Severe Versus Very Severe Pediatric Obstructive Sleep Apnea Outcomes After Adenotonsillectomy

Adenotonsillectomy: the good, the bad and the unknown

PURPOSE OF REVIEW

Adenotonsillar hypertrophy is the most common pathogenetic contributor to obstructive sleep apnea syndrome (OSAS) in childhood, and adenotonsillectomy is the standard initial treatment. Here, we summarize the most recent evidence on the efficacy and complications of adenotonsillectomy and explore knowledge gaps in clinical management.

RECENT FINDINGS

Favorable adenotonsillectomy effects have been reported in children with very severe OSAS [apnea-hypopnea index (AHI) >20 episodes/h] and extremely severe OSAS (AHI >100 episodes/h), without postoperative mortality, need for endotracheal intubation, prolonged hospital stay or re-admission after hospital discharge. However, the risk of residual OSAS after adenotonsillectomy, which may reach 30-60%, has not been thoroughly established. Behavior, OSAS-related symptoms and quality of life improve postoperatively even in children with AHI 1-5 episodes/h. Natural history of enuresis resolution is accelerated postadenotonsillectomy and office-based systemic blood pressure is decreased in OSAS and hypertension. However, which children younger than 2 years should undergo adenotonsillectomy instead of adenoidectomy only to prevent recurrence of OSAS symptoms and revision surgery remains unclear. Adenotonsillectomy in children with Prader-Willi syndrome is frequently accompanied by postoperative residual OSAS while complications are not uncommon.

SUMMARY

In the last 2 years, several studies have provided evidence supporting the efficacy and safety of adenotonsillectomy as treatment intervention for otherwise healthy children with OSAS.

Clinical Characteristics and Post-Operative Outcomes in Children with Very Severe Obstructive Sleep Apnea

Available information on clinical characteristics and post-operative outcomes in children with very severe obstructive sleep apnea (OSA) is limited. Our study evaluates the clinical features and polysomnographic (PSG) variables that predict post-operative outcomes in children with an obstructive apneal hypopnea index (AHI) of more than 25 events/hr. In this study from a single tertiary care center, we performed a retrospective chart review of patients with an AHI > 25/hr, who underwent tonsillectomy and adenoidectomy (T&A) between January 2016 and September 2021. In total, 50 children were included in the study: 26.0% (13/50) of children experienced post-operative respiratory events and four children needed intubation and ventilator support. Compared with children without respiratory events, children requiring post-operative respiratory interventions were younger (4.4 ± 5.2 vs. 8.0 ± 5.2 years; p = 0.04), had higher pre-operative AHI (73.6 ± 27.4 vs. 44.8 ± 24.9; p < 0.01), lower oxygen nadirs (70.0 ± 13.0% vs. 83.0 ± 7.0%; p < 0.01), and had lower body metabolic index Z-scores (−0.51 ± 2.1 vs. 0.66 ± 1.5; p < 0.04). Moderate to severe residual OSA was identified in 70% (24/34) of children with available post-operative PSG; younger children had better PSG outcomes. Our study shows that post-operative respiratory events are frequent in children with very severe OSA, particularly with an AHI > 40/h, younger children (<2 years of age), lower oxygen saturation (SpO2), and poor nutritional status, necessitating close monitoring.