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There is also data reporting positive associations between OSA and sympathetic
tone, and endothelial dysfunction, both of which have been shown to improve after
T&A [27–31].
7.4 Diagnosis
7.4.1 History
Universal screening for snoring was rst recommended by the American Academy
of Pediatrics (AAP) in 2002 [32]. In addition to assessing for snoring, a comprehensive sleep history is essential to evaluate these children Table7.2. This evaluation
typically includes parental or caregiver input and should consist of information
about overall nighttime sleep duration (as well as daytime napping), bedtime routines, and time to fall asleep. Additionally, signs of OSA should be assessed including positions associated with and duration of snoring, restless sleep, gasping or
choking, night sweats, witnessed apneas, nocturnal enuresis (especially if secondary, i.e., recurrent after at least 6months of being dry at night) and abnormal sleep
behaviors, including night terrors, sleep walking, sleep talking and confusional
arousals.
A description of daytime symptoms should be solicited, including hyperactivity,
attention/focus issues, aggression, frequent mouth-breathing, nasal obstruction,
poor school performance, and excessive sleepiness (Table 7.2). While excessive
sleepiness is common in adults with OSA, it is less common in children with OSA
and is often not the primary complaint of children or their caregivers. Feeding difculty may also be reported for children with large tonsils, especially for bulky
foods such as meat.
Sleep questionnaires can be used to screen children at risk for OSA and assess
for symptoms commonly associated with SDB and OSA [33–35]. However, they
have not been validated to diagnose OSA as a solo method. A 2020 meta-analysis of
27 articles found poor diagnostic accuracy for clinical scoring tools when compared
to polysomnography (PSG) outcome measures [36].
Table 7.2 Frequent signs
and symptoms of obstructive
sleep apnea in children
Daytime symptoms Nighttime symptoms
Open mouth breathing Frequent snoring
Frequent nasal
obstruction
Hyperactivity Nighttime sweating
Aggressive behavior Witnessed apneas
Attention-decit disorder Paradoxical breathing
Poor school performance Restless sleep
Daytime sleepiness Hyperextension of the neck
Gasping or choking
Secondary nocturnal enuresis
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7.4.2 Physical Exam
A combination of upper airway narrowing, and neuromuscular factors contribute to
the development of pediatric SDB and OSA.Assessment of anatomic abnormalities
requires a complete head and neck exam (Table 7.3). The general examination
should include vitals with the body mass index and, ideally, a blood pressure measurement, an assessment of overall appearance, general head and neck appearance
with particular attention to any craniofacial abnormalities, and the presence or
absence of mouth breathing suggesting nasal obstruction. Voice should also be
assessed as large tonsils may cause a mufed voice, while large adenoids may result
in a hyponasal voice. Genetic consultation may be warranted for children with ndings suggestive of conditions that increase the risk of SDB and OSA (Table 7.1).
Table 7.3 Physical
examination in a child with
obstructive sleep apnea
General
General overall evaluation
Vital signs including body mass index (BMI) and
ideally blood pressure
Head and face including any craniofacial
abnormalities
Presence or absence of mouth breathing
Voice—Assess for mufed or hyponasal voice
Nasal
External deformity
Nasal valve function
Inferior turbinates
Nasal septum
Hypertrophy of the nasal swell body
Polyps and masses
Signs of chronic inammation including rhinorrhea,
erythema
Oral cavity
Dentition
Tongue size, position, and protrusion
Hard and soft palate
Uvula and posterior pharyngeal wall
Tonsil size
Modied Mallampati score
Neck
Neck size
Hyoid position, including submental-to-hyoid
distance
Tracheal position
Systemic
Chest wall evaluation
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Neck assessment should also include relative hyoid and tracheal positions and may
include circumference in teenagers.
