Effectiveness of Adenotonsillectomy vs Watchful Waiting in Young Children With Mild to Moderate Obstructive Sleep Apnea: A Randomized Clinical Trial

Outcome of tonsillotomy in children with obstructive sleep-disordered breathing

OBJECTIVE/BACKGROUND

Most children treated for obstructive sleep disordered breathing (oSDB) are not systematically assessed by polysomnography (PSG) nor by structuredsymptom quantification before surgical treatment. The main objective of this study wasto investigate the effect of adeno-tonsillotomy (ATO) on symptom burden and PSGparameters.

METHODS

Children aged 2-10 years with oSDB were selected for ATO based uponclinical findings according to current standards of care in Denmark. Each childunderwent standardized assessment before and 3 months after surgery, including aPSG, tonsil size assessment, and the Pediatric Sleep Questionnaire -Sleep RelatedBreathing Disorder (PSQ) to quantify symptom burden. Obstructive sleep apnea (OSA)was defined as an obstructive apnea-hypopnea index (oAHI) ≥2/h. Successfultreatment was defined as post-surgery oAHI ≤5/h, and complete cure as oAHI ≤2/h.

RESULTS

Fifty-two children were included. Mean age was 5.0 years (SD ± 1.76). Thirteen children were identified with baseline oAHI <2/h. Significant improvement inOSA severity was observed in children with moderate-to-severe OSA, in whom oAHI decreased from 15.7/h to 2.6/h (p < 0.001). Treatment success was obtained in 85% and cure was obtained in 42% of children. PSQ-score significantly improved from 0.52 (CI 0.47-0.56) to 0.26 (CI 0.21-0.32) (p < 0.001). Baseline OSA severity was notcorrelated to baseline symptom burden nor to symptom relief after ATO. There were noserious adverse events.

CONCLUSIONS

Adeno-tonsillotomy significantly reduced symptom burden in otherwise healthy children with oSDB symptoms. Significant improvement in oAHI was observedonly in children with moderate-to-severe OSA. We recommend combining clinicalevaluation with PSQ and oAHI.

Establishing a telehealth model addressing paediatric sleep health in remote and rural Northern Territory Australia: Overcoming the distance barrier

AIM

This study examined the outcomes of a telehealth model for sleep health assessment among Indigenous and non-Indigenous children residing in remote and regional communities at the Top End Northern Territory (NT) of Australia.

METHODS

Video telehealth consultation, that included clinical history and relevant physical findings assessed virtually with an interstate paediatric sleep physician was conducted remotely. Polysomnography (PSG) and therapeutic interventions were carried out locally at Darwin, NT. The study participants were children referred between 2015 and 2020.

RESULTS

Of the total 812 children referred for sleep assessment, 699 underwent a diagnostic PSG. The majority of patients were female (63%), non-Indigenous (81%) and resided in outer regional areas (88%). Indigenous children were significantly older and resided in remote or very remote locations (22% vs. 10%). Referral patterns differed according to locality and Indigenous status - (non-Indigenous via private (53%), Indigenous via public system (35%)). Receipt of referrals to initial consultation was a median of 16 days and 4 weeks from consult to PSG. Remote children had slightly longer time delay between the referral and initial consult (32 vs. 15 days). Fifty one percent were diagnosed to have OSA, 27% underwent adenotonsillectomy and 2% were prescribed with CPAP therapy.

CONCLUSIONS

This study has demonstrated that a telehealth model can be an effective way in overcoming logistical barriers and in providing sleep health services to children in remote and regional Australia. Further innovative efforts are needed to improve the service model and expand the reach for vulnerable children in very remote communities.

Advances in Pharyngeal Surgery Over the Past 10 Years: New Techniques and Technology

This article is a review of advances in pharyngeal surgery over the past 10 years regarding literature, surgical technique, assessment, collaboration, and future direction in the management of adult and pediatric obstructive sleep apnea.

Efficacy of adenotonsillectomy on pediatric obstructive sleep apnea and related outcomes: A narrative review of current evidence

This review summarizes the current evidence in systematic reviews, meta-analysis and randomized controlled trials regarding adenotonsillectomy outcomes in pediatric obstructive sleep apnea (OSA). Adenotonsillectomy is effective in treating OSA in children without co-morbidities, despite postoperative residual OSA remained in roughly half of these children. For children with comorbidities such as Down syndrome, Prader-Willi syndrome, sickle cell disease, or cerebral palsy, adenotonsillectomy is less effective and associated with more postoperative complications than that in children without comorbidities. For other OSA-related outcomes, evidence from meta-analyses and randomized controlled trials confirm adenotonsillectomy results in improvement of subjective OSA-related outcomes (e.g. symptoms, behaviors, and quality of life), but the results in objective OSA-related outcomes (e.g. cardiometabolic parameters or neurocognitive functions) are inconsistent. Future studies should focus on randomized controlled trials comparing objective OSA-related outcomes and the long-term effects of adenotonsillectomy in children with OSA.

