Variation in Tonsil Size in 4- to 17-Year
Transkript
Variation in Tonsil Size in 4- to 17-Year
The Journal of Otolaryngology, Volume 35, Number 4, 2006 Variation in Tonsil Size in 4- to 17-Year-old Schoolchildren Ahmet Akcay, MD, Ciineyt Orhan Kara, MD, Erol Dagdeviren, MD, and Mehmet Zencir, MD Abstract Objective: The purpose of this study was to evaluate the variation in tonsil size and prevalence of asymmetric tonsils in 4- to 17-year-old schoolchildren and the relationships between tonsillar hypertrophy and frequent tonsillitis, frequent fever, and sleep-related symptoms observed by parents. Design: Cross-sectional study. Setting: Six daycare centres, four primary schools, and four high schools. Methods: Questionnaire and physical examination. Main Outcome Measures: The size of the tonsils was evaluated and scored on a 4-point scale. The interrelationships between tonsillar hypertrophy and other studied symptoms were examined. Results: In the study, the parents of 1784 children, consisting of 803 (45%) boys and 981 (55%) girls, completed the questionnaires. The prevalence rates of snoring, habitual snoring, observed apnea, and habitual observed apnea were 24.6%, 4.1%, 3.8%, and 0.9%, respectively. The results of tonsil scoring were grade 1, 62.7%; grade 2, 28.4%; grade 3, 3.3%; and grade 4, 0.1%. The prevalence rate of grade 1 tonsils was increasing, whereas the prevalence rates of grade 2 and 3 tonsils were decreasing with increasing age. Tonsil size peaked in 4- to 8-year-old children. The prevalence rates of tonsillar hypertrophy and asymmetric tonsils were 3.4% and 1.7%, respectively. Tonsillar hypertrophy was found to be significantly associated with male gender, a history of frequent tonsillitis, a history of frequent fever, often or always snoring, and often or always observed apnea. Conclusions: A tonsil size curve was developed in 4- to 17-year-old schoolchildren. Children aged 4- to 8 years with oropharyngeal symptoms and particularly male gender should undergo consultation with otorhinolaryngology and pediatric pulmonology pliysicians for the evalution of adenotonsillar tissue. Sommaire Objectif: Le but de cette etude etait d'evaluer les variations dans le volume des amygdales et la prevalence d'une asymetrie amygdalienne chez les enfants de 4 a 17 ans et d'evaluer la relation entre l'hypertrophie amygdalienne et l'amygdalite recidivante, la fievre recidivante et les symptomes relies au sommeil notes par les parents. Devis: Etude de cohorte Localisation: Six garderies, 4 ecoles primaires et 4 ecoles secondaires. Metbodes: Questionnaire et examen physique. Variables evaluees: Le volume des amygdales a ete evalue sur une echelle en 4 points. Nous avons aussi evalue la relation entre l'hypertrophie amygdalienne et les autres symptomes. Resultats: Les parents de 1784 enfants (803 gar9ons (45%) et 981 filles (55%)) ont complete le questionnaire. La prevalence de ronflement, de ronflement regulier, d'apnee documentee et d'apnee reguliere documentee etait de 24.6%, 4.1%, 3.8%, 0.9% respectivement. Le volume des amygdales se presentait comme suit: grade 1, 62.7%; grade 2, 28.4%; grade 3, 3.3% et grade 4, 0.1%. La prevalence des grade 1 augmentait avec l'age a I'inverse de la prevalence de grade 2 et 3. Le volume des amygdales atteint un sommet entre l'age de 4 et 8 ans. La prevalence d'hypertrophie amygdalienne et d'asymetrie etait de 3.4% et del.7% respectivement. L'hypertrophie etait statistiquement associee aux garjons, a une histoire amygdalite a repetition, a une histoire de fievre frequente, a un ronflement occasionnel ou continuel et a des apnees occasionnelles ou regulieres. Conclusion: Nous avons developpe une courbe normative pour le volume amygdalien chez les enfants de 4 a 17 ans. Les jeunes de 4 a 8 ans avec des symptomes orophrynges, en particulier les gar^ons, devraient etre evalues en ORL et en pneumopediatrie. Key words: apnea, asymmetric tonsil, snoring, tonsil size, tonsillar hypertrophy 270 Akcay et al. Variation in Tonsil Size in Childhood T he tonsils and adenoids are part of Waldeyer's ring, the basic function of which is antibody formation; they react later against a great variety of antigens.' The tonsils and adenoids are very small at birth. Rarely, children are born with unusually large adenoid and tonsil tissues. The adenoid and tonsil tissues usually increase in size throughout childhood and tend to regress in adolescence.