The effect of obstructive sleep apnea syndrome on growth and development in nonobese children: a parallel study of twins

Perioperative Delta Weight and Pediatric Obstructive Sleep Apnea Resolution after Adenotonsillectomy

OBJECTIVE(S)

The first-line treatment for pediatric obstructive sleep apnea (OSA) is adenotonsillectomy. Post-operative weight gain is a well-documented phenomenon. We hypothesized that higher peri-adenotonsillectomy delta weight correlates with lower rates of OSA resolution in pediatric patients.

METHODS

This was a retrospective cohort study consisting of 250 patients from 2 to 17 years of age at a tertiary academic medical center between January 2021 and December 2022. Polysomnography results and body mass index (BMI) changes were collected through the electronic health record. Univariate and multivariate logistical regression analyses were performed, adjusting for confounding factors.

RESULTS

Perioperative delta weight and pre-operative baseline AHI values were significant predictors of residual OSA. For every 1-kilogram gain in weight, the odds of residual OSA (AHI >5) increase by 6.0% (OR = 1.06, 95% CI = 1.02-1.10, p < 0.002), and the odds of residual severe OSA (AHI > 10) increase by 8% (OR = 1.08, 95% CI = 1.04-1.12, p < 0.001). Increased AHI, Black/African American race, and male sex were also factors associated with incomplete OSA resolution.

CONCLUSIONS

Increased peri-adenotonsillectomy delta weight is associated with higher rates of residual OSA in children. Patients and families should be counseled about appropriate weight loss and control methods before adenotonsillectomy.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:4141-4147, 2024.

Protocol for a Prospective Observational Study of Revision Palatoplasty Versus Pharyngoplasty for Treatment of Velopharyngeal Insufficiency Following Cleft Palate Repair

OBJECTIVE

To present the design and methodology for an actively enrolling comparative effectiveness study of revision palatoplasty versus pharyngoplasty for the treatment of velopharyngeal insufficiency (VPI).

DESIGN

Prospective observational multicenter study.

SETTING

Twelve hospitals across the United States and Canada.

PARTICIPANTS

Individuals who are 3-23 years of age with a history of repaired cleft palate and a diagnosis of VPI, with a total enrollment target of 528 participants.

INTERVENTIONS

Revision palatoplasty and pharyngoplasty (either pharyngeal flap or sphincter pharyngoplasty), as selected for each participant by their treatment team.

MAIN OUTCOME MEASURE(S)

The primary outcome is resolution of hypernasality, defined as the absence of consistent hypernasality as determined by blinded perceptual assessment of a standard speech sample recorded twelve months after surgery. The secondary outcome is incidence of new onset obstructive sleep apnea. Statistical analyses will use propensity score matching to control for demographics, medical history, preoperative severity of hypernasality, and preoperative imaging findings.

RESULTS

Study recruitment began February 2021. As of September 2022, 148 participants are enrolled, and 78 have undergone VPI surgery. Enrollment is projected to continue into 2025. Collection of postoperative evaluations should be completed by the end of 2026, with dissemination of results soon thereafter.

CONCLUSIONS

Patients with VPI following cleft palate repair are being actively enrolled at sites across the US and Canada into a prospective observational study evaluating surgical outcomes. This study will be the largest and most comprehensive study of VPI surgery outcomes to date.

Effect of surgical intervention for childhood OSA on blood pressure: A randomized controlled study

OBJECTIVE

To investigate the effect of surgical intervention on 24-h ABP in children with OSA. It was hypothesized that blood pressure would improve following adenotonsillectomy.

METHODS

This was a two-centered investigator-blinded randomized controlled trial. Non-obese pre-pubertal children aged 6-11 years with OSA (obstructive apnea-hypopnea index, OAHI >3/h) underwent 24-h ABP monitoring at baseline and 9 months after the randomly assigned intervention, i.e. Early Surgery (ES) or Watchful Waiting (WW). Intention-to-treat analysis was performed.

