Comparing Tonsillectomy Options to Treat OSA in Children with Trisomy 21

Adequate sleep is essential for children, and insufficient amounts can have a detrimental effect on health, behavior and cognition. The prevalence of obstructive sleep apnea (OSA) in the regular pediatric population ranges from 1.2% to 5.7%. Conversely, OSA is quite common among children with Trisomy 21 (T21) with some reports indicating a prevalence of between 40% and 80%.

The American Academy of Otolaryngology recommends tonsillectomy and adenotonsillectomy (T&A) as the first-line treatment for pediatric OSA. Over the past 20 years, many surgeons have turned to intracapsular tonsillectomy and adenoidectomy (iTA) as an alternative to the more traditional approach, extracapsular tonsillectomy and adenoidectomy (TT). iTA is an effective treatment for pediatric OSA, and it has lower rates of postoperative bleeding and faster recovery. However, physicians have been hesitant to perform iTA in children with Trisomy 21 because of the known high rates of persistent sleep apnea after surgery and concern that revision tonsillectomy would need to be performed if a patient continues to exhibit OSA after iTA.

A recent study appearing in Laryngoscope compared patients with T21 and OSA who underwent iTA with those who underwent TT. The authors looked at postoperative recovery, complications, sleep apnea outcomes as measured by polysomnography and the need for revision surgery.

“With such a high prevalence of OSA, many children with T21 have adenotonsillectomy as a first line of treatment,” says Alisa Timashpolsky, MD, a staff otolaryngologist in Cleveland Clinic’s Department of Otolaryngology-Head & Neck Surgery and lead author of the study. “But data has shown that these patients are at higher risk for both preoperative and postoperative complications from the procedure. They also have a more challenging and lengthier recovery and hospital stay. So, we wanted to better understand outcomes for this at-risk population in terms of these surgical approaches.”

Methods

The retrospective chart review included a total of 286 pediatric patients with T21. Of these, 62 (21.7%) underwent iTA, and 224 patients (78.3%) underwent TT. There were not any significant demographic differences (age, gender, race, ethnicity, gestational age and body mass index) between the two groups. However, patients undergoing iTA were more likely to use continuous positive airway pressure (CPAP) or biphasic positive airway pressure (BiBAP) machines preoperatively than the TT cohort (8.1% vs 2.2%, P = .04). There were also no differences in surgical indications between the two cohorts, with OSA being the primary reason for surgical intervention.

“Many of the patients who underwent TT had other concomitant procedures performed,” explains Dr. Timashpolsky. “To better compare surgical times, we excluded patients with multiple procedures, and when we did this, iTA and TT did not significantly differ in the average operative time.”

Additional analyses of intraoperative data, including tonsil size, adenoid size, and use of narcotics intraoperatively showed no differences between the two groups.

Postoperative findings

Among all patients, children undergoing iTA were more likely to be discharged within 24 hours (75.8% vs. 54.9%, P = .003), and these patients were less likely to be admitted longer than one day (19.4% vs. 40.2%, P = .002). The overall length of stay was not significantly different among the groups nor was the need for pediatric intensive care unit admission. During initial admission, there were no differences in bleeding or need to return to the operating room (OR). Patients in the iTA group reported lower pain levels on the morning of discharge than those in the TT group (0 [0–0] versus 0 [0–3] respectively, P < .001).

When comparing 30-day postoperative complications, the groups differed significantly. Patients undergoing iTA had a lower rate of total complications than those undergoing TT (19.4% vs. 37.1%, P = .009). Subgroup analysis revealed this was largely due to differences in postoperative pain tolerance. Postoperative bleeding rates were similar among both groups, but bleeding requiring a return to the OR was less frequent with the iTA group, though this difference did not reach statistical significance (1.6% vs. 2.7%, P = 1).

“We found that patients in the iTA group were less likely than the TT group to need oxycodone or other opioids to control their pain during their hospitalization,” says Dr. Timashpolsky. “The iTA group also had fewer postoperative respiratory complications, and the lower rates of opioid administration could be a factor here since these narcotics are known to cause respiratory depression.”

Patient sleep studies

A total of 253 patients (88.4%) had a preoperative sleep study available, and 133 (46.5%) patients had postoperative sleep study data available; a total of 125 patients had both pre- and postoperative sleep study data. The median time between surgery and the first postoperative sleep study was 119 days in the iTA group and 222 days in the TT group, P = .01. Of the patients with both pre- and postoperative data, 26 underwent iTA and 99 patients underwent TT.

Patients in both groups showed significant improvement in the median Apnea Index (AI) (2.5–0.2 for iTA, P < .001, and 2.4–0.35 for TT, P < .001), median Hypopnea Index (HI) (6.2–3.2 for iTA, P = .005, and 9–3.2 for TT, P < .001) and median Apnea/Hypopnea Index (AHI) (8.7–4 for iTA, P = .006, and 12.3–5.1 for TT, P < .001). Both groups also showed improvement in oxygen saturation (O2) nadir (85–88.5 for iTA, P = .046, and 85–88 for TT, P < .001), and neither group showed significant changes in the max end tidal CO2.

Follow-up data from ENT and/or pulmonology were available for 41 (66.1%) of iTA patients and 169 (75.4%) TT patients, although the iTA patients had a shorter mean follow-up time than the TT patients (1.8 years versus 2.6 years, P = .02). Twenty-one (52.5%) iTA patients and 83 (48.8%) TT patients still exhibited OSA symptoms (P = .73) at their last documented follow-up visit. ENT-specific follow-up data was available for 35 (56.4%) iTA patients and 154 (68.8%) TT patients. Three (8.6%) iTA and four (2.6%) TT patients had tonsillar regrowth (P = .17).

Only two of the iTA patients with follow-up data had further procedures performed; one underwent revision tonsillectomy (4.1 months after initial tonsillectomy), and the other underwent drug-induced sleep endoscopy (DISE) 4.8 years after initial iTA. Among the three patients who had TT and underwent revision surgery, one had revision adenoidectomy alone 2.2 years after TT, one underwent adenoidectomy + DISE 3.5 years after TT and the third patient underwent revision tonsillectomy 5.6 months after the initial surgery. However, the rates of repeat surgery were not significantly different between the two groups (P = .3).

Looking ahead

“Our findings indicate that patients with T21 who undergo iTA had a shorter length of stay in the hospital, improved postoperative pain, less need for steroids and narcotics and comparable short-term improvement in their OSA compared to patients with T21 undergoing TT,” says Dr. Timashpolsky. “While there has been some hesitancy towards iTA as a viable option in these cases, surgeons may want to reconsider it as a way to improve postoperative recovery.”

She notes that about half the patients from both the iTA and TT cohorts exhibited persistent OSA, which is in line with the existing literature. However, the persistent OSA is not related to tonsillar regrowth since the regrowth and revision rates were exceptionally low.

Dr. Timashpolsky also explains that the median follow-up with an ENT was 1.8 years for the iTA group and 2.6 years for the TT group. So, while this study was able to compare short-term results, more work centered around the long-term success rates of the procedure is still needed to better understand the risk of tonsillar regrowth and the need for revision surgery in this patient population.