Effects of adenoidectomy/adenotonsillectomy on ADHD symptoms and behavioral problems in children

Abstract

In children, the most common reason of upper airway obstruction (UAO) is adenotonsillar hypertrophy. In literature, the adverse effects of UAO and obstructive sleep apnea syndrome on behavior and attention in children have been reported in several articles. However, the methods used for the evaluation of behavioral disorders have not been standardized in those studies. The aim of this study was to investigate the behavioral and attention characteristics of children before and after adenoidectomy/adenotonsillectomy using an internationally valid method.
A total of 41 patients, between 6 and 11 years of age and having a medical history of UAO for at least one year for which adenotonsillectomy procedure was indicated, were enrolled in the study. The patients were evaluated for signs of attention/behavioral disorders by a child-adolescent psychiatrist and Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children: Present and Lifetime Version (K-SADS-PL) and The Turgay DSM-IV-Based Child and Adolescent Disruptive Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S), before and at the 6th month following the operation.
In the preoperative period, a psychiatric disorder was identified by K-SADS-PL in 41.4% (n=17) of patients. Of these, 11 patients had attention deficit hyperactivity disorder (ADHD), 6 had enuresis nocturna, and 2 had separation anxiety disorder. Pre- and postoperative mean scores in T-DSM-IV-S parent scale were 31.3±8.5 and 20.2±10.3, respectively, and this difference was statistically significant (p<0.001).
The relationship of UAO and attention/behavioral disorders should be taken into consideration by child-adolescent psychiatrists together with ENT specialists and a multidisciplinary approach is important for the treatment team.
Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Full text

Effects
of
adenoidectomy/adenotonsillectomy
on
ADHD
symptoms
and
behavioral
problems
in
children
Hatice
Aksu
a,
*,
Ceren
Gu
¨nel
b
,
Bo
¨rte
Gu
¨rbu
¨z
O
¨zgu
¨r
a
,
Ali
Toka
b
,
Sema
Bas¸
ak
b
a
Department
of
Child
and
Adolescent
Psychiatry,
Adnan
Menderes
University,
Aydın,
Turkey
b
Department
of
ENT,
Adnan
Menderes
University,
Aydın,
Turkey
1.
Introduction
The
presence
of
additional
psychosocial,
developmental,
emotional
and
behavioral
problems
in
pediatric
patients
admitted
to
otorhinolaryngology
clinics
is
a
fairly
common
situation.
Therefore,
regarding
children
who
are
admitted
to
otorhinolaryn-
gology
clinics,
consultations
of
pediatric
psychologist
or
other
behavioral
health
professional
in
terms
of
psychosocial
and
behavioral
disorders
is
suggested
to
be
a
standard
part
of
the
examination
by
specialists
[1].
In
children,
one
of
the
most
common
reasons
of
upper
airway
obstruction
(UAO)
is
adenotonsillar
hypertrophy.
In
children
with
adenotonsillar
hypertrophy,
various
sleep-related
complaints
may
be
encountered.
These
complaints
may
be
in
the
range
from
simple
snoring
to
obstructive
sleep
apnea
syndrome
(OSAS).
Upper
airway
obstruction,
by
affecting
many
systems,
may
lead
to
many
serious
clinical
conditions
such
as
maxillomandibular
anomalies,
growth
retardation,
enuresis
nocturna,
cor
pulmonale,
right
cardiac
failure,
and
systemic
hypertension
in
children
[1–6].
Moreover,
UAO
has
been
suggested
to
be
associated
with
symptoms
such
as
learning
difficulties,
attention
deficit,
hyperactivity,
aggression
and
antiso-
cial
personality
[1,6–8].
Recently
conducted
studies
have
reported
that
attention
deficit
hyperactivity
disorder
(ADHD)
frequently
accompanied
adenotonsillar
hypertrophy
and
associated
respira-
tory
problems
in
children
and
in
the
postoperative
period,
positive
changes
in
their
attention
and
behavioral
problems
were
observed
[3,6].
Among
neurodevelopmental
disorders,
ADHD
is
the
most
common
disorder;
it
affects
5.3–7%
of
school-aged
children
throughout
the
world
[9–11].
Three
subtypes
were
described
for
International
Journal
of
Pediatric
Otorhinolaryngology
79
(2015)
1030–1033
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
29
January
2015
Received
in
revised
form
15
March
2015
Accepted
12
April
2015
Available
online
18
April
2015
Keywords:
Adenoidectomy
Tonsillectomy
Attention
deficit
Disruptive
behavior
disorder
Obstructive
sleep
apnea
A
B
S
T
R
A
C
T
Objectives:
In
children,
the
most
common
reason
of
upper
airway
obstruction
(UAO)
is
adenotonsillar
hypertrophy.
In
literature,
the
adverse
effects
of
UAO
and
obstructive
sleep
apnea
syndrome
on
behavior
and
attention
in
children
have
been
reported
in
several
articles.
