Evaluation of Obstructive Sleep Apnea by Polysomnography Prior to Pediatric Adenotonsillectomy—Reply

In reply

I agree with Pelayo et al that otolaryngologists and sleep medicine physicians should aim to improve the health of children. However, I do not agree that every child who snores, is a constant mouth breather, has daytime symptoms, and has big tonsils and adenoids needs to have a sleep study prior to tonsillectomy and adenoidectomy.

In their letter, Pelayo et al equate sleep apnea in adults to that in children. Children are not small adults. Children's sleep apnea is much more commonly caused by enlarged tonsils and adenoids; it is consistently although not universally cured by tonsillectomy and adenoidectomy.¹

After careful review of the medical literature, I concluded that the published studies regarding the accuracy of clinical diagnosis in sleep disorders were severely flawed. More research on this subject using sleep study parameters appropriate for children needs to be completed. Pelayo et al refer to the sleep study as the gold standard. This implies that it is always right (ie, it correctly diagnoses 100% of children who have a sleep disorder and does not overdiagnose anyone). I disagree. The sleep study is an excellent test; it is the best we have, but it is not a gold standard. Prior to the 1990s, it was thought that the sleep study was the gold standard, but in hindsight many children with upper airway resistance syndrome were not diagnosed because there was no esophageal probe used in those early studies.² (In many centers, this is still the case.) Now we know better, but how much more is there that we don't know on this subject?

Part of quality of care is not traumatizing children. At best, my patients report that a night in the sleep center is uncomfortable and difficult. Currently, this is the only way to do a sleep study with an esophageal probe. My patients do not mind the portable studies that are performed in the patient's home, but getting the results from these studies delays treatment by at least 2 months, since we need to obtain authorization, schedule the study, get the results, and discuss the results with the family. There are also no studies showing that in-home polysomnogram results for a pediatric patient are comparable in accuracy to inpatient study results.

Pelayo et al suggest that the "average surgeon" does not provide an "unbiased description of continuous positive airway pressure." Do they really think this is a good treatment option for an otherwise healthy child with no craniofacial anomalies who has big tonsils and adenoids? Studies show that long-term compliance with continuous positive airway pressure is lousy for adults. It can only be worse for children.

Pelayo et al state that the "challenge we face in sleep medicine is providing easily accessible and cost-effective care" (ie, sleep studies). I could not agree more. Unfortunately, we are not there yet. Sleep studies are expensive, are not readily accessible, can be uncomfortable, and can delay treatment significantly. They should be reserved for the child with equivocal symptoms; for the child with other medical problems, such as craniofacial disorders; and for the child whose sleep and behavior issues are not completely resolved after tonsillectomy and adenoidectomy. I look forward to the day when sleep studies will be inexpensive, accurate, and readily accessible and hope to work with Pelayo et al to make this happen.