Intranasal Steroids and Oral Leukotriene Modifier Therapy in Residual Sleep-Disordered Breathing After Tonsillectomy and Adenoidectomy in Children

Abstract

Financial Disclosure: Drs Kheirandish and Gozal are the recipients of an investigator-initiated grant from Astra Zeneca Ltd for an unrelated research project on the effect of intranasal budesonide in mild sleepdisordered breathing in children. Dr Gozal serves on the national speaker bureau of Merck. ABSTRACTOBJECTIVE. Tonsillectomy and adenoidectomy (T&A) is the primary therapeutic approach for sleep-disordered breathing (SDB) in children. However, residual mild SDB will be found in more than one third of these patients after T&A. We hypothesized that combined therapy with the leukotriene receptor antagonist montelukast and intranasal budesonide would result in normalization of residual SDB after T&A.METHODS. During the period of October 2002 to February 2005, children who underwent T&A for SDB underwent a routine postoperative (second) overnight polysomnographic evaluation (PSG) 10 to 14 weeks after T&A surgery. In children with residual apnea hypopnea index (AHI) Ͼ1 and Ͻ5/hour of total sleep time (TST), treatment with montelukast and intranasal budesonide aqueous solution was administered for a period of 12 weeks (M/B group), at which time a third PSG was performed. Children who had residual SDB and did not receive M/B therapy from their treating physicians were recruited as control subjects.RESULTS. Twenty-two children received M/B, and 14 children served as control subjects. Mean age, gender distribution, ethnicity, and BMI were similar in the 2 treatment groups. The mean AHI at the second PSG was 3.9 Ϯ 1.2/hour of TST and 3.6 Ϯ 1.4/hour of TST in M/B-treated and control patients, respectively. Similar nadir arterial oxygen saturation (87.3 Ϯ 1.2%) and respiratory arousal index (4.6 Ϯ 0.7/hour of TST) were recorded for both groups. However, the M/B group demonstrated significant improvements in AHI (0.3 Ϯ 0.3/hour of TST), in nadir arterial oxygen saturation (92.5 Ϯ 3.0%), and in respiratory arousal index (0.8 Ϯ 0.7/hour of TST) on the third PSG, whereas no significant changes occurred over time in control subjects.CONCLUSIONS. Combined anti-inflammatory therapy that consists of oral montelukast and intranasal budesonide effectively improves and/or normalizes respiratory and sleep disturbances in children with residual SDB after T&A. O BSTRUCTIVE SLEEP APNEA and sleep-disordered breathing (SDB) is a common and highly prevalent disorder in the pediatric age range that affects 2% to 3% of all children. 1 When left untreated, SDB is associated with substantial morbidity, primarily affecting neurobehavioral and cardiovascular systems. 2-9 Thus, because in otherwise normal children SDB is attributed primarily to adenotonsillar hypertrophy, 10,11 tonsillectomy and adenoidectomy (T&A) is currently the most common treatment for children with SDB. 12 However, although a recent meta-analysis of the published literature suggested a relatively high success rate for T&A, averaging ϳ85%, 13 the overall short-term cure rates for this surgical procedure in otherwise healthy children may not be as favorable as previously an...

Evaluation of the effects of montelukast, mometasone furoate, and combined therapyon adenoid size: a randomized, prospective, clinical trial with objective data

“…They observed that the combined therapy was effective and reported that surgery might be replaced by antiinflammatory therapy in patients with mild obstructive sleep apnea (OSAS) or postoperative residual OSA (29). In a study by Khirandish with 22 patients, a combination of budesonide and montelukast was administered for 12 weeks for OSAS due to residual adenoid tissue following adenotonsillectomy and a significant improvement in the apnea hypopnea index was found (30). According to our results, the combination therapy is effective at reducing adenoid size, but superiority over montelukast or steroid alone could not be established.…”

Medical treatment (excluding CPAP and orthodontics) of Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS)

“…Finally, an association of the above (antileukotrienes and intranasal corticosteroids) was tested in children with mild residual OSAHS (AHI 1-5/h) following adenotonsillectomy 6 . All 4 study indices (apnea, apnea/ hypopnea, micro-arousal and lowest percutaneous arterial oxygen saturation during sleep) were significantly improved in the treatment group (n = 22) compared to the group without treatment (n = 14).…”

Respiratory medications and sleep

“…It has been reported that there is increased expression of leukotriene receptors in adenotonsillar tissue of children with OSA [67]. In clinical trials, montelukast was effective in improving sleep-disordered breathing as both a first-line therapy for mild OSA and as a second-line treatment (in combination with nasal steroids) for residual OSA after adenotonsillectomy [68,69].…”