Kids with mild OSA also benefit from adenotonsillectomy

4 minute read

But an Australian expert says there are some lower risk paths that could get the same result.

Adenoidectomy is on the table for children with mild or moderate sleep apnoea, US research has confirmed.

And an Australian expert says it adds to the range of other good options available for these kids.

Surgery can objectively improve quality of life, behaviour, symptoms and blood pressure, but not cognition, in children with habitual snoring, including those with an Apnoea-Hypopnoea Index score lower than 3, the randomised trial of 459 children aged 3-12 years found.

The children in the study received either an early adenoidectomy or were assigned to watchful waiting and were followed up for 12 months. All of the children had a polysomnogram to confirm that they had mild sleep apnoea.

Those in the surgery group improved more in terms of behavioural problems, sleepiness, symptoms, and quality of life than the children in the watchful waiting group. They also had greater reduction in systolic and diastolic blood pressure percentile levels in those 12 months (-9.2 vs -6.2) and fewer had their sleep apnoea progress to an AHI score of 3 or above (1.3% vs 13.2%). None of the children who had surgery went on to develop moderate OSA (AHI greater than 5), compared with 7.2% in the watchful waiting group.

In a commentary published in JAMA, paediatric ENT Professor Norman Friedman from the Children’s Hospital Colorado, said the research was useful for shared decision-making and “a must-read for all physicians who take care of children.”

“For otherwise healthy children with substantial quality-of-life and behaviour concerns, an [adenotonsillectomy] is an option to improve symptoms. For any families who are unsure about the need for surgery, [polysomnography] plays a pivotal role. For those who chose watchful waiting, families need to be educated on [sleep disordered breathing] symptoms, since some of these children will progress to develop moderate OSA,” he wrote.

“[C]hildren with habitual snoring/mild [sleep disordered breathing] but a low AHI may be candidates for an [adenotonsillectomy] when daytime symptoms are present and caregivers feel that the risks of surgery are outweighed by the disease burden.”

Associate Professor Larry Kalish, head of the Ear Nose and Throat Department at Sydney’s Concord Hospital, told TMR the research confirmed that surgery was a useful option in some cases, but that other treatments were available which in many cases could provide similar benefit for less risk.

“In the rural areas or even just outskirts of city, the demand for and volume of these operations is high,” he said.

“And you’ll find the majority of patients have got severe obstructive sleep apnoea. In the centre of the cities, you’ll find that there’s a more select cohort and a lot of these patients probably have mild to moderate [OSA].

“We don’t push [the latter] patients to have an operation. There are quality of life improvements. There are definitely benefits, but watchful waiting is very sensible.”

Sleep studies were difficult to access and expensive, said Professor Kalish, and so his practice was to recommend them for “mismatched” patients; that is, those for whom surgery was clearly indicated but were not sure of the need, and those who wanted the operation but there wasn’t clinical justification for it.

For many patients, improving nasal airflow could make a big difference, said Professor Kalish, because blocked nose was a big driver of daytime somnolence, behavioural changes and facial growth.

“The discussion for most contemporary doctors is addressing the nose without touching the tonsils,” he said.

So if you’ve got a child that has grade one, two, maybe even smaller tonsils, just addressing the nose may be very beneficial.

“That might be addressing the allergy, the congestion, removing the adenoids or even surgically addressing the turbinates. It can really impact quality of life and improvements, probably to a similar extent.”

Steroid sprays for the nose could help, he said. Commercially available phone apps could also give a good indication of whether the child was mouth breathing by monitoring and reporting their snoring more reliably than a parent’s observations and seeing whether that improved by addressing the blocked nose. The nose could be further investigated with an X-ray or a camera to look for large adenoids.

When surgery was the chosen path, most doctors were now looking at tonsillotomy, rather than tonsillectomy, which would get the same outcomes as those seen in the study with a lower risk profile, said Professor Kalish.

“You don’t remove the whole tonsil. You just shave it back using a coblation device. It’s less painful and there’s lower bleed risk. The study had a 2.6% bleed rate, whereas a tonsillotomy has less than 0.4% bleed rate,” he said.

JAMA Otolaryngol Head Neck Surg. 2023, Online 5 December 2023

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