Management of paediatric sleep-disordered breathing

Paediatric sleep-disordered breathing is a common condition which varies in severity from snoring to obstructive sleep apnoea. Paediatric sleep-disordered breathing is usually diagnosed clinically, with investigations such as polysomnography reserved for more complex cases. Management can involve watching and waiting, medical or adjunct treatments and adenotonsillectomy. National working groups have sought to standardise the pathway for surgery and improve the management of surgical and anaesthetic complications. Current guidelines use age, weight and comorbidities to stratify risk for these surgical cases. This article summarises these recommendations and outlines the important factors that indicate cases that may be more suitable for management in secondary and tertiary units. Appropriate case selection will reduce pressure on tertiary units while maintaining training opportunities in district general hospitals.

Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial

Importance

The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown.

Objectives

To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB.

Design, Setting, and Participants

Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months.

Intervention

Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228).

Main Outcomes and Measures

The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes.

Results

Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: -3.1 for adenotonsillectomy vs -1.9 for watchful waiting; difference, -0.96 [95% CI, -2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, -0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, -9.02 [97% CI, -15.49 to -2.54] and -6.52 [97% CI, -11.59 to -1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, -11.2% [97% CI, -17.5% to -4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy.

Conclusions

In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT02562040.

Is adenotonsillectomy effective in improving central apnea events in patients with obstructive sleep apnea? A systematic review and meta-analysis

PURPOSE

To evaluate the effects of adenotonsillectomy on improving central sleep apnea events in children with obstructive sleep apnea (OSA).

METHODS

We searched four online databases for relevant articles published from inception until October 2022. We included studies that measured the number of central apnea events per sleep and central apnea-hypopnea index (CAHI) or central apnea index (CAI) scores in children with OSA before and after adenotonsillectomy. Our primary outcomes were changes in CAI scores, the number of central apnea events per sleep, and CAHI scores after surgery. Our secondary outcomes were changes in total and mixed apnea events, improvement of sleep outcomes, and differences in oxygen or carbon dioxide saturation during sleep. We performed meta-analyses by pooling the mean changes of all included studies with a 95% confidence interval using Stata 17. Subsequently, we performed subgroup analyses based on the presence of comorbidities.

RESULTS

We included 22 studies comprising 1287 patients. Central and total sleep apnea parameters, except for CAHI and mixed apnea index scores, showed significant improvements after surgery. In addition, all respiratory parameters and second and third stages of non-rapid eye movement sleep showed significant postsurgical improvements. Patients with comorbidities showed significant improvements only in the total apnea-hypopnea index, oxygen desaturation index, and minimal oxygen saturation.

CONCLUSION

Adenotonsillectomy improves central apnea events in patients with OSA but not in those with comorbidities.

Clinical Impact of Preoperative Tonsil and Adenoid Size on Symptomatic Outcomes Following Adenotonsillectomy in Pediatric Patients

Background Adenotonsillar hypertrophy is a common clinical problem in pediatric patients. Adenotonsillectomy is a surgical intervention to remove airway obstruction and alleviate symptoms. However, some children continue to experience persistent symptoms after surgery. Objective This study aimed to investigate the relationship between preoperative tonsils and adenoid size and the persistence of symptoms, including snoring, mouth breathing, noisy breathing, and sleep apnea, after adenotonsillectomy in pediatric patients. Method This study was conducted in Taif, Saudi Arabia, and included 109 pediatric patients aged three to 14 years who underwent adenotonsillectomy. Data on preoperative and postoperative symptoms were collected through patient records and follow-up surveys. Tonsil and adenoid size were assessed using the Brodsky scale and endoscopic grading scales, respectively. Statistical analysis was performed using SPSS Version 26 (IBM Corp., Armonk, NY). Results The most prevalent presenting symptoms were snoring, mouth breathing, and noisy breathing. Tonsil size grades 3+ and 4+ were significantly more prevalent than the other grades (p<0.05). Adenoid size grades 3 and 4 were also significantly more prevalent than the other grades (p<0.05). Significant associations were observed between tonsil and adenoid size grades and specific presenting symptoms, such as snoring, mouth breathing, and noisy breathing. No significant correlations were found between preoperative tonsil or adenoid size and postoperative persistent symptoms. Conclusion While tonsil and adenoid size are essential factors in determining the need for surgery, they may not predict postoperative resolution of symptoms. A comprehensive evaluation of various clinical factors is necessary to understand the persistence of symptoms after surgery. Although adenotonsillectomy is an effective treatment for upper airway obstruction in pediatric patients, some individuals may experience residual symptoms.

Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy

OBJECTIVE

To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged.

METHODS

An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey.

RESULTS

After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care.

CONCLUSION

The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.

An observational pragmatic quality-of-life study on paediatric tonsillectomy and waiting for surgery

PURPOSE

To investigate parental perceptions of the effects of tonsillectomy on their child's quality of life while awaiting and following surgery in an Australian public health system.

METHODS

An observational pragmatic study was undertaken at a tertiary Australian hospital. Parents of paediatric patients (2-16 years of age) listed for tonsillectomy completed a validated quality-of-life questionnaire (T-14 Paediatric Throat Disorders Outcome Test) at the initial consultation, on day of surgery, 6 weeks post-operatively and 6 months post-operatively. T-14 scores were compared using the Related-Samples Wilcoxon Signed Rank Test.

