11 mmHg preoperative in group 1 and 19.84 ± 5.0 mmHg in group 2 (p <0.001). PAP decrease to 22.38 ±4.28 mmHg postoperatively in group 1 (p <0.001). Arterial oxygen saturation (spo2%) increase from 93.5 ± 1.9% preoperatively to 95.3 ± 1.3% post operatively (p < 0.001). percent reduction of PAP postoperatively correlates to age (t=-2.3, p= 0.02), preoperative PAP (p =0.01) but no correlation was found with BMI. In conclusions, this Study showed that obstructed and hypertrophy of tonsils causes higher mean pulmonary artery pressure in adult & revealed that tonsil& adenoid is effective therapeutic measure in such patients. With early intervention is necessary to avoid progressive cardiopulmonary disease. Keywords: Pulmonary hypertension • Chronic upper airway obstruction • Tonsils and adenoid

© Versita Warsaw and Springer-Verlag Berlin Heidelberg.

1. Introduction that mostly affects adult males of over forty years of age. It is a result of soft tissue laxity in buccal and pharyngeal

musculatures and enlargement of tonsils and adenoid. Tonsillar and or adenoid hypertrophy is most common Longstanding OSA induces intermittent hypoxia and cause for upper airway obstruction. Often this is mild & secondary . The spectrum of has no sequel. When constant and severe obstruction is severity of OSA has been graded over scale 5. The grade present a condition of obstructive sleep syndrome 5 severity represented corpulmonale, cardiomegaly, (OSA) develops which leads to disturbed sleep, congestive heart failure and death. Tonsillectomy and and behavioral abnormalities [1]. OSA is a syndrome

* E-mail: [email protected] 482 S. Abdelwhab et al.

Adenoidectomy removed upper airway obstructions and Grade Degree of Obstruction % lead to complete reversal of these complications in 3 0 0-30 months times [2]. 1 30-59 Cor pulmonale as a consequence of chronic 2 60-99 upper airway obstruction by hypertrophied tonsils and 3 100 adenoids seems relatively common Prompt relief of Exclusion criteria are: obstruction, either by the establishment of an adequate 1. Patients with chronic disease.eg; HTN, CAD, airway or surgical removal of the tonsils and adenoids, Valvular heart disease, COPD and recurrent is indicated to avoid potentially lethal consequences. . The cardiovascular findings appear to be completely 2. History of sedatives or tranquilizers intake. reversible [3]. The aim of the study is to detect the 3. History of prior oropharyngeal surgery. effect of upper airway obstruction by enlarged tonsils on pulmonary artery pressure and the degree of reversibility In preoperative period all subjects had of PAP after tonsillectomy. 1- Routine general Examinations to detect vital signs eg; HTN & Arrhythmias. BMI=weight / height. Investigations done are; 2. Material and Methods 2- ECG(arrthymia, Rt axis and P pulmonal) 4- Chest X ray (cardiomegaly or chest disease). The study was carried out on 50 patients and 25 5- Arterial blood gases (Hypoxia) which is repeated age and gender matched control subjects. Patients postoperatively at the time of repeating randomly selected from an adult who referred them echocardiography. to the Department of Otolaryngology-Head and surgery (study group). Initially 67 patients were recruited 2.1. Echocardiography consecutively but 17 patients were lost at the post Examination, including 2-dimensional, M mode, Doppler, operative assessment stage. and color Doppler, were done by a cardiologist who did Subjects having the following criteria were included not know the diagnosis of patients, with Hewlett Packard in the study. Sonos 5500 System Andover Echocardiography 1- Inclusion criteria: Hypertrophic tonsils causing (Palo Alto,CA). In parasternal short-axis position oropharyngeal airway obstruction. A standardized pulmonary valve was imaged first, pulmonary flow was grading classification described by Broadsky was determined by color Doppler. To estimate the mean PAP, used for the clinical examination (Grade I: tonsils echocardiographic records of the pulmonary flow trace are in the tonsillar fossa, barely seen behind the were calculated with the Mahan formula (mPAP mm Hg anterior pillars; Grade II: tonsils are visible behind = 79 – [0.45x Act]) where Act is Acceleration time of the the anterior pillars; Grade III: tonsils extended three pulmonary flow trace is the time interval between the quarters of the way to the midline; Grade IV: tonsils beginning of the flow and its peak velocity). The upper are completely obstructing the airway) [4]. limit of mean pulmonary arterial pressure is 30 mm Hg 2- Obstructive symptoms such as long lasting therefore; values exceeding this limit were evaluated nocturnal snoring, sleep apnea, open mouth as pulmonary hypertension. The patients were seen , difficulty in swallowing, and poor appetite. 3 to 4 months postoperatively, and the mean PAP According to that scale, grade 3 and 4 hypertrophic measurements were repeated. tonsils were included. 3- Adenoid hypertrophy with partial or complete 2.2. Statistical analysis obstruction of the posterior choana without any The Statistical Package for Social Sciences (SPSS). other reasons causing nasal obstruction such as Version 15.0 was used to analyze the data. Numerical acute infection, allergic , septal deviation, or data are expressed as mean ± S.D. nominal data are anatomic deformities. Because objective evaluation expressed as numbers and percentages. Preoperative of blocking adenoidsis difficult, anterior rhinoscopy, and postoperative PAP and spo2% of the patients lateral radiographs, palpation, and flexible against the control group were compared by Student’s fiberoptic examination if tolerated by the patient t-test. Kolmogorov-Smirnov test accepted normal were performed alone or combined together for distribution. Paired t test was used to compare pre and the assessment. The following grading system was postoperative data of the patients group. Regression used to standardize the assessment of the degree analyses were performed by linear regression analysis. of airway obstruction due to adenoid tissue [5]: A p value below 0.05 was considered as significant.