However,
the
methods
used
for
the
evaluation
of
behavioral
disorders
have
not
been
standardized
in
those
studies.
The
aim
of
this
study
was
to
investigate
the
behavioral
and
attention
characteristics
of
children
before
and
after
adenoidectomy/
adenotonsillectomy
using
an
internationally
valid
method.
Methods:
A
total
of
41
patients,
between
6
and
11
years
of
age
and
having
a
medical
history
of
UAO
for
at
least
one
year
for
which
adenotonsillectomy
procedure
was
indicated,
were
enrolled
in
the
study.
The
patients
were
evaluated
for
signs
of
attention/behavioral
disorders
by
a
child-adolescent
psychiatrist
and
Kiddie-Schedule
for
Affective
Disorders
and
Schizophrenia
for
School-Age
Children:
Present
and
Lifetime
Version
(K-SADS-PL)
and
The
Turgay
DSM-IV-Based
Child
and
Adolescent
Disruptive
Behavioral
Disorders
Screening
and
Rating
Scale
(T-DSM-IV-S),
before
and
at
the
6th
month
following
the
operation.
Results:
In
the
preoperative
period,
a
psychiatric
disorder
was
identified
by
K-SADS-PL
in
41.4%
(n
=
17)
of
patients.
Of
these,
11
patients
had
attention
deficit
hyperactivity
disorder
(ADHD),
6
had
enuresis
nocturna,
and
2
had
separation
anxiety
disorder.
Pre-
and
postoperative
mean
scores
in
T-DSM-IV-S
parent
scale
were
31.3

8.5
and
20.2

10.3,
respectively,
and
this
difference
was
statistically
significant
(p
<
0.001).
Conclusion:
The
relationship
of
UAO
and
attention/behavioral
disorders
should
be
taken
into
consideration
by
child-adolescent
psychiatrists
together
with
ENT
specialists
and
a
multidisciplinary
approach
is
important
for
the
treatment
team.
ß
2015
Elsevier
Ireland
Ltd.
All
rights
reserved.
*Corresponding
author.
Tel.:
+90
5323020048;
fax:
+90
2562144086.
E-mail
address:
aksubhatice@yahoo.com
(H.
Aksu).
Contents
lists
available
at
ScienceDirect
International
Journal
of
Pediatric
Otorhinolaryngology
jo
ur
n
al
ho
m
ep
ag
e:
ww
w.els
evier
.c
om
/lo
cat
e/ijp
o
r
l
http://dx.doi.org/10.1016/j.ijporl.2015.04.018
0165-5876/ß
2015
Elsevier
Ireland
Ltd.
All
rights
reserved.

attention
deficit
hyperactivity
disorder
in
Diagnostic
and
Statisti-
cal
Manual
of
Mental
Disorders,
fourth
edition
(DSM-IV)—1994:
predominantly
inattentive
type,
predominantly
hyperactive–
impulsive
type
and
combined
type,
possessing
the
characteristics
of
both
groups
simultaneously
[12].
Attention
deficit
hyperactivity
disorder
is
a
disorder
having
a
chronic
clinical
course;
even
if
a
reduction
is
observed
in
severity
of
symptoms
as
child
grows.
In
addition,
depression,
psychosocial
problems,
alcohol
and
sub-
stance
abuse,
educational
and
unemployment
problems
might
develop
in
adulthood,
if
they
left
untreated.
The
main
treatment
options
are
psycho-behavioral
interventions
directed
to
the
family
and
the
child,
arrangement
of
the
classroom
environment,
and
pharmacotherapy
[13].
Children
having
UAO
related
to
adenotonsillar
hypertrophy
frequently
manifest
symptoms
of
attention
deficit
hyperactivity
disorder,
behavioral
problems
and
impulsiveness
with
varying
degrees
of
severity
[14].
While
OSAS
is
suggested
to
affect
central
nervous
system
through
sleep
fragmentation
and
intermittent
hypoxia,
inflammatory
mechanisms
are
also
contemplated
to
have
an
important
role
in
the
development
of
behavioral
disorder
[2,4,5].
In
the
literature,
there
is
a
few
studies
reporting
the
negative
effects
of
UAO
and
OSAS
on
behavior
and
attention
of
children
evaluated
using
standardized
semi-structured
diagnostic
inter-
views
done
by
child
psychiatrist.
[8,15,16].
Most
of
the
studies
have
been
based
on
the
statements
of
the
caregiver
or
evaluation
of
the
night
behaviors
of
the
child
[15–17].
The
number
of
studies
in
which
the
psychosocial
and
behavioral
assessment
was
made
by
a
child-adolescent
psychiatrist
and
internationally
valid
and
reliable
psychiatric
diagnostic
guidelines
were
used
is
insufficient
[18,19].
