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Clinical Scenario

7-year-old obese male with a past medical history of obstructive sleep apnea (OSA) presents to the ER with excessive sleepiness and daytime drowsiness x 2 days. Per patient’s father, this is an ongoing issue and he wants to know if there is a permanent solution for his sons worsening OSA. The attending suggests that in most cases, an adenotonsillectomy can help relieve symptoms and improve the overall quality of life in patients with OSA.

Clinical Question:

In pediatric patients with obstructive sleep apnea, is adenotonsillectomy an effective treatment in improving quality of life?

PICO Question:







Search Strategy:

Trip Database:

–       “Adenotonsillectomy obstructive sleep apnea” = 453 results

o   Filters used: Systematic Review = 7 results


–       “Adenotonsillectomy obstructive sleep apnea” = 871 results

o   Filters used: Meta-analysis = 20 articles

o   Additional 5 years and humans = 14 articles


–       “Adenotonsillectomy obstructive sleep apnea” = 547 results

–       Filters used: Cochrane Evidence = 539 results

–       Child health & Lung/Airway = 55 results

–       Review sorted by date = 53 results


Articles Chosen (3-5):

1. Cameron A. Todd, Anna K. Bareiss, MD, Edward D. McCoul, MD, MPH, , Kimsey H. Rodriguez, MD. Adenotonsillectomy for Obstructive Sleep Apnea and Quality of Life: Systematic Review and Meta-analysis. Sage Journal: Otolaryngol Head Neck Surg. 2017 Nov;157(5):767-773. doi: 10.1177/0194599817717480. Epub 2017 Jul 4.

Adenotonsillectomy for Obstructive Sleep Apnea and Quality of Life: Systematic Review and Meta-analysis.


Objective To determine the impact of adenotonsillectomy on the quality of life of pediatric patients with obstructive sleep apnea (OSA) and to identify gaps in the current research. Data Sources The MEDLINE, EMBASE, and Cochrane databases were systematically searched via the Ovid portal on June 18, 2016, for English-language articles. Review Methods Full-text articles were selected that studied boys and girls <18 years of age who underwent adenotonsillectomy for OSA or sleep-disordered breathing and that recorded validated, quantitative quality-of-life outcomes. Studies that lacked such measures, performed adenotonsillectomy for indications other than OSA or sleep-disordered breathing, or grouped adenotonsillectomy with other procedures were excluded. Results Of the 328 articles initially identified, 37 were included for qualitative analysis. The level of evidence was generally low. All studies involving short-term follow-up (≤6 months) showed improvement in quality-of-life scores after adenotonsillectomy as compared with preoperative values. Studies involving long-term follow-up (>6 months) showed mixed results. Modifications to and concurrent procedures with conventional adenotonsillectomy were also identified that showed quality-of-life improvements. Three studies were identified for meta-analysis that compared pre- and postoperative Obstructive Sleep Apnea-18 scores. Short- and long-term follow-up versus preoperative scores showed significant improvement ( P < .001). Short- and long-term scores showed no significant difference. Conclusion This systematic review and meta-analysis demonstrate adenotonsillectomy’s effectiveness in improving the quality of life of pediatric patients with OSA. This is well demonstrated in the short term and has strong indications in the long term.


2. Venekamp RP, Hearne BJ, Chandrasekharan D, Blackshaw H, Lim J, Schilder AGM. Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD011165. DOI: 10.1002/14651858.CD011165.pub2.

Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children.



Obstructive sleep-disordered breathing (oSDB) is a condition that encompasses breathing problems when asleep, due to an obstruction of the upper airways, ranging in severity from simple snoring to obstructive sleep apnoea syndrome (OSAS). It affects both children and adults. In children, hypertrophy of the tonsils and adenoid tissue is thought to be the commonest cause of oSDB. As such, tonsillectomy – with or without adenoidectomy – is considered an appropriate first-line treatment for most cases of paediatric oSDB.


