Associations between

Adenotonsillar Hypertrophy, Age,

and Obesity in Children with
Obstructive Sleep Apnea
Conselours :
dr. Afif Zjauhari, Sp. THT-KL
dr. Agus Sudarwi, Sp. THT-KL
Created by :
Bintan Tsabatus Silmi_012106107
Dewi Intisari_012106123

Obstructive sleep apnea

(OSA)
Respiratory disorder upper airway
collapse during sleep

Adverse condition

Major determinants of OSA:

The upper airway

morphology
Facial growth
patterns

Adenotonsillar

Display discrepancies in OSA

children of different ages and
levels of adiposity
Obesity

Age

The magnitude of
adenotonsillar
effects

The relationships between :

Adenotonsillar size and OSA
in detailed age groups
Effect of adenoid and tonsil
size on OSA in obese and
non-obese children
have not been well
investigated

Correlations between
adenoidal size, tonsil
size, and OSA in children
:
detailed age groups
(i.e., toddler,
preschool, school, and
adolescent)
different levels of
adiposity (i.e., obese
and non-obese)

Further elucidate the

respective
contributions of
adenoidal hypertrophy
and tonsillar
hypertrophy to
childhood OSA

Genetic
disorders,
neuromuscular
Previous tonsil,
diseases,
adenoid, or
cognitive
pharyngeal
deficits, or
surgery
mental
Exclusio retardation
Suboptimal

sleep studies
(total sleep
time <4 hours,
or sleep
efficiency
<60%)

n
criteria

Children
younger 12
months of
age

Craniofacial
anomalies

Children under 18 years of

age with OSA related
symptoms
Age
Gender
Symptoms and signs of
sleep disturbances
History of nasal allergy
Otitis media with effusion
Sinusitis or asthma
Overnight
polysomnographic sleep
study

To quantify the
presence and
severity of OSA

Full night PSG

Obstructive apnea

Hypopnea

50% decrease in
The presence of
airflow for duration
continued inspiratory
of 2 breaths
arousal,
effort
>90% decrease in
awakening, or
reduced arterial
airflow for duration of
2 breaths
oxygen saturation of
3%
Diagnosis of pediatric OSA :
the presence of an apnea/hypopnea index (AHI)
1 event per hour in the overnight
polysomnographic study

Toddler
(age
1-3)

Obese

Preschool
(age 3-6)

Grouping
School (age 612)

Adolescen
ce
(age 1218)

Non-obese

Body Mass Index (BMI)

Person's weight in
kilograms divided by the
square of height in
meters

For children and teens,

BMI is age- and sexspecific and is often
referred to as BMI-for-age

 Adenoid size was

determined based on a
lateral cephalometric
radiographs
The adenoidalnasopharyngeal (AN)
ratio was ratio of
adenoidal depth to
nasopharyngeal
diameter (Fujioka et al.)
Adenoidal hypertrophy
the AN ratio was
higher than 0.67

The adenoidal-nasopharyngeal (AN)

ratio
The adenoidal
measurement :
A represents the
distance from A to a line
B

A : the point of
maximal convexity
along the inferior
margin of the adenoid
shadow
Line B : drawn along
the straight part of the
anterior margin of the
basiocciput

The nasopharyngeal space

N : C to D
C : the posteriorsuperior edge of the hard
palate
D : the anteroinfenior
edge of the sphenobasioccipital
synchondrosis
When the synchondrosis is
not clearly visualized :
point D the point of
crossing of the
posteroinferior margin of
the lateral pterygoid plate
(P) and the floor of the bony
nasopharynx

The tonsils were graded using the scheme by

Brodsky et al.
I small tonsils confined to the tonsillar
pillars
II tonsils that extend just outside the
pillars
III tonsils that extend outside the pillars,
but do not meet in the midline
IV large tonsils that meet in the midline
Tonsillar hypertrophy = as grade III or above