The
aim
of
this
study
was
to
determine
the
comorbid
psychiatric
disorders
of
children
with
UAO
related
to
adenoid/adenotonsillar
hypertrophy
in
the
preoperative
and
postoperative
period
by
using
semi-structured
diagnostic
interview
and
to
evaluate
the
effect
of
adenoidectomy/adenotonsillectomy
on
attention
and
behavioral
symptoms
severity
using
parent
reported
scale.
2.
Materials
and
methods
This
study
was
in
accordance
with
Declaration
of
Helsinki
for
human
subjects
and
has
been
approved
by
Adnan
Menderes
University
Local
Ethics
Committee
for
the
ethical
care
on
13.09.2012
with
approval
number
2012/126.
The
procedure
was
described
in
detail
to
all
volunteers
who
participated
in
the
study
and
informed
consent
was
obtained
from
all
parents
and
guardians
prior
to
enrollment.
A
total
of
41
patients,
between
6
and
11
years
of
age
children
and
preadolescents,
admitted
to
Adnan
Menderes
University,
Ear,
Nose
and
Throat
Clinic
with
symptoms
defining
UAO
such
as
mouth
breathing,
snoring
and
interruption
of
sleep
and
whose
detailed
ENT
examinations,
made
by
the
same
physician
(CG),
revealed
adenoid/adenotonsillar
hypertrophy
were
enrolled
in
the
study.
Patients
were
enrolled
in
the
study
consecutively,
according
to
their
order
of
admittance.
The
patients
who
have
been
suffering
of
UAO
symptoms
at
least
for
one
year
and
having
adenoid
vegetation
with
or
without
tonsillar
hypertrophy
that
caused
an
obstruction
of
more
than
75%
at
nasopharyngeal
passage
using
flexible
nasopharyngoscopeand
giving
consent
for
the
operation
have
been
included
in
the
study
[20].
The
exclusion
criteria
from
the
study
were:
adenotonsillectomy
performed
with
the
indication
of
infection
with
no
airway
obstruction,
craniofacial
anomalies,
continuous
drug
therapy
due
to
chronic
disorders,
patients
with
neuromuscular
diseases,
patients
with
mental
retardation,
and
medical
history
revealing
previous
treatment
for
ADHD.
Adenoi-
dectomy/adenotonsillectomy
were
performed
by
the
same
sur-
geon
(CG)
using
the
method
of
curettage
and
cold
dissection.
All
patients
were
assessed
preoperatively
and
at
6th
month
following
surgery
by
the
same
child-adolescent
psychiatrist
(HA)
in
terms
of
psychiatric
disorders
and
symptom
severity
using
the
semi-structured
psychiatric
diagnostic
interview
and
scale
men-
tioned
below.
2.1.
Semi-structured
psychiatric
diagnostic
interview
and
scale
used
2.1.1.
Schedule
for
Affective
Disorders
and
Schizophrenia
for
School-
Age
Children:
Present
and
lifetime
version
(K-SADS-PL)
Schedule
for
Affective
Disorders
and
Schizophrenia
for
School-
Age
Children:
Present
and
Lifetime
Version
is
a
semi-structured
instrument
developed
by
Kaufman
and
colleagues
to
screen
psychopathology
in
children
and
adolescents
between
ages
6
and
18
by
gathering
information
from
both
parents
and
the
offsprings
[21].
Mood
disorders,
psychotic
disorders,
anxiety
disorders,
disruptive
behavioral
disorders,
elimination
disorders,
eating
disorders,
tic
disorders
and
alcohol
and
other
substance
use
disorders
are
the
psychiatric
conditions
included
in
this
instru-
ment.
K-SADS-PL
is
administered
in
consideration
of
DSM-IV
diagnostic
criteria.
Reliability
and
validity
of
K-SADS-PL
were
adapted
to
Turkish
in
2004
[22].
Certified
specialist
made
the
K-SADS-PL
interview
with
both
child
and
the
caregiver
before
and
after
the
surgical
operation.
The
implementation
period
of
the
test
was
2.5
h
in
average.
2.1.2.
The
Turgay
DSM-IV-Based
Child
and
Adolescent
Disruptive
Behavioral
Disorders
Screening
and
Rating
Scale
(T-DSM-IV-S)
The
T-DSM-IV-S
is
a
well
known
and
widely
used
questionnaire
which
was
developed
by
Turgay
and
translated
and
adapted
into
Turkish
by
Ercan
et
al.
[23].
The
T-DSM-IV-S
is
based
on
the
DSM-IV
diagnostic
criteria
and
assesses
hyperactivity/impulsivity
(9
items),
inattention
(9
items),
opposition/defiance
(8
items),
and
conduct
disorder
(15
items).
The
symptoms
are
scored
by
assigning
a
severity
estimate
for
each
symptom
on
a
four-point
Likert-type
scale.
The
diagnosis
of
the
disorders
was
made
by
the
child-
adolescent
psychiatrist,
using
K-SADS-PL.