Nasal evaluation should include an assessment of the external nose, the nasal
valve, the nasal septum, inferior turbinates, and an evaluation for polyps or masses
and signs of chronic inammation. In newborns, patency may be assessed by passing an 8 or 6 French catheter through each nare and into the oropharynx. Signs of
chronic inammation include erythema, rhinorrhea, duskiness of the nasal mucosa
and polyposis. However, polyposis is rare in children except for those with cystic
brosis. Anterior rhinoscopy is useful to identify septal deviation, turbinate hypertrophy, and nasal swell body hypertrophy contributing to nasal obstruction. Chronic
rhinorrhea may also be seen in children with obstruction secondary to nasal masses,
chronic sinusitis, or adenoid hypertrophy. Assessment of the nasal valve also
includes evaluation for functional nasal valve collapse while the child undergoes
deep inspiration. Nasal endoscopy can also be used to evaluate the nasal cavity for
nasal polyps or masses, choanal atresia or stenosis, pyriform aperture stenosis, or
adenoid hypertrophy.
Initial oral cavity and oropharynx evaluation should assess the mandible size and
position as well as dental occlusion. Tongue size and position should also be evaluated for macroglossia and glossoptosis. The palate evaluation should include uvular
evaluation for bidity, inspection for an overt or submucosal cleft of the hard or soft
palate, and documentation of palatal masses or a narrowed or high arched palate.
The tonsils are then graded based on the four-point Brodsky scale: 0 for surgically
absent tonsils, 1 for tonsils within pillars, 2 for tonsils just beyond the pillars, 3 for
tonsils more than 50% beyond the midline, and 4 for tonsils that approximate the
midline. The modied Mallampati score [37–39] is also useful for characterizing
the oropharynx with the mouth open while the tongue is in a resting position. Grade
I is scored when the entire uvula is visible, grade II when part of the uvula is visible,
grade III when none of the uvula but some of the soft palate is visible, and grade IV
when only the hard palate is visible.
Flexible laryngoscopy is recommended for infants and older children who
require further evaluation. This procedure allows assessment of the nasal cavity,
adenoidal tissue, velar closure, pharyngeal wall closure, the base of tongue, vallecula, epiglottis, hypopharynx, vocal folds, and frequently, a portion of the subglottis.
It is important to evaluate adenoidal hypertrophy, laryngomalacia, and lingual tonsil
hypertrophy, as well as vocal cord mobility and to evaluate for pharyngeal or hypopharyngeal masses.
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7.5 Additional Studies
Lateral neck lms can also be used to identify adenoidal size, nasal structural abnormalities, as and lingual tonsil hypertrophy [40]. Alternatively, cine magnetic resonance imaging (MRI) has been used to assess children with persistent sleep apnea
[41]. Drug-induced sleep endoscopy (DISE) is a valuable diagnostic tool to evaluate
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children with persistent OSA following T&A.Workup should include electrocardiograms and echocardiograms in children with underlying congenital cardiac
anomalies.
7.6 Polysomnography
The gold standard diagnostic method for OSA is a nocturnal in-laboratory PSG
[42]. A typical PSG includes 16 simultaneously recorded channels during sleep as
noted in Table7.4 [43]. This test’s output includes objective measurements that
characterize airway obstruction severity during sleep. These include sleep staging,
such as rapid eye movement (REM), and non-REM staging (stages 1, 2 and 3). The
apnea–hypopnea index (AHI) is also routinely reported to describe OSA severity;
calculated as the mean number of apneas and hypopneas per hour of sleep.
Hypopneas are considered a reduction in airow of at least 30% for ≥2 breaths
associated with either an oxygen desaturation of 3% or greater or an arousal [44].
Apneas are characterized by a complete cessation of airow for at least 2 respiratory
cycles. The obstructive AHI includes all apneas and hypopneas, including respiratory effort events. Unlike in adults, where an event must last at least 10s, ow limitation in children only needs to last for two or more consecutive breathing cycles
due to the differences in respiratory rates seen as children age [44]. Multiple studies
have reported good test–retest reliability when comparing multiple nights of overnight pediatric PSG in the same child [45–48]. OSA severity in children is based on
assessments of normal values. Currently, mild OSA is dened as an obstructive AHI
between 1 and <5 events per hour, moderate OSA is 5 to <10, and severe OSA is 10
or greater events per hour.