^ Several authors have reported that grossly enlarged tonsils have serious symptoms and complications.^"^ Although it is well known that adenotonsillar hypertrophy is a childhood disease, epidemiologic studies on the prevalence of adenotonsillar hypertrophy in childhood are rarely seen in the literature. Tonsillar asymmetry is usually secondary to benign hyperplasia. However, asymmetric tonsils may indicate a serious underlying disorder, such as lymphoma, lipid storage disease, or Langerhans' cell histiocytosis.^"^ Asymmetry of tonsils that arouses a suspicion of malignancy is one of the indications of tonsillectomy.'" As with the variation in tonsil size, there is a lack of knowledge about the prevalence of tonsil asymmetry in the literature. This study was performed to evaluate the variation in tonsil size and the prevalence of asymmetric tonsils in 4- to 17-year-old schoolchildren and the relationships between tonsillar hypertrophy and frequent tonsillitis, frequent fever, and sleep-related symptoms observed by parents. Methods Between March and May 2003, 2000 children aged 4 to 17 years in six daycare centres, four primary schools, and four high schools in DenizH, Turkey, were surveyed. From these children, 1784 questionnaires were completed appropriately, with an overall response of 89.2%. The questionnaire included questions concerning histories of tonsillectomy and/or adenoidectomy, frequent tonsillitis, frequent fever, and symptoms of sleepdisordered breathing, such as regularity in snoring, observed apneas, sleeping disturbances, and constant mouth breathing during sleep. The Obstructive Sleep Apnea Syndrome Expanded Childhood Questionnaire Received 08/08/05. Received revised 10/03/05. Accepted for publication 10/04/05. Ahmet Akcay and Erol Dagdeviren: Department of Pediatrics, Ciineyt Orhan Kara: Department of Otorhinolaryngology, and Mehmet Zencir: Department of Public Health, Faculty of Medicine, Pamukkale University, Denizli, Turkey. Address reprint requests to: Dr. Ahmet Akcay, Department of Pediatrics, Faculty of Medicine, Pamukkale University, 20100, Denizli, Turkey. e-mail:aahmetakcay@hotmail.com. DOI: 10.2310/7070.2005.0118 271 formulated by Carroll and colleagues" was used. Parents reported snoring and apnea on a 4-point scale: 0 = never, 1 = seldom, 2 = often, and 3 = always. Habitual snoring and apnea were considered present if parents reported snoring and apnea as either often or always. A detailed form was completed for each child by the parents. Thereafter, the size of the tonsils was evaluated by the first author in all children and scored on a 4-point scale as follows: grade 1, tonsils were in the tonsillary fossa and were barely seen behind the anterior pillars; grade 2, tonsils were visible behind the anterior pillars; grade 3, tonsils extended three-quarters of the way to the midline; grade 4, tonsils were completely obstructing the airway.^''^"'^ Tonsillar asymmetry was determined to be present when there was at least a +1 difference in the two tonsils.''