The
severity
of
the
attention
and
behavioral
symptoms
before
and
after
the
operation
were
assessed
by
parent
form
of
T-DSM-IV-S.
Patients
were
followed-up
till
6th
month
after
the
operation
without
giving
any
treatment
for
psychiatric
conditions.
2.2.
Statistical
analysis
SPSS
20.0
statistical
software
package
for
Windows
was
used
for
evaluation
of
the
data
[24].
Compliance
with
the
normal
distribution
was
assessed
by
Kolmogorov–Smirnov
test.
Paired
t
test,
which
is
one
of
parametric
tests,
was
used
for
data
with
normal
distribution.
Wilcoxon
paired
two-sample
test
and
Mann–
Whitney
U
test
were
used
for
the
comparison
of
paired
data
which
did
not
fit
a
normal
distribution.
For
the
comparison
of
qualitative
data,
the
chi-square
and
McNemar
tests
were
used.
Yates
correction
was
used.
Spearman
correlation
analysis
was
used
for
relational
evaluation.
Data
were
shown
as
the
number,
percentage,
and
mean

standard
deviation.
For
statistical
significance,
p
<
0.05
was
selected.
3.
Results
The
mean
age
of
41
patients
enrolled
in
the
study
(21
females,
20
males),
was
7.2

1.5
years.
There
was
no
significant
difference
between
the
average
ages
of
females
and
males
(p
>
0.05).
A
psychiatric
diagnosis
was
made
according
to
the
implemented
K-SADS-PL
scale,
meeting
the
DSM-IV
diagnostic
criteria,
in
41.4%
(n
=
17)
of
the
patients
(Table
1).
The
most
common
psychiatric
H.
Aksu
et
al.
/
International
Journal
of
Pediatric
Otorhinolaryngology
79
(2015)
1030–1033
1031

diagnosis
in
these
patients
was
attention
deficit
hyperactivity
disorder
(ADHD)
(64.7%,
n
=
11).
Enuresis
nocturna
(35.2%,
n
=
6)
and
separation
anxiety
disorder
(11.7%,
n
=
2)
were
the
other
less
commonly
diagnosed
psychiatric
disorders.
In
11.7%
of
the
patients
(n
=
2),
the
association
of
ADHD
and
enuresis
nocturna
was
identified.
Of
11
(26.8%)
patients
diagnosed
with
ADHD,
3
(27.3%)
were
female
and
8
(72.7%)
were
male.
ADHD
subtypes
of
the
patients,
meeting
the
diagnostic
criteria
of
attention
deficit
hyperactivity
disorder,
were
shown
in
Table
2.
There
was
no
significant
difference
between
genders
in
terms
of
preoperative
psychiatric
diagnoses
(p
>
0.05,
Yates
value
1.9).
A
statistically
significant
reduction
was
determined
in
the
compari-
son
of
patients
diagnosed
with
psychiatric
disorders
before
and
after
the
operation
(Table
1)
(p
<
0.01).
The
reduction
in
frequency
of
ADHD
diagnosis
was
also
statistically
significant
(p
<
0.05).
The
average
T-DSM-IV-S
parental
score
of
all
patients
(n
=
41)
in
the
preoperative
period
was
18.6.
The
relationship
between
preoperative
T-DSM-IV-S
parental
score
and
patient
age
was
not
significant
(p
>
0.05,
Spearman
correlation
analysis).
There
was
also
no
significant
relationship
between
parental
score
and
gender
of
the
patient
(p
>
0.05,
Mann–Whitney
U
test).
A
statistically
significant
reduction
was
found
when
preopera-
tive
and
postoperative
T-DSM-IV-S
parent
median
scores
were
compared
(Z
=
5.04,
p
<
0.001,
Wilcoxon
test).
When
preoperative
and
postoperative
T-DSM-IV-S
parental
scores
of
patients
with
ADHD
(n
=
11)
were
evaluated,
the
preoperative
average
score
was
determined
as
31.3

8.5
and
postoperative
average
score
as
20.2

10.3.
The
reduction
was
statistically
significant
(p
<
0.001,
paired
t
test).
Most
of
the
patients
(83.3%,
n
=
5)
having
the
diagnostic
criteria
of
enuresis
nocturna
recovered
within
the
first
6
months,
without
any
additional
treatment.
There
was
no
significant
difference
between
preoperative
and
postoperative
diagnosis
of
enuresis
nocturna
(p
>
0.05,
McNemar
test).
4.
Discussion
In
many
studies,
psychiatric
disorders,
attention
and
behavioral
disorders
have
been
suggested
to
be
frequently
met
in
children
having
upper
airway
obstruction
or
OSAS
[8,16–19,25–27].
However,
few
studies
are
available
demonstrating
the
prevalence
of
psychiatric
disorders
in
cases
with
an
indication
for
adeno-
tonsillectomy,
with
a
semi-structured
scale
based
on
preoperative
DSM-IV
diagnostic
criteria,
by
a
child-adolescent
psychiatrist
[18,28].