RESULTS

137 subjects were randomized. Sixty-two (Age: 7.9y ± 1.3, 71% boys) and 47 (Age: 8.5y ± 1.6, 77% boys) participants from the ES and WW groups, respectively completed the study. Changes in ABP parameters were similar in the ES and WW groups (nighttime systolic BP z-scores: +0.03 ± 0.93 vs. -0.06 ± 1.04, p = 0.65; nighttime diastolic BP z-scores: -0.20 ± 0.95 vs. -0.02 ± 1.00, p = 0.35) despite a greater improvement in OSA in the ES group. However, a reduction in nighttime diastolic BP z-score correlated with improvements in OSA severity indexes (r = 0.21-0.22, p < 0.05), and a significant improvement in nighttime diastolic BP z-score [-0.43 ± 1.01, p = 0.027] following surgery was observed in participants with severe preoperative OSA (OAHI ≥10/h). The ES group had a significant increase in body mass index z-score after surgery [+0.27 ± 0.57, p < 0.001], which correlated with the increase in daytime systolic BP z-score (r = 0.2, p < 0.05).

CONCLUSION

Surgical treatment did not lead to significant improvements in ABP in OSA children except in those with more severe disease. The improvement in BP was partially masked by the weight gain following surgery.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn.

REGISTRATION NUMBER

ChiCTR-TRC-14004131).

Effect of Otolaryngology Residency Program Training on Obstructive Sleep Apnea Practice

According to the importance of management of obstructive sleep apnea syndrome by otolaryngologists, this study was designed to investigate knowledge, attitudes and practice of junior and senior residents of otolaryngology and evaluate the effect of current residency training program on choosing the first lines of treatment. A total of 110 residents of otolaryngology were selected. Our study tools were obstructive sleep apnea knowledge and attitudes (OSAKA and OSAKA-KIDS) questionnaires. The participants were classified as junior and senior. Senior residents had significantly higher total knowledge score for OSAKA based on independent t test (12.73 Vs. 10.52). No significant difference was observed for OSAKA-KIDS (11.31 Vs. 10.69). The most frequent choice for the first line was CPAP (63.8%) and weight loss (41.5%) among junior and senior residents, respectively. Although the knowledge of otolaryngology residents increased during their program, the choice of first line treatment in obstructive sleep apnea was different between junior and senior residents. We found a need for further multidisciplinary education for residents especially in the management of sleep apnea particularly toward CPAP usage and this syndrome in pediatrics.

The impact of sleep events on weight gain following early adenotonsillectomy compared to supportive care for pediatric OSA

OBJECTIVES

Children with obstructive sleep apnea (OSA) who undergo adenotonsillectomy (AT) often experience post-operative weight gain, although the mechanism remains unclear. Our aim is to understand how changes in sleep events impact changes in weight in children with OSA following adenotonsillectomy compared to watchful waiting with supportive care.

METHODS

We performed a secondary analysis of the Childhood adenotonsillectomy trial (CHAT) dataset in which children with OSA were randomized to undergo early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC). The primary outcome measures included changes in body mass index (BMI) percentile, apnea-hypopnea index (AHI) and arousal index (AI) during rapid eye movement (REM) sleep. The change in BMI percentile attributable to changes in AHI and AI during REM sleep was determined using causal mediation analysis.

RESULTS

Of the 453 children with OSA randomized to eAT or WWSC, 397 children were included in the analysis. Children in the eAT arm experienced a greater increase in their weight as measured by BMI percentile, compared to children who received WWSC (WWSC 4.12 (2.70, 5.55) vs. eAT 6.62 (4.87, 8.38), Cohen's d = 0.22 (0.02, 0.42), p = 0.02). A significant proportion of the weight gain was attributable to decreases in apneic events (proportion mediated 19% (2-97%), p = 0.03) and arousals (proportion mediated 20% (5-78%), p = 0.01) during REM sleep.

CONCLUSION

A significant proportion of post-adenotonsillectomy weight gain in children with OSA is attributable to polysomnographic changes during REM sleep, potentially due to the mitigation of REM-related sleep fragmentation and subsequent reduction in metabolic expenditure.

