Biomedical & Pharmacology Journal

Vol. 10(2), 959-967 (2017)

Differences in Pediatrics Quality of Life (PEDS-QL) Test in

Children Before and After Adenotonsillectomy In 2016
ARTA EKA PUTRA, LELY RAHAYU and EDWARD LIMANTARA

Department of Otorhinolaryngology, Medical Faculty of Udayana University,

Sanglah Hospital, Denpasar, Indonesia.
*Corresponding author E-mail : [email protected]

http://dx.doi.org/10.13005/bpj/1191

(Received: May 18, 2017; accepted: May 30, 2017)

ABSTRACT

In children, adenoid and tonsil infection tends to reccurent and chronic infection in both
lymphoid tissue leads into oxygenation obstruction in airway, especially in sleep, that resulted in
altered quality of life in children. Breathing disorder in sleep, obviously in children, will affect their
routines in daytime including studying, learning, and attention deficit disorder. This research is a
pre-experimental study with one group pre-post test design (before-after study). In this study, we
have one group of children undergoing adenotonsillectomy. Then we will assess the quality of life by
using PedsQL before adenotonsillectomy and after adenotonsillectomy, and then we will compare
the PedsQL score between before and after adenotonsillectomy. In this study, we can obtain an
improvement of physic activity function, feeling or emotion function (mental), sociality function, child
function in school, and significant quality of life based on PedsQL score in children with chronic
adenotonsilitis after underwent adenotonsillectomy operation.

Keyword: Adenotonsillectomy, PEDS-QL, children, RSUD Badung.

INTRODUCTION Bhatt et al. (2014) mentioned that chronic

adenotonsilitis in children also cause sleep disorder
Upper respiratory tract infection is one (sleep disordered breathing) which result in
of the most common diseases in primary care decreasing quality of sleep. Decreased of muscle
centers and specifically in the Ear Throat Ears tone in sleeping can cause the airway to become
(ENT), infection in adenoids and tonsils are also narrower and when accompanied by chronic
one of the most common diseases. In children, adenotonsilitis, it will increase an airflow resistance
adenoid and tonsils infections remain recurrent and cause severe breathing work. 2
and chronic infection in both lymphoid tissue can
cause oxygenation obstruction in respiratory tract, Ilias et al. (2012) conducted a quality of
especially during sleep that will ultimately affect life research in 79 children under the age of 15 with
the quality of life in children. Sleep disordered chronic adenotonsilitis.3 They obtained a conclusions
breathing is commonly found in 11-40% of the of decreased quality of life during activity, sleep
children population, especially those with chronic diordered breathing, increased number of visits to
adenotonsillitis. Sleeping breathing disorders in the doctor, decreased of concentration in school
children will affect routine activities during the and frequent absences. Children with chronic
daytime including playing, studying, and attention adenotonsilitis tend to have lower quality of life that
distraction.1 affects health status, daily physical activity, playing
960 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017)

