Adenotonsillectomy or watchful waiting in the management of childhood obstructive sleep apnea.
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ABSTRACT:
SUBMITTER: Witmans M
PROVIDER: S-EPMC3805813 | biostudies-literature | 2013 Nov
REPOSITORIES: biostudies-literature
Publications
Adenotonsillectomy or watchful waiting in the management of childhood obstructive sleep apnea.
Witmans Manisha M Shafazand Shirin S
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 20131115 11
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Project description:The treatment of children with Obstructive Sleep Apnea Syndrome (OSAS) remains a point of debate among otorhinolaryngologists worldwide. This study aims to comparatively assess the clinical outcomes of adenotonsillectomy (ATE) and watchful waiting in children with OSAS. We searched the databases of PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL), until the 1st of October 2023. Comparative trials assessing the efficacy of adenotonsillectomy and watchful waiting in children with OSAS were considered. The primary outcome measure was the apnea-hypopnea index (AHI), and secondary outcomes included quality of life as measured by OSA-18 score, and mean SpO2 levels. A subgroup analysis evaluating the changes in AHI depending on the severity of the initial disease was also executed. We conducted a random-effects pairwise meta-analysis of change scores to include randomized and non-randomized controlled trials. The quality assessment was carried out by using the Cochrane risk of bias tool for randomized and the ROBINS-I tool for non-randomized trials, respectively. Two randomized and five non-randomized trials were included. There was a statistically significant difference regarding AHI in favor of the ATE group compared to the watchful waiting group (Standardized mean difference [SMD] was - 0.60, 95%CI -0.79 to -0.41, p < 0.001). Likewise, a statistically significant decrease in change scores for OSA-18 between ATE and watchful waiting was noted (SMD was - 0.79, 95%CI -0.97 to -0.61, p < 0.001). On the other hand, there was no significant difference when ATE and watchful waiting groups were compared for SpO2 levels between each other (SMD was 0.52, 95%CI -1.53 to 2.56, p < 0.62). In the subgroup analysis assessing mild OSAS, there was a significant difference in favor of ATE compared to watchful waiting (SMD was -0.91, 95%CI -1.35 to -0.47, p < 0.0001). For mild to moderate OSAS, similar results were noted favoring ATE as well (SMD was - 0.53, 95%CI -0.87 to -0.19, p < 0.003). This study provides evidence of moderate strength supporting the superiority of ATE over the watchful waiting approach in terms of AHI and OSA-18. This also appears to be the case for AHI in children with mild and mild to moderate OSAS.Supplementary informationThe online version contains supplementary material available at 10.1007/s12070-024-04738-0.
| S-EPMC11456012 | biostudies-literature
Project description:ImportanceAdenotonsillectomy (ATE) is one of the most common surgical procedures to treat children with obstructive sleep apnea (OSA), but to our knowledge there are no randomized clinical trials confirming the benefit of surgery compared with watchful waiting in children between 2 and 4 years of age.ObjectiveTo determine whether ATE is more effective than watchful waiting for treating otherwise healthy children with mild to moderate OSA.Design, setting, and participantsThis randomized clinical trial was conducted from December 2014 to December 2017 at the Otorhinolaryngology Department of the Karolinska University Hospital, Stockholm, Sweden. A total of 60 children, 2 to 4 years of age, with an obstructive apnea-hypopnea index (OAHI) score of 2 or greater and less than 10, were randomized to ATE (n = 29) or watchful waiting (n = 31). A total of 53 participants (88%; ATE, n = 25; watchful waiting, n = 28) completed the study. Data were analyzed from August 2018 to December 2018.InterventionsAdenotonsillectomy.Main outcomes and measuresThe primary outcome was the difference between the groups in mean OAHI score change. Secondary outcomes were other polysomnography parameters, score on the Obstructive Sleep Apnea-18 (OSA-18) questionnaire, and subgroup analyses. Polysomnography and the OSA-18 questionnaire were completed at baseline and after 6 months.ResultsOf the 60 included children, 34 (57%) were boys and the mean (SD) age at first polysomnography was 38 (9) months. Both groups had a decrease in mean OAHI score, and the difference in mean OAHI score change between the groups was small (-1.0; 95% CI, -2.4 to 0.5), in favor of ATE. However, there were large differences between the groups in favor of ATE regarding the OSA-18 questionnaire (eg, total OSA-18 score: -17; 95% CI, -24 to -10). Also, a subgroup analysis of 24 children with moderate OSA (OAHI ≥5 and <10) showed a meaningful difference in mean OAHI score change between the groups in favor of ATE (-3.1; 95% CI, -5.7 to -0.5). Of 28 children, 10 (36%) in the watchful waiting group received ATE after the follow-up, and 7 of these had moderate OSA at baseline.Conclusions and relevanceThis randomized clinical trial found only small differences between the groups regarding changes in OAHI, but further studies are needed. However, there were large improvements in quality of life after ATE. These results suggest that otherwise healthy children with mild OSA and mild effect on quality of life may benefit from watchful waiting, while children with moderate OSA should be considered for ATE.Trial registrationClinicalTrials.gov Identifier: NCT02315911.
