Adenotonsillectomy less beneficial for sleep apnea in older and obese children

Article Outline

• Tauman R, Gulliver TE, Krishna J, Montgomery-Downs HE, O’Brien LM, Ivanenko A, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 2006;149:803-8
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Tauman R, Gulliver TE, Krishna J, Montgomery-Downs HE, O’Brien LM, Ivanenko A, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 2006;149:803-8 

Question In children with obstructive sleep apnea (OSA), are there factors that predict whether symptoms will resolve after adenotonsillectomy (T&A)?

Design Cohort study.

Setting Children’s Hospital, Louisville, Kentucky.

Participants 110 children, age 1 to 16 years (mean age, 6.4 years), along with 22 control children.

Intervention The intervention group underwent 2 polysomnographic evaluations before and after T&A. History of allergy and family history of sleep-disordered breathing was obtained before each polysomnographic evaluation.

Outcome Persistence of sleep-disordered breathing, as defined by an apnea/hypopnea index (AHI) > 5/hour of total sleep time (TST).

Main Results Significant changes in sleep stage percentages and sleep fragmentation were found in the postsurgery study compared with the presurgery study; 25% of the children had an AHI < 1, 46% had an AHI of 1 to 5, and 29% had an AHI > 5 in the postsurgery study. The frequency of children with an AHI > 5/h of TST after surgery was higher in the obese subjects than in the nonobese subjects (36.4% vs 17.6%, P < .05).

Conclusions T&A yields improvements in respiratory abnormalities in children with OSA syndrome, although complete normalization occurs in only 25% of patients. Obesity and AHI at diagnosis are the major determinants of surgical outcome. When normalization of respiratory measures occurs after surgery, normalization of sleep architecture will also ensue.

Commentary OSA is common and potentially harmful. T&A is often used to treat OSA in children. Previous studies have shown that abnormal polysomnographic findings persist after T&A in up to 40% of cases. In the present study, 29% of the patients continued to have more than 5 apneic or hypopneic episodes per hour of sleep time after T&A. Older patients and patients with high body mass index were even more likely to continue to experience OSA after surgery. However, no data on patient symptoms were obtained. It is possible that even patients with an AHI > 5 after T&A experienced improvement in symptoms after the procedure. Notably, children with genetic disorders, cerebral palsy, neuromuscular disease, or any underlying systemic disease were excluded from the study, so it is unclear how these children might benefit from T&A. It also is unclear whether the initial group of 110 patients was chosen prospectively or retrospectively, which could affect the validity of the data. When recommending T&A to parents as a treatment for OSA, physicians need to provide appropriate education so that parents will have realistic expectations. Families should be told that T&A may not cure OSA, particularly in older and obese patients. In addition, this study suggests that postoperative polysomnography should be considered in patients undergoing T&A for OSA.