OVERVIEW OF PEDIATRIC SLEEP APNEA SURGERY
Kasey K. Li, MD, DDS, FACS
Obstructive sleep apnea was first described in children in 1976 by Guilleminault.1 The prevalence of pediatric obstructive sleep apnea has been estimated to be between 1% to 3% in preschool and school-aged children. 2 More recently, the estimated pediatric obstructive sleep apnea prevalence has increased due to better monitoring techniques during polysomnography (PSG). 3 However, definitive data are still lacking. Although medical treatment such as nasal continuous positive airway pressure (CPAP) can be successful in treating pediatric obstructive sleep apnea and nasal steroid sprays can be effective in reducing the severity of OSA in children with allergic rhinitis, 4-7 most investigators would agree that these approaches are not the ideal long-term treatment for pediatric obstructive sleep apnea. Today, surgery remains as the first-line treatment, and adenotonsillectomy (T&A) is the most commonly performed surgical procedure for the treatment of pediatric obstructive sleep apnea.
THE PEDIATRIC OSA AIRWAY
In order to understand how T&A can impact OSA in children, one must understand how the airway is affected in pediatric obstructive sleep apnea. It has been demonstrated that the airway is smaller in children with obstructive sleep apnea compared to controls. 8,9 The adenoid and tonsils are larger and the airway is most restricted where adenoid and tonsils overlap. 8,9 In addition, a significant correlation between percent difference of the combined adenoid and tonsils volume and the apnea/hypopnea index (AHI) is found. 9 The adenoid and tonsils clearly play an important role in contributing to obstructive sleep apnea in children. Indeed, the disorder is most common between 2 to 6 years of age and correlates to the age of lymphoid hyperplasia during childhood. 10,11
WHY SHOULD WE TREAT PEDIATRIC SLEEP APNEA
It is clear that children with obstructive sleep apnea have associated morbidities. The cardiovascular risks due to obstructive sleep apnea are clearly demonstrated in adults with obstructive sleep apnea. Although there are less data on cardiovascular morbidities in children with obstructive sleep apnea, the existing evidence cannot be ignored. Children with obstructive sleep apnea have been shown to have an increased risk in developing systemic hypertension as well as right ventricular dysfunction due to elevated pulmonary arterial pressure. 12-15 Children with obstructive sleep apnea also have a higher risk of failure to thrive and impairment of growth development. Evidence suggests that growth hormone secretion is impaired, thus affecting growth. 16-18
The most extensive evidence on the impairment of obstructive sleep apnea in children is the neurocognitive and behavioral consequences. Although the hallmark of excessive daytime sleepiness seen in adults does not appear to be the major symptom in children, 19-21 behavior problems including hyperactivityinattention, aggression, sleepwalking and night terrors as well as impaired learning and diminished academic performance are the common symptoms. 22-28
Historically, the most common indication for T&A was for infectious etiology. With the advances in antimicrobial therapy, we have witnessed a reduction in the frequency of this surgical procedure. Interestingly, an increase in airway compromise from adenotonsillar hypertrophy has been observed during the same period. 29 Today, obstructive sleep apnea is the most common indication for T&A. 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). 30
As stated earlier, T&A is the first line treatment for pediatric obstructive sleep apnea. Some surgeons perform only adenoidectomy in selected patients because of the concern with pain and suffering associated with post-operative recovery following tonsillectomy. It is important to emphasize that both tonsillectomy and adenoidectomy should be performed if the objective of the operation is to improve airway obstruction in obstructive sleep apnea. Although isolated adenoidectomy or tonsillectomy procedure does improve obstructive sleep apnea, the improvement may be insufficient, thus leading to further surgical procedures at a later date due to persistent symptoms. 31-35 In a review of 2,462 patients who underwent adenoidectomy during a five-year period, Kay and colleagues identified 108 patients who underwent subsequent tonsillectomy within 5.4 years of the adenoidectomy procedure. 34 The authors also found that the risk of subsequent tonsillectomy increased when the initial adenoidectomy was performed for upper airway obstruction.
