Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis

Int J Pediatr Otorhinolaryngol. 2019 Jun;121:179-187. doi: 10.1016/j.ijporl.2019.02.030. Epub 2019 Mar 3.


Objective: To evaluate the efficacy of upper airway surgery for children with persistent obstructive sleep apnea after adenotonsillectomy and to assess sleep study outcomes when Drug Induced Sleep Endoscopy, Cine MRI, or other imaging procedure is performed to assist in identifying the location of obstruction and planning surgery.

Methods: Systematic review and meta-analysis was performed. Inclusion criteria was English-language studies with original data including pediatric patients with persistent OSA after T&A. Exclusion criteria included case reports and lack of pre and post-operative sleep study data. Data Sources were PubMed, Cochrane Central, and Embase from 2000 to 2018. PRISMA standards were followed for the selection and review of articles. The Newcastle-Ottawa Quality Assessment scale was used to score the quality of evidence of the studies. All manuscripts were reviewed independently by two investigators. Primary outcome measures were apnea-hypopnea index and minimum oxygen saturation. Data was pooled using a random-effects model.

Results: Of the 1902 abstracts identified, 11 studies (214 patients) met inclusion criteria for systematic review, 5 with Drug Induced Sleep Endoscopy as the diagnostic technique, 4 with Cine MRI, and 2 with MRI/CT. All studies were case series. Most subjects had syndromic comorbidities and/or obesity. Ten studies (198 patients) were included in the meta-analysis. Overall, there was a change in apnea hypopnea index of -6.51 (95% CI, -8.17 to - 4.85; p < 0.001) and an increase in minimum oxygen saturation by 3.24% (95% CI, 1.49%-4.98%; p < 0.001) following surgical intervention. Both Drug Induced Sleep Endoscopy and Cine MRI directed surgeries resulted in significant improvement in sleep study parameters. The two techniques could not be directly compared due to significant differences in co-morbidity rates between patients.

Conclusions: Surgery for pediatric persistent obstructive sleep apnea improves apnea hypopnea index and minimum oxygen saturation but does not resolve the disease. This is true when both Drug Induced Sleep Endoscopy and Cine MRI findings were used to direct surgery.

Keywords: Drug induced sleep endoscopy; Pediatric obstructive sleep apnea; Pediatric sleep apnea; Persistent obstructive sleep apnea; cineMRI.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adenoidectomy
  • Adolescent
  • Child
  • Child, Preschool
  • Chronic Disease
  • Comorbidity
  • Endoscopy / methods*
  • Female
  • Humans
  • Infant
  • Magnetic Resonance Imaging, Cine*
  • Multimodal Imaging
  • Reoperation
  • Severity of Illness Index
  • Sleep Apnea, Obstructive / diagnostic imaging*
  • Sleep Apnea, Obstructive / surgery*
  • Tomography, X-Ray Computed*
  • Tonsillectomy