Adenotonsillectomy in obstructive sleep apnea syndrome. Proposal of a surgical decision-taking algorithm.

OBJECTIVE: The incidence of snoring in the pediatric population is 10% and the incidence of OSAS is equal to 2-3%. Sometimes, primary snoring and OSAS overlap and only polysomnography can differentiate the two disorders but its use is complex, expensive and highly controversial. The purpose of this paper is to demonstrate the value of the clinical assessment associated with the patient's history in selecting children with OSAS and to validate the therapeutic algorithm, thereby employing polysomnography only for selected cases.

METHODS: A population of 118 patients was considered, selected by means of a questionnaire that indicated OSAS and a clinical evaluation that confirmed the diagnosis. The studied group underwent clinical assessment complete with fibreoptic survey as well as nocturnal pulse oxymetry, orthodontic and phoniatric evaluation. Regardless of the adenotonsillar size, all the selected children underwent adenotonsillectomy and were evaluated after 3 months with the help of a questionnaire, ORL examination and nocturnal pulse oxymetry.

RESULTS: In all the patients we witnessed the disappearance of apnea. A 80.5% of children benefited from the surgical procedure. A 12.7% continued to present minor symptoms. A 6.8% continued to snore in a discontinuous manner, but without apnea: these children were re-assessed after a further 6 months with nocturnal pulse oxymetry and no oxymetric alteration was demonstrated. There were no significant differences between the degree of upper airway obstruction and the surgical outcome.

CONCLUSION: The history and clinical exam are sensitive tools, even though relatively aspecific. Our results confirm the validity of the history and clinical exam as a screening method as well as the role of the surgical procedure that can re-establish the patency of the upper airways and to contrast the neuromuscular hypotonia as a result of the effect of the surgical scar. If it is true that primary snoring and OSAS are a continuum, our approach regarding surgery may be defined as a form of prevention regarding a pathology with potential complications. Polysomnography cannot be carried out routinely due to the lack of specialised centres and because of its excessive cost. It is an option to be used only in unsuccessful adenotonsillectomies and for those children who have complicated presentations from the outset.