Obstructive Sleep Apnea Management in Children Despite Adenotonsillectomy: Guidelines From the American Thoracic Society

Obstructive sleep apnea (OSA), with repeated episodes of upper airway obstruction during sleep, affects up to 5% of children. Although adenotonsillectomy is the first-line management for OSA in children, up to 40% of children will have five or more apnea or hypopnea episodes per hour (ie, apnea–hypopnea index of 5 or more) while sleeping despite surgery. The risk of persistent OSA is greater in children with an apnea–hypopnea index of 10 or more at baseline (indicating severe OSA), obesity, craniofacial or genetic disorders, or chronic cardiopulmonary and neuromuscular disorders. The American Thoracic Society (ATS) published guidelines on the management of persistent OSA in children after adenotonsillectomy. All recommendations are suggestions that apply to some patients, but they are not strong recommendations because of very low-quality evidence.

Up to 22% of children with persistent OSA will have maxillary constriction because of posterior crossbite, in which the upper and lower back teeth do not mesh properly due to the narrow width of one arch compared with the other. For these patients, the guidelines suggest rapid maxillary expansion via orthodonture using a palatal expander in patients from the eruption of the first molars at 6 or 7 years of age to the onset of puberty.

Observational studies demonstrate that rapid maxillary expansion reduces average apnea–hypopnea index to less than 1 per hour in patients with persistent OSA after surgery and maxillary constriction. Most children also experience an improvement in snoring. Adverse effects include the inability to make clicking sounds with the tongue, inability to protrude the tongue toward the nose, and, less commonly, difficulty swallowing liquids.

Lingual Tonsillectomy

Hypertrophy of lingual tonsils resulting in tongue elevation that produces airway obstruction of 50% or greater is a common cause of persistent OSA. This cause of airway obstruction can be measured by drug-induced sleep endoscopy or imaging studies.

The guidelines suggest lingual tonsillectomy in children with lingual tonsillar hypertrophy based on very low-quality evidence of improving apnea–hypopnea index. Up to 19% of patients who undergo this procedure will develop airway edema, and up to 8% will experience adhesions between the epiglottis and tongue base.

Supraglottoplasty

Sleep-dependent laryngomalacia, commonly caused by the inspiratory collapse of redundant mucosa in the supra-arytenoid larynx, is an increasingly recognized cause of persistent OSA. Sleep-dependent laryngomalacia is best diagnosed via drug-induced sleep endoscopy.

The guidelines suggest supraglottoplasty based on very low-quality evidence of improving apnea–hypopnea index and snoring. Adverse effects include coughing, throat clearing, and dysphagia that can be transient or prolonged.