To assess the benefits and harms of tonsillectomy with or without adenoidectomy compared with non-surgical management of children with oSDB.


We searched the Cochrane Register of Studies Online, PubMed, EMBASE, CINAHL, Web of Science,, ICTRP and additional sources for published and unpublished trials. The date of the search was 5 March 2015.


Randomised controlled trials comparing the effectiveness and safety of (adeno)tonsillectomy with non-surgical management in children with oSDB aged 2 to 16 years.


We used the standard methodological procedures expected by The Cochrane Collaboration.


Three trials (562 children) met our inclusion criteria. Two were at moderate to high risk of bias and one at low risk of bias. We did not pool the results because of substantial clinical heterogeneity. They evaluated three different groups of children: those diagnosed with mild to moderate OSAS by polysomnography (PSG) (453 children aged five to nine years; low risk of bias; CHAT trial), those with a clinical diagnosis of oSDB but with negative PSG recordings (29 children aged two to 14 years; moderate to high risk of bias; Goldstein) and children with Down syndrome or mucopolysaccharidosis (MPS) diagnosed with mild to moderate OSAS by PSG (80 children aged six to 12 years; moderate to high risk of bias; Sudarsan). Moreover, the trials included two different comparisons: adenotonsillectomy versus no surgery (CHAT trial and Goldstein) or versus continuous positive airway pressure (CPAP) (Sudarsan). Disease-specific quality of life and/or symptom score (using a validated instrument): first primary outcomeIn the largest trial with lowest risk of bias (CHAT trial), at seven months, mean scores for those instruments measuring disease-specific quality of life and/or symptoms were lower (that is, better quality of life or fewer symptoms) in children receiving adenotonsillectomy than in those managed by watchful waiting:- OSA-18 questionnaire (scale 18 to 126): 31.8 versus 49.5 (mean difference (MD) -17.7, 95% confidence interval (CI) -21.2 to -14.2);- PSQ-SRBD questionnaire (scale 0 to 1): 0.2 versus 0.5 (MD -0.3, 95% CI -0.31 to -0.26);- Modified Epworth Sleepiness Scale (scale 0 to 24): 5.1 versus 7.1 (MD -2.0, 95% CI -2.9 to -1.1).No data on this primary outcome were reported in the Goldstein trial.In the Sudarsan trial, the mean OSA-18 score at 12 months did not significantly differ between the adenotonsillectomy and CPAP groups. The mean modified Epworth Sleepiness Scale scores did not differ at six months, but were lower in the surgery group at 12 months: 5.5 versus 7.9 (MD -2.4, 95% CI -3.1 to -1.7). Adverse events: second primary outcomeIn the CHAT trial, 15 children experienced a serious adverse event: 6/194 (3%) in the adenotonsillectomy group and 9/203 (4%) in the control group (RD -1%, 95% CI -5% to 2%).No major complications were reported in the Goldstein trial.In the Sudarsan trial, 2/37 (5%) developed a secondary haemorrhage after adenotonsillectomy, while 1/36 (3%) developed a rash on the nasal dorsum secondary to the CPAP mask (RD -3%, 95% CI -6% to 12%). Secondary outcomesIn the CHAT trial, at seven months, mean scores for generic caregiver-rated quality of life were higher in children receiving adenotonsillectomy than in those managed by watchful waiting. No data on this outcome were reported by Sudarsan and Goldstein.In the CHAT trial, at seven months, more children in the surgery group had normalisation of respiratory events during sleep as measured by PSG than those allocated to watchful waiting: 153/194 (79%) versus 93/203 (46%) (RD 33%, 95% CI 24% to 42%). In the Goldstein trial, at six months, PSG recordings were similar between groups and in the Sudarsan trial resolution of OSAS (Apnoea/Hypopnoea Index score below 1) did not significantly differ between the adenotonsillectomy and CPAP groups.In the CHAT trial, at seven months, neurocognitive performance and attention and executive function had not improved with surgery: scores were similar in both groups. In the CHAT trial, at seven months, mean scores for caregiver-reported ratings of behaviour were lower (that is, better behaviour) in children receiving adenotonsillectomy than in those managed by watchful waiting, however, teacher-reported ratings of behaviour did not significantly differ.No data on these outcomes were reported by Goldstein and Sudarsan.


