Testing Recommendation for Children with Sleep-Disordered Breathing

Sleep-disordered breathing affects about 12 percent of children, with manifestations ranging from simple snoring to potentially serious conditions, including sleep apnea (Otolaryngol Head Neck Surg. 2011;145:S1-S35). Before determining the need for tonsillectomy, it is highly beneficial to refer children with sleep-disordered breathing for polysomnography (PSG).

PSG is the gold standard for diagnosing and quantifying sleep-disordered breathing in children. Until the release of the AAO-HNS tonsillectomy guidelines last year, there was no consensus or guideline on when candidates for tonsillectomy aged 2 to 18 years are advised to have PSG (Otolaryngol Head Neck Surg. 2011;144:S1-S30). The committee made the following recommendations:

1. Before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for PSG if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease or mucopolysaccharidoses.
2. The clinician should advocate for PSG prior to tonsillectomy for sleep-disordered breathing in children without any of the above comorbidities for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing.
3. Clinicians should communicate PSG results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing.
4. Clinicians should admit children with obstructive sleep apnea documented on PSG for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea.

Although a multicenter study showed that adenotonsillectomy can lead to significant improvements in indices of sleep-disordered breathing in children, residual disease occurs in a large proportion of this population afterward, particularly among children older than 7 years of age or in those who are obese. (Am J Respir Crit Care Med. 2010;182(5):676-683).—SK