* The interrelationships between tonsillar hypertrophy and other studied items were examined by chisquare tests, and those with tonsillectomy and/or adenoidectomy were excluded from statistical analysis. A significant difference was indicated by a p value < .05. Results Two hundred sixteen children were excluded from the study owing to incomplete or improperly completed questionnaires. A total of 1784 questionnaires, from 803 (45%) boys and 981 {55%) girls, were completed by parents. The prevalence rates of frequent tonsillitis and fever were 19.9% and 24.7%, respectively. The prevalence rates of snoring, habitual snoring, observed apnea, and habitual observed apnea were 24.6%, 4.1%, 3.8%, and 0.9%, respectively (Table 1). The prevalence rates of often or always snoring and observed apnea, frequent Table 1 Summary of the Results of the Questionnaire Questions n (%) Sex Male Female History of frequent tonsillitis < 2 episodes in year > 2 episodes in year History of frequent fever < 2 episodes in year > 2 episodes in year Snoring Never Seldom Often Always Observed apnea Never Seldom Often Always 803 (45) 981 (55) 1406 (80.1) 349 (19.9) 1326 (75.3) 436 (24.7) 1325 (75.4) 361 (20.5) 44 (2.5) 28 (1.6) 1676 (96.2) 51 (2.9) 4 (0.2) 12 (0.7) 272 The Journal of Otolaryngology, Volume 35, Number 4, 2006 fever, and tonsillitis decreased with increasing age (Figure 1). The results of tonsil scoring were as follows: grade 1, 62.7%; grade 2, 28.4%; grade 3, 3.3%; and grade 4, 0.1%. Ninety-eight children had tonsillectomy and/or adenoidectomy operation before the study. The prevalence rate of tonsillar hypertrophy in schoolchildren was 3.4%. Forty-seven children (1.7%) were determined to have asymmetric tonsils (Table 2). The prevalence rate of grade 1 tonsils was increasing, whereas the prevalence rates of grade 2 and 3 tonsils were decreasing with increasing age. Grade 4 tonsils were determined in only 6- and 7-year-old schoolchildren. Tonsil size peaked in 4- to 8-year-old children (Figure 2). For statistical comparisons, grade 3 and 4 tonsils were grouped as obstructive tonsil size and grade 1 and 2 tonsils were grouped as nonohstructive tonsil size. Ninety-eight children with tonsillectomy and/or adenoidectomy were excluded from the statistical analysis. The interrelationships between obstructing tonsil size and all other studied items were examined hy chi-square tests (Table 3). Tonsillar hypertrophy was found to be significantly associated with male gender (p = .007, odds ratio [OR] 1.99), a history of frequent tonsillitis (p < .001, OR 3.4), a history of frequent fever (p < .001, OR 2.7), often or always snoring (p < .001, OR 15.1), and often or always observed apnea {p = .017, OR 6.62) (see Table 3). Discussion Lymphoid tissue in Waldeyer's ring is sparse at birth. This is followed by a period of proliferation and eventual involution.'^ Tonsillar hypertrophy begins in early childhood and continues until puberty, after which atrophic changes may occur.'^ In the literature, there is a lack of knowledge about variation in tonsil size in children. This is the first report that evaluated tonsil size by physical examination in 4- to 17-year-old schoolchildren. Previously, Fujioka and colleagues found that the adenoids peak in size between 3 and 6 60 LU n (%) Size of tonsils Grade 1 Grade 2 Grade 3 Grade 4 Tonsillectomy Tonsillar hypertrophy Asymmetric tonsils — 0 bserved apnea '\ * * ^ 20 /— " z_ 10 — ^ 5 6 7 8 9 1119 (62.7) 507 (28.4) 58 (3.3) 2 (0.1) 98 (5.5) 60 (3.4) 31 (1.7) years of age and then begin to atrophy according to radiographic evaluation of adenoid size.'^ We similarly found tonsil size to be the greatest in 4- to 8-year-old children and to gradually decrease in the following years. Grade 2 tonsils were most frequently encountered in the 4-year-old age group, whereas grade 3 tonsils constituted only 14% of this group. In our study, tonsillar hypertrophy was found to be significantly associated with male gender. Greenfeld and colleagues reported male dominance among children with obstructive sleep apnea syndrome, which is compatible with our results.'^ Male gender may be a risk factor for tonsillar hypertrophy. This may be due to anatomic structure and hormonal profile. Hypertrophic tonsils may cause obstruction or accompany chronic or recurrent tonsillitis in some children. They are also accused of repeated attacks of local or systemic infections.'