Adenotonsillectomy as First-Line Treatment for Sleep-disordered Breathing in Obese Children

Abstract

We read with great interest the article by Dr. Amin and colleagues, who assessed risk factors for recurrence of sleepdisordered breathing in children 1 year after adenotonsillectomy (1). The authors demonstrated that there was a high risk of recurrence—that is, 79% of the obese children studied still had sleep-disordered breathing 1 year after surgery. Postoperative gain in body mass index (BMI), obesity, and being African American increased the risk of reappearance of sleep apnea. In their conclusion, the authors advocate long-term follow-up of children with sleep-disordered breathing, monitoring of BMI gain, and reevaluation of children who demonstrate rapid BMI gain. We would like to add two other important implications for clinical practice and for future research, specific for obese children. It has already been documented that overweight children with sleep apnea gain weight after upper airway surgery (2), which is possibly mediated by a decrease in sleep and waking motor activity (3). In view of the finding by Amin and coworkers that accelerated weight gain is a significant risk factor for recurrence of apnea, we would like to recommend that weight loss strategies be implemented prior to upper airway surgery in obese children. Possibly, weight loss therapy could also be considered as a first-line treatment for obstructive sleep apnea syndrome in obese children. However, to date there are no systematic studies investigating the effects of spontaneous weight loss on the severity of sleep-disordered breathing in childhood obesity (2). It is clear that more research on this topic is urgently needed. Second, this study confirmed that adenotonsillectomy is only successful in a subset of the obese population with obstructive sleep apnea (2). Since obesity can be considered as a risk factor for postoperative complications, it is worthwhile to develop imaging techniques which could preoperatively assess airway anatomy and functional characteristics to identify patients who are likely to benefit from surgical intervention. One of these possible techniques is computational fluid dynamics, which is now being increasingly used in the field of sleep-disordered breathing both in children (4) and adults (5). In conclusion, we would like to recommend more research on the influence of weight management and on patient selection criteria for adenotonsillectomy in obese children with obstructive sleep apnea syndrome.