Pragmatic Use of Polysomnography in Snoring Children.

Abstract

Thepro/conperspectivearticleby Ishman1on theuseofpolysomnography(PSG) insnoringchildrenanalyzesaclinicalquestion that faces numerous primary care physicians, otolaryngologists, andsleepmedicine clinicians on a daily basis: “Should I order a sleep study for this child knowing it is an expensiveand limited resource?”Thescopeof the issue isvast, involving hundreds of thousands of children annually in the United States alone. Thus, there have been substantial efforts made todevelopclinicalpracticeguidelines toassist theevaluating clinician in making an appropriate recommendation to the patient and family. However, as presented by Dr Ishman, there aremany conflictingpointswithin these guidelines that may confuse the matter further. Looking first at the use of PSG in the patient being considered for adenotonsillectomy (A/T), ie, a preoperative PSG, Dr Ishman1 appropriately elucidates that the usual reasons for considering this are typically flawed by a modern understanding of the pertinent pathophysiology. First and foremost, a “normal” PSG finding in a habitually snoring child does not exclude clinically significant sleep-disordered breathing (SDB). Habitual snoring has been consistently linked with measurable neurocognitive and behavioral morbidity that is similar to levels measured for obstructive sleep apnea (OSA).2 This of course begs the question that T/A is an appropriate and effective treatment for pediatric snoring. Although limited evidence suggests that T/A is effective in reducing pediatric snoring,3 it may be more treatment than is necessary: other treatments such as topical nasal steroids4 may also be highly effective. Given the scope of the problem, more detailed study in this area should be a public heath priority. Dr Ishman1alsoappropriatelypointsoutotherexisting, imperfect rationales for the prevalent use of preoperative PSG. The clinical tonsil size assessmenthasbeenextensively evaluated and has been shown to have at most a weak association withpediatric SDB severity.5 Thus, if the clinical symptomsof SDBare clearlypresent, theobservationof small tonsils on the physical examination in and of itself should not be considered a reason to doubt the SDBdiagnosis andpursue a PSG. In addition, as a result of thewell-publicized patient safety concerns with codeine after T/A, the widespread use of the combinationof ibuprofenandacetaminophenhasbeenstudiedand hasbeenfoundtobeveryeffective inchildrenafterT/A.6Therefore, seeking a PSG to guide postoperative narcotic usewould seem to be superfluous and unnecessary. Regarding the use of PSG after T/A, ie, the postoperative PSG, Dr Ishman1 clearly points out the central role of PSG in this instance. Adenotonsillectomy is universally considered first-line therapy for uncomplicated pediatric SDB, but it is appropriately pointed out that surgical success is not 100%. Thus, the use of PSG to assess the persistently symptomatic child after surgery for the presence and severity of SDB is likely its most essential role. Moreover, the success rates for surgery in obese and syndromic children are well accepted to be even lower, and the use of postoperative PSG in these cases should be universal. And while the assessment of persistent OSA in the postoperative child is undoubtedly of value, the clinician who orders a postoperative PSG to assess for residual OSA should be forewarned that the treatment of persistent OSA in children is not well described. The potential treatment options of persistent OSA with medical therapy using topical nasal steroids and/or leukotriene inhibitors, continuous positive airway pressure, or other options can be problematic in terms of compliance and the absence of long-term outcomes data. Overall, thewidespreadprevalenceofpediatricSDBshould not translate intowidespreaduseofpediatricPSGwithout first careful contemplation of what the true benefits and limitations of its use in each instance will bring to physicians and patients in specific settings. In most cases, preoperative use of PSG should be quite limited andwould ideally beusedonly to inform true diagnostic uncertainty and/or to assess preoperative risk when indicated (eg, bleeding dyscrasias or anesthetic risk). Postoperative use of PSG likely provides much greater yield and contribution to clinical decisionmaking for thepersistently symptomatic child.Moreover, it shouldbeconsideredauniversal part of thepostoperative follow-upplan for high-risk pediatric patients with obesity and/or craniofacial syndromes.Of interest for the future,pediatrichomesleeptesting may become a viable alternative to PSG that could providemore readily available, cost-effective data for the evaluating clinician.