In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time.For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG.We are unable to present data on the benefits of adenotonsillectomy in children with oSDB aged under five, despite this being a population in whom this procedure is often performed for this purpose.


3. Lee, C., Hsu, W., Chang, W., Lin, M., & Kang, K. (2016). Polysomnographic findings after adenotonsillectomy for obstructive sleep apnoea in obese and non-obese children: A systematic review and meta-analysis. Clinical Otolaryngology, 41(5), 498-510. doi:10.1111/coa.12549

Polysomnographic findings after adenotonsillectomy for obstructive sleep apnoea in obese and non-obese children: a systematic review and meta-analysis.

Use of polysomnography (PSG) is the gold standard of diagnosis and measurement of treatment effectiveness for paediatric obstructive sleep apnoea (OSA). Although adenotonsillectomy (T&A) is effective in diminishing the apnoea-hypopnoea index (AHI), a meta-analysis of postoperative changes for all other PSG parameters and outcome comparisons between obese and non-obese children following T&A have never been conducted.

To comprehensively review polysomnographic findings after surgery for obese and non-obese children with OSA.

Study protocol was registered on PROSPERO (CRD42013004737). Two authors independently searched databases including PubMed, MEDLINE, EMBASE and Cochrane Review from January 1997 to July 2014. The keywords used included the following: sleep apnea, OSA, sleep apnea syndromes, tonsillectomy, adenoidectomy, infant, child, adolescent, and Humans.

A comprehensive systematic review and meta-analysis for literature for OSA children treated by T&A with polysomnography data. Random-effects model was applied to determine postoperative sleep parameter changes and the surgical success rate between obese and non-obese groups. The quality of studies was assessed using the Newcastle-Ottawa Scale.

In total, 51 studies with 3413 subjects were enrolled. After surgery, sleep architecture was altered by a significant decrease in sleep stage 1, and an increase in slow-wave sleep and the rapid eye movement stage, and enhanced sleep efficiency. The mean difference between pre- and postoperative was a significant reduction of 12.4 event/h in AHI, along with a reduction of obstructive index, hypopnoea index, central index and arousal index. Mean and minimum oxygen saturation increased significantly after surgery. The overall success rate was 51% for postoperative AHI <1 (obese versus non-obese versus combined, 34% versus 49% versus 56%), and 81% for AHI <5 (obese versus non-obese versus combined, 61% versus 87% versus 84%). Meta-regression analyses demonstrate that postoperative AHI was positively correlated with AHI and body mass index z score before surgery.

Meta-analysis of current literature shows T&A offers prominent improvement in a variety of sleep parameters. Improvements in non-obese children exceeded those for obese children. Postoperative residual OSA remained in roughly half of the children, especially those with severe disease and obesity, making additional treatment strategies and/or long-term follow-up highly desirable.


4. Chinnadurai S, Jordan AK, Sathe NA, Fonnesbeck C, McPheeters ML, Francis DO. Tonsillectomy for Obstructive Sleep-Disordered Breathing: A Meta-analysis. Pediatrics. 2017;139(2):e20163491. doi:10.1542/peds.2016-3491.

Tonsillectomy for Obstructive Sleep-Disordered Breathing: A Meta-analysis.


The effectiveness of tonsillectomy or adenotonsillectomy (hereafter, “tonsillectomy”) for obstructive sleep-disordered breathing (OSDB) compared with watchful waiting with supportive care is poorly understood.

To compare sleep, cognitive or behavioral, and health outcomes of tonsillectomy versus watchful waiting with supportive care in children with OSDB.

