Pediatric obstructive sleep apnea (OSA) represents a different entity from its adult counterpart and therefore requires a different therapeutic approach. Adenotonsillectomy (AT) is the primary treatment of pediatric OSA, and evidence shows it is very effective. However, there is a growing understanding that residual OSA is common, and next steps for patients who fail primary AT are less certain. This article reviews current methods of evaluating and treating these complex patients.
The reasons adenotonsillectomy (AT) fails to improve obstructive sleep apnea (OSA) are diverse and include increased severity of OSA, obesity, craniofacial syndromes, and neuromuscular syndromes.
Evaluation of patients after failed AT includes repeat polysomnography (PSG), physical examination, drug-induced sleep endoscopy (DISE), and cine magnetic resonance imaging (MRI).
Surgical therapy should be directed at specific sites of obstruction, including the nose, palate, tongue base, and supraglottis.
Close follow-up and repeat PSG are important after salvage treatment.
The field of pediatric sleep has been growing over the last 2 decades. Obstructive sleep apnea (OSA) has a high prevalence in the pediatric population, ranging from 2% to 4% of American children. The severe metabolic, neurocognitive, and cardiovascular consequences make it important to effectively treat OSA [
Children with OSA present differently than adults. The typical syndrome of daytime sleepiness is absent and replaced by hyperactivity, restlessness, and learning difficulties [
]. Polysomnography (PSG) typically shows continuous snoring with hypopneas rather than alternating snoring seen in adults with obstructive apneas [ ]. The definition of pediatric OSA, as outlined by the International Classification of Sleep Disorders 3rd Edition, (ICSD-3) is: (1) clinical criteria with observed obstruction during sleep or daytime consequences such as hyperactivity and learning difficulties, and (2) PSG criteria defined as apnea-hypopnea index (AHI) > 1. An AHI of 1 to 5 events/h is considered mild, 5 to 10 events/h is moderate, and > 10 events/hr is severe [
The Childhood Adenotonsillectomy Trial (CHAT) results published in 2013 showed that adenotonsillectomy (AT) had a definitive benefit for children with OSA, with multiple objective and subjective parameters significantly improving after surgery compared with watchful waiting [
]. However, 20% of patients after AT had persistent OSA on PSG. While an AHI > 1 implies there is at least mild OSA, the definition of residual OSA varies. In the context of performing repeat interventions, some define residual OSA as persistent severe disease (AHI > 10 events/h) or an AHI between 2 and 10 events/h with continuing daytime or nighttime symptoms [ ]. More complex pediatric patients (morbid obesity, craniofacial syndromes, Down syndrome, neuromuscular disorders) have a much lower success rate than healthy patients with enlarged tonsils and adenoids [ ]. The subset of the pediatric population whose OSA is not cured after AT can be particularly difficult to evaluate and treat. OSA treatments, once confined to AT, have now expanded to include a wide variety of new pathways for evaluation and treatment. We review treatment options for pediatric patients who have persistent OSA after AT.