Reduced circulating growth hormone and insulin-like growth factor-1 and delayed growth of premature rats are aggravated by longer daily duration of chronic intermittent hypoxia exposure

OBJECTIVE

This study mainly aimed to investigate the effect of daily duration of chronic intermittent hypoxia (CIH) exposure on circulating growth hormone (GH)/insulin-like growth factor-1 (IGF-1) concentrations and body weight changes of premature rats.

METHODS

40 healthy male SD rats aged six weeks were enrolled in this study. These rats were randomly divided into four groups (n = 10 per group), including normal control (NC) group (normal oxygen exposure every day), CIH-1 group (daily CIH exposure for 2 h), CIH-2 group (daily CIH exposure for 4 h), and CIH-3 group (daily CIH exposure for 8 h). The serum GH/IGF-1 concentrations and body weights in all rats were determined after 30 days of normal oxygen or CIH exposure.

RESULTS

No significant difference was found with respect to the baseline body weight among the four groups of rats. After establishments of animal models with a duration of 30 days, significant differences were found respect to body weight, body weight changes, and serum GH/IGF-1 concentrations among the four groups of rats with a same trend (all P < 0.05): the highest values were all in NC group rats, followed CIH-1 group, CIH-2 group, and CIH-3 group rats. Among all the rats, the body weight changes correlated significantly with both serum GH and IGF-1 concentrations (both P < 0.05).

CONCLUSION

CIH decreases circulating GH/IGF-1 concentrations and causes growth delay in premature rats. Such effects could be aggravated by increased daily duration of CIH exposures.

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.

Improvement in BMI z-score following adenotonsillectomy in adolescents aged 12-18 years: a retrospective cohort study

BACKGROUND

Characteristics of obstructive sleep apnea (OSA) changes with age. Infants, toddlers and prepubertal children with OSA are usually underweight and may suffer from failure to thrive (FTT). Adenotonsillectomy (T&A) is the first line of treatment for OSA in childhood. In adults OSA is commonly associated with obesity and the metabolic syndrome. The change in body mass index (BMI) in adolescents with OSA following T&A was only sporadically studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.

METHODS

Clalit Health Services is the largest health care organization in Israel with the largest patient registry (more than 50% of the population). Two hundred and forty two adolescents aged 12-18 who underwent T&A between 2006 and 2015 were identified in the Clalit registry and their characteristics including height and weight were retrieved. The BMI z-score of these adolescents at baseline (up to 3 months prior to T&A) and during the consecutive 3 years after T&A were analyzed and compared.

RESULTS

Changes in BMI Z-score were observed to all directions following T&A with overall small increase, not statistically significant (P = 0.26) from a median of 0.79 prior to T&A to a median of 0.835 after it. There was a minimal trend toward BMI z-score reduction in overweight children (n = 74) from 1.508 to 1.48 following T&A (p = NS), and in obese children (n = 33) from 2.288 to 2.000 (P = 0.06, 2 tailed). Interestingly thin individuals (n = 6) increased their BMI z-score following T&A from - 2.4 to - 0.59 (p = 0.046).

CONCLUSIONS

Adolescents show variable changes in their BMI z-score following T&A. In this aspect their BMI z-score change is closer to the change seen in adults treated for OSA and not that of young children. The changes observed show a trend toward normalization of the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.

Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

Weight change before and after adenotonsillectomy in children: An analysis based upon pre-surgery body mass category

OBJECTIVES

To determine the standardised body mass index (BMIz) trajectory before and after adenotonsillectomy/tonsillectomy between children in different weight classifications in a larger sample than has been studied previously, and to identify which patient factors would explain the difference in these outcomes.

DESIGN

We used a retrospective chart review and leveraged data of weight status pre- and post-adenotonsillectomy/tonsillectomy from a cohort of paediatric patients seen between May 2004 and April 2017.

SETTING

Data were collected from an electronic medical record at a single Midwest paediatric health system.

PARTICIPANTS

The study population included a convenience sample of 1,751 paediatric patients who underwent adenotonsillectomy or tonsillectomy and had at least two height and weight measurements recorded on the same date both before and after surgery.

MAIN OUTCOME MEASURES

Change in BMIz trajectories before and after surgery.

