The effect of adenotonsillectomy on children suffering from obstructive sleep apnea syndrome (OSAS): The Negev perspective

Summary

Objective

To present the Negev perspective in recent decades as to the effect of adenotonsillectomy regarding clinical and polysomnographic features, cardiopulmonary morbidity, growth, neurocognitive function, health care services utilization, and enuresis by reviewing current related literature.

Methods

All relevant published data by the Soroka University Medical Center and related community medical services were reviewed and compared to MEDLINE linked literature regarding aspects of childhood obstructive sleep apnea published through November 2005.

Results

Published data support a significant effect of adenotonsillectomy on the associated co morbidities: adenotonsillectomy resulted in the reduction of pulmonary hypertension, improved growth as a result of an increase in growth hormone secretion, improvement of neurocognitive function to the normal range, reduction in nocturnal enuresis, as well as reducing general morbidities, as reflected by the reduction in health care utilization. However, there are still uncertainties relating to major aspects. There is no specific definition for OSAS grading, or for generating a guideline for surgical treatment and refinement of the indications of T&A.

Conclusions

Adenotonsillectomy has a beneficial effect on children with OSAS, however, further research is required before recommendations for the treatment of OSAS in children can be formulated.

Introduction

Obstructive sleep apnea syndrome (OSAS) in children is characterized by a combination of prolonged partial upper airway obstruction (obstructive hypopnea) and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep pattern [1]. OSAS is clinically characterized by snoring, difficulty in breathing during sleep, and repeated obstructive apnea. The syndrome occurs in 0.7–4% of children [2]. The vast majority of cases of OSAS in children are associated with adenotonsillar hypertrophy. In obese children with OSAS the degree of the syndrome is proportional to the degree of obesity. Childhood OSAS occurs mainly at 2–8-years-of-age, which is the age when the tonsils and adenoid are the largest in relation to the underlying airway size [3]. Complications of OSAS may include pulmonary hypertension, neurobehavioral morbidity, failure-to-thrive (FTT), and nocturnal enuresis [4]. It is not clear to what extent OSAS complications are due to sleep fragmentation or to intermittent nocturnal hypoxemia, as there is uncertainty of the ability of polysomnographic parameters to predict morbidity [3], [5]. Adenotonsillar hypertrophy is the most common cause of OSAS in children; therefore, the definitive treatment is adenotonsillectomy (T&A). Other modalities used to treat OSAS include nocturnal oxygen, nasal spray of corticosteroids, nasopharyngeal tube, nasal CPAP, and tracheostomy [3], [6]. There is still a debate as to the absence of prospective randomized controlled trials investigating the efficacy of treatment of obstructive sleep apnea with T&A in children [7]. In this paper we present the Negev perspective in recent decades as to the effect of T&A regarding clinical and polysomnographic (PSG) features, cardiopulmonary morbidity, growth, neurocognitive function, health care services utilization, and enuresis. A team approach has included a pediatric pulmonologist, a polysomnography expert, and a pediatric otolaryngologist.