Research Underway Explores Surgery For Children With Sleep Apnea

May Is Better Sleep Month

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.

There is a good chance the child's tonsils may be to blame. And the problem may be corrected with a new surgery that results in far less pain and a much quicker recovery than traditional treatment of tonsillectomy.

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.

"Partial Tonsillectomy" Reduced Recovery Time

Now physicians at six hospitals in the US are 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 physicians 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, an enlarged 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. He says there is 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, April, and the physicians 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 have performed.

Koltai will present data on 700 partial tonsillectomies at the annual meeting of the American Society of Pediatric Otolaryngology in May.

Koltai does not 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 is 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.

Some Surgeons Look for More Results First

However, the possible regrowth of tissue is a concern for some physicians who have not 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," Harley says. "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."

Always consult your child's physician for more information.

Botox Helps Kids with Cerebral Palsy

Botox is being used to treat everything from migraines to wrinkles, and researchers from the Walter Reed Army Medical Center have now confirmed another safe and effective use for the toxin: helping children with cerebral palsy.

Lead researcher Dr. Marc DiFazio reports that botulinum toxin type A helps improve movement in youngsters who have the neurological disorder.

"The most important part of the study was not so much that we were demonstrating improvement in the kids, but that we demonstrated that this medication is really safe," says DiFazio, who presented his findings at the annual meeting of the American Academy of Neurology.

As many as 500,000 Americans have cerebral palsy, according to the National Institute of Neurological Disorders and Stroke, and 4,500 babies are diagnosed with the disorder every year. Symptoms vary from person to person, but cerebral palsy generally causes stiff, spastic muscles. Children with severe cases may be unable to walk or control the movement of their limbs.

Botox helps, says DiFazio, by interrupting the communication between the nerves and the spinal cord, which lets muscles relax.

Two hundred and fifty children who had already received at least one treatment of botulinum toxin were enrolled in this study. They were between the ages of one and 16. Two hundred and six youngsters received more than one treatment, and 148 were followed for an average of two years.

Significant improvement in movement was seen in 86 percent of the children. Only 2 percent had side effects, which included flu-like symptoms and mild weakness in the legs. Many older medications used to treat muscle spasms and stiffness have significant side effects, such as drowsiness and cognitive impairment, DiFazio notes.

The results also appear to last longer than the medication does. Even though Botox wears off in about three to four months, DiFazio says many of the children were still seeing improvements six-to nine-months later. He says this is probably because once they were able to use their muscles, those muscles became stronger and more flexible.

Always consult your child's physician for more information.

Online Resources

American Academy of Neurology

American Academy of Otolaryngology

American Academy of Pediatrics

American Society of Pediatric Otolaryngology

National Institute of Neurological Disorders and Stroke