PETER NIEMINEN, UOLEVI TOLONEN AND HEIKKI LÖPPÖNEN
Departments of Otolaryngology and Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
Arch. Otolaryngol. Head Neck Surg., 126: 481–486, 2000
Children who snore may present with symptoms that suggest obstructive sleep apnea syndrome (OSAS). Various and controversial methods to establish the diagnosis and choose the mode of treatment have been proposed. Overnight polysomnography (PSG) was used to evaluate the effectiveness of adenotonsillectomy as a treatment for pediatric OSAS and to clarify the natural history of OSAS and primary snoring. The controlled, prospective, nonrandomized clinical trial was conducted in an academic medical center and involved 58 snoring but otherwise healthy children aged 3 to 10 yr who had symptoms that suggested OSAS. The subjects each underwent PSG twice, 6 mos apart. Thirty healthy children served as controls. Twenty-seven of the children were found to have OSAS with an obstructive apnea/hypopnea index greater than 1, whereas 31 had primary snoring. Statistical differences existed in the signs and symptoms among the three study groups. Adenotonsillectomy cured OSAS in 21 children who underwent surgery. Obstructive apneas and hypopneas in the healthy, nonsnoring children were virtually nonexistent in this study. Half the children or fewer with symptoms that suggested OSAS actually had the condition, demonstrating that whereas clinical symptoms may raise suspicion, it is not possible to establish the diagnosis without PSG. Because snoring and obstructive symptoms may resolve over time, a normal PSG finding may be useful in helping the clinician decide on an observation period. Whereas adenotonsillectomy is curative in many cases of pediatric OSAS, obstructive symptoms may continue if only an adenoidectomy is performed.
First of all, it is important to note that this study was facilitated by taking place in a country with a national health system. It is unlikely this study design would be acceptable to most institutional review boards in the United States. In fact, there is no mention in the methodology of review board approval.
Essentially, children with symptoms of upper airway obstruction were tested with polysomnography. Unlike most sleep studies, testing did not include end tidal carbon dioxide monitoring. Results were graded based on duration of apnea episodes rather than hypoxia/hypercarbia.
Children with positive apnea scores underwent tonsillectomy and adenoidectomy and reportedly all were cured of apnea. Children with snoring but no apnea underwent a 6-mo period of watchful waiting. About half got better and some got worse, developing apnea symptoms.
This study supports what is commonly believed among practitioners: that snoring does not necessarily mean apnea. It also supports the common clinical observation that all children with obstructive apnea do not necessarily have identical clinical symptoms; some have daytime somnolence and some do not. Further, it substantiates the premise that children with snoring and/or apnea improve with tonsillectomy and adenoidectomy. And certainly, few will argue that children without definitive apnea can postpone surgical intervention—unless the parents are convinced that they have directly observed the apnea or equally alarming symptoms.
In the United States current medical economics often dictate following the most cost-effective treatment plan. Few health care plans will pay for sleep studies. Few families can afford the extra money, time, and stress of spending a night in the hospital having polysomnography when they have observed sleep and breathing disturbances in their children. Few otolaryngologists will demand sleep studies on clinically symptomatic patients with apparent tonsillar hypertrophy, particularly when worried parents want treatment and when (long-term) morbidity is low. It will require more than a loosely controlled observational study to change current practice.
Charlotte Bell M.D.