The most common cause of respiratory obstruction in children with obstructive sleep disorders and recurrent upper respiratory tract infections is adenotonsillar hyperplasia [1] In patients with Obstructive sleep apnoea the disease has an impact in terms of health related quality of life (HRQL) [2]. Obstructive problems like long lasting snoring, difficulty in breathing during sleep, sleep-apnoea, restless sleep have been associated with several health-related consequences [3]. Adenotonsillectomy found to be a curative procedure in most cases [4,5]. VAS is a psychometric response scale used to measure subjective characteristics or attitudes and is being used in clinical research for multitude of disorders and social science investigations [6]. The Obstructive Sleep Disorders-6 survey (OSD-6) was modelled in a format analogous which is a disease-specific instrument designed to assess quality of life in children with obstructive sleep disorders before and after surgical treatment. The OSD-6 was composed of 6 domains relating to the patient’s OSD and associated symptoms; (1) physical suffering, (2) sleep disturbance, (3) speech and swallowing difficulties, (4) emotional distress, (5) activity limitations, and (6) level of concern of the caregiver, which reflected functioning of the child. Each domain was represented by a question designed to reflect the global effect of an OSD-related symptom cluster for an individual child. A lower survey score indicated a better QOL [7].

The current study aims to study the impact of adenoidectomy and tonsillectomy on quality of life of children in terms of improvement in physical as well as mental state of health of child and improvement in symptoms, using VAS and OSD-6 survey score.

This interventional prospective study was done in department on otorhinolaryngology, at a tertiary care centre, from 1st October 2021 to 31st July 2022.  40 patients with adenotonsillar hypertrophy were  included in the study in the age group between 4 to 16 years, with nasal obstruction, each patient had a history of 4 or more episodes of recurrent upper respiratory tract infection, adenoid tonsillar hypertrophy causing obstructive sleep apnoea, otitis media with effusion, recurrent rhinosinusitis, adenoid facies, hyponasal speech, growth & oro-facial disturbances, and cardiopulmonary complications and behavioral changes like restlessness, irritability, tiredness during the day or upon waking up, bad school performance.

Patients greater than 16 years of age (or) less than 4 years of age, patients with psychiatric and behavioural disorder, coagulation disorders, cleft palate (or) submucosal cleft palate, syndromic patients, patients with history of upper airway obstruction not matching physical exam findings, with sinonasal polyposis, choanal atresia, tumours of nose and nasopharynx were excluded from the study.

A fully explained written consent stating the voluntary participation of subjects in the study was taken before the enrolment of the subjects. A detailed history was taken. All patients underwent thorough history and clinical examination. A battery of investigations including routine blood investigation, urine examination, X-ray nasopharynx lateral view for adenoids, X-ray chest, ECG were performed in all patients.

Adenoids and tonsils size were graded by clinical examination, and per-operative diagnostic nasal endoscopy. All the patients and their parents were asked to respond the subjective level of complains on visual analogue scale and OSD 6 Survey Score pre-operatively and 3 month after surgery. They were also be asked to report for specific complains in throat, nose, ear and behaviour of child. Then they were jointly asked to grade these symptoms 0 to 6 (increasing severity level) according to OSD 6 survey score. The mean OSD 6 survey score was calculated. Symptom scores for same was  assessed post-operatively after 3 months.  Minimum the score, better is the state of health of the child.  Post-operative symptoms were evaluated using VAS and symptom based questionnaire at 3 months post-operatively.

Data were analysed using tables, graphs and percentage and test of significance. Correlation of preoperative and post operative scores were performed and statistically analysed. A P value <0.05 was considered significant The primary outcome measure was a change in general quality of life using OSD-6 Survey score and VAS score.

Table 1- Demographic characteristics

Table 1 shows distribution of study population according of their age. Maximum 55% of patients were in 6-10 years age group. Mean age of study population is 9.28+2.53 years. Male predominance was seen with 29:11 male: female ratio. Majority (57.5%) of study population were residing in urban area whereas 42.5% of study population were from rural area.

Table 2- Clinical presentation

Main clinical symptoms of patients at presentation were nasal obstruction, snoring and mouth breathing, which were present in all (40) patients, 26 (65%) patients had sleep disturbance, 17 (42.5%) patients had complaints related to throat, behavioural issues were discerned in 14 patients and 5 (12.5%) patients (12.5%) had complaints related to ear.

Clinical examination

50% of patients had Grade III tonsils followed by grade II tonsils in 13 (32.5%) patients. Grading of adenoids was done by radiological/endoscopic examination. Maximum 17 (42.5%) patients had Grade II adenoids. 40% (n=16) patients had Grade III adenoids and  7 (17.5%) patients had Grade IV adenoids.

Table 3- Comparative evaluation of Pre operative and post operative VAS score

The mean VAS score was 7.83+0.64 pre-operatively, whereas 2.58+1.17 post operatively. The difference between VAS score was statistically significant (P<0.0001)

Table 4- pre operative and post operative OSD-6 survey score

Comparison of study population was done according to their pre and post operatively OSD-6 survey score. Mean OSD-6 survey score pre-operatively was high 4.28+0.51 whereas, post operative mean value was 0.67+0.18. The difference between OSD-6 survey score pre and post operatively was statistically significant (P<0.0001).

