Although useful for many, the popular adenotonsillectomy treatment is not a cure-all.

Adenotonsillectomy

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

BEYOND ADENOTONSILLECTOMY
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.

REFERENCES
1. Guilleminault C, Eldridge FL, Simmons FB, Dement WC. Sleep apnea in eight children. Pediatrics. 1976;58:23-30.
2. Ali NJ, Pitson DJ, Stradling JR. Snoring, sleep disturbance, and behaviour in 4-5 year olds. Arch Dis Child. 1993;68:360-366.
3. Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med. 1998;157:1098-1103.
4. Sofer S, Weinhouse E, Tal A, et al. Cor pulmonale due to adenoidal or tonsillar hypertrophy or both in children. Noninvasive diagnosis and follow-up. Chest. 1988;93:119-122.
5. Tal A, Leiberman A, Margulis G, Sofer S. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonal. 1988;4:139-143.
6. Gorur K, Doven O, Unal M, Akkus N, Ozcan C. Preoperative and postoperative cardiac and clinical findings of patients with adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol. 2001;59:41-46.
7. Nieminen P, Lopponen T, Tolonen U, et al. Growth and biochemical markers of growth in children with snoring and obstructive sleep apnea. Pediatrics. 2002;109:e55.
8. Bar A, Tarasiuk A, Segev Y, Phillip M, Tal A. The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome. J Pediatr. 1999;135:76-80.
9. Yilmaz MD, Hosal AS, Oguz H, Yordam N, Kaya S. The effects of tonsillectomy and adenoidectomy on serum IGF-I and IGFBP3 levels in children. Laryngoscope. 2002;112:922-925.
10. Gozal D, Wang M, Pope DW. Objective sleepiness measures in pediatric obstructive sleep apnea. Pediatrics. 2001;108:693-697.
11. Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest. 1995;108:610-618.
12. Stein MA, Mendelsohn J, Obermyer WH, Amromin J, Benca R. Sleep and behavior problems in school-aged children. Pediatrics. 2001:107:e60.
13. Guilleminault C, Korobkin R, Winkle R. A review of 50 children with obstructive sleep apnea syndrome. Lung. 1981;159:275-287.
14. Ali NJ, Pitson D, Stradling JR. Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological functioning. Eur J Paediatr. 1996;155:56-62.
15. Chervin RD, Dillon JE, Bassetti C, Ganoczy DA, Pituch KJ. Symptoms of sleep disorders, inattention, and hyperactivity in children. Sleep. 1997;20:1185-1192.
16. Gozal D, Pope DW Jr. Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics. 2001;107:1394-1399.
17. Chervin RD, Archbold KH. Hyperactivity and polysomnographic findings in children evaluated for sleep-disordered breathing. Sleep. 2001;24:313-320.
18. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102:616-620.
19. Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleepwalking and night terrors in prepubertal children: what triggers them? Pediatrics. 2003;111:e17-e25.
20. Marcus CL, Ward SL, Mallory GB, et al. Use of nasal continuous positive airway pressure as treatment of childhood obstructive sleep apnea. J Pediatr. 1995;127:88-94.
21. Waters KA, Everett FM, Bruderer JW, Sullivan CE. Obstructive sleep apnea: the use of nasal CPAP in 80 children. Am J Respir Crit Care Med. 1995;152:780-785.
22. Mansfield LE, Diaz G, Posey Cr, Flores-Neder J. Sleep disordered breathing and daytime quality of life in children with allergic rhinitis during treatment with intranasal budesonide. Ann Allergy Asthma Immunol. 2004;92:240-244.
23. Hughes K, Glass C, Ripechinski M, et al. Efficacy of the topical nasal steroid budesonide on improving sleep and daytime somnolence in patients with perennial allergic rhinitis. Allergy. 2003;58:380-385.
24. Arens R, McDonough JM, Corbin AM, et al. Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2003;167:65-70.