The
differences
of
this
study
from
similar
studies
were
implementation
of
K-SADS-PL
by
a
child-adolescent
psychiatrist
in
the
preoperative
period,
and
reassessment
of
symptom
severity
at
the
6th
month
following
the
operation
with
the
same
scale.
Ivanenko
et
al.,
in
their
study
with
46
patients
have
reported
that
they
determined
a
50%
rate
for
psychiatric
disorders,
meeting
DSM-IV
diagnostic
criteria
[28].
In
our
study,
psychiatric
disorders
were
determined
in
41.4%
of
41
patients
(n
=
17)
as
the
result
of
K-SADS-PL
evaluation
which
was
based
on
DSM-IV.
The
most
common
psychiatric
disorder
was
ADHD
(26.8%)
in
our
patients.
In
a
prevalence
study
conducted
in
Turkey,
ADHD
incidence
was
found
to
be
12.5%
in
primary
school-aged
children
[29].
Its
worldwide
prevalence
was
reported
as
5%
[9].
When
these
data
were
taken
into
consideration,
an
approximately
2–3
fold
increased
prevalence
rate
was
determined
for
ADHD
in
our
patient
group
with
adenotonsillectomy
indication.
Soylu
et
al.,
in
their
study
in
2013
with
children
having
adenotonsillar
hypertrophy
using
the
inven-
tory
in
our
country,
have
determined
that
ADHD
and
sleep
disorders
were
the
most
common
psychiatric
disorders
[27].
In
the
study
by
Dillon
et
al.,
a
structured
diagnostic
interview
based
on
DSM-IV
(The
Diagnostic
Interview
Schedule
for
Children)
was
implemented
in
79
patients
who
were
planned
to
undergo
adenotonsillectomy
opera-
tion,
and
ADHD
was
reported
to
be
present
in
27.8%
of
the
patients
[18].
Li
et
al.
reported
the
incidence
of
ADHD
in
children
with
adenotonsillar
hypertrophy
as
40%
[19].
The
high
detection
rate
of
ADHD
in
our
study,
as
well
as
other
studies,
suggests
that
children
with
UAO
should
be
consulted
with
child-adolescent
psychiatrists
in
terms
of
early
diagnosis
of
ADHD
and
preventive
mental
health.
On
the
other
hand,
several
studies
evaluating
the
incidence
of
OSAS
in
children
with
ADHD
have
reported
rates
of
more
than
50%
[30,31].
The
assessment
of
children
with
attention
and
behavioral
problems
in
terms
of
UAO
symptoms
is
an
important
issue.
When
the
preoperative
and
6th
month
postoperative
T-DSM-IV-
S
parental
scores
of
patients
diagnosed
with
ADHD
were
compared,
the
observed
reduction
in
symptom
severity,
although
not
being
a
complete
remission,
even
when
psychiatric
treatment
was
not
given
during
the
postoperative
period,
is
a
quite
significant
result.
In
the
literature,
several
studies
conducted
in
Turkey
have
suggested
that
significant
reductions
in
severity
of
the
disorder
were
observed
following
surgery
directed
to
UAO
and
have
reported
similar
results
to
our
study
[27,32].
Dadgarnia
et
al.
have
recently
conducted
a
quasi-experimental
study
investigating
the
effects
of
adenotonsil-
lectomy
on
symptoms
of
ADHD
and
behavioral
disorders;
they
have
determined
a
statistically
significant
improvement
in
symptom
severity
in
the
postoperative
period
[3].
In
all
patients
enrolled
in
our
study,
reduction
in
postoperative
scores
was
present
in
terms
of
T-DSM-IV-S
parental
scale;
when
preoperative
and
postoperative
scores
were
compared,
the
difference
was
statistically
significant
(p
<
0.001).
In
the
literature,
Table
1
The
distribution
of
psychiatric
diagnoses
of
the
cases
before
and
after
the
operation,
according
to
gender.
K-SADS
diagnoses
Before
the
operation
After
the
operation
Statistics
*
Female
(n,
%)
Male
(n,
%)
Total
(n,
%)
Female
(n,
%)
Male
(n,
%)
Total
(n,
%)
No
psychiatric
diagnosis
15,
36.4
9,
21.8
24,
58.3
17,41.4
17,41.4
34,
82.9
p
<
0.01
Psychiatric
diagnosis
7,
17.0
12,
29.2
17,
41.4
4,
9.7
3,
7.3
7,
17.1
p
<
0.01
ADHD
3,
7.3
8,
19.4
11,
26.8
1,
2.4
3,
7.2
4,
9.6
p
<
0.05
Enuresis
nocturna
**
2,
4.8
4,
9.6
6,
14.4
1,
2.4
0
1,
2.4
p
>
0.05
Separation
anxiety
2,
4.8
0
2,
4.8
2,
4.8
0
2,
4.8
p
>
0.05
*
McNemar
test.