^''^ In our study, there was a statistically significant association between tonsillar hypertrophy and a history of frequent tonsillitis and fever (see Table 3). On the other hand, in the studied population, 55% of children with tonsillar hypertrophy had no history of recurrent tonsillitis. It is well known that tonsillar hypertrophy can be present even in the absence of a history of infection.^ Snoring, restless sleep, observed apnea, and constant oral breathing during sleep are nocturnal signs of pharyngeal obstruction owing to tonsillar or adenoid q noring ^40 O \k 30 LU Q. Tonsillar Tissue — 0ften tonsillitis - 0 ften fever 50 Q LU Table 2 Tonsillar Tissue in 4- to 17-Year-Old Children {n •• 1784) 10 11 12 13 14 15 16 17 AGE Figure 1 The variation in snoring, observed apnea, frequent tonsillitis, and frequent fever among 4- to 17-year-old schoolchildren. Akcay et al. Variation in Tonsil Size in Childhood 273 100 90 2 80 LU =^ g 70 — G rade 1 ^ 60 O u. 50 O H 40 LU O ^^ X on 30 - G rade II - G rade III V- — G rade IV ~\ E 20 '^ 10 ——\ - 0 4 5 6 7 8 9 10 11 12 13 14 15 16 17 AGE Figure 2 Tonsil size variation among 4- to 17-year-old schoolchildren. hypertrophy in children. In previous studies, the prevalence of snoring every night (described as habitual snoring in this study) was found to be between 6.2 and 12.1 in children up to 7 years old.^"'^^ In this study, habitual snoring was found to be 4.1%, and this is lower than the results of previous studies^""^^ but higher than the results of Kara and colleagues' study done in Denizli {7.A°/o)P The different age groups could explain these varying rates. As clearly seen in our results, the prevalence of snoring reaches its maximum at age 4 years and gradually decreases parallel to the prevalence of tonsillar hypertrophy. On the other hand, the prevalence rate of habitual snoring was found to be higher than the prevalence rate of tonsillar hypertrophy. Therefore, habitual snoring could not be explained only with tonsillar hypertrophy. Observed apnea is an associated symptom of obstructive adenotonsillar hypertrophy. In this study. the rate of observed apnea prevalence was found to be 3.8%, which was higher than the results of Kara and colleagues' study {2.J°/o)P The different age groups could explain these varying rates. Also in our study, there was a statistically significant relationship between tonsillar hypertrophy and observed apnea, which agrees with the results in the literature. There are not enough studies on the prevalence of tonsil asymmetry. The prevalence of asymmetric tonsils was uncommon among 4- to 17-year-old schoolchildren in Denizli. Although the asymmetry of tonsils arouses a suspicion of malignancy, it may often be an illusion secondary to a difference in the depth of the tonsillar fossa.''' The presence of tonsil asymmetry without factors such as significant systemic signs and symptoms, progressive enlargement of the tonsil, ipsilateral cervical adenopathy, and a history of malignancy may not indicate malignancy.''' In our study. Table 3 Interrelationships between Tonsillar Hypertrophy and Studied Factors [n = 1686) Factors Grades 3 and 4 n (%) Grades 1 and 2 n (%) 37(2.2) 23 (1.4) 725 (43) 901 (53.4) .007 1.99 (1.18-3.39) 1.00 26(1.5) 32(1.9) 309(18.3) 1293 (76.7) <.OO1 3.40 (2.00-5.79) 1.00 27(1.6) 31 (1.8) 387(22.9) 1221 (72.4) <.OO1 2.75 (1.62-4.66) 1.00 19(1.1) 39 (2.3) 50 (3.0) 1554(92.1) <.OO1 15.14 (8.17-28.04) 1.00 3 (0.2) 55 (3.3) 13 (0.8) 1578 (93.5) .017 6.62 (1.83-23.90) 1.00 Sex Male Female History of tonsillitis > 2 episodes in year < 2 episodes in year History of often fever > 2 episodes in year < 2 episodes in year Snoring Often or always Never or seldom Observed apnea Often or always Never or seldom CI = confidence interval; OR = odds ratio. p Value OR (95% CI) 274 The Journal of Otolaryngology, Volume 35, Number 4, 2006 because children with asymmetric tonsils did not have these warning sign and symptoms, the tonsils were not considered to be malignant. 8. 