and learning activity when compared with children had performed adenotonsillectomy,12 there was a
without chronic adenotonsillitis.4 significant improvement in the quality of life in daily
physical activity, a decrease in the number of visits
Adenotonsillectomy (ATE) is considered to doctors or health services due to a decrease
effective because it can reduce the rate of recurrence in recurrence rate. Alcantara et al. (2008) also
of throat infection in children.5 Another consideration reported significant improvements in quality of life
of adenotonsillectomy is the provision of antibiotic after ATE,13 especially in sleep quality as many as
therapy that is less successful against recurrence of 62%, improvements in learning ability and school
chronic adenotonsilitis.6 attendance were 75% and 76%. Patient parents
satisfaction after their children underwent ATE is
In the United States, each year more than quite high, namely 75%, as the feel that their children
500,000 ATE procedures are performed and is the has been significantly improved.13
third most surgical procedure done after circumcision
and ear tube installation. Europan statistics noted Research about improvement in children
that by 2013, in Germany and Finland, 170 ATE quality of life before and after the ATE has been
operations are performed per 100,000 population. done in overseas, but in Indonesia, especially in Bali
New Zealand’s health quality and safety supervisory province has not been done so that researchers are
agency in 2010-2015 noted that ATE procedure interested to know the improvement of quality of life
has been done by 4 per 1000 children. In Indonesia before and after doing ATE procedure.
there is still no official data on the number of ATE
procedur, only mentioning about the prevalence METHOD
of chronic tonsillitis in Indonesia, especially in 7
provinces during 1994-1996, was 3.8%.7 Based Study Design
on the Household Health Survey in 1995, chronic This research will be a pre-experimental
adenotonsilitis was ranked five among the common study with pre-post test design (before-after
diseases found in children and occured at most in study). The reason for choosing the design is
the age of 5 to 14 years.7 At RSCM Jakarta in 1999- that this study has one group of children who will
2003, 427 procedure of ATE8 were obtained. undergo adenotonsillectomy. Then a quality of life
evaluation was performed by using PedsQL before
The quality of life assessment is an adenotonsillectomy and after adenotonsillectomy
assessment that encompasses broad physical and then we compared the PedsQL score between
and psychological characteristics that describe a before and after adenotonsillectomy. The design
person’s ability to play a role in his environment of this research can be made as scheme, just as
and gain satisfaction from what he does. The quality follows:
of life assessment is influenced by the physical,
mental, social and emotional state. This assessment
can be done using quality of life instrument,
such as the pediatrics quality of life (PedsQL).9
The importance of assessing the quality of life
in pediatric patients with chronic adenotonsilitis
is to determine the improvement of quality of life
gained between before and after ATE procedure.
Ramin et al. (2014) suggests that ATE in children
with chronic adenotonsillitis is expected to improve
quality of life, especially improvements in sleep
quality.10 Most ATE measurement (79%) are aimed
at improving the quality of life of children, especially
sleep quality and improving the quality of physical
activity by decreasing recurrence.11 Goldstein et
al. (2008) reported in his study of 92 children who
 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017) 961

Explanation: Data analysis in this research consisted

O1 : pre test in group before undergo an intervention of descriptive statistical analysis and comparison
X : Treatment in intervention group compatible with analysis of paired sample mean. Descriptive statistical
the protocol analysis aims to describe the characteristics of
O2 : post test in group after underwent an intervention research subjects and research variables. Scaled
numerical data variables are displayed in the mean
Study Sample and standard deviation. Categorical data-scale
Prospective study will conducted in THT- variables are displayed by using numbers and
KL policlinic RSUD District Badung Mangusada, percentages. By knowing the characteristics of
from June 1st until August 15th , 2016. Each children research subjects then it can be assessed later on
with age of 5 until 12 years old, appropriate with the representation of the population.
inclusion criteria, that come into THT-KL Policlinic
RSUD District Badung Mangusada, and will be done Mean comparison analysis is for paired
adenotonsillectomy drom June 1st until August 15th, samples. To perform this analysis, firstly, we tested
2016, will included to be subject in this research, the normality of the study. Normality test aims to
until minimal number has been fulfilled. Election determine whether the data distribution from the
way of the sample will be done by using consecutive quality of life scores have normal distribution or not.
sampling method To perform the normality test, we used the normality
test from Saphiro-Wilk. It is called normal distribution
Number of samples will be calculated by if the p value of the normality test of Saphiro-Wilk
using formula : > 0.05. If the distribution of data on the two quality

n=

Explanation :
n : number of samples
SD : Standard deviation from the mean of
difference = 10 (Goldstein dkk., 2008; Ericson dkk.,
2009)
Zá : type I error, á: 0,05 so Zá=1,96
Zâ : type II error, â: 80% so Zâ=0,842
D : Mean difference between the two clinically
important groups (clinical judgement) = 5 (Ericson
dkk., 2009)

n = [(1,96 + 0,842) x 10 / 5]2

n = [2,802 x 10 / 5]2
n = 31,404 samples à rounded up to 32
samples
So, for this study, we need 32 samples of children
that will undergo adenotonsillectomy procedure.