483 Effect of tonsillectomy and/or adenoidectomy on pulmonary arterial pressure in adults

Table 1. Data of studied groups. variable Group 1 Group 2 P value Age (years) 28.76 ± 6.68 27.0 ± 5.6 0.28 BMI (%) 26.06 ±4.08 24.84 ± 4.04 0.22 *pulmonary artery pressure 28.34 ±5.11 19.84 ± 5.0 <0.001** (mmHg) *spo2% 93.48 ± 1.93 95.92 ± 1.382 <0.001** *preoperative in group 1. ** Significant p value <0.05. comparing group 1 and 2. Table 2. Pre and postoperative pulmonary artery pressure and arterial oxygen saturation in group 1. variable Pre-operativeMean ± S.D Post-operative Mean ± S.D P value Pulmonary artery pressure 28.34 ± 5.11 22.38 ±4.28 < 0.001* Arterial oxygen saturation 93.5 ± 1.9 95.3 ± 1.3 < 0.001* * Significant p value <0.05. comparing pre and post operative data. Table 3. Echocardiographic parameters pre and postoperative. parameter Pre operative Postoperative Control group TV max. E velocity, cm/s 59 ± 9 62 ± 7 63 ± 4 TV max. A velocity, cm/s 33 ± 10 33 ± 8 33 ±7 E/A ratio (tricuspid) 1.78 ± 0.9 1.87 ±0.87 1.90 ± 0.75 TV : tricuspid valve Figure 1. Correlation between percent reduction of PAP and 5 patients and grade 2 in 3 patients. In the control group preoperative PAP. 22 subjects have tonsil size grade 1 and 3 subjects have grade 2. Data of groups studied is shown in Table 1. Pulmonary artery pressure was found above 30 mmHg in 15 patients (30%) preoperatively. Comparing preoperative and postoperative pulmonary artery pressure and arterial oxygen saturation in group 1 is shown in Table 2. All patients had PAP below 30 mmHg except one patient who had 31 mmHg; this patient had preoperative PAP 41 mmHg. The percent of postoperative reduction of pulmonary arterial pressure in group 1 was found to be 20.77 ± 8.7 %. Regression study shows percent reduction in PAP correlates negatively with age (t=-2.3, p= 0.02), and positively with preoperative PAP (t=2.6, p =0.01) and preoperative spo2% (t= 2.4, p=0.02). No correlation was found with BMI (p= 0.37). Figure 1 shows the correlation between percent reduction of PAP and preoperative PAP. Echocardiographic parameters 3. Results pre and postoperative is shown in Table 3.

Group 1 includes 27 females (54%) and 23 males (46%), while group 2 includes 11 females (44%), and 14 4. Discussion males (56%). Mean age is 28.7 ± 6.6 years for group 1 and 27.0 ± 5.6 years for group 2. Tonsillectomy alone Previous studies demonstrated the relationship between was done in 42 patients of group 1 adenoidectomy and diastolic dysfunction, hypertension, LV hypertrophy, tonsillectomy was done in 6 patients and adenoidectomy and the development of congestive heart failure and alone was done in 2 patients. Tonsillar size grade 4 was obstructive sleep apnea in adult patients [6]. present in 5 patients, grade 3 was present in 42 patients and grade 2 in 3 patients. Adenoid size was grade 1 in