25. Arens R, McDonough JM, Tayag-Kier CE, et al. MRI measurements of the upper airway structure in children with obstructive sleep apnea. Am J Respir Crit Care Med. 2001;164:698-703.
26. Zucconi M, Caprioglio A, Calori G, et al. Craniofacial modifications in children with habitual snoring and obstructive sleep apnoea: a case-control study. Eur Respir J. 1999;13:411-417.
27. Kawashima S, Peltomaki T, Sakata H, et al. Craniofacial morphology in preschool children with sleep-related breathing disorder and hypertrophy of tonsils. Acta Paediatr. 2002;91:71-77.
28. Marcus CL, McColley SA, Carroll JL, Loughlin GM, Smith PL, Schwartz AR. Upper airway collapsibility in children with obstructive sleep apnea syndrome. J Appl Physiol. 1994;77:918-924.
29. Guilleminault C, Li KK, Khramtsov A, Pelayo R, Martinez S. Sleep disordered breathing: surgical outcome in prepubertal children. Laryngoscope. 2004;114:132-137.
30. Guilleminault C, Li KK, Quo S, Inouye RN. A prospective study on the surgical outcomes of children with sleep-disordered breathing. Sleep. 2004;27:95-100.
31. Nieminen P, Tolonen U, Lopponen H. Snoring and obstructive sleep apnea in children. A 6-month follow-up study. Arch Otolaryngol Head Neck Surg. 2000;126:481-486.
32. Kay DJ, Bryson PC, Casselbrant M. Rates and risk factors for subsequent tonsillectomy after prior adenoidectomy: a regression analysis. Arch Otolaryngol Head Neck Surg. 2005;131:252-255.
33. de Serres LM, Derkay C, Sie K, et al. Impact of adenotonsillectomy on quality of life on children with obstructive sleep disorders. Arch Otolaryngol Head Neck Surg. 2002;128:489-496.
34. Flanary VA. Long-term effect of adenotonsillectomy on quality of life in pediatric patients. Laryngoscope. 2003;113:1639-1644.
35. Stewart MG, Glaze DG, Friedman EM, Smith EO, Bautista M. Quality of life and sleep study findings after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2005;131:308-314.
36. Mitchell RB, Kelly J, Call E, Yao N. Quality of life after adenotonsillectomy for obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg. 2004;130:190-194.
37. Avior G, Fishman G, Leor A, Sivan Y, Kaysar N, Derowe A. The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the test of variables of attention (TOVA) in children with obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2004;131:367-371.
38. Miman MC, Kirazli T, Ozyurek R. Doppler echocardiography in adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol. 2000;11:21-26.
39. Tarasiuk A, Simon T, Tal A, Reuveni H. Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization. Pediatrics. 2004;113:351-356.
40. Lipton AJ, Gozal D. Treatment of obstructive sleep apnea in children: do we really know how? Sleep Med Rev. 2003;7:61-80.
41. Morton S, Rosen C, Larkin E, Tishler P, Aylor J, Redline S. Predictors of sleep-disordered breathing in children with a history of tonsillectomy and/or adenoidectomy. Sleep. 2001;24:823-829.
42. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg. 1995;121:525-530
43. Mitchell RB, Kelly J. Outcome of adenotonsillectomy for severe obstructive sleep apnea in children. Int J Pediatr Otolaryngol. 2004;68:1375-79.
44. Guilleminault C, Partinen M, Praud JP, Quera-Salva MA, Powell N, Riley R. Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr. 1989;114:997-999.
45. Tasker C, Crosby JH, Stradling JR. Evidence for persistence of upper airway narrowing during sleep, 12 years after adenotonsillectomy. Arch Dis Child. 2002;86:34-37.
46. Mitchell RB, Kelly J, Call E, Yao N. Long-term changes in quality of life after surgery for pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2004;130:409-412.
47. Guilleminault C, Lee JH, Chan A. Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med. 2005;159:775-785.