Surgery
Childhood OSA is typically recognized between two and eight years of age when the tonsils and adenoids are the largest in relation to the underlying airway size.² Adenotonsillar hypertrophy in the presence of a narrow airway and/or decreased oropharyngeal muscle tone is considered the most common cause of OSA in children. Therefore, adenotonsillectomy (TNA) is considered first-line therapy for OSA in children. In fact, OSA currently exceeds recurrent tonsillitis as the leading indication for pediatric TNA in the US.³

However, it is important to mention that when evaluating a child suspected of having sleep-disordered breathing a multidisciplinary approach involving a sleep specialist, otolaryngologist, maxillofacial surgeon, and orthodontist should be utilized. Children with OSA often have enlarged tonsillar and adenoid tissue in the setting of an already narrowed or floppy airway. Therefore, even though TNA has a high initial success rate for improving OSA and associated symptoms of OSA, if not curative it may do little to affect craniofacial development in the long term, and the child remains at risk for worsening OSA in adulthood. The multidisciplinary approach assures a comprehensive plan to address all aspects of the child’s orofacial anatomy and positively affects craniofacial and upper airway development in a child at risk for OSA in adolescence or adulthood.

Understandably, parents may be reluctant to subject their child to surgeries or procedures that require general anesthesia or sedation and that cause pain or discomfort. However, if parents understand the implications of untreated OSA, appreciate the imperative nature of correcting abnormalities within a developmental window when upper airway and jaw development can be maximally influenced, and are approached with a comprehensive stepwise plan from the beginning, they are more likely to accept the idea of surgery, repeated polysomnographs (PSGs), and additional interventions as needed.

A controversial matter is how early to perform this surgery. Most agree that TNA can be performed successfully and without complications after 24 months of age. However, OSA can occur as early as three weeks of age, and TNA has been performed as early as six months.⁴

When performing TNA in children with OSA, it is advisable to maximize the size of the upper airway and prevent collapse of the soft palate and lateral pharyngeal walls. Techniques such as suturing the tonsillar wound to reduce collapsibility of the pharynx and to prevent scarring and narrowing of the posterior pharynx are used in adults, but are often neglected in children with OSA. Again, enlarged tonsils and adenoids are not always sufficient to cause OSA in children. These children often have coexisting narrow upper airways from either redundant soft tissue or maxillomandibular deficiency. Therefore, the same procedure of complete tonsillar and adenoid removal with wound suturing to maximize the airway is recommended not only in adults but also in the treatment of pediatric OSA.