Hindawi International Journal of Otolaryngology Volume 2018, Article ID 7920907, 7 pages https://doi.org/10.1155/2018/7920907 Research Article Drug Induced Sleep Endoscopy Identification of Adenoid Regrowth in Pediatric Obstructive Sleep Apnea Habib G. Zalzal ,1 Michele Carr ,1 Nainika Nanda,2 and Steven Coutras1 1 Department of Otolaryngology, Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA 2West Virginia University School of Medicine, Morgantown, WV, USA Correspondence should be addressed to Habib G. Zalzal; [email protected] Received 19 November 2017; Revised 24 February 2018; Accepted 13 March 2018; Published 26 April 2018 Academic Editor: Leonard P. Rybak Copyright © 2018 Habib G. Zalzal et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To establish the incidence and possible contributing factors leading to adenoid regrowth in children with pediatric sleep apnea using drug induced sleep endoscopy (DISE). Methods. Children treated for obstructive sleep apnea following previous adenoidectomy were evaluated using DISE. Adenoid regrowth was scored by the same attending physician using a 5-point grading scale. Age, sex, body mass index (BMI) percent for age, polysomnogram results, initial adenoid size before adenoidectomy, and postoperative complications were evaluated. Results. Fify-six patients (age range 22 months to 16 years) met inclusion criteria. Twenty-fve children (44.6%) had Grade 2 adenoid or larger. Mean age at the time of DISE was 7.11years, with an average of 1.75 years since initial adenoidectomy. Mean preadenoidectomy size based on intraoperative nasopharyngeal mirror assessment was Grade 2.55 (95% CI 2.30–2.79). Adenoid size at time of sleep endoscopy was Grade 1.64 (95% CI 1.30–1.98). Characteristics associated with adenoid regrowth were higher body mass index for age percentile at time of endoscopy (� < 0.05), initial adenoid size (� < 0.01), and time between initial adenoidectomy and endoscopy (� = 0.05). Conclusions. Body mass index for age percentile, initial adenoid size, and time between initial adenoidectomy and drug induced sleep endoscopy correlate with regrowth in childhood obstructive sleep apnea. 1. Introduction patient, DISE allows for identifcation of sites of obstruction of the upper respiratory tract during simulated sleep and Adenoidectomy, with or without tonsillectomy, is one of the complete visualization of the upper respiratory tract. DISE more frequently performed operations within otolaryngol- is an efective tool for surgical planning in children with ogy, estimated to be about 129,540 operations per year in persistent OSA afer adenotonsillectomy or if their physical the United States [1, 2]. Indications for adenoidectomy range exam is not consistent with adenotonsillar hypertrophy [7]. from adenoid-induced obstruction of the nasopharynx to Tis study uses DISE as the main diagnostic tool to deter- chronic infections of the middle ear, sinuses, and adenoid mine the incidence of adenoid regrowth at our institution itself. Ofen, symptoms resolve following successful surgical and identify risk factors associated with recurrent symptoms intervention, but recurrence of symptoms with adenoid leading to revision adenoidectomy. regrowth has been documented in 1–25% of patients who have an adenoidectomy [2–4]. 2. Materials and Methods Obstructive sleep apnea (OSA) afects 1–4% of children [5]. In children who require revision adenoidectomy, up to Tis study was a retrospective case series with chart review 94%ofpatientshavesymptomsassociatedwithnasopharyn- performed at a large tertiary academic facility following geal obstruction including snoring and sleep disturbance [6]. institutional review board approval. A computational search Children with persistent OSA following adenotonsillectomy using the EPIC electronic medical record was performed may undergo drug induced sleep endoscopy (DISE) to for the term “fexible laryngoscopy for sleep endoscopy,” identify the location of upper airway obstruction. In a sedated consistent with the phrase used for DISE at our institution. 