Table 5-  Comparison of study population according to their OSD-6 survey score

Table 5 depicts comparison of study population according to their OSD-6 survey score. All domains of OSD-6 survey score had high scoring pre operatively and, low scoring post operative and results were statistically significant.

Table 6- CHANGE score

Change score was obtained by subtracting mean survey score pre operatively with mean survey score  post operatively which is >1.5. It reflects large level of change in quality of life.

Figure 1: Grade 3 Tonsillar Hypertrophy

Figure 1: Grade 4 Adenoid Hypertrophy

The present study is planned in symptomatic pediatric patients due to adenoid and tonsillar hypertrophy to assess improvement in quality of  life after adenotonsillectomy using VAS and OSD-6 Survey score. In our clinical practice, we have chosen this questionnaire because it is brief, easy to complete for the patient and specific for symptomatic pediatric patients.

In our study out of 40 patients 11 were girls and 29 were boys. Male to female ratio was 2.63:1. The study conducted by VA Lachanas et al [8] showed M:F 1.63 : 1. Similar study was conducted by B. Ramya et al. [9] showed a male: female ratio of 3:2, which reflected a male predominance in an Indian scenario. In our study children between the age group 6-10 years were commonly affected. Out of the total children (n=40)  in the study 22/40 children were in the age group between 6-10 years and mean age was 9.28 ± 2.53. In a study by Bamaniya et al.[10]the age of the patients ranged from 4 to 15 years and the mean age was 8.6 years.

Most of the patients in our study presented with snoring, nasal obstruction and mouth breathing. All 100% of the patients had these symptoms. 60% of the patients had restless sleep.  42.5% of the patients had difficulty while swallowing and shortness of breath and 35% of the patients had speech problems or  behavioural complaints. A study by Beraldin BS et al [11] showed higher symptoms patients concern with snoring (78%) followed by physical suffering (43%), sleep disturbance (41.5%) while least symptom was activity limitation (7.5%). In the study conducted by Serres et al 100% of the children had snoring, 91% of the children had restless sleep, 80% of the patients had shortness of breath [12]. 

In our study 32.5% of the patients had grade II tonsils. 50% of the patients had grade III tonsils and 17.5% patients had grade IV tonsils. In study conducted by Serres et al 45.8% of patients had grade III tonsils and 50% of the patients were having grade IV tonsils [12]. In our study 42.5% patients have Grade II adenoid hypertrophy, 40% patients had grade III and 7% patients had grade IV adenoid hypertrophy. In a study conducted by Alacantra et al  41% patients had grade III adenoid hypertrophy while 39% had grade IV adenoid hypertrophy [13]. In our study the highest rated symptom was nasal obstruction. The mean score was 4.6 before surgery. The post operative score was 0.7. According to the study conducted by Lauro Alacantra et al 51% of the children had pre operative score of 5 and post operative score was 0 in 49% of patients [13]. In our study all patients had sleep disturbance with snoring pre-operatively while 42.5% patients had no snoring post operatively. Alacantra et al in his study concluded that all 100% of the patients had snoring while sleep, 53%  patients had a score of 5 pre operative after the surgery 23% of these patients had a score of 1 [13].

Pre operative symptoms were statistically improved after surgery which gave positive impact on improvement in quality of life in children.

The OSD-6 mean survey score of our study was 4.28+0.51 and 0.67+0.18 preoperatively and post operatively, respectively. The difference was statistically significant (p<0.0001).  In a study conducted by VA Lachanas et al mean OSD-6 survey score was 2.57+1.08 pre operatively and 0.47+0.53 post operatively [8]. Similar study conducted by Francesco et al the mean survey score was 6.98 before surgery and 2.00 post operatively [14]. The mean OSD-6 survey score was statistically significant which gave positive impact on improvement in quality of life in children after adenotonsillectomy.

CHANGE score denotes the change in quality of life. The levels of change in quality of life were classified as trivial ( <0.5), small (0.5 – 0.9), moderate (1.0 – 1.4) and large ( >1.5) according to standard definitions for a survey on a 7- point scale [15]. In our study the mean change score was 4.02 ( >1.5) and it indicates mean change in quality of life after surgery up to a large extent. Serres et al in his study obtained a mean change score of 2.3 which indicates large improvement in quality of life [12].

The mean pre and post operative VAS Score of our study were 7.83+0.64  and 2.58+1.17, respectively and statistically significant (p<0.0001) difference were obtained. Similar results have been reported by Col. R Datta et al [16].

Quality of life questionnaire is easy and valid tool in estimating the amount of improvement in nasal obstruction and mouth breathing for patients undergoing adenotonsillectomy. The OSD-6 questionnaire has satisfactory internal consistency, reliability, responsiveness and validity. Furthermore our study demonstrates that OSD-6 survey is a valid and easy to use instrument for assessing children with OSA. Both the OSD-6 survey score and VAS score provide effective and easy tool for evaluation of treatment responses.

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