Adenotonsillectomy for obstructive sleep apnoea in children

Evidence Summaries

Level of Evidence = B
Adenotonsillectomy compared with watchful waiting appears to be effective in uncomplicated paediatric patients with obstructive sleep apnoea/hypopnoea syndrome in improving behavioral, quality-of-life and polysomnographic findings and reducing symptoms. The quality of evidence is downgraded by imprecise results (few patients)

A Cochrane review 1 included 3 studies with a total of 562 subjects. The results were not pooled because of substantial clinical heterogeneity. The studies evaluated 3 different groups of children: those diagnosed with mild to moderate obstructive sleep apnoea syndrome (OSAS) by polysomnography (PSG) (453 children aged 5 to 9 years), those with a clinical diagnosis of obstructive sleep-disordered breathing (oSDB) but with negative PSG recordings (29 children aged 2 to 14 years) and children with Down syndrome or mucopolysaccharidosis (MPS) diagnosed with mild to moderate OSAS by PSG (80 children aged 6 to 12 years).

Otherwise healthy children without a syndrome diagnosed with mild to moderate OSAS by PSG: at 7 months, mean scores for instruments measuring disease-specific quality of life and/or symptoms were lower (better quality of life or fewer symptoms) in children receiving adenotonsillectomy than in those managed by watchful waiting: OSA-18 questionnaire (scale 18 to 126): 31.8 versus 49.5 (MD -17.7, 95% CI -21.2 to -14.2); PSQ-SRBD questionnaire (scale 0 to 1): 0.2 versus 0.5 (MD -0.3, 95% CI -0.31 to -0.26); Modified Epworth Sleepiness Scale (scale 0 to 24): 5.1 versus 7.1 (MD -2.0, 95% CI -2.9 to -1.1). More children in the surgery group had normalisation of respiratory events during sleep as measured by PSG than those allocated to watchful waiting: 153/194 (79%) versus 93/203 (46%) (RD 33%, 95% CI 24% to 42%). Neurocognitive performance and attention and executive function had not improved with surgery; scores were similar in both groups. Mean scores for caregiver-reported ratings of behaviour were lower (better behaviour) in children receiving adenotonsillectomy than in those managed by watchful waiting, however, teacher-reported ratings of behaviour did not significantly differ. There was no difference between groups in serious adverse event: 6/194 (3%) in the adenotonsillectomy group and 9/203 (4%) in the control group (RD -1%, 95% CI -5% to 2%).

Non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings: At six months, PSG recordings were similar between groups.

Children with Down syndrome or mucopolysaccharidosis (MPS) diagnosed with mild to moderate OSAS by PSG: The mean OSA-18 score at 12 months did not significantly differ between the adenotonsillectomy and CPAP groups. The mean modified Epworth Sleepiness Scale scores did not differ at 6 months, but were lower in the surgery group at 12 months: 5.5 versus 7.9 (MD -2.4, 95% CI -3.1 to -1.7). Resolution of OSAS (Apnoea/Hypopnoea Index score below 1) did not significantly differ between the adenotonsillectomy and CPAP groups. 2/37 (5%) developed a secondary haemorrhage after adenotonsillectomy, while 1/36 (3%) developed a rash on the nasal dorsum secondary to the CPAP mask (RD -3%, 95% CI -6% to 12%).

A systematic review 2 1 including 14 studies (all were case series) with a total of 355 subjects was abstracted in DARE. The summary change in Apnea Hypopnea Index (AHI events/hour) was a reduction of 13.92 events per hour (95% CI 10.05 to 17.79) from adenotonsillectomy. The summary success rate of adenotonsillectomy in normalizing polysomnogram (PSG) was 82.9% (95% CI 76.2% to 89.5%; 11 studies, range of success rate: 52.9 to 100%).

References

1. Venekamp RP, Hearne BJ, Chandrasekharan D et al. Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev 2015;(10):CD011165.  [PMID:26465274]

2. Brietzke SE, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg 2006 Jun;134(6):979-84.  [PMID:16730542]


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