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In our study we found elevated PAP preoperatively patients’ PAP returned to normal at postoperative in 30% of adults undergoing tonsiloadenectomy. None echocardiography assessment except for one patient of those patients has chest x ray change of pulmonary who had initial high PAP although there is reduction of hypertension this may be because they don’t have PAP from 41 to 31 mmHg. In Guney’s study recorded advanced or prolonged disease. a significant recovery in respiratory function tests and This high percentage indicates the importance of blood gas levels after tonsiloadenectomy [7]. Marcus relieving chronic upper airway obstruction to prevent et al. reported that apnea episodes disappeared, and progress of cardiovascular disease. Especially it is O2 saturations increased after tonsilloadenectomy [12]. undetected clinically or by routine x-ray. Mustafa et al Mustafa, et al. reported mPAP values of the children .found that elevated PAP is present in 50 % of children decreased to normal values after tonsiloadenectomy [7]. undergoing tonsiloadenectomy [7]. Mehmet et al. found Our results show that percent of postoperative PAP a decrease in estimated pulmonary artery systolic reduction is significantly related to age with higher level pressure from 31±4.2 to 13.1 ± 2.3 after tonsillectomy at younger age the explanation of this is not clear but and/ or adenoidectomy in adult [8]. this may be related to the duration of upper airway The mechanisms by which Hypertrophic tonsils obstruction and reversibility of airway obstruction at and adenoids can cause elevated PAP are diverse. a younger age. Also the degree of postoperative PAP Hypertrophic tonsils and adenoids are believed to lead reduction increase with higher preoperative PAP which to increased mPAP, pulmonary hypertension, and cor is related to relief of obstruction. So PAP reduction pulmonale [9]. occurs more in patients with high PAP than those with Nasal obstruction by hypertrophied tonsils and normal values. Another factor which determines the post adenoid increases resistance to air flow and if air flow operative reduction in PAP is preoperative spo2% this is not sufficient it force to which is finding appears to be contradictory to the association associated with turbulence of air flow, this turbulence between percent reduction and preoperative PAP. But fail to keep nasopharyngeal structures open in supine this may indicate that hypoxia is not a major determinant position and finally occur 10[ ]. Enlarged of PAP and other factors may be more important such tonsils cause mechanical difficulties in breathing as hypercapnea due to hypoventilation. through the upper airways. It is just as difficult to breathe Our results show no correlation between BMI and through less resistant air passages, such as the mouth. the degree of postoperative reduction in PAP. Echo However, with time, they make less effort to breathe, cardiographic parameters show impairment of the right demanding less force from respiratory muscles, which ventricular function which improved at postoperative leads to muscle weakness. period. Dursun et al. found that grade 3 and grade 4 CO2 retention caused by alveolar hypoventilation ATH (adenotonsillar hypertrophy) causes increased has an important role in development of cor pulmonale right ventricular performance index which reflects [5]. Hypoxia has effects on the cardiopulmonary subclinical RV dysfunction and surgical intervention by system. Firstly, it leads to pulmonary vasoconstriction, adenotonsillectomy may reverse these cardiac changes an increase in mPAP, and right ventricular afterload, [13]. finally causing right ventricular hypertrophy and right In conclusion, elevated pulmonary artery ventricular heart failure. Secondly, it causes pulmonary pressure is common in adults with adenoid and tonsil edema by increasing capillary permeability. Other hypertrophy. Early interference is necessary to prevent authors claimed that thickening of the muscular layer of progressive cardiopulmonary disease as the condition the small arteries and pulmonary arterioles may cause is usually completely reversible at early stage. The pulmonary hypertension [6]. cardiopulmonary complications are not evident by clinical Also hypoxaemia depresses myocardial function, examination or x ray at an early stage. The symptoms but the hypercarbia potentiates the pulmonary of progressive pulmonary hypertension are minimal vasoconstrictive reaction to hypoxic stimulation until the rapid onset of severe cardiac decompensation ending with cor pulmonale [11]. Mehmet et al. found occurs. Therefore, early detection of subclinical cardiac that obstructive sleep apnea is associated with right impairment may be crucial for the decision of early ventricular diastolic dysfunction without effect on surgical approach [13]. ventricular muscle but this effect is reversible after tonsillectomy and/or adenectomy. Our results show that there is significant decrease of both PAP and arterial oxygen saturation; it dropped significantly 3 to 4 months postoperatively. All our

485 Effect of tonsillectomy and/or adenoidectomy on pulmonary arterial pressure in adults

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