RESULTS

Parents of 167 children participated in this study. There was a median wait time of 174 days (IQR 108-347) from the initial consultation until the day of surgery, with no significant change in median T-14 scores (35 [IQR 22-42] vs 36 [IQR 22-42]; n = 63; p > 0.05). There was a significant decrease from pre-operative T-14 scores to 6 weeks post-operatively (33.5 [IQR 22-42] vs 2 [IQR 0-5]; n = 160; p < 0.001), and this was sustained with a minor improvement at 6 months post-operatively (6 weeks 2 [IQR 0-5] vs 6 months 0 [IQR 0-2]; n = 148; p < 0.001).

CONCLUSIONS

Paediatric tonsillectomy improves quality of life with a sustained benefit in the long term. There is no improvement to the patient's quality of life while awaiting tonsillectomy, thus patient welfare can be improved through reducing waiting times for surgery.

The effect of OSA on the negative pressure and acoustic compliance of middle ear cavity in children

OBJECTIVE

To explore the effect of obstructive sleep apnea (OSA) on the negative pressure and acoustic compliance of middle ear cavity in children.

METHODS

The clinical data of 258 children with suspected OSA, who complained of mouth breathing or snoring at night in the Department of Otolaryngology Head and neck surgery of the Second Affiliated Hospital of Xi'an Jiao Tong University from August 2020 to March 2022, were enrolled and analyzed retrospectively. The OSA and otitis media with effusion (OME) were determined by polysomnography (PSG) and acoustic immittance examination, respectively. Then, the parameters of tympanometry were compared between OSA and non-OSA children or among the children with various severity of OSA.

RESULTS

There was no significant difference in the incidence of OME between children with OSA and those with non-OSA (15.80% vs 11.80%, P = 0.422). Compared with non-OSA children, OSA children had lower negative pressure (-56.42 vs -12.38, P < 0.001) and higher acoustic compliance (0.45 vs 0.38, P = 0.030) in middle ear cavity. There were also significant differences in negative pressure and acoustic compliance among children with mild, moderate and severe OSA (P < 0.001; P = 0.001). However, only the absolute value of negative pressure was markedly decreased after surgical therapy accompanied with transformation from OSA to non-OSA (-156.67 vs -45.67, P < 0.05), while this was not observed for acoustic compliance (0.48 vs 0.40, P > 0.05).

CONCLUSION

OSA may have an adverse influence on the negative pressure and acoustic compliance of middle ear cavity in children.

Investigating factors influencing post-operative growth in pre-pubertal children after adenotonsillectomy

PURPOSE

To check the change in growth-for-age after adenotonsillectomy in pre-pubertal children and investigate the affecting factors.

METHODS

Two hundred and six pediatric patients who underwent adenotonsillectomy by a single surgeon between January 2011 and December 2014 were included for the retrospective cohort study. The z-scores of height-, weight-, and body mass index (BMI)-for-age were measured before adenotonsillectomy and 1 year after the operation. The Korean version of the obstructive sleep apnea-18 questionnaire (OSA-18), symptom questionnaire, physical examinations, demographic data, and pre-operative z-scores were used to analyze the factors affecting z-score change.

RESULTS

Among 206 pediatric patients, 167 patients were normal growth; 19 were undergrowth; and 20 were obese. After the operation, height, weight, and BMI z-scores all increased both in 167 normal-growth patients and 19 undergrowth patients (p value < 0.05). However, in 20 obese patients, only height z-score significantly increased (p value = 0.028). The multiple regression test showed that the sleep disturbance domain of OSA-18 was positively correlated with height z-score change (p value = 0.041), and age was negatively correlated with weight z-score change (p value = 0.016). Pre-operative BMI z-score was negatively correlated (p value = 0.019) and adenoid grade was positively correlated (p value = 0.023) with BMI z-score change.

CONCLUSIONS

These findings suggest that adenotonsillectomy may positively affect growth in pre-pubertal children, without undesirable weight gain. Additionally, the sleep disturbance domain of OSA-18 may play a role in predicting post-operative height increase in pre-pubertal children.

Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea

STUDY OBJECTIVES

Adenotonsillectomy (AT) forms part of first-line management for pediatric obstructive sleep apnea. In nonrandomized studies of preschool-aged children, postoperative weight gain has been seen following AT, raising concerns regarding later obesity. Using longitudinal data from a multicenter randomized controlled trial, we assessed the impact of AT on growth trajectories in preschool-aged children with mild-moderate obstructive sleep apnea.

METHODS

A total of 190 children (aged 3-5 years) with obstructive apnea-hypopnea index ≤ 10 events/h were randomly assigned to early (within 2 months) or routine (12-month wait) AT. Anthropometry and polysomnography were performed at baseline, 12-month, and 24-month time points for 126 children. Baseline characteristics were compared using a Mann-Whitney or t test for continuous variables and Fisher's exact test for categorical variables. Longitudinal data underwent linear mixed modeling.

