Adenotonsillectomy or Watchful Waiting for Pediatric Sleep-Disordered Breathing
Myron Yaster MD, Lynne G. Maxwell MD, and Melissa Brooks Peterson MD
I used to joke that there were 3 common reasons for tonsillectomy: recurrent infection, obstructive sleep apnea (OSA) (“sleep disordered breathing”), and/or a “positive wallet biopsy sign”, that is, presence of health insurance. Today’s PAAD1 and accompanying editorial2 provides evidence-based data on the benefits and limitations of surgical intervention in children with snoring or mild obstructive sleep apnea (OSA).
On a visiting professorship to Japan more than a decade ago, I was shocked that they did almost no tonsillectomies. I wondered: “How could this be? Why do they do so few and we do so many?” Indeed, annually more than 500,000 children in the United States undergo tonsillectomy. How many of these are really necessary? How many children who snore are described by their surgeons as having OSA without a formal sleep study simply for insurance billing approval? Is this a legitimate reason or deception? And are we complicit with this deception when we provide anesthesia for the procedure without a formal sleep study? Further, can you imagine what would happen to your practice and income if this surgical procedure was significantly reduced or even eliminated? But first a word from Dr. Glaucomflecken. Myron Yaster MD
Original article
Redline S, Cook K, Chervin RD, Ishman S, Baldassari CM, Mitchell RB, Tapia IE, Amin R, Hassan F, Ibrahim S, Ross K, Elden LM, Kirkham EM, Zopf D, Shah J, Otteson T, Naqvi K, Owens J, Young L, Furth S, Connolly H, Clark CAC, Bakker JP, Garetz S, Radcliffe J, Taylor HG, Rosen CL, Wang R; Pediatric Adenotonsillectomy Trial for Snoring (PATS) Study Team. Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial. JAMA. 2023 Dec 5;330(21):2084-2095. doi: 10.1001/jama.2023.22114. PMID: 38051326; PMCID: PMC10698619.
Editorial
Hazkani I, Billings KR, Thompson DM. Adenotonsillectomy or Watchful Waiting for Pediatric Sleep-Disordered Breathing. JAMA. 2023 Dec 5;330(21):2057-2058. doi: 10.1001/jama.2023.22373. PMID: 38051336.
Commentary
Friedman NR. Adenotonsillectomy for Treatment of Mild Sleep-Disordered Breathing in Children. JAMA Otolaryngol Head Neck Surg. 2023 Dec 5. doi: 10.1001/jamaoto.2023.3808. Epub ahead of print. PMID: 38051526.
“Sleep-disordered breathing (SDB) includes a spectrum of disorders ranging from habitual snoring to frequent episodes of obstructive breathing during sleep. The disorder affects 6% to 17% of children, with a higher prevalence among children from racially minoritized or low-income backgrounds.3 Consequences of untreated SDB potentially include behavior problems; daytime sleepiness; impairment of growth, neurodevelopment, and quality of life; and increased prevalence of cardiovascular and metabolic diseases4.”1
“Adenotonsillar hypertrophy is the most recognized risk factor for pediatric SDB. Consequently, adenotonsillectomy is the first-line treatment for SDB in otherwise healthy children. There are limited data addressing the benefits of surgery. The current study… was designed to assess the effectiveness of early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) in children aged 3 to 12.9 years with mild SDB.”1
In this multicenter, single-blind, randomized trial, eligible children were aged 3 to 12.9 years, had tonsillar hypertrophy and mild SDB (defined by habitual snoring [occurring most of the night on at least 3 nights per week, for at least 3 months], an obstructive apnea index [number of complete obstructive breathing pauses per hour of sleep] <1, and an obstructive AHI [number of complete and partial obstructive episodes per hour of sleep] <3) [as determined by polysomnography], and were considered appropriate candidates for adenotonsillectomy by an otolaryngologist. Exclusion criteria included recurrent tonsillitis, a z score based on the body mass index (BMI, calculated as weight in kilograms divided by the square of the height in meters) of 3 or more, and severe comorbidities.1
“458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, −9.02 [97% CI, −15.49 to −2.54] and −6.52 [97% CI, −11.59 to −1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, −11.2% [97% CI, −17.5% to −4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy.”1
OK, what does this mean? Although tonsillectomy did not improve the study’s primary outcome of executive function or attention at 12 months compared to watchful waiting, other outcomes like quality of life and worsening of OSA (increasing AHI as measured by polysomnography) did. There were 6 cases of serious postoperative complications: 5 bleeding in the tonsillectomy group, 1 aspiration pneumonia. “Minor” complications” in the surgery group: 11 patients with significant postoperative pain, and 3 patients with dehydration. One patient in the watchful waiting group crossed over to surgery.
Based on these findings, if it was your own child or grandchild would you opt for surgery or watchful waiting? Are we doing too many tonsillectomies? Send your thoughts and comments to Myron who will post in a Friday Reader response.
References
1. Redline S, Cook K, Chervin RD, Ishman S, Baldassari CM, Mitchell RB, Tapia IE, Amin R, Hassan F, Ibrahim S, Ross K, Elden LM, Kirkham EM, Zopf D, Shah J, Otteson T, Naqvi K, Owens J, Young L, Furth S, Connolly H, Clark CAC, Bakker JP, Garetz S, Radcliffe J, Taylor HG, Rosen CL, Wang R: Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial. Jama 2023; 330: 2084-2095
2. Hazkani I, Billings KR, Thompson DM: Adenotonsillectomy or Watchful Waiting for Pediatric Sleep-Disordered Breathing. Jama 2023; 330: 2057-2058
3. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130: 576-84
4. Thomas S, Patel S, Gummalla P, Tablizo MA, Kier C: You Cannot Hit Snooze on OSA: Sequelae of Pediatric Obstructive Sleep Apnea. Children (Basel) 2022; 9: 261