RESULTS

Of 1751 paediatric patients (ages 3-11) underwent adenotonsillectomy/tonsillectomy procedures. Age at time of surgery and gender were not significant predictors. Children in different weight classifications demonstrated differences in BMIz trajectory after surgery. Children with overweight/obesity experience a decrease in BMIz, whereas children with underweight or normal weight experience an increase in BMIz.

CONCLUSIONS

Improvement in weight status is seen after surgery: increased BMI for those underweight and decreased BMI for those with overweight/obesity. We advocate for behavioural strategies as a first-line treatment in children with underweight or overweight/obesity, and results suggest that coordinating these efforts alongside adenotonsillectomy/tonsillectomy when indicated for medical reasons may be warranted. However, further research is needed to confirm these findings due to the observational nature of this study.

Beyond the growth delay in children with sleep-related breathing disorders: a systematic review

INTRODUCTION

The availability of high-quality studies on the association between sleep-disordered breathing in children and delayed growth associated with the hormonal profile recorded before surgery and at follow-up is limited.

EVIDENCE ACQUISITION

Medline PubMed, Scopus and WebOfScience databases were searched for relevant publications published between January 2008 to January 2020 and a total of 261 potentially eligible studies were identified.

EVIDENCE SYNTHESIS

Following review 19 papers were eligible for inclusion: seven reported a significant postsurgical increase in growth regardless of initial weight status, type of surgery, type of study design, and length of follow-up period. The only high-quality study was a randomized controlled trial that found an increased risk of obstructive sleep apnea syndrome relapse in overweight children. Twelve studies reported the significant increase in growth parameters showing that IGF-1, IGFBP-3, and ghrelin may boost growth after surgery.

CONCLUSIONS

The current systematic review demonstrates a scarcity of high-quality studies on growth delay in children with sleep-disordered breathing. Significant catch-up growth after surgery in the short term and changes in IGF-1, IGFBP-3, ghrelin, and leptin levels has been reported in most published studies.

Time-Course Evaluation of Body Mass Index in Japanese Children With Obstructive Sleep Apnea Syndrome After Adenotonsillectomy: A Three-Years Follow-Up Study

Delayed physical growth is a common complication of pediatric obstructive sleep apnea syndrome (OSAS). Adenotonsillectomy (AT) is the first-line treatment for pediatric OSAS. Only a few studies have performed time-course BMI evaluation in pediatric OSAS patients post-operatively. Thus, we aimed to evaluate the time-course changes in pediatric OSAS patients after AT. Thirty-three children with OSAS who underwent AT were included and divided into two groups on the basis of their BMI z-scores (delayed physical growth group, n = 15; non-delayed physical growth group, n = 18). Clinical records of height and weight were collected before AT and at 6, 12, 24, and 36 months after AT. Changes in the mean BMI z-scores of the two groups were assessed up to 36 months. The mean BMI z-score was significantly increased in the delayed physical growth group at 6 months after AT. In contrast, the increase in mean BMI z-score was not observed in the non-delayed physical growth group. Growth improvement was noted in pediatric OSAS patients with delayed physical growth after AT. Our results suggest that AT is a promising therapy for improving the physical growth of pediatric OSAS patients with such problems.

The Impact of Altitude on Sleep-Disordered Breathing in Children Dwelling at High Altitude: A Crossover Study

Study Objectives

Sleep-disordered breathing (SDB) is prevalent among children and is associated with adverse health outcomes. Worldwide, approximately 250 million individuals reside at altitudes higher than 2000 meters above sea level (masl). The effect of chronic high-altitude exposure on children with SDB is unknown. This study aims to determine the impact of altitude on sleep study outcomes in children with SDB dwelling at high altitude.

Methods

A single-center crossover study was performed to compare results of high-altitude home polysomnography (H-PSG) with lower altitude laboratory polysomnography (L-PSG) in school-age children dwelling at high altitude with symptoms consistent with SDB. The primary outcome was apnea-hypopnea index (AHI), with secondary outcomes including obstructive AHI; central AHI; and measures of oxygenation, sleep quality, and pulse rate.