RESULTS

For body mass index (BMI) z-score there was a significant increase in the early surgery group between 0 and 12 months (0.4, 95% confidence interval 0.1-0.8) but not from 12-24 months. For the routine surgery group there was an identical significant BMI z-score increase in the first 12 months following surgery, ie, between 12- and 24-month time points (0.45, 95% confidence interval 0.1-0.8) but not from 0-12 months (preoperative time). Final BMI z-score was similar between groups. Findings for weight-for-age z-score were similar to the findings for BMI z-score. Height-for-age z-score was not significantly different between different time points or intervention groups.

CONCLUSIONS

This study provides randomized controlled trial evidence of notable, but time-limited, increase in the BMI and weight of preschool children with mild-moderate obstructive sleep apnea in the months immediately following AT.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: POSTA Child Study (Preschool Obstructive Sleep Apnea Tonsillectomy Adenoidectomy Study); URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336273&isReview=true; Identifier: ACTRN12611000021976.

CITATION

Kevat A, Bernard A, Harris M-A, et al. Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea. J Clin Sleep Med. 2023;19(1):55-62.

Sleep-disordered breathing, sleep apnea, and other obesity-related sleep disorders: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of sleep-disordered breathing, (e.g., sleep-related hypopnea, apnea), and other obesity-related sleep disorders.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Obesity contributes to sleep-disordered breathing, with the most prevalent manifestation being obstructive sleep apnea. Obesity is also associated with other sleep disorders such as insomnia, primary snoring, and restless legs syndrome. This CPS outlines the evaluation, diagnosis, and treatment of sleep apnea and other sleep disorders, as well as the clinical implications of altered circadian system.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on "Sleep-Disordered Breathing, Sleep Apnea, and Other Obesity-Related Sleep Disorders" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.

Admission practices following pediatric tonsillectomy: A survey of ASPO members

OBJECTIVES

Although evidence-based Clinical Practice Guidelines (CPGs) have specified postoperative admission criteria for pediatric tonsillectomy, there is substantial variation in guideline implementation and adherence among otolaryngologists in practice. We aimed to assess pediatric otolaryngologists' post-tonsillectomy admission practices and to examine patient and surgeon factors associated with differences in admission practices.

METHODS

An electronic cross-sectional survey was distributed to members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices regarding admission practices following pediatric tonsillectomy. Chi-square and Fisher's exact tests were performed to compare differences in adherence to tonsillectomy CPGs by respondent characteristics.

RESULTS

The survey was sent to 644 pediatric otolaryngologists with a response rate of 19.1%. 37% of respondents reported "always" and 60% "often" using the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) CPG to guide decision for admission. Years in practice was the factor most strongly associated with admission practices, with 10 or fewer years in practice significantly correlated with stricter adherence to the AAO-HNS CPG of overnight observation when Apnea-Hypopnea Index (AHI) ≥10, age <3 years, or O2 nadir <80%) (OR 4.2, p <0.001), as well as specific individual criteria such as an AHI ≥10 (OR 4.1, p = 0.03). Respondents in an academic practice setting were more likely to admit children <3 years of age than those in private practice (OR 5.0, p = 0.01).

CONCLUSION

Admission practices varied among pediatric otolaryngologist survey respondents, and strict AAO-HNS CPG adherence was associated with fewer years in practice and academic practice setting. These results suggest that further study investigating factors influencing guideline adherence and post-tonsillectomy admission practices is warranted.

Secondary Analyses of the Childhood Adenotonsillectomy Trial: A Narrative Review

Importance

Adenotonsillectomy, performed for approximately 500 000 children annually in the US alone, is the first line of treatment of pediatric obstructive sleep apnea (OSA). The Childhood Adenotonsillectomy Trial (CHAT), the first randomized clinical trial to test the efficacy of adenotonsillectomy, compared the management of pediatric nonsevere OSA by early adenotonsillectomy (eAT) vs watchful waiting with supportive care. Since the publication of the primary article in 2013, the CHAT study data set were made available via the National Sleep Research Resource, which allowed researchers to address a range of additional clinical questions relevant to the care of children with OSA. This review focuses on secondary analyses associated with the CHAT data set as grouped by the outcome of interest.

Observations

The results of most secondary analyses suggest that children who underwent eAT experienced the greatest improvements in symptom burden, sleepiness, parent-reported behavior, and quality of life. Changes in other domains, such as cognition, cardiovascular physiology, and metabolic indicators, were modest and selective. The associations between most treatment outcomes and polysomnographic parameters were weak. Symptoms were poor predictors of OSA severity. The results from these secondary analyses benefitted from the rigor of multicenter design and centralized polysomnography interpretation in CHAT. However, the exclusion of younger preschool-aged children and children with primary snoring limited the generalizability of findings. In addition, because caregivers were not masked, some of the parent-reported outcomes may have been inflated.