Data Collection
Children population in age of 5 until 12
years old with chronic adenotonsilitis that fulfill
inclusion criteria will be choose as a sample. Then,
we asked them to fill the PedsQL questionnaire
before undergo adenotonsillectomy procedure and
30 days after adenostonsillectomy
962 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017)

of life measurements before and after are normal The whole process of data analysis above
distribution, the test used will be paired t-test at the is done by using the help of SPSS 20.0 software.
0.05 significance margin and if the data distribution
of one measurement or both does not normally Research result
distributed then we used non parametric test from This research was conducted at RSUD
Wilcoxon. District Badung Mangusada. This study is an
experimental pre-post test design (before-after
Table 1: Characteristic of research sample
based on gender, age group, AN-ratio, and
degree of tonsil enlargement

Characteristic n = 32

Gender
Boy 20 (62,5%)
Girl 12 (37,5%)
Age (years old)
Mean ± SD 8,5 ± 1,9
Minimal – maximal 12-May
AN-ratio
Median (Inter Quartil Range/IQR) 0,75 (0,037)
Degree of tonsil enlargement
T2 13 (40,6%) Fig. 1: Differences in median value and inter-
T3 16 (50%) quartile range in physical activity function
T4 3 (9,4%) between before and after adenotonsillectomy

Table 2: Improvement in physical activity function after

adenotonsillectomy based on PedsQL

Quality of Life Physical

Activity

Median (IQR) Adenotonsilectomy Before 90,6 (11,7)

After 90,6 (6,25)
Minimal Maximal Adenotonsilectomy Before 62,5 (100)
After 68,75 (100)
P value <0,001

Table 3: Improvement of feeling/emotional function after

adenotonsillectomy based on PedsQL

Quality of Life Feeling

/Emotion

Median (IQR) Adenotonsilectomy Before 90,0 (10)

After 95 (5)
Minimal Maximal Adenotonsilectomy Before 75,8 (100)
After 85 (100)
P value <0,001
963 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017)

study) in which the subjects were patients aged Characteristics of Research Subjects
5-12 years who suffered from chronic adenotonsillitis Characteristics of research subjects
and underwent adenotonsillectomy. Then a quality observed included gender, age, adenoid hypertrophy
of life evaluation was performed by using PedsQL (assessed by looking at the AN-ratio, equal to or
before adenotonsillectomy and 30 days after greater than 0.73) and the degree of enlarged
adenotonsillectomy and then we compared tonsils. Of the 32 research subjects obtained 20 boy
the PedsQL score between before and after children and 12 girl children. Subject characteristics
adenotonsillectomy. Through the sample calculation by gender, age group, AN-ratio and degree of tonsil
formula, obtained the number of samples as much enlargement can be seen in Table 1.
as 32 people and the selection of samples we
performed a consecutive sampling.

Fig. 2: Differences in median value and Fig. 3: Differences in median value and inter-
inter-quartil range in feeling/emotional quartil range of socialization function between
function between before and after doing before and after adenotonsillectomy procedure
adenotonsillectomy procedure

Fig. 4: Differences in median value and IQR of Fig. 5: Differences in median value and inter-
children function at school between before and quartil range (IQR) in overall score of PedsQL
after adenotonsillectomy between before and after adenotonsillectomy
 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017) 964