Results

Twelve participants were enrolled, with 10 included in the final analysis. Median altitude was 1644 masl on L-PSG and 2531 masl on H-PSG. Median AHI was 2.40 on L-PSG and 10.95 on H-PSG. Both obstructive and central respiratory events accounted for the difference in AHI. Oxygenation and sleep fragmentation were worse and pulse rate higher on H-PSG compared to L-PSG.

Conclusions

These findings reveal a clinically substantial impact of altitude on respiratory, sleep, and cardiovascular outcomes in children with SDB who dwell at high altitude. Within this population, L-PSG underestimates obstructive sleep apnea and central sleep apnea compared to H-PSG. Given the shortage of high-altitude pediatric sleep laboratories, these results suggest a role for home sleep apnea testing for children residing at high altitude.

Intermittent hypoxia causes mandibular growth retardation and macroglossia in growing rats

INTRODUCTION

In this study, we aimed to examine the role of intermittent hypoxia (IH) in dentofacial morphologic changes in growing rats.

METHODS

Seven-week-old male rats were exposed to IH at 20 cycles per hour (nadir of 4% oxygen to peak of 21% oxygen) for 8 hours per day for 6 weeks. Control rats were exposed to normoxia (N). Maxillofacial growth was compared between the 2 groups by linear measurements on cephalometric radiographs. To examine the dental arch morphology, study models and microcomputed tomography images of the jaws were taken. Additionally, tongue size was measured.

RESULTS

The gonial angle and the ramus of the mandible were smaller in the IH group than in the N group, whereas the body weights were not different between the 2 groups. Morphometric analysis of the dentition showed a significantly wider mandibular dentition and narrower maxillary dentition in the IH than in the N group. The relative width (+4.2 %) and length (tongue apex to vallate papillae, +3.5 %) of the tongue to the mandible were significantly greater in the IH group than in the N group.

CONCLUSIONS

IH induced dentofacial morphologic discrepancies in growing rats.

Sleep disordered breathing in bronchopulmonary dysplasia

BACKGROUND

There are limited data on the effect of bronchopulmonary dysplasia (BPD) on sleep disordered breathing (SDB). We hypothesized that both the severity of prematurity and BPD would increase the likelihood of SDB in early childhood. Our secondary aim was to evaluate the association of demographic factors on the development of SDB.

METHODS

This is a retrospective study of patient factors and overnight polysomnogram (PSG) data of children enrolled in our BPD registry between 2008 and 2015. Association between PSG results and studied variables was assessed using multiple linear regression analysis.

RESULTS

One-hundred-forty children underwent at least one sleep study on room air. The mean respiratory disturbance index (RDI) was elevated at 9.9 events/hr (SD: 10.1). The mean obstructive apnea-hypopnea index (OAHI) was 6.5 (9.1) events/hr and the mean central event rate of 3.0 (3.7) events/hr. RDI had decreased by 22% or 1.5 events/hour (95%CI: 0.6, 1.9) with each year of age (P = 0.005). Subjects with more severe respiratory disease had 38% more central events (P = 0.02). Infants exposed to secondhand smoke had 2.4% lower (P = 0.04) oxygen saturation nadirs and a pattern for more desaturation events. Non-white subjects were found to have 33% higher OAHI (P = 0.05), while white subjects had a 61% higher rate of central events (P < 0.001).

CONCLUSIONS

RDI was elevated in a selected BPD population compared to norms for non-preterm children. BPD severity, smoke exposure, and race may augment the severity of SDB. RDI improved with age but was still elevated by age 4, suggesting that this population is at risk for the sequelae of SDB.

Pediatric Pulmonology year in review 2015: Part 2

Pediatric Pulmonology covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review (Part 2) covers articles on sleep-disordered breathing. Pediatr Pulmonol. 2016;51:740-746. © 2016 Wiley Periodicals, Inc.

Velopharyngeal Dysfunction and Sleep Apnea-A Survey to Ascertain Surgical Practice Patterns

OBJECTIVE

To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD).

DESIGN

A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice.

MAIN OUTCOME MEASURES

We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons' evaluation of OSA and their approaches to VPD.

RESULTS

A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038).

CONCLUSIONS

Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.