Table 7.4 Parameters recorded during nocturnal polysomnography (PSG)
PSG measurement parameters Electroencephalography (EEG)
PSG output REM vs. non-REM sleep
Abbreviations: REM rapid eye movement, Hg mercury, PSG polysomnography, mm millimeters
Electrooculography (EOG)
Submental and leg electromyography (EMG)
Electrocardiogram (EKG)
Respiratory effort measurement
Respiratory inductance plethysmographic (RIP)
Oxygen saturation
End tidal carbon dioxide
Airow measurement (oronasal)
Pressure transducer
Thermistor
Body position
Apnea–hypopnea index (AHI)
Obstructive AHI
Peak-end tidal carbon dioxide
Time with carbon dioxide >50mm hg
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PSG is nearly universally used by adult practitioners to diagnose OSA.However,
children often undergo treatment for SDB without a formal diagnosis of OSA [49].
In addition, the 2012 AAP guidelines acknowledged that there are not enough sleep
centers to accommodate all children with SDB and suggested that alternative testing, such as pulse oximetry, may be helpful in assessing children [42]. When a child
does undergo a PSG in an adult sleep center, it is critical that pediatric scoring criteria are used to score the study.
Guideline recommendations regarding pediatric PSG indications vary. The
American Academy of Sleep Medicine (AASM) recommends PSG whenever OSA
is suspected based on clinical assessment, prior to decannulation, after T&A in children with symptoms of persistent OSA, and children at high risk for persistent disease after T&A [50]. Alternatively, 2019 practice guidelines from the American
Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) recommend
PSG for all children under 2years old, for children in whom the need for surgery is
uncertain and when there is a discordance between the physical exam and symptoms [51]. These guidelines also recommend PSG for children with obesity, Down
syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease,
or mucopolysaccharidoses [51].
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7.7 Treatment ofOSA
7.7.1 Medical Treatment
While a trial of oral steroids was not shown to be an effective treatment for OSA,
nasal steroids have been shown to reduce the number of respiratory events by up to
5 events/h [52, 53]. Leukotriene modiers, specically Montelukast, have been
shown to reduce lymphoid tissue, decrease AHI, and improve hypercarbia [54]. In
addition, combination therapy of montelukast and intranasal mometasone resulted
in symptomatic improvement in 12 weeks with the highest effective rate in the
group with combination therapy [55]. A 2019 meta-analysis included six studies
and 668 children aged 2–5years, which demonstrated that montelukast alone, or
combined with intranasal steroids, is potentially benecial for the management of
mild OSA [56]. These medications may also be helpful for children with persistent
OSA following T&A [57]. While montelukast is typically well-tolerated, the FDA
issued a warning for children that this medication may results in serious neuropsychiatric adverse drug reactions, especially for children with pre-existing mood disorders [58].
Weight loss has also been reported to decrease OSA, especially in children with
mild to moderate disease. In children with severe OSA, weight loss (whether
through medical or surgical means) may reduce OSA severity but not necessarily a
full resolution [59, 60]. However, adolescents are more likely to see complete resolution of their OSA when compared to adults undergoing bariatric surgery [61, 62].
Weight loss has also been reported to lower CPAP requirements [63].
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Oral appliance therapy has been reported as rst-line therapy for children with
mild and moderate OSA over a 6-month treatment period [64, 65]. Rapid maxillary
expansion has been shown effective for children with mild to moderate OSA [66].
A 2016 systematic review and meta-analysis of 17 studies with 314 children with
OSA and transverse maxillary deciency demonstrated improvements in AHI and
lowest oxygen saturation. However, follow-up was less than 3years in all these
studies. Long-term (12-year) follow-up (n=23) had demonstrated stable resolution
of OSA on PSG [66].
