Position Statment: Tonsillectomy and OSAs
In the adult population, tonsillectomy is the appropriate first line treatment in select patients (Epstein 2009, Evidence Based Clinical Guideline). After thorough examination, if the primary site of obstruction is hypertrophied tonsils, tonsillectomy has been shown to be a very effective treatment regardless of the severity of the OSA (Verse 2000, Level 3). While most of the articles supporting adult tonsillectomy for OSA are small, the results of these 7 articles strongly support this treatment. In Verse 2000, many of the studies prior to 2000 are reviewed. In this review, patients had a mean preoperative Apnea-Hypopnea Index (AHI) of 54.6 and mean post operative AHI of 3.6.
Surgical treatment of pediatric sleep disordered breathing with tonsillectomy and adenoidectomy is the recommended first line treatment. In the pediatric population, resolution of OSA occurs in 82% of patients who are treated with T&A. (Brietzke 2006, Meta-analysis) The effects of T&A include normalization of AHI, improvement of quality of life (QOL) measures, improved behavior, improved academic performance, and improved neurocognitive functioning. In snoring pediatric patients with symptoms of sleep disordered breathing in whom AHI is not normalized postoperatively, or in whom AHI was not elevated preoperatively, significant improvement are seen in all QOL measures, neurocognitive functioning and behavior (Chervin 2006,Level 2 evidence).
The clinical practice guideline for tonsillectomy in children (Roland, 2011), developed by the AAO-HNS in 2011, defines SDB as abnormalities of respiratory pattern or the adequacy of ventilation during sleep, which include snoring, mouth breathing, and pauses in breathing. SDB encompasses a spectrum of obstructive disorders that increases in severity from primary snoring to obstructive sleep apnea (OSA). Daytime symptoms associated with SDB may include excessive sleepiness, inattention, poor concentration, and hyperactivity (Marcus 2012). Children have been shown to have significant improvement in these symptoms with tonsillectomy and adenoidectomy (Chervin 2006).
- Epstein, Lawrence J. (Chair); Kristo, David; Strollo, Jr., Patrick J. ; Clinical Guidelines for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults, Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009.
- Verse, Thomas; Kroker, Beatrice; Pursig, Wolfgang, Tonsillectomy as a Treatment of Obstructive Sleep Apnea in Adults with Tonsillar Hypertrophy, Laryngoscope, 110: 1559, 2000.
- Brietzke S, Gallagher D, The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: A meta-analysis Otolaryngol Head Neck Surg, 134(6), 979-984, 2006.
- Chervin RD, Ruzicka DL, Giordani BJ, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 117:769-78,2006.
- Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, Kuhar S, Mitchell RB, Seidman MD, Sheldon SH, Jones S, Robertson P; American Academy of Otolaryngology Head and Neck Surgery Foundation. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jul;145(1 Suppl):S1-15. Epub 2011 Jun 15. PubMed PMID: 21676944.
- Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84. Epub 2012 Aug 27. PubMed PMID: 22926173.
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Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.