Effectiveness of Adenotonsillectomy vs Watchful Waiting in Young Children With Mild to Moderate Obstructive Sleep Apnea: A Randomized Clinical Trial

Abstract

Importance: Adenotonsillectomy (ATE) is one of the most common surgical procedures to treat children with obstructive sleep apnea (OSA), but to our knowledge there are no randomized clinical trials confirming the benefit of surgery compared with watchful waiting in children between 2 and 4 years of age.

Objective: To determine whether ATE is more effective than watchful waiting for treating otherwise healthy children with mild to moderate OSA.

Design, setting, and participants: This randomized clinical trial was conducted from December 2014 to December 2017 at the Otorhinolaryngology Department of the Karolinska University Hospital, Stockholm, Sweden. A total of 60 children, 2 to 4 years of age, with an obstructive apnea-hypopnea index (OAHI) score of 2 or greater and less than 10, were randomized to ATE (n = 29) or watchful waiting (n = 31). A total of 53 participants (88%; ATE, n = 25; watchful waiting, n = 28) completed the study. Data were analyzed from August 2018 to December 2018.

Interventions: Adenotonsillectomy.

Main outcomes and measures: The primary outcome was the difference between the groups in mean OAHI score change. Secondary outcomes were other polysomnography parameters, score on the Obstructive Sleep Apnea-18 (OSA-18) questionnaire, and subgroup analyses. Polysomnography and the OSA-18 questionnaire were completed at baseline and after 6 months.

Results: Of the 60 included children, 34 (57%) were boys and the mean (SD) age at first polysomnography was 38 (9) months. Both groups had a decrease in mean OAHI score, and the difference in mean OAHI score change between the groups was small (-1.0; 95% CI, -2.4 to 0.5), in favor of ATE. However, there were large differences between the groups in favor of ATE regarding the OSA-18 questionnaire (eg, total OSA-18 score: -17; 95% CI, -24 to -10). Also, a subgroup analysis of 24 children with moderate OSA (OAHI ≥5 and <10) showed a meaningful difference in mean OAHI score change between the groups in favor of ATE (-3.1; 95% CI, -5.7 to -0.5). Of 28 children, 10 (36%) in the watchful waiting group received ATE after the follow-up, and 7 of these had moderate OSA at baseline.

Conclusions and relevance: This randomized clinical trial found only small differences between the groups regarding changes in OAHI, but further studies are needed. However, there were large improvements in quality of life after ATE. These results suggest that otherwise healthy children with mild OSA and mild effect on quality of life may benefit from watchful waiting, while children with moderate OSA should be considered for ATE.

Trial registration: ClinicalTrials.gov Identifier: NCT02315911.

Conflict of interest statement

Conflict of interest Disclosures: Dr Fehrm reported grants from the Samaritan Foundation for Pediatric Research, from the ACTA Oto-Laryngologica Foundation, and from the Stockholm City Council during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Study Flowchart

ATE indicates adenotonsillectomy; PSG, polysomnography.

Figure 2.. Obstructive Apnea–Hypopnea Index (OAHI) Scores for the Adenotonsillectomy (ATE) Group and the Watchful Waiting Group

Box plots and line graphs illustrate the OAHI scores for ATE (A) and watchful waiting (B) at baseline and follow-up. Boxes include the median and interquartile range. Whiskers are within the 1.5 interquartile range, and circles are outliers.