Treatment
As mentioned earlier, OSAS in children is most commonly associated with adenotonsillar hypertrophy, even when obesity is present, such that the currently recommended initial treatment consists of T&A. Evidence suggests that this intervention will lead to significant improvements in most cases, as recently reported from a meta-analysis.
Attempts to reduce the considerable postoperative discomfort and minimize the risk of hemorrhage after T&A have led to the use of different surgical techniques, such as radiofrequency volume reduction or powered intracapsular tonsillectomy. These procedures may provide resolution of OSAS with more rapid recovery than total tonsillectomy techniques. However, there is a risk of regrowth of tonsillar tissue such that the issue of whether tonsillotomy is preferable to tonsillectomy is yet to be resolved.
Children with OSAS are at risk for respiratory compromise postoperatively, as a result of upper airway edema, increased secretions, respiratory depression secondary to analgesic and anesthetic agents, and post-obstructive relief pulmonary edema. A high risk of such complications is particularly encountered among children younger than 3 years of age, those with severe OSAS, and those with additional medical conditions such as obesity and craniofacial anomalies. These patients should not undergo outpatient surgery, and cardiorespiratory monitoring should be performed for at least 24 h postoperatively to ensure their stability.
Postoperative PSG evaluation 8–12 weeks after surgery is recommended for children who continue to snore, children with preoperative severe OSAS and children with additional risk factors such as obesity and craniofacial anomalies in order to ensure that additional interventions are not required.
In recent years, it has become apparent that the outcomes of T&A may not be as favorable as expected, particularly when OSAS is severe preoperatively or when obesity is present. Indeed, the frequency of residual OSAS after T&A is estimated at 45–50% after surgery. These findings have promoted a debate as to whether overnight sleep studies should routinely be conducted after T&A. These reports have also prompted the initiation of the currently ongoing randomized, single-blinded, controlled prospective study evaluating the effects of T&A on childhood OSAS.
Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) is considered the second line of treatment in children with unresolved OSAS after T&A. Although this intervention appears to be safe in children, the extensive behavioral conditioning needed to achieve adequate adherence in children precludes widespread implementation of this intervention. Nevertheless, several published studies have shown a beneficial response to CPAP/BiPAP in children, as well as favorable adherence rates.
Anti-inflammatory therapies aiming to reduce adenotonsillar hypertrophy or upper airway inflammation have also been recently used in pediatric OSAS. Topical intranasal steroids used to treat children with moderate to severe OSAS resulted in a significant reduction of the respiratory disturbance index, but did not achieve complete resolution of the disorder. More recent randomized controlled studies in patients with mild OSAS have further demonstrated the beneficial effects of intranasal steroids in pediatric OSAS. In addition, leukotriene receptor antagonists such as montelukast have also resulted in substantial improvements in sleep-related respiratory disturbance measures in children with mild OSAS. In the context of residual OSAS, the combination of intranasal steroids and oral montelukast after surgery promoted the likelihood of complete resolution of SDB.
For overweight and obese children, weight loss should also lead to improvement in number and severity of apneic episodes. In adults, the beneficial effects of weight reduction programs on OSAS are so well recognized that this intervention constitutes one of the principal recommendations for management of OSAS in adults. Although T&A should remain the primary approach for OSAS in obese children, every effort should be made to achieve significant weight reduction in these children. Indeed, resolution of sleep apnea after weight loss in five morbidly obese children has been reported, such that in special cases in whom surgery is not a viable option, intensive weight management may be particularly beneficial. An intensive weight reduction program is an important first line step towards a more definitive treatment for obese children with or without OSAS. Of note, weight loss improves not only the severity of SDB, but that of other complications of childhood obesity and OSAS, such as vascular dysfunction.
Children with abnormal craniofacial anatomy or abnormalities of neuromotor tone may require additional treatment of persistent OSAS, including pharyngeal surgery, craniofacial surgery, and even tracheostomy. Craniofacial procedures, such as mandibular distraction/advancement, genioglossus advancement and midfacial advancement, have been used to treat OSAS that results from craniofacial structural abnormalities.
The use of orthodontic devices in the treatment of OSAS in children seems promising while in its early stages of development. Orthodontic maxillary expansion can improve sleep-related airway obstruction in children with narrow palates, but further studies are necessary to define the specific indications, the processes leading to identification of suitable candidates, and to delineate the effectiveness of orthodontic treatment in the care of children with OSAS.