Although useful for many, the popular adenotonsillectomy treatment is not a cure-all.
While all medical procedures require careful patient counseling, this is especially so when the procedure in question will be performed on a pediatric patient. Giving parents an accurate assessment of the risks, benefits, and long-term prognosis for pediatric obstructive sleep apnea (OSA) patients is essential.
Guilleminault et al first described OSA in children in 1976.1 The prevalence of OSA in the pediatric population is currently estimated at up to 2% in all children.2 In addition, research has clearly demonstrated the morbidity of pediatric OSA. Children with OSA have been shown to have an increased risk in developing systemic hypertension as well as right ventricular dysfunction due to elevated pulmonary arterial pressure.3-6 Children with OSA also have a higher risk of failure to thrive and impairment of growth development. Research suggests that growth hormone secretion is impaired, thus affecting growth.7-9
The most extensive evidence on the impairment of OSA in children is the neurocognitive and behavioral consequences. Although the hallmark of excessive daytime sleepiness seen in adults does not seem to be the major symptom in children,10-12 behavior problems including hyperactivity, inattention, aggression, sleepwalking, and night terrors, as well as impaired learning and diminished academic performance, are the common symptoms.13-19
While medical treatment, such as CPAP, can be successful in treating pediatric OSA and nasal steroid sprays can be effective in reducing the severity of OSA in children with allergic rhinitis,20-23 most investigators would agree that these approaches are not the ideal long-term treatments for pediatric OSA. Today, surgery remains as the first-line treatment, and adenotonsillectomy (T&A) is the most commonly performed surgical procedure for the treatment of pediatric OSA.
THE PEDIATRIC OSA AIRWAY
Studies have demonstrated that the airway is smaller in children with OSA compared to controls.24,25 The adenoid and tonsils are larger and the airway is most restricted where the adenoid and tonsils overlap.24,25 The soft palate is also larger in children with OSA, thus adding further restriction. In addition, it is important to appreciate that many children with OSA have dentofacial abnormalities such as maxillomandibular constriction, maxillomandibular deficiency, and long face syndrome.26,27 The smaller airway found in children with OSA is possibly the result of these skeletal deficiencies.
PEDIATRIC OSA SURGERY
T&A is the first-line treatment for pediatric OSA. The rationale for the procedure as a treatment for OSA is simple. The removal of tissues in the airway lumen relieves obstruction and improves airway flow. Following T&A, the upper airway stability is improved due to reduction of collapsibility as measured by critical nasal pressure (Pcrit).28
It is important to emphasize that both tonsillectomy and adenoidectomy should be performed if the objective of the operation is to decrease airway obstruction in OSA. Although isolated adenoidectomy or tonsillectomy procedures do improve OSA, the improvement may be insufficient, thus leading to further surgical procedures at a later date due to persistent symptoms.29-32 In a review of 2,462 patients who underwent adenoidectomy during a 5-year period, Kay and colleagues identified 108 patients who underwent subsequent tonsillectomy within 5.4 years of the adenoidectomy procedure.32 The authors also found that the risk of subsequent tonsillectomy increased when the initial adenoidectomy was performed for upper airway obstruction.
There is extensive evidence validating the improvement of OSA after T&A. This surgery results in significant increase in patients quality of life based on validated questionnaires measuring sleep disturbance, physical symptoms, emotional symptoms, hyperactivity, and daytime functioning.33-37 The questionnaire results showed that for children who had the surgery, pulmonary hypertension was normalized based on echocardiography assessment,38 school performance was improved,14,18 and health care utilization was reduced.39 Resolution of abnormal sleep parameters, including respiratory disturbance index, oxygen saturation and arousal index, has been demonstrated by polysomnogram (PSG).29,31
However, despite the documented successes, many children continue to have residual OSA and remain symptomatic after surgery. In a review of 400 children who underwent surgical treatment of sleep-disordered breathing (SDB), Guilleminault and colleagues found persistent SDB in 58 (14.5%) of the children based on continual symptoms as well as PSG assessment.29 This is consistent with the cumulative cure rate of 80% in a pool of 401 patients from 11 studies based on a recent review.40 Factors contributing to residual OSA after T&A include severe OSA, obese children, positive family history of OSA, and African American ancestry. 41-43
It also appears that the initial success of T&A diminishes with time. Guilleminault and colleagues were the first to report the recurrence of snoring and OSA found in a group of pubertal and postpubertal teenagers who underwent T&A more than 10 years prior.44 The authors suggested that the presence of diminished airway dimension due to facial skeletal deficiency as a contributing factor leading to recurrence. Similarly, Tasker and colleagues found that a group of subjects with previous evidence of OSA prior to T&A continued to have evidence of narrower upper airways during sleep 12 years later.45 The authors postulated that this may be one of the risk factors for later development of adult OSA. A study on quality of life after T&A also found more pronounced improvement in the short-term (7 months) than in the long-term (9-24 months).46
There is convincing evidence that T&A improves OSA in children. There is also convincing evidence that the treatment of OSA may not end with T&A. Untreated nasal obstruction and maxillofacial deformity that contribute to diminished airway dimension are also frequent findings in children who are inadequately treated with T&A.47 Children with persistent OSA may require further treatment including jaw expansion by orthodontics, nasal airway reconstruction, or maxillofacial surgery to expand the upper airway.47 Nasal CPAP may also need to be considered. Therefore, parental counseling regarding the risk of recurrence and continual follow-up are essential in the management of pediatric OSA.
Kasey K. Li, DDS, MD, FACS, received his doctoral degrees in the medical and dental sciences at Harvard Medical School and UCLA Dental School, respectively. He has been certified by the American Board of Otolaryngology, the American Board of Oral and Maxillofacial Surgery, and the American Board of Facial Plastic and Reconstructive Surgery. He practices medicine at the Stanford University Sleep Disorders and Research Center in Stanford, Calif.
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