New Hope for Children With Sleep Apnea

Partial tonsillectomy cures problem that can leave kids fidgety, unfocused

SUNDAY, March 30, 2003 (HealthDayNews) -- The child is fidgety, unfocused and frequently disruptive in school.

A clear-cut case of attention-deficit hyperactivity disorder, right?

Maybe not. There's a good chance the child's tonsils may be to blame. And the problem can be corrected with a groundbreaking surgery that results in far less pain and a much quicker recovery than traditional treatment.

Sleep apnea is a condition that causes interrupted breathing during the night. While the problem is typically associated with adults, particularly overweight men, an estimated 1 percent to 3 percent of all children may suffer from pediatric sleep apnea, University of Michigan researchers say.

Although a restless night's sleep typically leaves adults feeling drained and listless the next day, that's not the case with many children, says Dr. Timothy Hoban, a pediatric sleep specialist at the University of Michigan Health System.

These children "may actually be inattentive, energetic or even hyperkinetic," Hoban says.

And enlarged tonsils that interfere with air flow in the breathing passages are frequently the cause of the interrupted sleep that leads to behavioral problems during the day.

Now, a small group of doctors in six hospitals throughout the country is performing what is called a "partial tonsillectomy" on children who have sleep apnea or other breathing problems.

Rather than a traditional tonsillectomy, which includes the removal of the tonsil and all the surrounding tissue, this procedure leaves a small layer of tonsil tissue intact along the throat. This protects the throat muscles and dramatically reduces the pain, bleeding and recovery time for the children, proponents say.

"We leave about 15 percent of the tissue in the throat so that no raw muscle is exposed, which reduces bleeding, scarring and pain," says Dr. Max April, of Lenox Hill Hospital in New York City, who with other doctors in his practice has performed about 300 partial tonsillectomies since 2000.

Dr. Peter J. Koltai, an otolaryngologist at the Cleveland Clinic, pioneered the operation in 1996, when trying to help a colleague's 1-year-old infant who had "enormous tonsils, a large adenoid and documented sleep apnea."

"A tonsillectomy is a terribly difficult procedure for young children," Koltai says. So, he thought of using on the child the same technique he used for removal of adenoids, which is shaving them down with a special tool rather than cutting them out, leaving a protective covering of tonsil tissue over the throat muscles.

The procedure is done on an out-patient basis, takes about 15 minutes and the results are excellent, Koltai says, with immediate improvement in a child's breathing as well as a relatively speedy recovery time.

He has performed about 400 of the operations to treat children's obstructed sleep or disordered breathing, and says that post-operative bleeding has been reduced by about half.

"Less pain medication is used, and children can resume their normal diet and normal activities much more quickly," in about two to three days compared to seven to 10 days with a total tonsillectomy, Koltai says.

Koltai doesn't use the procedure on children with tonsillitis, for which a complete tonsillectomy is the standard treatment. Tonsillitis is an infection in the tonsil and its surrounding tissue; by not removing all the tissue, there's a risk of future infection, he says.

"I am concerned that there could be tissue left that will become infected," Koltai says, which would mean the child would need a second surgery.

Two of the children on whom Koltai performed partial tonsillectomies for sleep apnea or breathing obstruction did have their tonsil tissue grow back and needed a second operation. He says regrowth of tissue can happen to a small percentage of children, even with total tonsillectomies.

However, the possible regrowth of tissue is a concern for some doctors who haven't adopted the partial tonsillectomy technique.

"I have reservations, mainly that I don't know what the potential is for regrowth of tissue, so that kids would be subjected to a second operation," says Dr. Earl Harley, an associate professor of otolaryngology and pediatrics at Georgetown University Hospital.

"If I were convinced that this would be a good operation, I'd do it. I'd love to get kids up and back to school in a week, but there is no long-term data on the procedure. The questions are still out there, and I just want to wait."

Koltai, April and the doctors who are performing the procedure in hospitals in other cities -- including Birmingham, Ala., Norfolk, Va., and Wilmington, Del. -- are collecting information on the procedures they've performed. And Koltai will present data on 700 partial tonsillectomies at the American Society of Pediatric Otolaryngology's annual meeting in May in Nashville, Tenn.

"The standard has been when you do a tonsillectomy you take out the whole tonsil. We are challenging that assumption, which is a deeply ingrained idea," says Koltai. "But this is wonderful for the child."

More information

For a description and photograph of tonsils, visit the Mount Sinai School of Medicine. For a report on Koltai's earlier data on partial tonsillectomies, check the Doctor's Guide.

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