There is a large body of evidence validating the improvement of obstructive sleep apnea after T&A. Methods that have been used in evaluating the outcomes of surgery include the comparison between pre- and post-operative symptomatology and school performance, as well as measurements such as PSG, echocardiogram, health-related quality-of-life surveys and neurocognitive testing. T&A results in significant improvement in the quality of life based on validated questionnaires measuring sleep disturbance, physical symptoms, emotional symptoms, hyperactivity and daytime functioning. 35-40 Pulmonary hypertension has normalized based on echocardiography assessment. 15, 41 School performance has improved23,27 and health care utilization has been reduced. 42 Abnormal PSG measurements including respiratory disturbance index, oxygen saturation and arousal index have also significantly resolved. 31,33,44 However, despite the documented success, many children continue to have residual OSA 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. 31 This is consistent with the cumulative cure rate of 80% in a pool of 401 patients from 11 studies based on a recent review. 45 These findings may help explain the "learning debt" theory by Gozal and Pope, 25 in that they found children with lower academic performance are more likely to have snored during early childhood and require T&A for snoring compared with better-performing schoolmates. It is possible that these "treated" children may still have persistent SDB. Factors contributing to residual obstructive sleep apnea after T&A include severe OSA, obese children, positive family history of obstructive sleep apnea as well as African American children. 46-48 Untreated nasal obstruction and maxillofacial deformity that contribute to diminished airway dimension are also frequent findings in children inadequately treated with T&A. 49 Children with persistent obstructive sleep apnea may require further treatment including jaw expansion by orthodontics, nasal airway reconstruction or maxillofacial surgery to expand the upper airway. 49 Nasal CPAP may also need to be considered.
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 obstructive sleep apnea found in a group of pubertal and postpubertal teenagers who previously underwent T&A more than 10 years prior. 50 The authors suggested the presence of diminished airway dimension due to facial skeletal deficiency as contributing factors leading to recurrence. Similarly, Tasker and colleagues found that a group of subjects with previous evidence of obstructive sleep apnea prior to T&A continue to have evidence of narrower upper airways during sleep 12 years later. 51 The authors postulated that this may be one of the risk factors for later development of adult obstructive sleep apnea. A study on quality of life after T&A also found more pronounced improvement in the short term (seven months) than in the long term (nine to 24 months). 52
TONSILLECTOMY AND PARTIAL TONSILLECTOMY
Tonsillectomy is one of the most frequently undertaken surgical procedures. The traditional technique of "cold" dissection tonsillectomy with scissors, dissector and snares was introduced approximately 100 years ago. 53 The principle of tonsillectomy has been the removal of the entire tonsillar tissue. Due to concerns of recovery courses associated with pain and difficulty in swallowing, many techniques have been developed to lessen the post-operative suffering. In recent years, partial tonsillectomy (intracapsular tonsillectomy) with the use of power instruments, radiofrequency energy (coblation) or laser has been advocated because the procedure has been shown to result in less post-operative pain, earlier return to normal diet and daily activity. 54-56 The fundamental difference of partial tonsillectomy and the traditional tonsillectomy is that the capsule of the tonsil is not disturbed during removal. This is accomplished by leaving a portion of the tonsillar tissue next to the capsule undisturbed. Therefore, the underlying muscle is not encountered, thus reducing pain and the associated morbidity. Although there are numerous studies demonstrating that partial tonsillectomy improves obstructive symptoms based on non-validated questionnaires, 54-57 this procedure does leave more tonsillar tissues behind. 58,59 Thus it is not known if greater numbers of children have residual obstructive sleep apnea after surgery or if the recurrence of obstructive sleep apnea due to tonsil regrowth60 would be greater over time. Sorin and colleagues reported 3.2% of the 278 children who underwent partial tonsillectomy experienced tonsillar regrowth and recurrence of snoring just during a two-year period. 60 Furthermore, there are currently no objective data demonstrating that the improvement of obstructive sleep apnea is comparable to traditional tonsillectomy.
PUTTING IT ALL TOGETHER
There is convincing evidence that T&A improves obstructive sleep apnea in children. There is also convincing evidence that the treatment of obstructive sleep apnea may not end with T&A. Recent T&A technique focuses on the post-operative recovery course rather than the efficacy of the procedure as compared to the traditional technique. Additionally, we already know that even with the traditional technique of total tonsillectomy, residual obstructive sleep apnea persists and recurrence of OSA occurs in many children. Clearly, T&A should be offered as the first line treatment. However, the identification of children with significant nasal obstruction or maxillomandibular deficiency, which could increase risk of persistent obstructive sleep apnea after T&A, should be routine practice. Multidisciplinary treatment including skeletal expansion by orthodontic expansion to widen the airway, further surgical management such as jaw advancement in children with significant facial skeletal deficiency, as well as nasal CPAP therapy must be considered in continual management of children with persistent difficulty. 49 Parental counseling regarding the risk of recurrence and continual follow-up is essential in the management of pediatric obstructive sleep apnea.
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