To what extent does tonsil size predict improvement in obstructive sleep apnea (OSA) severity after adenotonsillectomy in children?
Background: Polysomnogram (PSG) is the current standard for measuring the severity of OSA; however, in practice, diagnosis of the severity of OSA is typically based on the caregiver’s account of habitual snoring with pauses, as well as the physician’s anatomic assessment, including a subjective evaluation of tonsil size.
Study design: Case series with chart review.
Setting: Pediatric Otolaryngology Department, Johns Hopkins Hospital, Baltimore.
Synopsis: Consecutive children from 1 to 18 years of age who underwent adenotonsillectomy performed by a single surgeon who received pre- and post-surgical PSG and were included in the study. Children were stratified by tonsil size as 2+ (n=20), 3+ (n=36) and 4+ (n=14). There was no significant difference among the three groups with regard to age, sex, race, pre-operative obstructive apnea-hypopnea index (oAHI), or body mass index. Obstructive apnea index, oAHI, and oxygen saturation nadir improved significantly regardless of tonsil size. Tonsil size did not correlate with baseline OSA severity, even when adenoid hypertrophy was accounted for in the analysis.
The limitation of this study is that it is retrospective, so there may have been selection bias. Furthermore, volumetric analysis of tonsil size was not performed. Finally, a proper analysis of the contribution of adenoid size to oAHI in the 2+ tonsils group was not possible due to low numbers.
Bottom line: An evaluation of a child with sleep-disordered breathing requires a careful assessment of symptoms as well as tonsil size, and decisions to proceed to an adenotonsillectomy should take into account both the clinical history and physical exam.
Citation: Tang A, Benke JR, Cohen AP, Ishman SL. Influence of tonsillar size on OSA improvement in children undergoing adenotonsillectomy. Otolaryngol Head Neck Surg. 2015;153:281-285.