S. Ishman
7.8 Continuous Positive Airway Pressure
Positive airway pressure (PAP) is a rst-line therapy in adults but is more commonly
considered after surgery in children. Nasal continuous PAP (CPAP) has been
approved for treatment of pediatric OSA since 2006in the United States. CPAP is
typically started during an overnight titration study in a sleep laboratory, although
auto-titrating CPAP is also used in children before PSG evaluation. The range of
CPAP pressures used in children typically starts at 4cm of water, with a maximum
of 15cm for children under 12years of age or 20cm for those 12years or older [67].
As with adults, the goal of CPAP use and titration PSG is to provide adequate positive airow to overcome and eliminate obstructive events in order to maintain airway patency [68] . CPAP has been shown to be effective for OSA treatment in
children aged 2–16years; however, at least 30% to 50% stop using CPAP within
6months of initiation [69]. In addition, there are concerns that long-term use of a
CPAP mask in children may contribute to facial attening and worsen long-term
OSA as children develop and grow [70].
7.9 Surgical Treatment
7.9.1 Adenotonsillectomy
T&A is rst-line management for children with OSA.As of 2010, outpatient adenotonsillectomies were performed in approximately 289,000 children in the United
States under the age of 15 [71]. The Childhood Adenotonsillectomy Trial (CHAT),
a randomized controlled trial of tonsillectomy versus observation, reported normalization of PSG ndings in 79% of children who underwent T&A versus 46% who
were observed [13]. Symptomatic improvement occurred in 80% of those who
underwent T&A, but only 15% in the observation arm. The likelihood of persistent
OSA after T&A depends on patient characteristics with increased rates reported in
children with morbid obesity, craniofacial abnormalities, the genetic conditions
including Down syndrome and achondroplasia.
Several methods are used to remove tonsils and adenoids; however, there is no
universally recommended method. Common techniques include “cold steel,” electrocautery, and radiofrequency ablation although laser, microdebrider, and harmonic
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scalpel have all been used [72]. Each of these techniques aims to minimize time
under anesthesia as well as postoperative pain and bleeding.
The risk of bleeding after T&A is 1%–4%, depending on the technique. Other
complications associated with T&A are quite low and include airway res, anesthesia reactions, airway complications, nasopharyngeal stenosis, velopharyngeal insufciency (VPI) or incompetence, and atlantoaxial subluxation [73]. After surgery,
many children complain of pain and decreased oral intake. A return to the hospital
may result from nausea, vomiting, and/or dehydration.
Tonsillotomy, also known as partial or intracapsular or subtotal tonsillectomy,
has a lower risk of postoperative pain and hemorrhage than tonsillectomy although
does have a risk of recurrence and regrowth of the tonsils. A 2017 meta-analysis of
32 studies reported that children undergoing tonsillotomy had less postoperative
pain, quicker time to normal oral intake, and lower odds of hospital readmission,
with similar patient satisfaction rates, quality-of-life improvements, and PSG
improvements [74].
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7.9.2 Adenoidectomy
Adenoidectomy alone may be performed to treat OSA when adenoid hypertrophy is identied in the absence of tonsillar hypertrophy or if there is a patient
preference to attempt a lower morbidity surgery as rst-line therapy. Adenoids
can be assessed using either nasopharyngoscopy or lateral neck x-rays. A 2020
meta-analysis reported an adenoid regrowth rate of 8% (n=4950 primary adenoidectomies) [75]. This same analysis reported that among 119,369 published
primary adenoidectomies, there was a revision rate of 2%, with 26% of these
revision surgeries performed for children with OSA [75]. Adenoid regrowth is
reportedly more common in young children or when “blind” adenoidectomy
techniques (like with a curette) as there is a higher likelihood of leaving residual
adenoid tissue behind [76, 77]. A separate retrospective study of children who
underwent adenoidectomy for SDB reported that 38% required subsequent revision adenoidectomy or tonsillectomy [78]. A 2016 study (n=515) of children
with moderate to severe OSA compared those who underwent adenoidectomy
alone versus T&A and reported similar success rates for nonobese children with
AHI <10 and small tonsils (<3); those with severe OSA or large tonsils were less
likely to have resolution on a PSG with adenoidectomy alone when compared to
the T&A group [79].