| S-EPMC7256861 | biostudies-literature
Project description:To assess the effect of adenotonsillectomy for relieving obstructive sleep apnea syndrome (OSAS) symptoms in children on cardiac autonomic modulation. In 354 children enrolled in the Childhood Adenotonsillectomy Trial, randomized to undergo either early adenotonsillectomy (eAT; N = 181) or a strategy of watchful waiting with supportive care (WWSC; N = 173), nocturnal heart rate control was analyzed during quiet, event-free sleep at baseline and at 7 months using overnight polysomnography (PSG). The relative frequency of patterns indicating monotonous changes in heart rate was quantified. Children who underwent eAT demonstrated a significantly greater reduction in heart rate patterns postsurgery than the WWSC group. On assessing those heart rate patterns regarding normalization of clinical PSG, heart patterns were reduced to a similar level in both groups. In children whose AHI normalized spontaneously, heart rate patterns were already significantly less frequent at baseline, suggesting that upper airway obstruction was milder in this group at the outset. Adenotonsillectomy reduces monotonous heart rate patterns throughout quiet event-free sleep, reflecting a reduction in cardiac autonomic modulation. Heart rate pattern analysis may help quantifying the effect of OSAS on autonomic nervous system activity in children. Clinical Trial Registration: The study was registered at Clinicaltrials.gov (#NCT00560859).
| S-EPMC6231530 | biostudies-literature
Project description:Research reveals mixed evidence for the effects of adenotonsillectomy (AT) on cognitive tests in children with obstructive sleep apnea syndrome (OSAS). The primary aim of the study was to investigate effects of AT on cognitive test scores in the randomized Childhood Adenotonsillectomy Trial. Children ages 5 to 9 years with OSAS without prolonged oxyhemoglobin desaturation were randomly assigned to watchful waiting with supportive care (n = 227) or early AT (eAT, n = 226). Neuropsychological tests were administered before the intervention and 7 months after the intervention. Mixed model analysis compared the groups on changes in test scores across follow-up, and regression analysis examined associations of these changes in the eAT group with changes in sleep measures. Mean test scores were within the average range for both groups. Scores improved significantly (P < .05) more across follow-up for the eAT group than for the watchful waiting group. These differences were found only on measures of nonverbal reasoning, fine motor skills, and selective attention and had small effects sizes (Cohen's d, 0.20-0.24). As additional evidence for AT-related effects on scores, gains in test scores for the eAT group were associated with improvements in sleep measures. Small and selective effects of AT were observed on cognitive tests in children with OSAS without prolonged desaturation. Relative to evidence from Childhood Adenotonsillectomy Trial for larger effects of surgery on sleep, behavior, and quality of life, AT may have limited benefits in reversing any cognitive effects of OSAS, or these benefits may require more extended follow-up to become manifest.
