Of the five recommendations in the guidelines, the first two emphasize what the AAO-HNS consider the best indications for referring a child for a sleep study prior to surgery. These include children with sleep-disordered breathing who also have select comorbidities that place them at higher risk of perioperative complications.
Explore This IssueAugust 2011
These recommendations highlight a subpopulation of children in whom the committee felt that sleep studies are currently underutilized, according to another coauthor of the guidelines, Norman Friedman, MD, director of the Children’s Sleep Medicine Laboratory at the University of Colorado in Aurora, Colo.
Although supportive of these recommendations and the attempt by otolaryngologists to properly utilize sleep studies, Dr. Gozal emphasized that, under these guidelines, too many children will still receive suboptimal diagnosis and undergo unnecessary surgery. He said another challenge is determining the success of a surgery if the reason for the surgery is not sufficiently defined or known. Published evidence suggests that the overall cure rate of adenotonsillectomy for sleep apnea in children is much lower than previously anticipated (Otolaryngol Head Neck Surg 2008;138:265-273), he said.
But according to Pell Ann Wardrop, MD, medical director of the St. Joseph Sleep Wellness Center in Lexington, Ky., and an ENT Today editorial board member, the definition of sleep-disordered breathing in children is evolving. "It is not clear, based upon current research, that polysomnography identifies all children who have sleep-disordered breathing and will benefit from surgery," she said. "Children with snoring, and a negative standard PSG have an increased incidence of neurocognitive dysfunction and some derive benefit from adenotonsillectomy. The inclusion of nasal pressure monitoring in children, which became standard in 2007, has improved but not resolved this issue."
For Dr. Gozal, the 2002 guidelines published by the American Academy of Pediatrics (AAP) remain the most reliable (Pediatrics. 2002;109(4):704-12). These guidelines recommend a preoperative PSG for all children with symptoms of sleep-disordered breathing. According to Dr. Gozal, a member of the committee that is currently updating these guidelines, the upcoming updated AAP guidelines will recommend more frequent use of sleep studies based on evidence published over the past 10 years.
Are Guidelines Insufficient?
Sally R. Shott, MD, pediatric otolaryngologist, professor of otolaryngology at the University of Cincinnati College of Medicine in Cincinnati, Ohio, and a member of the Executive Committee of the Section on Otolaryngology-Head and Neck Surgery of the AAP, said both the AAO-HNS guidelines and the 2002 AAP guidelines correctly identify the inadequacies of clinical examination alone in differentiating between obstructive sleep apnea (OSA) and sleep-disordered breathing from primary snoring. She disagrees with both sets of guidelines as to who should be referred for a sleep study, however. Voicing her own personal opinion, and not that of the committee, she said that she does not think a preoperative sleep study is needed "if a child, even if in the high-risk groups, has symptoms of obstruction and sleep-disordered breathing and an exam matches that history."