Opinion statement
Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by episodes of upper airway collapse during sleep. The severity of OSA is categorized according to the apnea hypopnea index (AHI) found on polysomnogram. Pediatric OSA is classified as mild (AHI 1–5), moderate (AHI 5–10), or severe (AHI > 10). While the exact pathophysiology of OSA is still being investigated; adenotonsillar hypertrophy is the most common cause of obstruction in children. Thus, adenotonsillectomy is the mainstay of treatment for moderate to severe OSA. Patients at high risk for perioperative respiratory complications, including those less than 3 years of age and those with significant co-morbid medical conditions like Trisomy 21, should be monitored overnight following surgery. The management of patients with mild OSA is still evolving. Treatment options for children with mild OSA include watchful waiting, leukotriene inhibitors and/or inhaled nasal corticosteroids, and adenotonsillectomy. Treatment decisions should be made after a frank discussion of the risk and benefits of therapies between the patient, caregivers, and physician. Children with poor quality of life and school performance are candidates for adenotonsillectomy. Close clinical follow-up is necessary for children managed conservatively since a small number of patients, especially those who are obese, can develop more significant obstruction over time. Obese children and those patients with severe disease are at risk for persistent OSA following primary treatment with adenotonsillectomy. Historically, positive airway pressure (PAP) was the mainstay of treatment for persistent disease after adenotonsillectomy. While PAP can be effective in treating children with OSA, adherence is often poor. The utilization of drug-induced sleep endoscopy (DISE) has allowed for surgeons to identify and target additional sites of obstruction. Based on DISE findings, children with residual OSA may be candidates for surgical procedures such as lingual tonsillectomy, pharyngoplasty, supraglottoplasty, or tongue base reduction.