9. Conclusions A tonsil size curve was developed in 4- to 17-year-old schoolchildren in Denizli, Turkey. The rates of tonsillar hypertrophy and the prevalence of asymmetric tonsils were found to be low. Tonsillar hypertrophy was found to be significantly associated with the signs and symptoms of upper airway infection and upper airway obstruction. Tonsillar hypertrophy is most frequently encountered at age 4 years and gradually decreases in the following years. Children aged 4- to 8 years with oropharyngeal symptoms, such as a history of frequent tonsillitis and fever, snoring, observed apnea, and particularly male gender, should consult with otorhinolaryngology and pediatric pulmonology physicians for the evaluation of adenotonsillar tissue and polysomnography. 10. 11. 12. 13. 14. 15. 16. References 1. 2. 3. 4. 5. 6. 7. Gonzalez Rivera SR, Coromina Isern J, Gay Escoda G. Respiratory orofacial and occlusion disorders associated with adenotonsillar hypertrophy. An Otorrinolaringol Ibero Am 2004;31:265-82. Potsic WP. Assessment and treatment of adenotonsillar hypertrophy in children. Am J Otolaryngol 1992;13:259-64. Menashe V, Farrehi C, Miller M. Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J Pediatr 1965;67:198-203. Ahlqvist-Rastad J, Hultcrantz E, Svanholm H. Ghildren with tonsillar obstruction: indications for and efficacy of tonsillectomy. Acta Paediatr Scand 1988;77:831-5. Brodsky L, Moore L, Stanievich JF. A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 1987;13:149-56. Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Glin North Am 1989;36:1551-69. Berkowitz RG, Mahadevan M. Unilateral tonsillar enlargement and tonsillar lymphoma in children. Ann Otol Rhinol Laryngol 1999;108:876-9. 17. 18. 19. 20. 21. 22. 23. Gortez EA, Mattox DE, Holt GR, Gates GA. Unilateral tonsillar enlargement. Otolaryngol Head Neck Surg 1979;7:707-16. Dohar JE, Bonilla JA. Processing of adenoid and tonsil specimens in children: a national survey of standard practices and a five-year review of the experience at the Children's Hospital of Pittsburgh. Otolaryngol Head Neck Surg 1996;115:94-7. Ginar F. Significance of asymptomatic tonsil asymmetry. Otolaryngol Head Neck Surg 2004;131:101-3. Garroll JL, McGoUey SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Ghest 1995;108:610-8. Friedman M, Tanyeri H, La Rosa M, et al. Glinical predictors of obstructive sleep apnea. Laryngoscope 1999;109:1901-7. Walker RP. Snoring and obstructive sleep apnea. In: Bailey JB, Galhoun KH, Deskin RW, editors. Head & neck surgery-otolaryngology. 2nd ed. Philadelphia: LippincottRaven Press; 1988. p. 707-29. Harley EH. Asymmetric tonsil size in children. Arch Otolaryngol Head Neck Surg 2002;!28:767-9. Seigel G. Theoretical and clinical aspects of the tonsillar function. Int J Pediatr Otolaryngol 1983;6:61-71. Kornblut AD. Non-neoplastic disease of the tonsils and adenoids. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, editors. Otolaryngology. 3rd ed. Philadelphia: W.B. Saunders Gompany; 1991. p. 2129-47. Fujioka M, Young LW, Girdany BR. Radiographie evaluation of adenoidal size in children: adenoidal-nasopharyngeal ratio. AJR Am J Roentgenol 1979;133:401. Greenfeld M, Tauman R, DeRowe A, Sivan Y. Obstructive sleep apnea syndrome due to adenotonsillar hypertrophy in infants. Int J Pediatr Otorhinolaryngol 2003;67:1055-60. Ballantyne JG, Groves J, Edwards GH, Downton D. A synopsis of otolaryngology. Bristol (UK): John Wright and Sons; 1978. Hultcrantz E, Lofstrand-Tidestrom B, Ahlquist-Rastad J. The epidemiology of sleep related breathing disorder in children. Int J Pediatr Otorhinolaryngol 1995;32 Suppl:S63-6. Smedje H, Broman JE, Hetta J. Parents' reports of disturbed sleep in 5-7-year-old Swedish children. Acta Paediatr 1999; 88:858-65. Teculescu DB, Gaillier I, Perrin P, et al. Snoring in French preschool children. Pediatr Pulmonol 1992;!3:239-44. Kara GO, Ergin H, Kocak G, et al. Prevalence of tonsillar hypertrophy and associated oropharyngeal symptoms in primary school children in Denizli, Turkey. Int J Pediatr Otorhinolaryngol 2002;66:175-9.