Adenotonsillotomy Versus Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: An RCT

Abstract

BACKGROUND: Adenotonsillectomy (ATE) is a well-established and effective treatment of pediatric obstructive sleep apnea (OSA). In recent years, a more conservative method, adenotonsillotomy (ATT), has gained popularity because it is associated with less postoperative morbidity. Yet no previous randomized study has compared these 2 methods regarding their effectiveness in treating pediatric OSA in terms of polysomnographic data, which was the primary aim of this study. The hypothesis was that ATT is noninferior to ATE after 1 year. METHODS: Seventy-nine children, aged 2 to 6 years, with OSA (Apnea-Hypopnea Index [AHI] 5–30) were randomized to ATT (n = 40) or ATE (n = 39). Polysomnography (PSG) and questionnaire OSA-18 were assessed at baseline and 1 year postsurgery. RESULTS: Mean difference between groups in the primary outcome, change in AHI, was 0.83, 95% confidence interval –3.2 to 4.9, not exceeding the noninferiority margin of 5. After ATE, AHI decreased from median 12.7 (interquartile range 8.3–19.1) to 2.0 (1.2–3.1) and after ATT from 15.8 (8.5–21.2) to 4.0 (1.2–5.1). For both groups, significant improvements of PSG and OSA-18 questionnaire outcomes were observed, with no significant differences between groups. Five children (13%) in the ATT group needed repeated surgery for tonsil regrowth and recurrence of OSA. CONCLUSIONS: The results suggest that ATT is noninferior to ATE in treating pediatric OSA regarding PSG outcomes after 1 year. ATT could be considered an alternative to ATE for treatment of pediatric OSA. However, after ATT, there is a nonnegligible risk of recurrence of OSA, and this should be taken into account when selecting surgical method.

Management of paediatric obstructive sleep apnoea: A systematic review and network meta‐analysis

“…Brouillette 2001 reported oxyhaemoglobin desaturation (≥4%) index (ODI4). Others did not specify the criteria used to determine the index.…”

“…Networks of interventions for AHI, ODI, and lowest SaO 2 are presented in Figures A, respectively. Ten interventions were identified according to their different treatment philosophies, including adenotonsillectomy (number of participants, n = 412), adenotonsillectomy with pharyngoplasty (n = 30), adenotonsillotomy (n = 39), antimicrobial therapy (n = 11), intranasal corticosteroids (steroids; n = 80), leukotriene receptor antagonists (LTRAs; n = 83), steroids + LTRAs (n = 20), rapid maxillary expansion (RME; n = 15), placebo (n = 171), and no treatment (n = 246) . The participants primarily received adenotonsillectomy or no treatment.…”

“…Only 6/8 trials however have reported abnormal baseline ODI, 7/12 trials have reported abnormal baseline lowest SaO 2 , and none have reported the number of clusters of desaturation events or number of SaO 2 < 90%. Among the included trials, some reported ODI as oxyhaemoglobin desaturation (≥3%) index (ODI3), some reported ODI4, and others did not specify the criteria used to determine the index . Since pulse oximetry recording is performed simultaneously during nocturnal PSG, future trials are encouraged to specify the precise scoring rules and to report not only the lowest SaO 2 but also the numbers of desaturation and SaO 2 < 90% events to help improvement of diagnostic system with oximetry.…”

“…Pharyngoplasty in conjunction with adenotonsillectomy has been reported to achieve better cure rates, yet these surgical approaches are limited by their potential risks of complications. In recent years, adenotonsillotomy (with subtotal removal of the tonsils) has gained popularity because it is associated with less postoperative haemorrhage and pain . When adenotonsillectomy is not performed or has proved unsuccessful at curing the OSA, positive airway pressure (PAP) is often believed to be the next of therapy .…”

Pediatric pulmonology year in review 2017: Part 4 (Sleep medicine)

“…Therefore, adenotonsillotomy (ATT) has recently become popular due to research supporting less postoperative complications such as bleeding and pain. Borgström et al randomized 79 children with OSAS aged 2‐6 year to AT versus ATT with the primary outcome of establishing the difference in AHI changes between the two interventions. Participants underwent PSG and responded the OSA‐18 questionnaire at baseline and 1 year post surgery.…”