Adenoidectomy is also performed using several methods that include curette,
electrocautery, microdebrider, and radiofrequency ablation with no single method
recommended. Complications from adenoidectomy are rare, and recovery is typically quick. Postoperative bleeding is rare, and pain is signicantly less than that
seen with tonsillectomy. Much fewer common risks include VPI, nasopharyngeal
stenosis, and soft palate injury. Many surgeons leave the inferior portion of the
adenoids to reduce the risk of VPI, especially in children with submucous and overt
cleft palates where this risk is high.
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7.10 Pre-, Peri-, andPostoperative Management
Assessment of any child with OSA who is being considered for surgery should
include questions regarding a personal or family history of bleeding or easy bruising, difculty with anesthesia, history of cardiovascular issues or other medical
comorbidities. When a bleeding risk is suspected, a hematologic workup should be
considered. Of those children who present with bleeding after tonsillectomy, 19%
had elevated prothrombin time, partial thromboplastin time, or platelet function
assays, while only 4% were formally diagnosed with a coagulopathy [80]. For children with medical comorbidities, preoperative evaluation should be specically tailored to the condition and the individual which may include specialty assessment,
imaging, testing (e.g., electrocardiogram), or preoperative anesthesia consultation.
For all children with OSA, the AAO-HNS recommends good communication
between the surgeon and the anesthesia team regarding OSA severity and PSG ndings as children with OSA are noted to be at increased risk for anesthetic complications [42, 81].
In the recovery room, close monitoring for hypoxemia and hypercarbia is essential as these children are at high risk for complications compared to children without
OSA.For children 2 and younger, and those deemed high risk, overnight observation is recommended after surgery. The denitions of children at high risk by the
AAP and AAO-HNS can be found in Table7.5.
Children should also be sure to have adequate pain control. While opioids were
commonly used in the past after T&A, many children are now treated with acetaminophen, ibuprofen, and steroids as rst-line pain control. The use of opioids
decreased signicantly after the FDA issued a warning in 2013 that codeine use in
children after tonsillectomy could result in respiratory depression and death [82].
Considering this, the 2019 AAO-HNS Tonsillectomy clinical practice guidelines
Table 7.5 High-risk conditions which warrant overnight observation after adenotonsillectomy
per the American Academy of Pediatrics (AAP) and the American Academy of Otolaryngology—
Head and Neck Surgery (AAO-HNS)
AAP AAO-HNS
Children <3years Children <3years
Severe OSA (AHI>24) Severe OSA (AHI>10, sat nadir<80%)
Cardiac complications of
OSA
Failure to thrive Failure to thrive
Obesity Obesity with/without OSA
Current respiratory
infections
Craniofacial anomalies Craniofacial anomalies
Neuromuscular disorders Neuromuscular disorders
Abbreviations: OSA obstructive sleep apnea, AHI apnea–hypopnea index, Sat oxygen saturation
Cardiac complications of OSA
Current/recent respiratory infections
Down syndrome
Behavioral factors that predispose to poor oral intake/difcult
pain control
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recommend against codeine use after surgery for children under 12years old. The
FDA also recommends against codeine use in children with obesity and OSA
between 12 and 18years of age, and some pediatricians have recommended against
any codeine use for children in general [83].
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7.11 Persistent OSA After T&A
A 2009 systematic review and meta-analysis of 1079 children demonstrated that
PSG-assessed treatment success after T&A was 66.3% [84]. Risk factors associated
with persistent OSA after T&A include craniofacial/mandibular anomalies, cerebral
palsy, genetic disorders (e.g., Down syndrome), severe OSA, obesity, age over
7years, and asthma in nonobese children [85–88]. The 2023 AAO-HNS expert consensus statement regarding Persistent OSA recommends that PSG be obtained for
children with symptoms of OSA after T&A and children at high-risk for persistent
disease [89]. These authors also recommended alternative testing, including oximetry, cardiorespiratory studies, and home sleep testing when PSG is unavailable. In
addition, they noted that assessment of symptom burden and quality of life is useful
at baseline and after treatment.