**
In
2
cases,
comorbidity
of
ADHD
+
enuresis
nocturna
was
diagnosed
before
the
operation.
Table
2
The
distribution
of
ADHD
subtypes
according
to
gender.
Female
(n)
Male
(n)
Total
(%)
Inattentive
type
1
3
36.4
Hyperactive–impulsive
type
1
0
9.1
Combined
type
1
5
54.5
Total
3
8
100
H.
Aksu
et
al.
/
International
Journal
of
Pediatric
Otorhinolaryngology
79
(2015)
1030–1033
1032

studies
based
on
DSM-IV
diagnostic
criteria,
investigating
adeno-
tonsillectomy
and
behavioral
characteristics,
have
reported
similar
results
to
our
study
[18,27,32].
The
parents
stated
that
83.3%
of
patients
with
adenotonsil-
lectomy
indication
and
having
the
diagnostic
criteria
of
enuresis
nocturna
recovered
within
the
first
6
months,
without
any
additional
treatment
and
in
one
patient
with
ongoing
symptoms,
the
frequency
of
bedwetting
decreased.
In
the
literature,
similar
results
have
been
reported
regarding
the
frequency
of
enuresis
nocturna
[18].
In
a
study
conducted
by
Basha
et
al.
in
2005,
61.4%
of
107
children
having
the
diagnosis
of
enuresis
nocturna
and
adenotonsillectomy
indication
showed
complete
remission
and
22.8%
of
the
patients
had
reduction
of
enuresis
frequency
[33].
Besides
adenotonsillectomy,
the
normal
neurodevelopmental
stage
of
the
child
may
be
considered
as
a
contributing
factor
effective
for
decreased
frequency
of
enuresis.
Improvement
in
psychiatric
symptoms
should
not
suggest
that
the
primary
treatment
of
psychiatric
disorders
is
adenotonsillect-
omy
intervention.
However,
we
suggest
that
in
patients
having
attention
and
behavioral
problems,
if
symptoms
and
signs
of
UAO
are
present,
it
may
contribute
to
the
reduction
of
symptoms.
In
the
literature,
most
of
the
studies
used
various
parent
based
scales
for
diagnosing
attention
and
behavioral
problems.
In
our
study
K-SADS-PL
scale,
based
on
DSM-IV,
was
used
by
a
child-adolescent
psychiatrist
prior
and
after
the
adenotonsillectomy
operation,
in
order
to
investigate
the
diversity
of
psychiatric
diagnoses.
Limitations
of
our
study;
T-DSM-IV-S
teacher
form
could
not
be
evaluated
since
the
data
was
insufficient.
Also,
score
variations
according
to
ADHD
subtypes
could
not
be
analyzed,
because
the
patient
number
was
small.
Additionally,
another
limitation
of
the
study
was
not
to
compare
the
results
with
a
control
group.
In
conclusion,
by
using
a
parent
form
of
T-DSM-IV-S
and
different
semi-structured
diagnostic
interview
(K-SADS-PL)
from
other
studies
in
the
literature,
psychiatric
diagnoses
were
investigated
in
patients
with
adenotonsillar
hypertrophy
and
similar
results
were
found.
It
was
determined
that,
in
patients
with
upper
airway
obstruction,
attention
and
behavioral
problems
were
particularly
common.
However,
at
6th
month
following
the
treatment
of
obstruction
by
surgery,
a
statistically
significant
improvement
was
detected
in
the
attention
and
behavioral
problems.
We
suggest
that
the
close
relationship
of
attention
and
behavioral
disorders
with
upper
airway
obstruction
should
be
taken
into
consideration
by
child-adolescent
psychiatrists
together
with
ENT
specialists
and
multidisciplinary
approach
is
important
for
the
treatment
team.
Conflict
of
interest
statement
There
is
no
conflict
of
interest
in
this
paper.
Acknowledgement
This
research
was
funded
by
Adnan
Menderes
University
Scientific
Research
Projects
Unit
grant
(TPF-13034).
References
[1]
C.M.
Holder,
B.H.
Davis,
W.L.
Ward,
Comorbid
psychosocial
issues
seen
in
pediat-
ric
otolaryngology
clinics,
Otolaryngol.
Clin.
North
Am.
47
(5)
(2014)
779–794.
[2]
S.
Blunden,
R.D.
Chervin,
Sleep,
performance
and
behaviour
in
Australian
indige-
nous
and
non-indigenous
children:
an
exploratory
comparison,
J.
Paediatr.
Child
Health
46
(1–2)
(2010)
10–16.
[3]
M.H.
Dadgarnia,
M.H.
Baradaranfar,
R.
Fallah,
S.
Atighechi,
A.H.
Ahsani,
A.
Baradaranfar,
Effect
of
adenotonsillectomy
on
ADHD
symptoms
of
children
with
adenotonsillar
hypertrophy,
Acta
Med.
