Early adenotonsillectomy eases sleep apnea

Compared with watchful waiting, surgical treatment of children with obstructive sleep apnea syndrome reduced symptoms and improved behavior, quality of life, and polysomnographic findings, according to a study of 464 children aged 5 to 9 years. Early adenotonsillectomy did not significantly improve attention or executive function compared with watchful waiting, however.

Children in the study, nearly half of whom were overweight or obese, were assigned to early adenotonsillectomy (surgery within 4 weeks of randomization) or to a watchful-waiting strategy. They underwent standardized polysomnographic testing, cognitive and behavioral testing, and other clinical and laboratory evaluations at baseline and again 7 months after randomization. For both examinations, caregivers completed survey instruments and teachers provided behavioral assessments.

Polysomnographic findings normalized in some patients in both groups during the study period but in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs 46%, respectively). Relative improvements with early adenotonsillectomy were significantly smaller among black children than among children of other races with regard to behavior, executive function, and sleep-related breathing disorder symptoms (Marcus CL, et al. N Engl J Med. 2013;368[25]:2366-2376).

Commentary: The authors chose as the primary outcome of their study changes in measured scores of attention and executive function. For this outcome, they were unable to show a difference between the treatment and control groups. To be fair, this is a tough measure, especially since at baseline study participants had scores for this measure that were normal-no worse than the general population. This may reflect the exclusion from this study of children with severe sleep apnea, marked obesity, and attention-deficit/hyperactivity disorder on medication. It was in the secondary outcome measures that the results favored early surgical intervention in this group of children with mild-to-moderate, but not severe, sleep apnea. Most impressive was that a far larger proportion of children who had tonsillectomy showed normalized sleep studies at follow-up (79%) than children undergoing watchful waiting (46%)-a percentage point difference of more than 30. This means that for every 3 children treated with early tonsillectomy, measured sleep abnormalities will resolve in 1 child. -Michael Burke, MD

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