| S-EPMC4960728 | biostudies-literature
Project description:Background and objectivesAdenotonsillectomy for obstructive sleep apnea syndrome (OSAS) may lead to weight gain, which can have deleterious health effects when leading to obesity. However, previous data have been from nonrandomized uncontrolled studies, limiting inferences. This study examined the anthropometric changes over a 7-month interval in a randomized controlled trial of adenotonsillectomy for OSAS, the Childhood Adenotonsillectomy Trial.MethodsA total of 464 children who had OSAS (average apnea/hypopnea index [AHI] 5.1/hour), aged 5 to 9.9 years, were randomized to Early Adenotonsillectomy (eAT) or Watchful Waiting and Supportive Care (WWSC). Polysomnography and anthropometry were performed at baseline and 7-month follow-up. Multivariable regression modeling was used to predict the change in weight and growth indices.ResultsInterval increases in the BMI z score (0.13 vs. 0.31) was observed in both the WWSC and eAT intervention arms, respectively, but were greater with eAT (P < .0001). Statistical modeling showed that BMI z score increased significantly more in association with eAT after considering the influences of baseline weight and AHI. A greater proportion of overweight children randomized to eAT compared with WWSC developed obesity over the 7-month interval (52% vs. 21%; P < .05). Race, gender, and follow-up AHI were not significantly associated with BMI z score change.ConclusionseAT for OSAS in children results in clinically significant greater than expected weight gain, even in children overweight at baseline. The increase in adiposity in overweight children places them at further risk for OSAS and the adverse consequences of obesity. Monitoring weight, nutritional counseling, and encouragement of physical activity should be considered after eAT for OSAS.
| S-EPMC4187239 | biostudies-literature
Project description:BACKGROUND:Inflammation is often considered relating to pediatric obstructive sleep apnea (OSA). We conducted a study investigating cytokines, including Il-17 and Il-23, in children with OSA before and after adenotonsillectomy (T&A), compared with controls. METHODS:Children with OSA between age 4 and 12 receiving T&A were prospectively followed. Evaluation before and reevaluation six months after the treatment were done, including polysomnography (PSG), blood tests, and questionnaires. Blood samples were obtained to determine the values of high-sensitivity-C-reactive-protein (HS-CRP); tumor-necrosis-factor-alpha (TNF-?); and interleukin (IL)-1, 6, 10, 12, 17, and 23. We compared the results with an age-matched control group. RESULTS:We included 55 OSA children and 32 controls. Children with OSA presented significant improvement after T&A in complaints, signs, apnea hypopnea index (AHI) (p < 0.001), mean oxygen desaturation index (p < 0.001), and mean oxygen saturation (p = 0.010). Upon entering this study, children with OSA had significantly higher cytokine levels than the controls and significant changes in HS-CRP (p = 0.013), TNF-? (p = 0.057), IL-1? (p = 0.022), IL-10 (p = 0.035), and IL-17 (p = 0.010) after T&A. Children with improved but persistently abnormal AHI did not have all cytokine levels normalized, particularly IL-23 and HS-CRP. CONCLUSION:Sleep-disordered breathing can persist after T&A and can continue to have a negative inflammatory effect. HS-CRP and IL-23 may serve as blood markers for the persistence of sleep-disordered breathing after T&A.
| S-EPMC7230716 | biostudies-literature
Project description:Study objectivesThere is uncertainty over which characteristics increase obstructive sleep apnea syndrome (OSAS) severity in children. In candidates for adenotonsillectomy (AT), we evaluated the relationship of OSAS severity and age, sex, race, body mass index (BMI), environmental tobacco smoke (ETS), prematurity, socioeconomic variables, and comorbidities.DesignCross-sectional screening and baseline data were analyzed from the Childhood Adenotonsillectomy Trial, a randomized, controlled, multicenter study evaluating AT versus medical management. Regression analysis assessed the relationship between the apnea hypopnea index (AHI) and risk factors obtained by direct measurement or questionnaire.SettingClinical referral setting.ParticipantsChildren, ages 5 to 9.9 y with OSAS.Measurements and resultsOf the 1,244 children undergoing screening polysomnography, 464 (37%) were eligible (2 ≤ AHI < 30 or 1 ≤ obstructive apnea index [OAI] < 20 and without severe oxygen desaturation) and randomized; 129 (10%) were eligible but were not randomized; 608 (49%) had AHI/OAI levels below entry criteria; and 43 (3%) had levels of OSAS that exceeded entry criteria. Among the randomized children, univariate analyses showed significant associations of AHI with race, BMI z score, environmental tobacco smoke (ETS), family income, and referral source, but not with other variables. After adjusting for potential confounders, African American race (P = 0.003) and ETS (P = 0.026) were each associated with an approximately 20% increase in AHI. After adjusting for these factors, obesity and other factors were not significant.ConclusionsApnea hypopnea index level was significantly associated with race and environmental tobacco smoke, highlighting the potential effect of environmental factors, and possibly genetic factors, on pediatric obstructive sleep apnea syndrome severity. Efforts to reduce environmental tobacco smoke exposure may help reduce obstructive sleep apnea syndrome severity.Clinical trial registrationClinicaltrials.gov (#NCT00560859).