Conclusions and Relevance

The results of this narrative review suggest that CHAT provides a model for future OSA-related studies in children for design, conduct, and subsequent reuse of the study data set, and its findings have advanced our understanding of the pathophysiology and management of pediatric nonsevere OSA. Directions for future research include whether the findings from this landmark study are generalizable to younger children and children with primary snoring and severe OSA. Similar studies may help address practice variability associated with pediatric OSA and help identify children who are most likely to benefit from undergoing eAT.

Efficacy of orthodontic treatment versus adenotonsillectomy in children with moderate obstructive sleep apnoea and mandibular retrognathia: study design and protocol for a non-inferiority randomised controlled trial

INTRODUCTION

Orthodontic treatment and adenotonsillectomy (AT) are both conventional treatments for paediatric obstructive sleep apnoea (OSA). Each approach has distinct treatment advantages; however, there is currently a lack of solid evidence to support their efficacy comparison. We hypothesise that the objective effect of orthodontic treatment is not inferior to AT in children with moderate OSA and mandibular retrognathia, but orthodontic treatment has the advantage of promoting dentofacial growth.

METHODS AND ANALYSIS

This is a randomised, open-label, parallel-group, active controlled trial that will study the efficacy of orthodontic treatment versus AT in children with moderate OSA accompanied by tonsillar adenoid hypertrophy and mandibular retrognathia. A total of 98 patients will be enrolled and randomised in a 2:1 ratio to either orthodontic treatment or AT group. Participants will be recruited at Shanghai Stomatological Hospital, Shanghai Children's Hospital of Shanghai Jiaotong University and Children's Hospital of Fudan University, which are all located in Shanghai, China. The primary endpoint is the per cent change in the obstructive apnoea-hypopnoea index from baseline (month 0) to the primary endpoint (month 7), and the mean reduction in A point, nasion and B point angle on cephalometric measurements by lateral X-ray films. Important secondary efficacy endpoints include sleep duration with oxygen saturation below 90% according to polysomnography and subjective symptoms (assessed by the OSA-20 questionnaire), etc. Safety endpoints will also be evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of Shanghai Stomatological Hospital (approval no. (2021)002), Shanghai Children's Hospital of Shanghai Jiaotong University (approval no. 2021R046-F01) and Children's Hospital of Fudan University (approval no. (2021)136). Before enrolment, a qualified clinical research assistant will obtain written informed consent from both the participants and their guardians after full explanation of this study. The results will be presented at national or international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000037288.

Medical management of severe obstructive sleep apnoea in two cases during the coronavirus disease 2019 pandemic

OBJECTIVE

Severe paediatric obstructive sleep apnoea in typically developing children with adenotonsillar hypertrophy is primarily managed surgically. Non-emergency ENT surgery was paused early in the coronavirus disease 2019 pandemic and children were offered medical management for obstructive sleep apnoea.

METHODS

A service evaluation was performed to assess the impact of continuous positive airway pressure alongside medical management for severe obstructive sleep apnoea.

RESULTS

Over 5 months during 2020, in a tertiary care setting, two children (one boy and one girl), aged 2.7 years and 4.1 years, were offered continuous positive airway pressure and medical treatments for severe obstructive sleep apnoea whilst surgery was paused during the coronavirus disease 2019 pandemic. Both children failed to establish continuous positive airway pressure therapy because of ongoing disturbed sleep on ventilation, and they proceeded to adenotonsillectomy. Sleep-Related Breathing Disorder scale scores improved following surgical intervention.

CONCLUSION

Continuous positive airway pressure therapy is poorly tolerated in children with severe obstructive sleep apnoea secondary to adenotonsillar hypertrophy. Surgery remains the most appropriate treatment.

Smartphone videos to predict the severity of obstructive sleep apnoea

OBJECTIVE

Diagnosis of obstructive sleep apnoea (OSA) is made on overnight polysomnography (PSG). Given the widespread availability of smartphone video technology, we aimed to develop and test a standardised scoring system for smartphone videos and compare these scores to PSG results.

METHODS

Children aged 1-16 years undergoing PSG for suspected OSA were included. Parents were asked to take 1-2 min videos of the breathing they were concerned about. Videos were scored using a newly developed and tested tool on five components: inspiratory obstructive noises (1-4), presence of obstructive events (0-1), increased work of breathing (0-1), mouth breathing (0-1) and neck extension (0-1). Video scores and the Obstructive Apnoea Hypopnoea Index (OAHI) were compared using Spearman correlation. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for different cut-off scores to achieve the best results.

RESULTS

Videos from 43 children (28 men (65.1%), median age 5.7 years (range 2.6-14.0 years), median OAHI 3.8/hour (range 0-82 events/hour) were included. Nine children (20.9%) had a video score of <3, all of whom had an OAHI of ≤5 events/hour. For a video score of ≥3, sensitivity was 100%; specificity was 36%; positive predictive value was 53%; and negative predictive value 100% for moderate to severe OSA (OAHI>5 events/hour) .

CONCLUSION

We have developed and validated a simple clinical tool (the Monash Obstructive Sleep Apnoea Video Score) to quantify abnormalities in breathing seen on short video recordings made on a smartphone. A low score rules out moderate-severe OSA and may be valuable in the triage of children with symptoms of OSA.

