Effectiveness and safety of (adeno) tonsillectomy for pediatric obstructive sleep apnea in different age groups: A systematic review and meta-analysis

Revisiting the efficiency and necessity of adenotonsillectomy in children with mild obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

Adenotonsillar hypertrophy is the leading cause of obstructive sleep apnea (OSA) in children, with adenotonsillectomy (AT) being the most common surgical treatment. Although AT is widely performed, its efficacy in treating mild OSA remains uncertain. Current literature suggests that children with mild OSA might benefit from non-surgical management, but there is a lack of evidence ND studies evaluating the outcomes of AT specifically for mild OSA. The aim of this systematic review and meta-analysis is to provide conclusive insights into the effectiveness of adenotonsillectomy in improving health outcomes and quality of life for children with mild obstructive sleep apnea.

METHODS

PubMed, Scopus, Embase, Cochrane, and Web of Science databases have been searched for relevant studies. We included original studies that evaluated the safety or effectiveness of AT in the management of mild OSA among pediatric patients. For quantitative analysis, data were synthesized using a random-effects model in R (version 4.3.3), and heterogeneity was assessed using statistical methods including the restricted maximum-likelihood estimator and the I2 statistic. We also conducted analyses of change scores and covariance to estimate the effect of AT on the severity of mild OSAS.

RESULTS

Our review included 27 studies after screening 1851 citations. The meta-analysis demonstrated significant improvements with AT for mild OSA. The Pediatric Sleep Questionnaire scores improved with a mean difference (MD) of -0.32 (95% CI [-0.39; -0.25], p < 0.001). AHI decreased significantly with an MD of -1.45 (95% CI [-2.11; -0.80], p < 0.001). Comparison with watchful waiting revealed AT to be more effective: AHI showed an MD of -1.22 (95% CI [-1.92; -0.53], p < 0.001), and the arousal index had an MD of -1.73 (95% CI [-2.95; -0.51], p = 0.005). Safety data indicated that while AT is generally safe, it is associated with minor complications such as postoperative desaturation and occasional bleeding. Long-term serious adverse events were rare.

CONCLUSION

AT effectively improves symptoms in children with mild OSA, outperforming watchful waiting in several key metrics. This review supports AT as a viable option but underscores the importance of considering individual patient factors in treatment decisions.

Minimal to Mean Airway Area Ratio of the Pharynx: A Novel Predictor of Pediatric Obstructive Sleep Apnea in Three-Dimensional Imaging

OBJECTIVE

Reliable variables for detecting pediatric obstructive sleep apnea (OSA) using three-dimensional (3D) imaging are currently lacking. This study aimed to develop a novel predictor of OSA in children.

STUDY DESIGN

Prospective study.

SETTING

Tertiary care children's hospital.

METHODS

Pediatric patients (<18 years) with symptoms suggestive of OSA were enrolled. Polysomnography was used to categorize disease severities as primary snoring (apnea-hypopnea index, AHI < 1), mild OSA (AHI = 1-5), moderate OSA (AHI = 5-10), and severe OSA (AHI > 10). Cone-beam computed tomography was used to obtain 3D images. The minimal to mean airway area (AA) ratio was measured across the entire pharynx and its segment (nasopharynx, oropharynx, and hypopharynx).

RESULTS

The study included 104 children. For the entire pharynx, the minimal to mean AA ratio was 0.41, 0.36, 0.35, and 0.25 in the primary snoring, mild OSA, moderate OSA, and severe OSA groups, respectively (P = .001). Pearson's correlation revealed an inverse relationship between the minimal to mean AA ratio and OSA severity. The receiver operating characteristic curve identified the optimal cutoff point for predicting AHI ≥ 1 as 0.34 in the oropharynx (area under the curve [AUC] = 71%) and 0.39 in the entire pharynx (AUC = 67%). The minimal to mean AA ratio in the nasopharynx or hypopharynx indicated no significant difference between OSA severities.

CONCLUSION

A minimal to mean airway AA ratio of less than one-third in the pharynx serves as a novel predictor of pediatric OSA in 3D imaging.

Impact of adenotonsillectomy and palatal expansion on the apnea-hypopnea index and minimum oxygen saturation in nonobese pediatric obstructive sleep apnea with balanced maxillomandibular relationship: A cross-over randomized controlled trial

OBJECTIVE

To determine the impact and best management sequence between adenotonsillectomy (AT) and rapid palatal expansion (RPE) on the apnea-hypopnea index (AHI) and minimum oxygen saturation (MinSaO2) in nonobese pediatric obstructive sleep apnea (OSA) patients presenting balanced maxillomandibular relationship.

STUDY DESIGN/METHODS

Thirty-two nonobese children with balanced maxillomandibular relationship and a mean age of 8.8 years, with a graded III/IV tonsillar hypertrophy and maxillary constriction, participated in a cross-over randomized controlled trial. As the first intervention, one group underwent AT while the other underwent RPE. After 6 months, interventions were switched in those groups, but only to participants with an AHI > 1 after the first intervention. OSA medical diagnosis with the support of Polysomnography (PSG) was conducted before (T0), 6 months after the first (T1) and the second (T2) intervention. The influence of sex, adenotonsillar hypertrophy degree, initial AHI and MinSaO2 severity, and intervention sequence were evaluated using linear regression analysis. Intra- and intergroup comparisons for AHI and MinSaO2 were performed using ANOVA and Tukey's test.

RESULTS

The initial AHI severity and intervention sequence (AT first) explained 94.9% of AHI improvement. The initial MinSaO2 severity accounted for 83.1% of MinSaO2 improvement changes. Most AHI reductions and MinSaO2 improvements were due to AT.