Based on the characteristics of research between before and after ATE can be seen in
subjects such as gender, age, AN-ratio value and Figure 1.
the degree of tonsils enlargement in 32 selected
children as the subjects of the study then obtained Improvement in Feeling/emotion function after
boy childred as much as 20 patients or 62.5% and adenotonsillectomy based on PedsQL
the girl children as many as 12 patient or 37.5% and Improvement in feeling/emotional function
the mean age was 8.5 years with an SD score of ± after adenotonsillectomy based on PedsQL can be
1.9, the youngest age of pediatric patients who were viewed in Table 3. Feeling/emotional function before
the subject of the study was 5 years and the oldest adenotonsillectomy procedure, we obtained median
age was 12 years. The median AN-ratio obtained value as 90,0 with inter-quartil range (IQR) as 10
from 32 subjects of this study was 0.75 where the and after underwent adenotonsillectomy, reported a
inter quartile range (IQR) value was 0.037 and median value as 95,0 with inter-quartil range (IQR)
based on the degree of tonsil enlargement from 32 as many as , wehre p value < 0,001. Differences in
subjects it was obtained that T2 enlargement was median value and IQR in feeling/emotional function
13 or 40.6%, enlargement of T3 tonsils was 16 or between before and after adenotonsillectomy can
50.0% and T4 degrees was 3 or 9.4%. be seen in Figure 2.

Improved physical activity function after Improvement of socialization function after

adenotonsillectomy based on PedsQL adenotonsillectomy based on PedsQL
The improvement of physical activity Improvemnet of socialization function after
function after ATE based on PedsQL can be seen underwent adenotonsillectomy based on PedsQL
in Table 2. In the physical activity function before is listed in Table 4. In socialization function before
ATE procedure, the median value was 90.6 with adenotonsillectomy procedure, we obtained a
inter quartil range (IQR) of 11,7 and after ATE we median value as 90,0 with inter-quartil range (IQR)
obtained the score of 90.6 with inter quartile range as many as 5 and after adenotonsillectomy, we can
IQR) of 6.25 where p value < 0.001. The difference of obtain median value as 90,0 with inter-quartil range
median and IQR values on physical activity function (IQR) of 9, where p value < 0,001. Differences in

Table 4: Improvement of socialization function after

adenotonsillectomy based on PedsQL

Quality of Life Socialization

Median (IQR) Adenotonsilectomy Before 90,0 (5)

After 90,0 (9)
Minimal Maximal Adenotonsilectomy Before 65,00 (95,00)
After 70,00 (95,00)
P value <0,001

Table 5: ‘Improvement of children function at school after

adenotonsillectomy absed on PedsQL

Quality of Life At School

Median (IQR) Adenotonsilectomy Before 75 (15)

After 80 (9)
Minimal Maximal Adenotonsilectomy Before 50 (90)
After 60 (90)
P value =0,005
965 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017)

Table 6: Improvement of children overall quality of life between before and

after adenotonsillectomy based on PedsQL

Quality of Life Total Score of PedsQL

Median (IQR) Adenotonsilectomy Before 85,6 (5,6)

After 88,4 (4,7)
Minimal Maximal Adenotonsilectomy Before 66,88 (92,97)
After 77,81 (92,97)
P value <0,001