Assessment of the site of obstruction for children with persistent OSA should
start with a physical examination, including the nasal airway, adenoid regrowth, oral
cavity/oropharynx - including the palate and lateral pharyngeal walls hypopharynx
and larynx. Drug-induced sleep endoscopy is also commonly used to assess these
children using a exible endoscope while the child is in a pharmacologically
induced sleep-like state. This test is reported to have good interrater reliability as
well as good test–retest reliability [90, 91]. A 2016 meta-analysis of DISE reported
that the most common sites of obstruction were the tongue base, adenoids (based on
regrowth), inferior turbinates, velum, and lateral oropharyngeal walls [92]. There is
not yet a universally accepted grading system for pediatric DISE, although several
have been proposed (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) [93–99].
Classication systems typically include the nose/nasopharynx, velum, oropharyngeal walls, tongue base, epiglottis and larynx/supraglottis [95, 96]. Table7.5 summarizes the most commonly reported causes of persistent OSA as identied
during DISE.
Imaging studies can also be helpful to assess for possible sites of obstruction.
Lateral neck x-rays are useful for looking for adenoid regrowth and identifying
enlarged lingual tonsils [100]. For those children with craniofacial abnormalities
of the facial skeleton, CT scans can be help asses bony denition. Cine MRI is
sometimes used to provide a high-resolution real-time dynamic assessment of the
upper airway and identify sites obstruction [101]. Determining primary versus
secondary sites of obstruction, such as lingual tonsil hypertrophy causing palatal
narrowing/obstruction, is most helpful. It also is benecial to differentiate between
a large base of tongue with small overlying lingual tonsils versus true lingual
tonsillar hypertrophy.
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7.12 Treatment forPersistent OSA
A multidisciplinary approach is recommended for these children. It may include
primary care providers, sleep medicine clinicians, dentists, pulmonologists, and
otolaryngologists as well as additional providers as needed (genetics, Oro maxillofacial surgery, plastic surgery, behavioral nutritionists, and geneticists among
others).
7.12.1 Nonsurgical Treatment
CPAP therapy is a primary treatment for persistent OSA after T&A and should be
offered if no obvious anatomic target is identied. However, compliance is often
low, and mask tting can be problematic for very young children or those with craniofacial anomalies [102]. When used, ongoing reevaluation is necessary, given
concerns about facial growth and the need to assess changes in the severity of persistent OSA with development and the impact of weight gain.
Oral appliances may be used for children and are likely most effective for those
with permanent teeth in place, so regular replacement is less of an issue. While studies in children are limited, signicant reductions in AHI and improvements in subjective outcomes have been reported [103–105].
Rapid maxillary expansion has also been used effectively to resolve mild to moderate OSA in children with high-arched palates and maxillary constriction [106]. A
2016 systematic review and meta-analysis of 17 studies, including 314 children,
reported improvements in AHI and oxygen saturations after rapid maxillary expansion [66]. While numbers are minimal, a case series of 23 children followed for
12years reported persistently normal PSG ndings [66].
As with adults, weight loss has been shown to signicantly improve the AHI in
children [107]—whether medical or surgical. Medications such as Montelukast and
nasal steroids (alone or in combination)have also been shown useful for treating
mild OSA [108]. Positional therapy, including vibrational therapy, also appears to
be effective for children, although data is limited [109–111].
7.12.2 Surgical Treatment—Nasal
Similar to adult studies, children with persistent OSA typically have an obstruction
at multiple levels of the airway. Because oropharyngeal scarring and stenosis have
been reported in 8.2% of children undergoing multilevel surgery including lingual
tonsillectomy, many pediatric otolaryngologists consider staged surgery [112].
There is limited data regarding the impact of nasal surgery on OSA in children beyond adenoidectomy. Despite concerns regarding the impact of septoplasty on facial growth in children, long-term evidence (with 12.2 years of
follow-up) found that endoscopic septoplasty did not interfere with nasal growth
[113]. Studies of turbinate reduction in children with nasal obstruction and SDB
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