Editorial

Identification and evaluation of obstructive sleep apnea prior to adenotonsillectomy in children: is there a problem?

The reference standard for the diagnosis of pediatric sleep-disorder breathing (SDB) is a full polysomnography (PSG) (an overnight sleep study). There are many obstacles to children being able to undergo a full PSG; therefore, the authors evaluated the diagnostic value of alternative diagnostic methods (clinical history and physical examination) for pediatric SDB.

The authors selected articles in which the investigators' primary objective was to evaluate the diagnostic capability of physical evaluations and questionnaires compared with the current reference standard (that is, a full PSG) to diagnose SDB in children younger than 18 years. The authors searched several electronic databases without limitations.

Using a two-step selection process, the authors identified 24 articles and used them to conduct a qualitative analysis. They conducted a meta-analysis on 11 of these articles. Among these articles, only one involved a test that had diagnostic accuracy good enough to warrant its use as a screening method for pediatric SDB, but its diagnostic accuracy was not sufficient to be considered a true diagnostic tool (that is, a replacement for full PSG) for pediatric SDB.

The involvement of dentists in the screening process for pediatric SDB can contribute significantly to children's health. The identified questionnaire could be considered an acceptable screening test to determine which children to refer to a sleep medicine specialist.

The objective of this study was to characterize phenotypes of sleep disordered breathing (SDB) in early childhood that clinicians may find useful while monitoring symptom progression and associated SDB morbidity.

We performed a cluster analysis of SDB's primary symptoms: snoring, mouth-breathing, and apnea. Parents in the Avon Longitudinal Study of Parents and Children (ALSPAC) reported SDB symptoms by questionnaire for their child at 6, 18, 30, 42, 57, 69, and 81 months of age. Participants were those from the original cohort exclusive of children with congental or other medical conditions predisposing growth aberrations or respiratory problems (i.e. cleft palate, heart surgery and associated conditions, genetic syndromes—primarily Down's, cancer or kidney conditions, celiac disease, congenital adrenal hyperplasia), missing SDB measures for ≥2 timepoints, or missing birth length plus 2 subsequent height measures.

Five clusters emerged from 10,441 children and were characterized according to patterns of mean severity of SDB symptoms over time. “Normals” (50%) were asymptomatic throughout. The “late snores and mouth-breathing” cluster (20%) remained asymptomatic until 4 years old. The “early snores” (10%) and “early apnea” (10%) clusters had peak symptoms at 6 and 18 months, respectively. In “all SDB after infancy” (10%), symptoms peaked from 30 to 42 months and remained elevated. Exploratory analyses found that “early snores” were significantly shorter than “normals.” Associations with tonsillectomies and wheezing frequency supported external validation.

Cluster analysis has elucidated the dynamic multi-symptom expression of SDB. The utility of cluster analysis will be evaluated in future analyses to predict growth, cognition and behavior outcomes.

The purpose of this paper is to review pediatric obstructive sleep apnea syndrome (OSAS) with an emphasis on ambulatory adenotonsillectomy. Difficulties in establishing a diagnosis by clinical criteria alone are discussed. Diagnostic tests to establish a diagnosis of OSAS are discussed. The child with severe obstructive sleep apnea is at increased risk for post-adenotonsillectomy respiratory morbidity. The perioperative management with a focus on the ambulatory candidate is discussed.

The child with OSAS presents a challenge to ambulatory surgery because of the high prevalence of OSAS, difficulty in establishing a diagnosis of OSAS and the increased risk of respiratory morbidity.

While otolaryngologists consider growth failure an absolute indication for tonsillectomy and adenoidectomy (T&A), they may not be accustomed to screening for poor growth, and thus unlikely to consider it when recommending a T&A. This paper will (a) familiarize otolaryngologists with the definition, prevalence, and etiology of growth failure and (b) review the published findings that examine the inter-relationship among sleep disordered breathing, growth failure, and adentonsillar hypertrophy in children.

This paper is divided into three sections. The first section presents a brief overview of growth failure for the otolayngologist. The second section reviews the evidence base linking sleep disordered breathing, growth failure, and adenotonsillar hypertrophy in children. The anthropometric outcomes of children presenting for T&A, or having sleep symptoms assessed, are presented. The third section presents pilot data (n = 28) on the prevalence of growth failure and sleep disordered breathing among children presenting for T&A at our institution.

Among children presenting for T&A or having sleep symptoms assessed, growth failure was at least twice the expected rate in six of eight published studies. Across these six studies, this rate ranged from a low of 6% of children <3rd percentile for weight and 6% <3rd percentile for height in one study, to a high of 52% who were <3rd percentile in weight in a second study, and 44% who were ⩽5th percentile for height in a third. Among children presenting for T&A at our own institution, 14% were ⩽5th percentile in height, and 11% were ⩽5th percentile in weight. Among children under 6 years of age, 21% were either ⩽5th percentile in weight and/or height.

Published studies, as well as our own pilot data support the hypothesis that SDB, secondary to adenotonsillar hypertrophy increases the risk of growth failure in children. Adenotonsillar hypertrophy and sleep disordered breathing may be unrecognized risk factors in the etiology of growth failure. Otolaryngologists can play an important role in identifying growth failure, and referring children to the appropriate specialists.