CONCLUSIONS

Initial AHI severity and AT as the first intervention accounted for most of the AHI improvement. The initial MinSaO2 severity alone accounted for the most changes in MinSaO2 increase. In most cases, RPE had a marginal effect on AHI and MinSaO2 when adjusted for confounders.

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.

Effects of common lifestyle factors on obstructive sleep apnea: precautions in daily life based on causal inferences

Background

This study aimed to evaluate the causal impact of common modifiable lifestyles on obstructive sleep apnea (OSA), which is beneficial for recommendations to prevent and manage OSA.

Method

Published genome-wide association study (GWAS) summary statistics were used to perform two-sample Mendelian randomization (MR). Variants associated with each exposure of smoking, drinking, and leisure sedentary behaviors at the genetic level were used as instrumental variables (IVs). Then, inverse-variance weighting (IVW) was considered the primary result for causality. Moreover, several complimented approaches were also included to verify the observed associations. MR-PRESSO and MR-Egger intercept were applied to test the horizontal pleiotropy. To assess heterogeneity, Cochran's Q test by IVW and MR-Egger were applied.

Results

Regular smoking history increased OSA risk in all applied approaches [OR (95% CI)IVW = 1.28 (1.12, 1.45), p = 1.853 × 10-4], while the causality of lifetime smoking index [OR (95% CI)IVW = 1.39 (1.00, 1.91), p = 0.048], alcohol intake frequency [outliers removed OR (95% CI)IVW = 1.26 (1.08, 1.45), p = 0.002], and coffee intake behavior [OR (95% CI)IVW = 1.66 (1.03, 2.68), p = 0.039] on OSA risk were not always consistent in other approaches. In addition, no robust causal associations were observed for the effect of sedentary leisure behaviors on OSA risk. In sensitivity analysis, we observed no sign of horizontal pleiotropy or heterogeneity.

Conclusion

Ever regularly smoking has a robust causal role in increasing OSA risk, which should be discouraged as precautions from developing OSA.

Alterations of Gut Microbiome Composition and Function Pre- and Post-Adenotonsillectomy in Children with Obstructive Sleep Apnea

IMPORTANCE

Obstructive sleep apnea (OSA) in children is linked with alterations in the gut microbiome. The influence of adenotonsillectomy (AT), a primary intervention for OSA, on gut microbiota dynamics relative to disease severity remains to be elucidated.

OBJECTIVE

This study aimed to investigate the impact of OSA severity and AT on the gut microbiome in pediatric patients.

DESIGN

A prospective observational study.

SETTING

Tertiary referral center.

PARTICIPANTS

A cohort of 55 pediatric patients treated with AT for OSA.

INTERVENTION

Total tonsillectomy and adenoidectomy procedures.

MAIN OUTCOME MEASURES

Comprehensive evaluations included in-laboratory polysomnography and 16S rRNA gut microbiome profiling at baseline, and again at 3rd and 12thmonth following surgery.

RESULTS

Initial findings showed uniform α-diversity across different severities of OSA, while β-diversity was significantly elevated in the severe OSA subgroup. Certain gut microbiota taxa (Lachnospiraceae NK4A136 group, Ruminococcaceae UCG-002, Ruminococcaceae UCG-014, Alloprevotella, Christensenellaceae R-7 group, Ruminococcaceae UCG-005, Lactobacillus murinus, and Prevotella nigrescens) were found to inversely correlate with the apnea-hypopnea index (AHI). Significant post-AT improvements in AHI and other polysomnographic metrics were observed. Notably, AHI changes post-AT were positively associated with microbial α-diversity (species richness), β-diversity, and specific bacterial taxa (Enterobacter, Parasutterella, Akkermansia, Roseburia, and Bacteroides plebeius DSM 17135), but negatively with other taxa (Fusicatenibacter, Bifidobacterium, UBA1819, Ruminococcus gnavus group, Bifidobacterium longum subsp. Longum, and Parabacteroides distasonis) and specific metabolic pathways (purine metabolism, transcription factors, and type II diabetes mellitus). The postoperative patterns of α- and β-diversity mirrored baseline values.

CONCLUSIONS AND RELEVANCE

This study documents significant changes in the gut microbiome of pediatric patients after AT, including variations in α- and β-diversities, bacterial communities, and inferred metabolic functions. These changes suggest a potential association between the surgical intervention and microbiome alterations, although further studies are necessary to discern the specific contributions of AT amidst possible confounding factors such as antibiotic use.

A review of uvulopalatopharyngoplasty for pediatric obstructive sleep apnea

OBJECTIVES

To evaluate existing literature to understand the utility and safety of uvulopalatopharyngoplasty (UPPP) for treatment of pediatric obstructive sleep apnea (OSA).

METHODS

A literature review was conducted by two authors to search for studies from the inception of two databases until March 1, 2023. Studies in which participants were under 18 years of age and underwent UPPP for OSA or upper airway obstruction were selected. Data on variables such as pre- and postoperative severity, efficacy, complications, and follow-up were collected from all studies.

RESULTS

After applying inclusion criteria to the initial 91 abstracts that were screened, 26 studies remained that included 224 patients who underwent UPPP. Most children who underwent UPPP had neurologic impairment, developmental delay, craniofacial abnormalities, or were obese, and underwent several procedures for OSA treatment. Of the studies that reported outcomes, 85.6 % of patients had subjective improvement, and 25.6 % of patients had a reported complication.

CONCLUSIONS

Most children who underwent UPPP had serious medical comorbidities with moderate or severe OSA and a multi-procedural treatment plan. Although most patients had subjective improvement and there were low complication rates, the heterogeneity of existing literature makes it difficult to draw conclusions. Future multi-center, prospective studies should be conducted to analyze the true safety and efficacy of UPPP in pediatric patients.