Innovations in the Treatment of Pediatric Obstructive Sleep Apnea

Obstructive sleep apnea affects a large proportion of otherwise healthy children in the context of interactions between craniofacial elements, adenotonsillar hypertrophy and other anatomical factors, and neuromuscular reflexes of the upper airway. In light of the adverse consequences of sleep apnea, it is important not only to proceed with early diagnosis but also to implement adequate treatment that is guided by the pathophysiological determinants of the disease in each child. Here, we will describe the current standard of care approaches to the treatment of pediatric obstructive sleep apnea, and will also explore novel management strategies that should enable more personalized therapy in the near future.

A review of health-related quality of life issues in children suffering from certain key otolaryngological illnesses

BACKGROUND

The health-related quality of life (HRQoL) concept is nowadays increasingly and more broadly used for helping evaluate the effectiveness of medical treatment, superseding the earlier "quality of life" approach. The HRQoL concept likewise applies to otolaryngology and this narrative review study is focused on HRQoL outcomes in four key childhood otolaryngological diseases as reported in the literature.

STUDY AIM

To retrospectively evaluate the literature on measuring HRQoL in children suffering from selected otolaryngological illnesses, during treatment.

MATERIALS AND METHODS

Published studies/case reports were searched for in Medline, PubMed, Web of Science, Scopus and ORCID on the quality of life based on paediatric patient questionnaires, whether completed by subjects themselves or by their parents (by proxy). The following key words were used: health quality of life, otolaryngology/ENT, pediatrics/paediatrics. Studies before 1999 were omitted because hitherto, the "quality of life" had been imprecisely defined thus rendering any subsequent comparisions problematic.

RESULTS

HRQoL scores and well-being were found to significantly deteriorate in child patients suffering from four important otolaryngological disorders: chronic sinusitis, nasal septum deviation, adenoid hypertrophy and hearing disease. The main problems found were infection, inflammation, disruption to family life and child-parental interaction, fitness-related issues, reduced ENT patencies and apnea.

CONCLUSIONS

The HRQoL appears to significantly deteriorate in children suffering from otolaryngological diseases. Further such studies are needed for other ENT diseases.

Changes in childhood growth after adenotonsillectomy: a population-based cohort study

OBJECTIVES

This study aimed to investigate the association between adenotonsillectomy (T&A) and serial changes in growth in children through a population-based nationwide study as well as the national health insurance service (NHIS) database.

METHODS

Propensity score (PS) matched children with and without T&A were selected in NHIS database, which includes all individuals born in Korea in 2008-2009. Serial changes of BMI and height were compared in children with and without T&A, and growth changes depending on the time of operation were also considered. The outcomes were differences in age-/sex-standardized BMI (BMI-z) and height (height-z) between the groups. Changes in BMI-z and height-z were further analyzed according to the timing of operation.

RESULTS

Of 919,707 individuals born in Korea in 2008-2009, 3172 children were included in the operation group and 31,663 PS-matched children were included in the control group. T&A was related to increased weight and height in the operation group than in the control group. At 66-71 months of age, BMI-z and height-z were 0.41 (0.02) and 0.42 (0.02), respectively, in the operation group and 0.18 (0.01) and 0.35 (0.01), respectively, in the control group. On adjustment with preoperative BMI-z, more weight gain was noted in the operation group (p < 0.001). Shortly after T&A, BMI-z increased significantly in the operation group; a significant increase in height-z was observed more than 1 year after T&A.

CONCLUSIONS

Children who underwent T&A tended to experience a growth spurt; when surgical intervention such as T&A is required, care should be taken to minimize or reverse the anticipated weight gain.

Adenoidectomy and persistent velopharyngeal insufficiency: Considerations, risk factors, and treatment

IMPORTANCE

Persistent velopharyngeal insufficiency (VPI) is a rare but well-recognized complication of adenoidectomy. VPI can have a significant impact on the communication of a child.

OBJECTIVE

To describe the pathophysiology of post-adenoidectomy VPI, identify its associated risk factors, and illustrate the techniques used to treat the entity.

EVIDENCE REVIEW

A search of English or translated English articles concerning adenoidectomy, partial adenoidectomy, superior adenoidectomy; and velopharyngeal insufficiency, speech and voice from 1980 to 2021 was performed using Pubmed and Embase. Data from prospective and retrospective studies and their relevant references were pooled.

RESULTS

By objective measures, hypernasality is noted in many pediatric patients post-adenoidectomy, but this typically resolves in 3-6 months. Risk factors for the development of post-adenoidectomy VPI include low birth weight, family history of hypernasality, and history of speech problems or nasal regurgitation. The cleft palate, submucous cleft palate, poor palate mobility, and a deep pharynx may indicate susceptibility to VPI. Speech therapy is successful in up to 50% of patients, while surgical intervention may be tailored based on the diagnostic evaluation of the velopharynx with videofluoroscopy or nasoendoscopy.