| S-EPMC3900616 | biostudies-literature
Project description:BackgroundAdenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes.MethodsWe randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months.ResultsThe average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%).ConclusionsAs compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).
| S-EPMC3756808 | biostudies-literature
Project description:Background and objectivesData from a randomized, controlled study of adenotonsillectomy for obstructive sleep apnea syndrome (OSAS) were used to test the hypothesis that children undergoing surgery had greater quality of life (QoL) and symptom improvement than control subjects. The objectives were to compare changes in validated QoL and symptom measurements among children randomized to undergo adenotonsillectomy or watchful waiting; to determine whether race, weight, or baseline OSAS severity influenced changes in QoL and symptoms; and to evaluate associations between changes in QoL or symptoms and OSAS severity.MethodsChildren aged 5 to 9.9 years with OSAS (N = 453) were randomly assigned to undergo adenotonsillectomy or watchful waiting with supportive care. Polysomnography, the Pediatric Quality of Life inventory, the Sleep-Related Breathing Scale of the Pediatric Sleep Questionnaire, the 18-item Obstructive Sleep Apnea QoL instrument, and the modified Epworth Sleepiness Scale were completed at baseline and 7 months. Changes in the QoL and symptom surveys were compared between arms. Effect modification according to race and obesity and associations between changes in polysomnographic measures and QoL or symptoms were examined.ResultsGreater improvements in most QoL and symptom severity measurements were observed in children randomized to undergo adenotonsillectomy, including the parent-completed Pediatric Quality of Life inventory (effect size [ES]: 0.37), the 18-item Obstructive Sleep Apnea QoL instrument (ES: -0.93), the modified Epworth Sleepiness Scale score (ES: -0.42), and the Sleep-Related Breathing Scale of the Pediatric Sleep Questionnaire (ES: -1.35). Effect modification was not observed by obesity or baseline severity but was noted for race in some symptom measures. Improvements in OSAS severity explained only a small portion of the observed changes.ConclusionsAdenotonsillectomy compared with watchful waiting resulted in significantly more improvements in parent-rated generic and OSAS-specific QoL measures and OSAS symptoms.
| S-EPMC4306791 | biostudies-literature
Project description:The study aims to examine drug-induced sleep endoscopy (DISE) in the decision-making process of pediatric obstructive sleep apnea (OSA) patients with small tonsils. This was a retrospective study of children who underwent awake flexible endoscopy, DISE, and adenoidectomy with/without tonsillectomy at the Shanghai Children's Medical Center between 03/2015 and 12/2016. Tonsillectomy was performed for tonsillar obstruction found by DISE. Adenoidectomy was performed for all children. Cardio-pulmonary coupling (CPC) and oximetry were observed before/after surgery. The study included 126 children: 56 (44.4%) with grade 2 tonsils and 70 (55.6%) with grade 1. Mean age was 5.7±3.2 (range, 2.8-10.4) years and mean BMI of 15.7±5.5 kg/m2. Unexpectedly, DISE showed tonsillar obstruction in 57 (45.2%) children, including 44 (78.6%) with grade 2 tonsils and 13 (18.6%) with grade 1. Therefore, DISE-directed tonsillectomy was performed for 57 patients. There was an improvement in respiratory disturbance index (RDI) and oxygen saturation nadir in the DISE (P = 0.0007, P = 0.037) and control (P = 0.001, P = 0.023) groups 6 months after surgery, but RDI improvement was better in the DISE group compared with controls 1 year after surgery (P = 0.042). DISE is a good way to determine the necessity of tonsillectomy in pediatric OSA patients with small tonsils.
| S-EPMC6386441 | biostudies-literature