Adenotonsillectomy or watchful waiting in the management of childhood obstructive sleep apnea

Manisha Witmans, Shirin Shafazand

Research output: Contribution to journalComment/debatepeer-review

3 Scopus citations


Question: Compared with watchful waiting, does the treatment of childhood obstructive sleep apnea (OSA) with adenotonsillectomy improve cognitive outcomes, symptoms, behavior, quality of life, and polysomnography findings? Design: Multicenter, single-blind, randomized, controlled trial conducted at seven academic sleep centers; number, NCT00560859. Allocation: Children were randomly assigned to early adenotonsillectomy (EAT-surgery within 4 weeks after randomization) or a strategy of watchful waiting with supportive care (WWSC). Randomization was performed centrally using a web-based system that required confirmation of eligibility criteria prior to providing the treatment assignment. Blinding: Single-blind; personnel involved in conducting psychometric evaluations and measuring other study outcomes, as well as study investigators (other than the surgeons), were blinded to randomization assignments, study participants and families were not blinded. Follow-Up Period: 7 months. Setting: The study recruited children with symptoms of obstructive sleep apnea syndrome (OSAS) from primary care, otolaryngology, and sleep clinics at 7 academic centers in the United States. Subjects: 453 children, mean age 6.5 ± 1.4 years, 49% male, were randomized. Inclusion Criteria: Age between 5 to 9 years, polysomnographic diagnosis of OSAS without prolonged oxyhemoglobin desaturation, and considered to be suitable candidates for adenotonsillectomy. OSAS was defined as an apnea-hypopnea index (AHI) score of 2 or more events per hour or an obstructive apnea index (OAI) score of 1 or more events per hour. Exclusion Criteria: Children with an AHI score of more than 30 events per hour, an OAI score of more than 20 events per hour, or arterial oxyhemoglobin saturation of less than 90% for ≥ 2% of total sleep time, recurrent tonsillitis, a BMI z score of ≥ 3, and use of medication for attention deficit-hyperactivity disorder (ADHD). Intervention: Participants meeting eligibility criteria were randomized to early adenotonsillectomy or a strategy of watchful waiting with supportive care (WWSC). Children completed in lab polysomnography at baseline and 7 month follow-up. At both time points, caregivers were asked to complete survey instruments evaluating behavior, intellectual functioning, quality of life, symptoms of sleepiness and sleep apnea; teachers were mailed behavioral assessments. Neuropsychological testing was performed during a morning visit, on a separate day from the polysomnogram, to avoid the influence of atypical sleep related to overnight monitoring. Tests were administered by psychometrists, blinded to the polysomnographic results. Outcomes: The primary outcome was the change in the attention (A) and executive-function (E) score on the Developmental Neuropsychological Assessment (NEPSY). Secondary outcome measures were: 1) caregiver and teacher ratings of behavior measured by Conners' Rating Scale Revised: Long Version Global Index, comprising Restless-Impulsive and Emotional Lability factor sets and the Behavior Rating Inventory of Executive Function (BRIEF), comprising summary measures of behavioral regulation and metacognition; 2) symptoms of obstructive sleep apnea syndrome, as assessed by the Pediatric Sleep Questionnaire sleep-related breathing disorder scale (PSQ-SRBD); 3) sleepiness, assessed using the Epworth Sleepiness Scale modified for children; 4) global quality of life, evaluated by caregiver-rated total score from the Pediatric Quality of Life Inventory (PedsQL); 5) disease-specific quality of life measure based on the 18-item Obstructive Sleep Apnea assessment tool; 6) generalized intellectual functioning evaluated by the General Conceptual Ability score from the Differential Ability Scales-II (DAS); and 7) polysomnographic indexes. A study sample size of 400 children, randomized 1:1 between the 2 study arms allowed for detection of an effect size, for the primary endpoint of the NEPSY A/E domain score, of ≥ 0.32 (an effect size estimated from one prior study) with 90% power. Patient Follow-Up: 464 children were randomized between January 2008 and September 2011, 11 excluded due to lack of follow-up data, 35 were lost to follow-up, and 18 withdrew from the study. Follow-up visits were conducted for 400 children (86%), with 397 children having measurements of attention and executive function on the NEPSY (primary outcome) that could be evaluated. An intention to treat analysis was performed. Main Results: The baseline attention and executive function score on the NEPSY (primary outcome) was close to the population mean of 100 in both groups. Average scores increased in both groups at 7 month follow-up, but there was no statistically significant difference between the groups in the primary outcome (7.1 ± 13.9 in the early-adenotonsillectomy group and 5.1 ± 13.4 in the watchful-waiting group, p = 0.16). The AHI score improved in both groups, but significantly more so in the early-adenotonsillectomy group (Effect size 0.57, p < 0.001). There were statistically significant improvements in behavioral, quality of life measures, and greater reduction in symptoms in the early adenotonsillectomy group than in the watchful-waiting group. Neither obesity nor age significantly modified treatment responses for any of the outcomes reported. The relative improvements associated with early-adenotonsillectomy were significantly lower for African American children compared to children of other ethnic/racial backgrounds for the caregiver completed behavioral questionnaires. There were 15 post-randomization serious adverse events, six of which occurred in children randomized to early adenotonsillectomy and nine in the control group. Eight of the events were associated with peri-operative complications (bleeding, dehydration, and pain). Nine treatment failures were also considered adverse events, occurring in the watchful waiting group; treatment failures were attributed to: increased problems with sleep quality or sleepiness, school behavioral problems, morning headaches, asthma exacerbation, hypertension, and bacterial infections. Conclusion: Among school age children with obstructive sleep apnea syndrome without prolonged oxygen desaturation, early adenotonsillectomy, as compared with a strategy of watchful waiting with supportive care, did not result in significantly greater improvement in scores on a formal test of attention and executive function after a period of 7 months. However, early adenotonsillectomy was associated with statistically significant improvements in polysomnographic findings, caregiver and teacher reported measures of behavior, quality of life, and sleep apnea symptoms.

Original languageEnglish (US)
Pages (from-to)1225-1227
Number of pages3
JournalJournal of Clinical Sleep Medicine
Issue number11
StatePublished - 2013

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Neurology
  • Clinical Neurology


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