CONCLUSION

We present a comprehensive review of the literature on the pathophysiology, risk factors, and treatment of post-adenoidectomy VPI. We hope to bring awareness to the factors that can lead to a rare but potentially devastating complication in one of the most common procedures performed by Otolaryngologists.

Alternatives to surgery in children with mild OSA

Precision medicine requires coordinated and integrated evidence-based combinatorial approaches so that diagnosis and treatment can be tailored to the individual patient. In this context, the treatment approach to mild obstructive sleep apnea (OSA) is fraught with substantial debate as to what is mild OSA, and as to what constitutes appropriate treatment. As such, it is necessary to first establish a proposed consensus of what criteria need to be employed to reach the diagnosis of mild OSA, and then examine the circumstances under which treatment is indicated, and if so, whether and when anti-inflammatory therapy (AIT), rapid maxillary expansion (RME), and/or myofunctional therapy (MFT) may be indicated.

Geographic disparities in performance of pediatric polysomnography to diagnose obstructive sleep apnea in a universal access health care system

BACKGROUND

Diagnostic polysomnography (PSG) is recommended prior to adenotonsillectomy (AT) for children with obstructive sleep apnea (OSA) and certain high-risk characteristics, but resource limitations often prevent this practice.

OBJECTIVE

We performed a population-based assessment of children across Ontario, Canada to describe and quantify disparities in PSG.

METHODS AND MATERIALS

This retrospective cohort study was performed using provincial health administrative data held at ICES. We identified children 0-10 years old who underwent PSG and AT between 2009 and 2018, and those with a PSG within 18 months prior to and/or 12 months following AT. We calculated the odds of PSG prior to/following AT after adjustment for demographics, medical comorbidities, geographic and socioeconomic characteristics. Our main predictor was driving time/distance to the nearest pediatric sleep centre ascertained using spatial analysis and geographic information systems.

RESULTS

We identified 27,837 children <10 years old who underwent AT for OSA in Ontario. Only 12.8% had a PSG within 18 months prior and 5.7% had a PSG within 12 months following AT. Shorter driving time/distance, older age, male sex and certain comorbidities were associated with increased odds of PSG.

CONCLUSION

Only a small proportion of children in our cohort underwent PSG prior to or following AT surgery despite universal access to healthcare. This study suggests a need to increase overall PSG access, particularly for those living distant from existing pediatric sleep centres. Future studies could determine if increased PSG testing in 'underserviced areas' would reduce overall surgery rates and/or improve health outcomes.

Effect of adenotonsillectomy on blood pressure in children with obstructive sleep apnea: a meta-analysis

BACKGROUND

While adenotonsillectomy (T&A) is widely recognized as the first-line therapy for pediatric obstructive sleep apnea (OSA), effects of T&A on blood pressure (BP) remain unclear. This meta-analysis evaluates the associations between T&A and BP in children with OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42020154425). Two authors independently searched the PubMed, Medline, EMBASE, and Cochrane databases. The keywords used were "sleep apnea syndromes," "adenotonsillectomy," and "child." A random-effects model was applied to determine office systolic BP (SBP), diastolic BP (DBP), and ambulatory BP changes.

RESULT

Twelve studies with 1193 children were analyzed (mean age: 7.6 y; 54% boys). The apnea-hypopnea index significantly reduced of 9.4 events/h (95% CI, -12.0 to -6.8) after T&A. Office SBP (-0.24 mmHg; 95% CI, -1.64 to 1.16) and DBP (-1.65 mmHg; 95% CI, -3.47 to 0.17) did not decrease significantly after surgery. No significant decreases were observed in 24-h ambulatory BP after T&A. Subgroup analysis showed a significant postoperative decrease in office SBP (-6.23 mmHg; 95% CI, -7.78 to -4.67) and DBP (-7.93 mmHg; 95% CI, -10.37 to -5.48) among children with hypertension but a slight increase in office SBP (2.50 mmHg; 95% CI, 1.14 to 3.86) and DBP (1.98 mmHg; 95% CI, -0.02 to 3.98) in those without (P for heterogeneity < 0.001).

CONCLUSION

This meta-analysis suggests the office and ambulatory BP changes after T&A in children with OSA are trivial. Moreover, children with hypertension experience a significantly greater decrease in office BP than children without hypertension.

Assessment of Parental Choice Predisposition for Tonsillectomy in Children

Importance

The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known.

Objective

To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication.

Design, Setting, and Participants

Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist.

Main Outcomes and Measures

The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents).

Results

A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34).

Conclusions and Relevance

In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Prematurity: A Prognostic Factor for Increased Severity of Pediatric Obstructive Sleep Apnea

OBJECTIVE/HYPOTHESIS

Studies have suggested preterm birth, defined as gestational age (GA) <37 weeks, is a risk factor for obstructive sleep apnea (OSA) in later childhood. However, little is known about the characteristics, severity, and degree of intervention of childhood OSA in former preterm infants compared to term infants. This study compares polysomnographic characteristics and surgical interventions in former preterm and term infants presenting with sleep disordered breathing.

STUDY DESIGN

Retrospective cohort study from 2015 to 2019 at a single tertiary referral center.