median value and IQR of socialization function old. Ramya et al (2016) reported that in 100 children
before and after adenotonsillectomy can be seen in who went into adenotonsillectomy procedure had
Figure 3. a majority age research subject (65%), in group of
5-10 years old.14 In this study, we found a ratio of
Improvement of children function at school after boy children vs girl children, namely 1,6 : 1,0. Many
adenotonsillectomy based on PedsQL literatures did not say about the relationship between
Improvement of children function at school gender and incidence of chronic adenotonsillitis.
after adenotonsillectomy based on PedsQL is listed
in Table 5. In children function at school before Naiboglu and colleague (2010), in their
adenotonsillectomy, we obtained median value as study of 40 children who underwent ATE procedure,
75,0 with inter-quartil range (IQR) as 15 and after then assessed the quality of life by using PedsQL,
adenotonsillectomy procedure, median value was they reported any improvement in physical activity
80,0 with inter-quartil range (IQR) 9, where p value function, which is score of PedsQL before ATE
< 0,001. Differences in median value and IQR of procedure was 64,81, then after the patient had been
children function at school between before and after done the ATE procedure, the score was significantly
adenotonsillectomy can be seen in Figure 4. increased, into 83,67. So that, they obtained
an improvementacore by 18,86. 15 In this study,
Improvement of children quality of life from we found a median value of PedsQL in physical
overall score in PedsQL between before and after activity function before ATE was 90,6 and after ATE
adenotonsillectomy procedure, the score remained 90,6. Eventhough
Improvement of children overall quality median value in before and after ATE was still the
of life after adenotonsillectomy based on PedsQL same, but the inter-quartil range (IQR) score was
can be seen in Table 6. Overall score of PedsQL shortened, from 11,7 into 6,25. Even after that, we
before adenotonsillectomy was 85,6 with inter-quartil can state that there was an improvement statistically.
range (IQR) of 5,6 and after adenotonsillectomy, we
obtained the score was 88,4 with inter-quartil range Chronic adenotonsilitis that commonly
(IQR) of 4,7, where p value < 0,001. Differences found in children is one of the risk factors associated
in median value and inter-quartil range (IQR) in with sleep disordered breathing (SDB). Kaditis et
overall score PedsQL between before and after al. (2015) stated that SDB is a syndrome of upper
adenotonsillectomy can be seen in Figure 5. respiratory tract dysfunction that occurs at the
time of sleep one of which is marked by sound
DISCUSSION snoring.16 Kaditis et al (2015) also mentioned that
the presence of adenoid and tonsil hypertrophy
This research is a pre-experimental study contributed to SDB incidence but was not the sole
with one group pre-post test design (before-after determinant factor in the degree of severity of airway
study). This retrospective study was conducted in obstruction.16 In children, SDB is associated with
THT-KL policlinic RSUD District Badung Mangusada behavioral disorders.17,18 Gupta et al. (2013) in his
with target population of children patient who will be study of 131 children undergoing ATE treatment and
done adenotonsillectomy with the age of 5-12 years then observed for 2 years after ATE procedure, they
 PUTRA et al., Biomed. & Pharmacol. J., Vol. 10(2), 959-967 (2017) 966

assessed the improvement of emotional / feeling quality of life in children function at school, especially
function and concluded 50% of respondents stated in the number of attendance as it improved because
no change in feeling / emotional function and 30% the decreased of recurrence rate.20 In this study there
respondents stated that they got improvement on was also a significant improvement in the children
emotion / feeling function.19 In this study, the median function at school, namely from the median value
value of PedsQL in feeling / emotional function before of 75 before ATE into 80 after ATE and inter quartil
ATE procedure was 90.0 and 30 days after ATE with range (IQR) that narrowed from 15 before ATE to
median value was 95.0. Similarly, the value of inter 9 after ATE. Where the minimum-maximum score
quartile range (IQR) before ATE, 10 and 5 after ATE. range before ATE is 50-90 then the range narrowed
So it can be concluded that the ATE procedure is able into 60-90after ATE.
to provide improvements to the feelings / emotions
based on PedsQL. ATE procedure in pediatric patients with
chronic adenotonsilitis in overall can improve the
Naiboglu et al. (2010) in his study quality of life of children, this can be seen from various
of the quality of life in children with chronic studies of the children’s quality of life.10,12,13,14,21 This
adenotonsilitis using PedsQL questionnaire scored proves an improvement in quality of life based on
in the socialization function of pre ATE was 76.37 PedsQL score of 2.8%, which was observed 30 days
and obtained an increased into 85.75, marked an after the ATE procedure. So it can be said that with
improvement after ATE.15 Although the study found the ATE procedure in chronic adenotonsillitis could
no improvement in the socialization function, the give an improvement in children’s quality of life.
median value before ATE and after ATE was 90, for
each; and inter quartile range from before ATE was CONCLUSION
5 to 9 after ATE. Where the minimal-maximal score
range before ATE is 65-95 then the range narrowed From this research, we can obtain an
into 70-95 after ATE. improvement of physical activity function, feeling or
emotional function, children function at school, and
Barraclough & Anari (2014) in his meta- significant quality of life based on PedsQL score in
analysis study reported a study using PedsQL children with chronic adenotonsillitis after underwent
instruments after ATE, they found an improvement of adenotonsillectomy procedure.

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