Surgical removal of adenoid and tonsils benefits kids with sleep apnea

Children with obstructive sleep apnea who had a common surgery to remove their adenoids and tonsils had notable improvements in behavior, quality of life and other symptoms compared to those treated with "watchful waiting" and supportive care, according to a new study.

However, there was no difference between both groups in attention and executive functioning, as measured by formal neuropsychological tests.

The Childhood Adenotonsillectomy Trial (CHAT) studied 464 children, aged 5 to 9, at seven academic sleep centers.

"This was the first randomized clinical trial of surgery for obstructive sleep apnea in children," said the study's first author, Carole L. Marcus, M.D., a sleep specialist and director of the Sleep Center at The Children's Hospital of Philadelphia.

Obstructive sleep apnea syndrome (OSAS) is a condition of interrupted breathing caused by a narrowing in the throat or upper airway, resulting from enlarged tonsils and adenoid, obesity or other medical problems. Occurring in both adults and children, OSAS has a higher prevalence in African-American and obese patients.

Adenotonsillectomy (AT), the surgical removal of adenoid and tonsils, is the primary treatment for OSAS in children. Over half a million U.S. children undergo AT annually.

The study randomized 464 children to either receive AT or watchful waiting with supportive care from 2007 to 2011. Nearly half the children were overweight or obese. All underwent a sleep study at an outpatient sleep center at baseline and after seven months of treatment. The study did not include patients with the most severe sleep apnea.

The primary outcome of the CHAT trial was the Attention/Executive Function Domain score in a formal test, the Developmental Neuropsychological Assessment, administered by licensed psychometricians. The study found no significant difference between the treatment groups in these test results.

The secondary outcomes included ratings from parents and teachers who completed questionnaires rating a child's behavior, sleepiness, quality of life, and executive functioning, including details about activities of daily living. For instance, adults rated the degree to which a child kept up with tasks, had angry outbursts or mood changes, got along with other children, planned ahead, worried frequently, or had trouble sleeping.

The children who had surgery had significantly greater improvements, compared to children in the watchful waiting group, in the secondary outcomes listed above. Notably, added Marcus, the parents' ratings of their children's behavior were consistent with those from the teachers, suggesting that these results were not solely due to parental expectations.

Overall, both surgery and watchful waiting were safe in this clinical trial, so Marcus said that watchful waiting was a reasonable option for parents of children with less severe OSAS who opt not to have surgery, but that clinicians should carefully monitor these children to ensure their condition does not worsen.

The CHAT trial, added Marcus, left many questions for further research.

The researchers published their findings online today in the New England Journal of Medicine, in conjunction with a presentation at the American Thoracic Society annual meeting. Susan Redline, M.D., M.P.H., of Brigham and Women's Hospital, Boston, is the study's principal investigator.