METHODS

Electronic Medical Records of pediatric patients ages 0 to 18 presenting with sleep disordered breathing were reviewed for gestational age, polysomnographic findings, clinical characteristics, and OSA surgical interventions. Association between gestational age, polysomnographic characteristics, and surgical interventions for OSA were reported.

RESULTS

A total of 615 patient records were analyzed. Adjusting for covariates, prematurity was associated with a 2.97× higher likelihood of development of severe OSA (aOR (95%CI): 2.97 (1.40-6.32)), increased apneic-hypoxic index (AHI) (mean (SD): 6.5 (9.8) vs. 4.6 (6.4), P < .05), increased end tidal CO₂ (50.5 (5.11) vs. 48.5 (5.8), P < .05), decreased REM latency (116 (64.7) vs. 132.4 (69.9), P < .05), and increased number of surgeries for OSA (0.65 (.95) vs. 0.45 (0.69), P < .05) compared to children born at term. Children born with GA < 32 weeks presented at a significantly later age with sleep disordered breathing (7.04 (.80) vs. 5.1 (0.15), P < .05) than children born at term.

CONCLUSIONS

Prematurity was associated with increased likelihood of severe OSA, increased AHI, as well as increased number of surgical interventions for OSA compared to children born at term. These results suggest an association with preterm birth and increased severity of childhood OSA.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1909-1914, 2021.

Sleep Monitoring of Children With Nocturnal Enuresis: A Narrative Review

The purpose of this article is to provide a succinct summary of the sleep monitoring efforts that have been used in nocturnal enuresis (NE) and an overview of the knowledge that has accrued. This is not intended to be a comprehensive review, but rather is intended to highlight how polysomnography (PSG), a common sleep detection tool, has contributed to our understanding of NE, as arousal disorder is considered to be one of the important mechanisms. The authors have organized this report by analysis and display of different ingredients of PSG, starting with comparing the electroencephalogram (EEG) of controls and the enuretic children and then moving to evaluation of respiratory patterns of NE and comorbid disease obstructive sleep apnea (OSA). In addition, the authors' goal is to better understand the mechanism of NE by integrating various levels of sleep monitoring; those sleep-related clinical scale scores for NE are presented to date. Finally, we propose further research of NE to explore the microstructure alterations via PSG combined with EEG-fMRI or to use novel technology like portable device internet and deep learning strategy.

Incidence of cure and residual obstructive sleep apnea in obese children after tonsillectomy and adenoidectomy stratified by age group

OBJECTIVES

Current clinical guidelines by the American Academy of Pediatrics recommends adenotonsillectomy (T&A) as the first-line treatment for pediatric OSA. However, obese children experience a decreased incidence of cure from T&A compared to non-obese children, with obesity increasing risk of residual post-operative OSA by up to 3.7-fold. In addition to obesity, increased age has also been linked to more severe baseline OSA, among other factors. In this study, we examined how age effects the post-operative outcome in obese children with OSA.

METHODS

A retrospective chart review was performed to assess post-operative T&A polysomnography outcomes of obese children. Inclusion criteria included patients who were 17 years old and younger, underwent T&A, were obese and had both pre- and post-operative sleep studies. The patients were split into 3 different groups based on their age: Group 1 (0-6 years old), Group 2 (7-11 years old), and Group 3 (12-17 years old).

RESULTS

55 patients were included in the study: 13 in Group 1, 20 in Group 2, and 22 in Group 3. For Groups 1, 2, and 3 respectively, data averages were BMI percentile 99.20, 98.49, and 98.92 (P = 2.77); z-score 2.79, 2.36, and 2.45 (P = 0.026), tonsil size 3.17, 3.15, and 3.23 (P = 0.898), adenoid size 2.42, 2.05, and 1.77 (P = 0.015), time between the preoperative and postoperative PSG 179, 240, and 202 days (P = 0.481), and time from surgery to postoperative PSG 126, 170, and 127 days (P = 0.544). The average preoperative oAHI was 52.56, 41.23, and 43.49 (P = 0.732), post-operative oAHI was 1.94, 4.79, and 4.44 (P=.417); and change in oAHI was 50.62, 36.44, and 39.25 (P = 0.617). When comparing the age group of 0-6-year-olds to the older remaining patients, the post-operative oAHI was the only variable to show a significant difference between the two-groups with a P value of 0.038. The percentage of patients with post-operative resolution of OSA (oAHI<2), mild, moderate, and severe OSA, respectively, were 53%, 29%, 9%, and 9% for all patients, 70%, 23.1%, 7%, and 0% for group 1; 50%, 35%, 5%, and 10% for group 2; and 45%, 27%, 13%, and 13% for group 3. The percent of the patients requiring post-surgical nighttime airway support were 18%, 7%, 15%, and 26% for Groups All, 1, 2, and 3, respectively.

CONCLUSION

We found that despite having the highest rates of obesity and the most severe OSA, obese patients under 7 years old performed better following T&A, with greater cure rate, overall reduction of oAHI, and decreased need for post-surgical nighttime airway support.