Tonsil removal improves behavior, symptoms among kids with mild sleep-disordered breathing

Key takeaways:

• Tonsil removal reduced behavioral problems, sleep symptoms and blood pressure in children with mild sleep apnea.
• Disease-specific and generic life quality improved with adenotonsillectomy vs. watchful waiting.

Compared with watchful waiting, tonsil removal yielded improvements in behavior, symptoms and quality of life at 12 months among children with mild sleep-disordered breathing, according to results published in JAMA.

However, changes in executive function and attention from baseline to 12 months were similar between groups, according to researchers.

Susan Redline

“The lack of significant differences in cognitive measures in the surgery compared to the control group suggests that in children with mild sleep-disordered breathing, surgery should not be used with the goal of improving cognitive outcomes,” Susan Redline, MD, MPH, director of programs in sleep medicine epidemiology and sleep and cardiovascular medicine at Brigham and Women’s Hospital, told Healio. “However, the broad improvements in symptoms, daytime functioning and quality of life support the use of surgery for children who have snoring or mild sleep-disordered breathing who have sleep-related symptoms or behavioral problems.”

In a randomized, multicenter clinical trial, Redline and colleagues evaluated 458 children (mean age, 6.1 years; 50% girls; 26.9% Black/African American; 16.3% Hispanic) with mild sleep-disordered breathing — represented through an apnea-hypopnea index (AHI) score lower than three events per hour — to determine how neurodevelopmental, behavioral, health and polysomnographic outcomes at 12 months differ between those who underwent early adenotonsillectomy (n = 231) vs. those who received supportive care/watchful waiting (n = 227).

Main outcomes

To assess executive function between the two groups, researchers looked at changes between baseline and 12 months on the caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T-score.

Researchers also compared changes in Go/No-go (GNG) test d-prime signal detection scores, a computerized test of attention, between the adenotonsillectomy group and the watchful waiting group.

Twelve-month follow-up data were available for 394 children (86%).

When evaluating changes in the two main outcomes at 12 months, researchers found no significant differences in executive function (mean BRIEF-GEC T score: adenotonsillectomy, –3.1 points vs. watchful waiting, –1.9 points) or attention (GNG d-prime scores: 0.2 vs. 0.1) between the groups.

Secondary outcomes

In addition to executive function and attention, researchers assessed changes from baseline to 12 months for 22 secondary outcomes.

Adenotonsillectomy resulted in fewer behavioral problems, fewer symptoms, less daytime sleepiness and better quality of life vs. watchful waiting.

Using caregiver-reported child behavioral checklist (CBCL) scores, children who underwent tonsil removal vs. watchful waiting showed greater improvement in CBCL total problems scores (difference in changes, –3.09: 97% CI, –4.9 to –1.28) and CBCL internalizing subscale (difference in changes, –3.05; 97% CI, –5.07 to –1.04).

To assess changes in sleep-disordered breathing symptoms, researchers used the sleep-related breathing disorder scale of the pediatric sleep questionnaire (PSQ-SRBD), and to assess changes in sleepiness, researchers use the modified Epworth Sleepiness Scale (mESS).

The change from baseline to 12 months was greater among children in the adenotonsillectomy group vs. watchful waiting group when evaluating both PSQ-SRBD scores (difference in changes, –0.16; 97% CI, –0.2 to –0.12) and mESS scores (difference in changes, –1.18; 97% CI, –2.15 to –0.21).

These children also had better quality of life at 12 months based on OSA-18 scores (difference in changes, –9.75; 97% CI, –12.84 to –6.65) and Pediatric Quality of Life scores (difference in changes, 4.76; 97% CI, 1.44-8.09).

“Almost 80% of children had baseline scores for measures of behavioral problems, symptom burden or sleepiness at levels considered to be clinically significant, but we saw that the proportion of children with clinically significant scores declined to 37% after adenotonsillectomy (compared to 65% in the control group),” Redline told Healio.

Between the two groups, children who underwent adenotonsillectomy had greater decline in systolic blood pressure percentile level (difference in changes, –9.02; 97% CI, –15.49 to –2.54), as well as diastolic blood pressure percentile level (difference in changes, –6.52; 97% CI, –11.59 to –1.45) from baseline to 12 months. Redline noted that this was a surprising finding.

According to Redline, another unexpected finding was observed when they assessed AHI of children who had a 12-month polysomnography (n = 306). At baseline, 72.3% of children had an AHI less than one. During the 12-month follow-up, 13.2% of those in the watchful waiting group had an AHI of more than three events per hour, whereas only 1.3% of those in the adenotonsillectomy group had this score.

“We observed that no child in the surgery group studied with polysomnography at 12 months had progressed to moderate OSA (AHI 5) compared to 7% of children in the watchful waiting group,” Redline told Healio.

Within the adenotonsillectomy group, five children experienced serious bleeding following the procedure vs. one child in the watchful waiting group.

“We recommend greater focus on behavioral (compared to cognitive) outcomes [in future studies],” Redline told Healio.

Reference:

• Tonsil, adenoid removal improved sleep quality, some behavioral problems in children with mild sleep apnea. https://www.newswise.com/articles/tonsil-adenoid-removal-improved-sleep-quality-some-behavioral-problems-in-children-with-mild-sleep-apnea. Published Dec. 5, 2023. Accessed Dec. 5, 2023.