Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children
Authors: Susan Redline, Kaitlyn Cook, Ronald D. Chervin, Stacey Ishman, Cristina M. Baldassari, Ron B. Mitchell, Ignacio E. Tapia, Raouf Amin, Fauziya Hassan, Sally Ibrahim, Kristie Ross, Lisa M. Elden, Erin M. Kirkham, David Zopf, Jay Shah, Todd Otteson, Kamal Naqvi, Judith Owens, Lisa Young, Susan Furth, Heidi Connolly, Caron A. C. Clark, Jessie P. Bakker, Susan Garetz, Jerilynn Radcliffe, H. Gerry Taylor, Carol L. Rosen, Rui Wang, Michael N Rueschman, Meg Tully, Jean Arnold, Michelle Nicholson, Emily Kaplan, Dan Mobley, Michael Morrical, Laurie Karamessinis, Michelle Ward, Mary Ann Cornaglia, Ruth Bradford, Alyssa Ciampaglia, Hayley Groubert, Erica Denallo, Rasal Rajashari, Morgan Pyzoha, Heather Rogers, Kieran McKibben, Suzie Hicks, Belinda Carter, Melodie Boh, Krista Swegheimer, Stacey Niehaus, Emily Herresoff, Marianne Heffner, Judy Fetterolf, Bill Geal, Sarah Brand, Braden DeWeese, Libby Johnson, Kristin Brierly, Allison Jordan, Kacee Pavelka, Jay Sands, Ashley Szpara, Francesca Chambers, Laura Vargas, Constance Eshon, Florence George, Mary Martin, Vernell Sparks, Victoria Young, Laura Stone, Amy Boykin, Emily Riggan, Thomas Boswick, Michael Bailey, Amanda Stetler, Addy Tham
Journal: JAMA (2023)

Importance The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown. Objectives To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB. Design, Setting, and Participants Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months. Intervention Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228). Main Outcomes and Measures The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes. Results Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: −3.1 for adenotonsillectomy vs −1.9 for watchful waiting; difference, −0.96 [95% CI, −2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, −0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, −9.02 [97% CI, −15.49 to −2.54] and −6.52 [97% CI, −11.59 to −1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, −11.2% [97% CI, −17.5% to −4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy. Conclusions In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up. Trial Registration ClinicalTrials.gov Identifier: NCT02562040