Iran
50
(8)
(2012)
547–551.
[4]
H.
Engleman,
D.
Joffe,
Neuropsychological
function
in
obstructive
sleep
apnoea,
Sleep
Med.
Rev.
3
(1)
(1999)
59–78.
[5]
D.
Gozal,
Sleep-disordered
breathing
and
school
performance
in
children,
Pediat-
rics
102
(3
Pt
1)
(1998)
616–620.
[6]
F.
Horiuchi,
Y.
Oka,
K.
Komori,
Y.
Tokui,
T.
Matsumoto,
K.
Kawabe,
et
al.,
Effects
of
adenotonsillectomy
on
neurocognitive
function
in
pediatric
obstructive
sleep
apnea
syndrome,
Case
Rep.
Psychiatry
2014
(2014)
520215.
[7]
R.D.
Chervin,
J.E.
Dillon,
C.
Bassetti,
D.A.
Ganoczy,
K.J.
Pituch,
Symptoms
of
sleep
disorders:
inattention,
and
hyperactivity
in
children,
Sleep
20
(12)
(1997)
1185–1192.
[8]
N.A.
Goldstein,
J.C.
Post,
R.M.
Rosenfeld,
T.F.
Campbell,
Impact
of
tonsillectomy
and
adenoidectomy
on
child
behavior,
Arch.
Otolaryngol.
Head
Neck
Surg.
126
(4)
(2000)
494–498.
[9]
A.P.
Association,
Diagnostic
and
Statistical
Manual
of
Mental
Disorders,
fifth
ed.,
A.P.
Association,
Washington,
DC,
2013.
[10]
E.G.
Willcutt,
The
prevalence
of
DSM-IV
attention-deficit/hyperactivity
disorder:
a
meta-analytic
review,
Neurotherapeutics
9
(3)
(2012)
490–499.
[11]
H.
Perera,
S.M.
Fernando,
A.D.
Yasawardena,
I.
Karunaratne,
Prevalence
of
atten-
tion
deficit
hyperactivity
disorder
(ADHD)
in
children
presenting
with
self-
inserted
nasal
and
aural
foreign
bodies,
Int.
J.
Pediatr.
Otorhinolaryngol.
73
(10)
(2009)
1362–1364.
[12]
A.P.
Association,
Diagnostic
and
Statistical
Manual
of
Mental
Disorders,
fourth
ed.,
A.P.
Association,
Washington,
DC,
1994.
[13]
N.I.f.H.a.C.
Excellence,
NICE
clinical
guideline
72:
attention
deficit
hyperactivity
disorder:
diagnosis
and
management
of
ADHD
in
children,
young
people
and
adults,
2008.
[14]
M.
Ayral,
M.Y.
Baylan,
V.
Kinis,
Y.
Bez,
S.
Bakir,
M.
Ozbay,
et
al.,
Evaluation
of
hyperactivity:
attention
deficit,
and
impulsivity
before
and
after
adenoidectomy/
adenotonsillectomy
surgery,
J.
Craniofac.
Surg.
24
(3)
(2013)
731–734.
[15]
G.
Avior,
G.
Fishman,
A.
Leor,
Y.
Sivan,
N.
Kaysar,
A.
Derowe,
The
effect
of
tonsillectomy
and
adenoidectomy
on
inattention
and
impulsivity
as
measured
by
the
Test
of
Variables
of
Attention
(TOVA)
in
children
with
obstructive
sleep
apnea
syndrome,
Otolaryngol.
Head
Neck
Surg.
131
(4)
(2004)
367–371.
[16]
A.M.
Schatz,
A.O.
Ballantyne,
D.A.
Trauner,
Sensitivity
and
specificity
of
a
com-
puterized
test
of
attention
in
the
diagnosis
of
Attention-Deficit/Hyperactivity
Disorder,
Assessment
8
(4)
(2001)
357–365.
[17]
R.D.
Chervin,
D.L.
Ruzicka,
B.J.
Giordani,
R.A.
Weatherly,
J.E.
Dillon,
E.K.
Hodges,
Sleep-disordered
breathing:
behavior,
and
cognition
in
children
before
and
after
adenotonsillectomy,
Pediatrics
117
(4)
(2006)
e769–e778.
[18]
J.E.
Dillon,
S.
Blunden,
D.L.
Ruzicka,
K.E.
Guire,
D.
Champine,
R.A.
Weatherly,
et
al.,
DSM-IV
diagnoses
and
obstructive
sleep
apnea
in
children
before
and
1
year
after
adenotonsillectomy,
J.
Am.
Acad.
Child
Adolesc.
Psychiatry
46
(11)
(2007)
1425–1436.
[19]
H.Y.
Li,
Y.S.
Huang,
N.H.
Chen,
T.J.
Fang,
L.A.