2 International Journal of Otolaryngology Polysomnography No/mild adenoid Polysomnography regrowth (N=31) Subsequent Adenoidectomy DISE Further (N=2977) (N=56) sleep surgery work-up (N=48) (N=13) Adenoid Inclusion criteria: regrowth Subsequent surgeries included: (N=25) (i) Under 18 years old (i) Lingual tonsillectomy (N=42) (ii) Initial adenoidectomy at our (ii) Epiglottoplasty or laryngoplasty (N=32) institution (iii) Revision adenoidectomy (N=32) (iii) Polysomnogram for work-up of (iv) Turbinate reduction (N=24) obstructive sleep apnea (v) Posterior midline glossectomy (N=15) (iv) DISE from Oct 2010 to Jan 2017 (vi) Palatine tonsillectomy (N=6) Figure 1: Methodology for inclusion criteria and data accumulation for obstructive sleep apnea patients undergoing drug induced sleep endoscopy (DISE). Search was limited to patients under 18 years identifed as with likely presence of scarring, Grade 1 signifes <40% having undergone polysomnography (PSG) prior to sleep obstruction, Grade 2 signifes 41–70% obstruction, Grade 3 endoscopy from October 13, 2010, to January 1, 2017 (Fig- signifes 71–90% obstruction, and Grade 4 signifes complete ure1).Allpatientsweremanagedbythesameattending obstruction (91–100%) of the choanae with lymphoid tissue otolaryngologist. Sleep endoscopy was performed afer a touching the sof palate at rest. positive polysomnogram for sleep apnea with no obvious BMIforagepercentilewasseparatedintofourgroups: source of airway obstruction on physical exam. “underweight” if BMI was less than the 25th percentile, Inclusion criteria involved children (age < 18 years) “normal weight” if between 25 and 84.9%, “overweight” if who underwent primary adenoidectomy with or without between 85 and 94.9%, and “obese” if in the 95th percentile or tonsillectomy at our institution and subsequently required greater. Adenoid regrowth was present if endoscopic visual- DISE for evaluation of PSG confrmed persistent obstructive ization of the adenoid showed a Grade 2 or larger adenoid on sleep apnea. Patients were excluded if they previously had postadenoidectomy DISE. All children undergoing revision primary adenoidectomy at an outside facility or did not have adenoidectomy had an adenoid of Grade 2 or larger. documentation of adenoid size during primary adenoidec- Statistical evaluation was executed using IBM5 SPSS tomy. Data extracted from the electronic medical record Statistics5 (Version 24.0. Armonk, NY: IBM Corp) sofware. included gender, birthdate, initial adenoidectomy technique, Chi-square analysis was performed for nominal data with adenoid size per surgical and endoscopic evaluations, date Pearson’s correlation, while independent samples t-tests were of adenoidectomy, date of sleep endoscopy, body mass index performed for interval data (time between procedures and (BMI) and weight at the time of sleep endoscopy, allergic age characteristics). Ordinal data (BMI, adenoid size) was rhinitis/allergies, asthma, behavior disorders, developmental analyzed using Kruskal Wallis testing and Spearman’s Rho delay, refux, other comorbidities, and subsequent sleep correlation. Statistical signifcance was defned as � ≤ 0.05. surgeries. Six diferent otolaryngologists with resident assis- tance were responsible for the initial adenoidectomy of the 3. Results patients since electronic medical record keeping began at this institution in 2009. Adenoidectomies were performed for a Fify-six patients (age range 22 months to 16 years) met the variety of reasons, the majority for OSA, but also for middle inclusion criteria for having undergone primary adenoidec- ear disease and chronic adenoiditis. Techniques employed tomy prior to DISE. Table 1 summarizes the demographic included suction electrocautery or coblation of the adenoid data of these patients. Mean age at the time of DISE was tissue. 7.11 years, with an average of 1.75 years since initial ade- Diagnosis of medical conditions (allergies, asthma, etc.) noidectomy. Many children in our study had a BMI greater wasbasedontheirpresenceeitherinthemedicalnotationby than the 95th percentile for age (46.4%). Allergic rhinitis the treating otolaryngologist or within the medical record via was common in this population (46.4%). For behavioral International Classifcation of Diseases, Tenth Revision (ICD- issues, the majority of diagnoses were attention defcit dis- 10) codifcation at the time of initial sleep endoscopy. Ade- order (ADHD) and oppositional defant disorder (ODD). noid size at the time of primary adenoidectomy (preoperative Subsequent sleep surgery was performed afer DISE in 86% adenoid size) was obtained from the operative notes. Adenoid of patients (Figure 1). size at DISE was subjectively graded by the same attending Adenoid characteristics are described in Table 2. Te surgeon using a descriptive scale used at our institution mean initial adenoid size based on preoperative assessment and reported in the operative note (Figure 2). An adenoid was Grade 2.55 (95% CI 2.30–2.79). Upon postoperative size of Grade 0 signifes 0% obstruction of the choanae DISE, this improved to Grade 1.64 (95% CI 1.30–1.98). Te International Journal of Otolaryngology 3 (a) (b) (c) (d) (e) Figure 2: Adenoid hypertrophy grading system used at West Virginia University for Drug Induced Sleep