Obstructive sleep apnea (OSA) is common in children with an estimated prevalence of 1-6%.
Untreated pediatric OSA is associated with hypertension, autonomic dysfunction,
attention-deficit / hyperactivity disorder, neurocognitive deficits, poor school
performance, poor quality of life, and a >200% increase in health care utilization
compared to controls. Adenotonsillar hypertrophy is the primary risk factor for pediatric
OSA, and adenotonsillectomy (AT) is the recommended first line treatment. However, the
prevalence of persistent OSA after AT has been reported to be at least 20% among children
with large tonsils, indicating that AT may not be the optimal intervention in all cases.
Although the prevalence of small tonsils in children with OSA symptoms is up to 70%,
there is currently no clear evidence on the outcome of AT in children with small tonsils.
It has been shown that clinic assessments of tonsil size do not correlate with OSA
severity or response to AT, leaving confusion about how best to treat OSA in children
with small tonsils. This knowledge gap represents an opportunity to apply a personalized
treatment approach and improve outcomes.
DISE entails passage of a flexible endoscope through the nose into the pharynx and
enables direct observation of the sites and patterns of upper airway obstruction during
sedated sleep. DISE was developed to guide surgical decisions in adult OSA, and in recent
years has also been used to design personalized surgical interventions in children. To
help standardize DISE assessments, the investigators previously developed and validated
the DISE Rating Scale in children based on ordinal ratings of maximal airway obstruction
(none, partial, complete) at six anatomic sites from the nose to the larynx.
The investigators also demonstrated that DISE ratings of adenotonsillar obstruction
during sedated sleep are strongly associated with both OSA severity and response to AT,
unlike clinic assessments of tonsil size. The investigators' preliminary data and other
published studies have identified a high prevalence of non-adenotonsillar obstruction
that can occur at the nose, palate, base of tongue, and larynx. Surgery that is tailored
to the specific anatomic sites of obstruction observed during DISE may improve pediatric
OSA outcomes, but existing studies are small, uncontrolled case series in heterogeneous
study populations. There are no trials directly comparing AT and DISE-directed surgery in
the common scenario of surgically naïve children with small tonsils.
The purpose of this study is to compare the effectiveness of a novel personalized
surgical approach to the standard AT in children with small tonsils (ST). This will be
accomplished by randomizing children with ST and OSA to one of these two treatments and
comparing outcomes after 6 months. It is the investigators' central hypothesis that a
personalized drug-induced sleep endoscopy (DISE)-directed surgical approach that uses
existing procedures to address the specific fixed and dynamic anatomic features causing
obstruction (i.e., anatomic endotypes) in each child with ST will perform better than the
currently recommended standard first line approach of AT. This novel approach may improve
OSA outcomes and reduce the burden of unnecessary AT or secondary surgery for persistent
OSA after an ineffective AT. To test this hypothesis, the investigators propose to study
children aged 2-17 years with small tonsils and OSA.