Age Groups

89

42
164

200

Total 495
subjects

toddler
pre-school age
school age
adolescents

Mean age : 7.94.2 years

Boys comprised 69.5 %
(344/495)

Level of Adiposity

Obese
Non-Obese

4 Additional Groups
180
160
140
120
100
80
60
40
20
0

172
103

93

127

Subjects with adenotonsillar hypertrophy and

tonsillar hypertrophy only >> higher OSA risk
than children without adenotonsillar
hypertrophy
Adenotonsillar hypertrophy also increased OSA
risk compared with adenoidal hypertrophy only
or tonsillar hypertrophy only
OSA risk did not differed significantly among
subjects with adenoidal hypertrophy only and
tonsillar hypertrophy only

 A positive association existed

between the tonsil grade and an AHI
in the toddler group, preschool group,
school group, and the adolescence
Adenoid size and AHI were positively
related in the toddler, preschool, and
school children, but not in the
adolescent group

 For
children
with
tonsillar
hypertrophy, obese children had a
higher AHI than non-obese children
Obese
children
with
adenoidal
hypertrophy had a higher AHI than
non-obese children

 Obesity, tonsillar hypertrophy, and

adenoidal hypertrophy significantly
increased the risk of OSA for children
Age and gender was not significantly
correlated with pediatric OSA

Discussion

This study elucidates the disparities in effects of adenoid size and tonsi

Methods for evaluating adenoid

size ?
Acoustic rhinometry cross-sectional area
evaluation in the nose.
Fiberoptic endoscopy accurate diagnostic
method that allows examiners to obtain a
three-dimensional view of adenoid size.
A lateral cephalometric radiograph
simple, economical, and reproducible way
to measure adenoid size

Acoustic
rhinometry

Fiberoptic
endoscopy

lateral
cephalometric
radiograph

Adenoid
size and the
apnea in
index
were
significantly
Higher tendency
of apnea
young
children
with corr

 The adenoidalnasopharyngeal
space is narrowest at
4.5 years of age, and
then the adenoid
reaches its greatest
size at 710 years,
when the facial frame
develops rapidly.

The adenoidalnasopharyngeal
space gradually
decreases until 12
years of age, and
sharply diminished
from ages 12 to 15

The analytical results obtained

 Obesity is an independent risk factor for

OSA in children. Adipose tissue deposited
around the pharynx and neck, along with
hypertrophic adenoids and tonsils
Physicians rationally infer that obese
children, with equal adenotonsillar size,
have a higher AHI than non-obese
children.

Dayyat

Based o

 All these findings suggest that

adenoidal hypertrophy and tonsillar
hypertrophy have an additive effect
on pediatric OSA treatment for
childhood OSA include tonsillectomy
and adenoidectomy, rather than
tonsillectomy
or
adenoidectomy
alone,
to
achieve
optimum
postoperative results.

Limitations
1

Future studies should develop

equation models incorporating
adenotonsillar size, age, and obesity
to predict the surgical outcomes for
OSA in children.

conclusion
Adenoidal hypertrophy, tonsillar hypertrophy
and obesity are major determinants of
childhood OSA.
Adenotonsillar hypertrophy increases OSA risk
significantly more than adenoidal or tonsillar
hypertrophy alone.
The impact of adenotonsillar size on OSA
does not differ between obese and non-obese
children, but differ in children of different
ages, and the influence of adenoid size

polysomnography

EEG
EOG
EMG
ECG
Limb Movement
Upper Airway Sound
Recording

Instruments :
Electrodes
Nasal canule
Video monitor
Pulse oxymetry

Respiration (Measures of
Airflow and Respiratory
Effort)
Blood Oxygenation
(Oxygen Saturation - SpO2)
Capnography
Body Position
Behavioral Observation

2012 American Association of Sleep

Technologists

PSG

Fujioka Method
A/N ratio was calculated by dividing the
distance from the outermost point of
convexity of adenoid shadow to basiocciput
to the distance between sphenobasiocciput
and posterior end of hard palate.