Clinical Practice Guideline: Polysomnography for Sleep‐Disordered Breathing Prior to Tonsillectomy in Children

Abstract

Objective. This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders.Purpose. There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.Results. The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.

Utility of Symptoms to Predict Treatment Outcomes in Obstructive Sleep Apnea Syndrome

“…Practice guidelines from the American Academy of Sleep Medicine and American Academy of Pediatrics recommend PSG to confirm and characterize OSAS before adenotonsillectomy, 1,2,11 whereas the American Academy of Otolaryngology-Head and Neck Surgery recommends PSG for children with certain complex medical conditions or when there is discordance between tonsil size and reported severity of OSAS symptoms. 12 Less work has been done to define what adjunctive measures, in addition to PSG, may assist pediatricians, otolaryngologists, and families who are considering adenotonsillectomy to understand what adverse impact OSAS is having for the child and what the probability is that this adverse impact will be ameliorated by surgery. For example, few studies have examined whether baseline OSAS symptoms can predict postoperative changes in parentperceived behavior, sleepiness, and quality of life, outcomes that assume key importance to families, regardless of PSG results.…”

Adenotonsillotomy Versus Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: An RCT

“…The study patients underwent an overnight, in-laboratory attended PSG at baseline (PSG1), with follow-up 1 year after surgical intervention (PSG2 There is no international consensus regarding which AHI cutoff values to use when grading pediatric OSA, but according to clinical practice and several other authors, 14,15 an AHI ≤1 is considered normal, AHI >1 to <5 corresponds to mild OSA, AHI 5 to <10 moderate OSA, and AHI ≥10 severe OSA. In the current study, the upper limit of AHI 30 was chosen to avoid extreme values because AHI >30 is rare in children.…”

Clinical Practice Guideline Development Manual, Third Edition

“…Conference call 3 Review guideline appraisal report; remedy deficiencies [10][11] Prerelease peer review External review of draft guideline by representatives of target audience and practice settings 12 Public comment Guideline draft released for a period of public comment and review [13][14] Organizational board review and journal peer review Review and approval guideline by the board of directors of the sponsoring organization(s), with simultaneous submission to the journal for editorial peer review…”

“…Many online services are now freely available for online collaboration and storage. Materials specific to the guideline that should be distributed include Agenda for the conference call Working group contact information grid with conflict of interest disclosures Summary grid of relevant systematic reviews and guidelines identified in the stage 1 literature search Relevant sections of the guideline development manual General materials that should be distributed include A copy of 1 or more recently published guidelines from the sponsoring organization [4][5][6][7][8][9][10][11] to serve as a model of how the finished product will look (all previously published AAO-HNSF guidelines are available at www.entnet.org/guidelines) Reporting checklist from the COGS 20 Articles by Norris and colleagues 30 and by Choudhry and coworkers 42 about conflict of interest disclosure and its relevance to guideline developers…”