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Sleep Apnea in Children: What Parents Need to Know About Surgery

Two studies shed light on the benefits and risks of tonsillectomy, adenoidectomy, a modified tonsillectomy, and combined surgeries in children diagnosed with sleep apnea.

With Danielle Friberg, MD, PhD, and Nina Shapiro, MD

The usual surgical procedures aimed at opening the airway to improve sleep in children diagnosed with sleep apnea are typically effective, but refinements to these procedures do not always add benefit, and long-term risks can occur. 

To add support to this understanding, a modified surgery to remove the tonsils and adenoids offers no additional benefit over the standard surgical procedures in children with the sleep disorder known as obstructive sleep apnea (OSA),1 according to a study published in JAMA Otolaryngology.

Researchers compared adenotonsillectomy (removal of tonsils and adenoids) with a procedure called the adenopharyngoplasty, which also surgically pulls back added tissue behind the tonsils (the tonsillar pillars), during removal of the tonsils and adenoids.1

"The suturing of the palatal pillars during tonsillectomy is not better than a tonsillectomy alone in treating pediatric OSA," says study leader Danielle Friberg, MD, PhD, associate professor at Karolinska Institute, Stockholm, and a lecturer at Uppsala University in Sweden. “The idea was to open up the small airway even more by pulling back these pillars, but it did not make a difference in improving the apnea.”

Tonsillectomy may improve sleep initially but increase other health problems long-term.

Do the Benefits of Tonsillectomy Outweigh the Risks?

Removing a child’s tonsils has become a routine procedure. About 400,000 tonsillectomies are done each year in the US, usually on children.2 One major reason for tonsil removal is sleep apnea; another common reason is frequent infections (ie, of the ears, strep throat).3

Typically, when treating for sleep apnea, both the tonsils and the adenoids are removed to open up the airway and ease breathing. The tonsils are soft masses of tissue at the rear of the throat, the adenoids are masses of soft tissue behind the nasal cavity. Both are part of the immune system so some surgeons opt to leave the adenoids in place.

To improve the effectiveness of these procedures in reducing sleep apnea, surgeons tested alternative methods, such as the adenopharyngoplasty to see if this approach is better, according to Dr. Friberg's team. They examined 83 children, ages 2 to 4 years, all with OSA—36 of whom had the modified surgery and 47 who underwent the traditional surgery.1

The researchers used a score to evaluate the severity of the OSA, known as the obstructive apnea-hypopnea index (OAHI). At the start, the average score in both groups was 23.8.1 That means they had on average of 23 episodes in which breathing stopped for each hour of sleep. More than 5 breathing stops an hour is considered above normal, and more than 30 is considered severe obstructive sleep apnea. By the end of the study,  both groups had a similar decline in the OAHI of 21 events.Therefore, there was no appreciable difference with more surgery.

For parents, the message is that the modified surgery that includes stitching down the tonsil pillars ''is not a recommended treatment in otherwise healthy children with OSA," Dr. Friberg tells EndocrineWeb.

Sometimes obstructive sleep apnea can result from anatomical issues, such as a narrow airway, or enlarged tonsils due to infection. Sleep apnea is even more likely to occur in children (and adults) with obesity.3 However, in the Swedish study, only seven children were overweight, Dr. Friberg says.

The researchers will continue to follow these children for another three years, but Dr. Friberg suspects the results will hold.

A Second Look at Surgery for Sleep Apnea in Children

In a second, related study,4 Australian researchers followed nearly 1.2 million children from a national registry in Denmark, born from 1979 through 1999, to evaluate the long-term effectiveness of tonsillectomy, adenoidectomy or both compared to none of these surgeries.

Among these children, more than 60,000 had had one of the three types of surgery during the first nine years of their lives.4 The researchers then calculated the long-term risks for 28 different diseases experienced by the participants for up age 40 years.

They found that children who had had either a tonsillectomy, an adenoidectomy, or both surgeries, were two to three times more likely to have upper respiratory tract diseases in later years.4 The children experienced a two to three-fold increase in upper respiratory tract infections but fewer infections, in general, and a reduction in allergic diseases.

However, the frequency of upper respiratory infectious disease was put in perspective when compared to the general population, dropping it to just a slight 2% increase, suggesting less of a concern,4 according to the authors. 

In contrast, the surgeries that were intended to treat conditions in young children had very mixed outcomes later in life, with surgery reducing the long-term risk for seven of 21 conditions, but not changing the risk for nine others and actually increasing the risk for five measured health concerns.4

For instance, while adenoid removal was linked with a reduced risk of sleep disorders, no change in risk occurred for abnormal breathing but the risk for middle ear infection and sinusitis increased.4

Advice for Parents: Tonsillectomy Reasonable Option for Some

The finding reported by the Swedish team that the adding the suturing to the removal of tonsils and adenoids does not give added benefit is not surprising,1 says Nino Shapiro, MD, professor of head and neck surgery at the UCLA David Geffen School of Medicine. "The majority of the obstruction is due to the massive tonsils and adenoids blocking the airway," she says, ''and not from lax (soft) tissue."

Concern about soft tissue is often a more relevant consideration in adults, says Dr. Shapiro, who is a co-author of Hype: A Doctor's Guide to Medical Myths, Exaggerated Claims and Bad Advice (2018, St. Martin's Press).

When suturing is done, she says, the sutures often come out accidentally after the surgery; and while others think suturing the pillars might reduce bleeding that has not been proven.

As for the long-term risk study? Dr. Shapiro tells EndocrineWeb that parents should not be overly concerned. It is hard to truly evaluate the risks of these procedures.

"A lot of these kids will have the propensity to other sorts of health issues anyway," she says. While the surgery does generally help with the sleep apnea, which was the point of recommending the procedure in the first place, other more solutions with fewer long-term risks ought to be considered.

Experts suggest the use of a CPAP machine, for continuous positive airway pressure therapy, which delivers air directly through a facemask during sleep to lessen episodes of apnea,particularly in children with obesity.

Disrupted sleep should be addressed. When children don't have enough hours of sound sleep, it puts their growth and development at risk, she says. And often these children have obesity.6

A test known as oximetry, which measures the oxygen saturation of the blood, can help a doctor decide if surgery should be considered to help improve breathing issues, according to findings from yet another study.5 The pulse oximetry test can be done as an initial at-home sleep study and is not invasive. 

Researchers from the United Kingdom and Greece evaluated results of the oximetry tests among 141 children who were diagnosed with symptoms of regular snoring and enlarged tonsils; these children were referred for surgery.7 If the patients' oximetry test results indicated an oxygen desaturation hemoglobin index of 3.5 or more episodes an hour, and they had the surgery, their nighttime low oxygen episodes improved compared with similar children who did not have the surgery.

The severity of the sleep apnea as informed by a sleep study (oximetry test) might be the best way to help inform your decision on moving forward with surgery to treat sleep apnea in your child.

Neither Dr. Friberg nor Dr. Shapiro has any relevant disclosures.

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