Surgical Versus Medical Management of Pediatric Obstructive Sleep Apnea

Abstract

Introduction: Adenotonsillectomy (AT) is first-line for pediatric obstructive sleep apnea (OSA). However, watchful waiting and intranasal corticosteroids (INCS) are alternatives for mild cases. Optimal thresholds for surgery remain debated. Methods: Systematic review of 9 RCTs (n=1,507) comparing early AT versus medical management (INCS +/‑ leukotriene receptor antagonist) in children 2–10 years with mild-to-moderate OSA (AHI 1–10). Primary outcome: change in AHI and quality of life (OSA-18). Secondary: behavior (Conners) and attention (CPT). Results: AT reduced AHI by –5.2 events/hour (medical: –1.8, p<0.001). OSA-18 improved more with AT (–32 vs –14 points). Behavior and attention were not significantly different at 12 months except in children with baseline AHI >5 (improvement in Conners: –4.1 vs –0.9). Surgical complications: post-tonsillectomy bleeding (2.8%), dehydration (1.9%). Discussion: AT provides superior polysomnographic and quality-of-life improvement, but neurobehavioral benefits are limited to moderate-severe OSA. Conclusion: Adenotonsillectomy is indicated for AHI >5. Mild OSA (AHI 1–5) may be managed medically with monitoring.