Adenotonsillectomy Improves Asthma in Children
By American Society of Pediatric Otolaryngology
May 30, 2005, 20:41
Asthma or “reactive airway disease” is a chronic inflammatory disease that causes hypersensitivity of the airways. Hypersensitive airways result from too many stimuli, triggering narrowing and/or obstruction of the airways. This narrowing is caused by airway inflammation, often mediated by cellular elements such as mast cells, eosinophils, T-lymphocytes, alveolar macrophages, neutrophils and epithelial cells. During an asthmatic response, sufferers experience epithelial damage, excessive airway fluid, mucous hyper secretion and hyper responsiveness of bronchial smooth muscle causing difficulty in airflow in and out of the lungs.
Past research has found that improvement of upper airway disease ( i.e. tonsillitis, sinusitis, nasal congestion ) positively impacts lower airway disease. Adult asthmatics who have undergone endoscopic sinus surgery have been shown to have improvement in their sinus disease and a decrease in their medication requirements. Cystic fibrosis patients who are candidates for lung transplantation are generally recommended to undergo sinus surgery prior to transplantation surgery. Several small studies seem to suggest that tonsillectomy and adenoidectomy may decrease asthma severity in patients postoperatively.
A new study suggests that an adenotonsillectomy, which provides improvement in the upper airway of children, may in turn lead to improvement of the lower airways of children, especially those with bronchial asthma.
One explanation for improvement observed in these children postoperatively is that there is a decreased irritation to the bronchial system.
This occurs as a result of the decreased microaspiration of infectious secretions, which when present in the tracheobronchial tree may exacerbate asthma. In other words, removing the adenoids and tonsils causes a decrease in the amount of mucopurulent drainage from the upper airways which subsequently seed and irritate the lower airways. This study will examine the effect of adenotonsillectomy on reducing the impact of asthma on children and their families.
A retrospective review was conducted of patients that underwent adenoidectomy and/or tonsillectomy within the last five years and carried a diagnosis of asthma. These charts were reviewed to glean demographic information on the patient in order to conduct caregiver interviews. Eighty seven charts were identified for review, 33 were excluded because parents could not be contacted, and 16 were excluded for comorbidities, such as cystic fibrosis, immunologic deficiencies, severe gastroesophageal reflux, etc. which left 38 patients for evaluation.
Patients were included in the study if they had undergone adenoidectomy and/or tonsillectomy within the last five years, and carried a diagnosis of asthma without a significant co-morbidity. Indications for surgery included obstructive sleep apnea, chronic tonsillitis, chronic sinusitis, or other related disorders. Both cold-knife and electrocautery techniques of tonsillectomy were included and adenoidectomies performed by both curettage and cautery were included. Asthma was diagnosed by a primary care physician or a pediatric pulmonologist.
A questionnaire was designed for caregivers to assess pre and post operative signs and symptoms of asthma in the patient. The parent was asked to answer the same set of questions for before surgery and after surgery. The survey was given no less than six months after surgery and no more than five years after surgery.
The mean age of the 38 patients included in the study was 5.4 years, ranging from 2 to 12 years. The male to female ratio was 1.92 ( 25 males, 13 females ). The mean post operative follow up period was 1.5 years, ranging from seven months to four years. Eight patients ( 21 percent ) underwent adenoidectomy alone, and 30 patients ( 79 percent ) underwent adenotonsillectomy. Key findings included:
* Medication use dropped greatly after surgery. Use of inhaled steroids decreased from 26 patients ( 68 percent ) to 17 patients ( 45 percent ), and Albuterol use decreased from 34 patients ( 89 percent ) to 18 patients ( 47 percent ). Use of long acting beta2-agonists decreased from four patients ( 10 percent ) to zero patients, and use of leukotriene moderators dropped from 12 patients ( 31 percent ) to 11 patients ( 28 percent ).
* Before surgery, 19 patients ( 50 percent ) had used systemic steroids at least once per year. After surgery, only seven patients ( 18 percent ) used systemic steroids.
* A decrease in severity of asthma was also observed. The average asthma severity score decreased from 2.12 preoperatively to 0.74 postoperatively.
* Of the children who attended school, the average number of missed school days/year decreased from 7.76 to 3.28; the average number of missed work days/year for working parents decreased from 7.35 to 1.8.
Despite the small number of subjects, the study revealed clear improvement of asthma symptoms for patients who had an adenotonsillectomy performed.
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