Medline, Embase, and the Cochrane Library.

Two investigators independently screened studies against predetermined criteria.

Two investigators independently extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. Investigators synthesized data qualitatively and meta-analyzed apnea-hypopnea index (AHI) scores.

We included 11 studies. Relative to watchful waiting, most studies reported better sleep-related outcomes in children who had a tonsillectomy. In 5 studies including children with polysomnography-confirmed OSDB, AHI scores improved more in children receiving tonsillectomy versus surgery. A meta-analysis of 3 studies showed a 4.8-point improvement in the AHI in children who underwent tonsillectomy compared with no surgery. Sleep-related quality of life and negative behaviors (eg, anxiety and emotional lability) also improved more among children who had a tonsillectomy. Changes in executive function were not significantly different. The length of follow-up in studies was generally <12 months.

Few studies fully categorized populations in terms of severity of OSDB; outcome measures were heterogeneous; and the durability of outcomes beyond 12 months is not known.

Tonsillectomy can produce short-term improvement in sleep outcomes compared with no surgery in children with OSDB. Understanding of longer-term outcomes or effects in subpopulations is lacking.


Summary of the Evidence:


Obstructive sleep apnea (OSA) is a common condition that affects many patients across the country. The appraised articles above all provide evidence to support the treatment of OSA with a surgical adenotonsillectomy. Although all the articles came down to the same general conclusion, the level of evidence provided by Todd et. al and Lee et. al, was significantly higher and superior when compared to the other two articles. Results from Todd et. al, provided evidence to support that treatment with adenotonsillectomy greatly improves patient symptoms as evidenced by the overall decrease in the subjective OSA – 18 survey score. Since this article failed to analyze the long-term effects, this conclusion can only be used to generalize OSA-18 scores within the first 12 months after surgery. Results from the large Lee et. al study containing 51 articles, provided more parameters in regard to the symptomatic improvement of OSA patients after surgery. Since all the studies included had patients perform a sleep studies before and after surgery, all the results obtained were objectively recorded and are therefore stronger evidence. The increased sleep efficacy, increased O2 saturation, decreased end tidal CO2 and decreased incidence of apnea-hypopnea events all provide strong evidence to support the effective use of adenotonsillectomy for OSA treatment and QOL improvement. Although the study contained international patients which could have produced extra bias, the results still showed a steady significant change that is important in this clinical question.

The last two articles by Venekamp et. al and Chinnadural et. al show low quality evidence to support the use of adenotonsillectomy to treat OSA. Venekamp et. al, contained only 3 articles all of which had different ways of surveying changes in QOL of individual patients which made it hard when analyzing the information to make a final conclusion. Chinnadural et. al, contained 11 articles all of which collectively determined adenotonsillectomy significantly improves QOL but there is no significant evidence to show any cognitive or behavioral improvement. Both articles support the conclusion that adenotonsillectomy is effective for treating OSA and improving symptoms but the level of evidence itself is minimal.

Clinical Bottom Line:

The clinical bottom line is that treating obstructive sleep apnea with adenotonsillectomy is more effective than non surgical treatment in overall improvement of quality of life. Collectively, data from all four appraised articles strongly suggests that treating OSA with adenotonsillectomy leads to a significant increase in the overall quality of life, improved sleep apnea symptoms and improved behaviors. More specifically, there is an overall increase in the sleep efficacy of patients and oxygen saturation as well as a decrease in carbon dioxide saturation, respiratory events and patients arousal index.

However, since all four studies fail to determine the long-term effectiveness of adenotonsillectomy, patients should be informed about the possibility of recurrence of symptoms after 12 months of surgery. More research in the future is needed, specifically to track the long-term side effects of adenotonsilectomy, the overall rate of OSA recurrence and OSA relation to the future onset of other pulmonary conditions. Additionally, the overall improvement of quality of life in patients with OSA after adenotonsilectomy should be researched specifically in terms of improvement in sleep and oxygenation.