Lee,
Impact
of
adenotonsillectomy
on
behavior
in
children
with
sleep-disordered
breathing,
Laryngoscope
116
(7)
(2006)
1142–1147.
[20]
J.H.
Cho,
D.H.
Lee,
N.S.
Lee,
Y.S.
Won,
H.R.
Yoon,
B.D.
Suh,
Size
assessment
of
adenoid
and
nasopharyngeal
airway
by
acoustic
rhinometry
in
children,
J.
Laryngol.
Otol.
113
(10)
(1999)
899–905.
[21]
J.
Kaufman,
B.
Birmaher,
D.
Brent,
U.
Rao,
C.
Flynn,
P.
Moreci,
Schedule
for
Affective
Disorders
and
Schizophrenia
for
School-Age
Children-Present
and
Lifetime
Ver-
sion
(K-SADS-PL):
initial
reliability
and
validity
data,
J.
Am.
Acad.
Child
Adolesc.
Psychiatry
36
(7)
(1997)
980–988.
[22]
B.
Go
¨kler,
F.
U
¨nal,
B.
Pehlivantu
¨rk,
E.
Ku
¨ltu
¨r,
D.
Akdemir,
Y.
Taner,
Reliability
and
validity
of
Schedule
for
Affective
Disorders
and
Schizophrenia
for
School
Age
Children-Present
and
Lifetime
Version-Turkish
Version
(K-SADS-PL-T),
Turk.
J.
Child
Adolesc.
Ment.
Health
11
(3)
(2004)
109–116.
[23]
E.
Ercan,
S.
Amado,
O.
Somer,
A
work
for
developing
a
test
for
attention
deficit
hyperactivity
disorder
and
disruptive
behaviours
disorders,
Turk.
J.
Child
Adolesc.
Mental
Health
8
(2001)
132–144.
[24]
IBM
Corp.,
IBM
SPSS
Statistics
for
Windows,
IBM
Corp.,
Armonk,
NY,
2011.
[25]
E.T.
Aronen,
K.
Liukkonen,
P.
Simola,
P.
Virkkula,
A.
Uschakoff,
M.
Korkman,
et
al.,
Mood
is
associated
with
snoring
in
preschool-aged
children,
J.
Dev.
Behav.
Pediatr.
30
(2)
(2009)
107–114.
[26]
R.B.
Mitchell,
J.
Kelly,
Child
behavior
after
adenotonsillectomy
for
obstructive
sleep
apnea
syndrome,
Laryngoscope
115
(11)
(2005)
2051–2055.
[27]
E.
Soylu,
N.
Soylu,
Y.S.
Yildirim,
C.
Polat,
O.
Sakallioglu,
The
prevelance
of
psichiatric
symptoms
in
preschool
children
with
adenotonsillar
hypertrophy,
Int.
J.
Pediatr.
Otorhinolaryngol.
77
(7)
(2013)
1094–1098.
[28]
A.
Ivanenko,
M.E.
Barnes,
V.M.
Crabtree,
D.
Gozal,
Psychiatric
symptoms
in
children
with
insomnia
referred
to
a
pediatric
sleep
medicine
center,
Sleep
Med.
5
(3)
(2004)
253–259.
[29]
E.S.
Ercan,
R.
Kandulu,
E.
Uslu,
U.A.
Ardic,
K.U.
Yazici,
B.K.
Basay,
et
al.,
Prevalence
and
diagnostic
stability
of
ADHD
and
ODD
in
Turkish
children:
a
4-year
longi-
tudinal
study,
Child
Adolesc.
Psychiatry
Ment.
Health
7
(1)
(2013)
30.
[30]
N.
Golan,
E.
Shahar,
S.
Ravid,
G.
Pillar,
Sleep
disorders
and
daytime
sleepiness
in
children
with
attention-deficit/hyperactive
disorder,
Sleep
27
(2)
(2004)
261–266.
[31]
Y.S.
Huang,
N.H.
Chen,
H.Y.
Li,
Y.Y.
Wu,
C.C.
Chao,
C.
Guilleminault,
Sleep
disorders
in
Taiwanese
children
with
attention
deficit/hyperactivity
disorder,
J.
Sleep
Res.
13
(3)
(2004)
269–277.
[32]
T.
Fidan,
V.
Fidan,
The
impact
of
adenotonsillectomy
on
Attention-Deficit
Hyperactivity
and
Disruptive
Behavioral
Symptoms,
Eurasian
J.
Med.
40
(2008)
14–17.
[33]
S.
Basha,
C.
Bialowas,
K.
Ende,
W.
Szeremeta,
Effectiveness
of
adenotonsillectomy
in
the
resolution
of
nocturnal
enuresis
secondary
to
obstructive
sleep
apnea,
Laryngoscope
115
(6)
(2005)
1101–1103.
H.
Aksu
et
al.
/
International
Journal
of
Pediatric
Otorhinolaryngology
79
(2015)
1030–1033
1033