Snoring may indicate sleep apnea, but is also common in childhood.
2-3% of children have obstructive sleep apnea, however about 9-10% have benign primary snoring, which means that though there is snoring, the snoring itself is not causing arousal nor sleep fragmentation.
Is a sleep study needed for tonsil surgery?
A sleep study is not indicated every time ENT surgery or TnA is needed. If there is a medical reason to perform the surgery, such as frequent strep throat infections, this does not need a sleep study. However, many times the surgical procedure is done for “sleep apnea” – but there has never been a sleep study to document that there actually is sleep disorder.
What if the child still does not sleep after tonsil surgery?
Sometimes because the child cannot sleep, it is decided to take the tonsils and adenoids out. After the surgery, the child no longer snores, but still the child does not sleep through the night. If a sleep study was not done prior to confirm the presence of sleep apnea, the snoring may have just been from primary snoring.
Sometimes there may be other problems occurring with sleep, and it may be misattributed to snoring. I always find it a paradigm how a parent may complain there child does not sleep, however when the child sleeps in the parent room the child sleeps through the night. I frequently make a similar observation in the sleep lab. A parent complains the child does not sleep through the night, the pediatrician sees the tonsils are big. Some pediatricians obtain a sleep study, and the child sleeps through the night on the sleep study. The difference is in the sleep lab the parent needs to sleep in the same room, and the parent has the soothing association with the parent.
These examples are not primary sleep disorders, but rather they are problems with the association of sleep onset that is affecting the parents sleep more then the child’s.
Would you have appendicitis surgery if you don’t have appendicitis?
You don’t just take out somebody’s appendix because they might get appendicitis. Same should go for tonsil surgery. If there is not other medical reason, Then evaluation for obstructive sleep apnea by polysomnography sleep study is advised.
Then when is a sleep study and/or tonsillectomy indicated?!?
First, let me note that these are not my personal recommendations, but rather directly the standard of care. I have also listed my references below.
- 1.All children should be screened for snoring.
- 2.High risk patients should be sent directly to a sleep specialist. These may include patients with obesity, craniofacial syndromes, Down syndrome, patients with changes in muscle tone (cerebral palsy, hypotonia).
- 3.Sleep study is advised for differentiating between Primary Snoring and Obstructive Sleep Apnea.
- 4.Tonsillectomy is first-line treatment in pediatric OSA, however at times other treatments are indicated.
- 5.High risk patients should be observed overnight in hospital after tonsillectomy, and may require a follow up sleep study 6 weeks after the procedure.
References:
Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome.
- 1)All children should be screened for snoring;
- 2)Complex high-risk patients should be referred to a specialist;
- 3)Patients with cardiorespiratory failure cannot await elective evaluation;
- 4)Diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography;
- 5)Adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery;
- 6)High-risk patients should be monitored as inpatients postoperatively;
- 7)Patients should be reevaluated postoperatively to determine whether additional treatment is required.
Reference: Pediatrics 2002; 109:4 704-712
Classification of OSA (Obstructive Sleep Apnea) Severity
· Mild OSA is classified by AHI 1-4, SpO2 nadir 86-91 percent, ETCO2 peak >50 mmHg, or ETCO2 >50 for 10 to 24 percent total sleep time.
· Moderate OSA is classified by AHI 5-10, SpO2 nadir 76-85 percent, ETCO2 peak >60 mmHg, or ETCO2 >50 for 25 to 49 percent total sleep time.
· Severe OSA is classified by AHI >10, SpO2 nadir <75 percent, ETCO2 peak >65 mmHg, or ETCO2 >50 for >50 percent total sleep time.
Reference: (Paruthi. UpToDate online) (Colon. Pediatric Polysomnography – Encyclopedia of Sleep Medicine, Elsevier, 1st Edition)
American Academy of Pediatrics Clinical Practice Guidelines for Treatment of Pediatric OSA:
· In Moderate to Severe disease (AHI>10) – Definitely treat.
· In Mild to Moderate OSA (AHI 5-10) – Treatment is recommended.
· In Borderline to Mild OSA (AHI 1-5) – Individualized treatment is advised.
In primary snoring with Neurobehavioral symptoms – Treatment should be considered.
TnA (tonsillectomy and adenoidectomy) is first line treatment for most children with OSA (Obstructive Sleep Apnea). CPAP (Continuous Positive Airway Pressure) is an option for those who are not TnA candidates or do not respond to surgery. Other treatments may include weight loss, positional sleeping, or Medical Management. Re-evaluation of patients postoperatively to determine if additional treatment is required is advised.
Reference: Pediatrics 2002; 109:4 704-712
In treatment of OSA (Obstructive Sleep Apnea) with TnA (tonsillectomy and adenoidectomy), High risk patients should be monitored as inpatients postoperatively. These may include:
· Patients less then 2 years of age
· Associated medical conditions: Obesity, Congenital syndromes
· When complications of OSA are already present: Cor pulmonale, FTT (Failure To Thrive)
· Severe OSA documented by Polysomnogram. Note: In RDI >19 Follow up Polysomnogram is indicated, And RDI >40 has high correlation with residual OSA after TnA.
References: (Pediatrics 2002; 109:4 704-712) (Berry. Sleep Medicine Pearls, 2nd Edition) (Colon. Pediatric Polysomnography – Encyclopedia of Sleep Medicine, 1st Edition)
Pediatric Recommendations for Repeat Polysomnogram (PSG) after TnA (Tonsillectomy and Adenoidectomy): Repeat polysomnography is indicated in children 6-8 weeks postoperative TnA in patients with additional risk factors such as Obesity, Craniofacial abnormalities (Pierre Robin syndrome, Down Syndrome), Cor pulmonale, or RDI greater then 19/hr. Reference: (Berry. Sleep Medicine Pearls, 2nd Edition) (Colon. Pediatric Polysomnography – Encyclopedia of Sleep Medicine, 1st Edition)
