By William Wood, MD
The most common reason for a child’s family to consider tonsil & adenoid surgery is obstructive sleep apnea (OSA). The American Academy of Pediatrics (AAP) published a guideline in 2002 stating that tonsil and adenoid surgery “is the first line of treatment for most children” who have been diagnosed with OSA.
But just what is OSA, and why does it matter, in kids?
If a child pauses for two full breathing cycles while asleep, that is abnormal, and should be discussed with the child’s physician. (Adults can pause for longer, and still have normal sleep.) A child might breathe, on average, roughly 20+ times per minute, or every three seconds or so. This varies by child.
So, a pause in breathing for two cycles might last, for example, roughly six seconds. That is apnea.
In kids, apnea is usually from obstruction, or blockage of the airway, and this is usually from large adenoids and tonsils. That is OSA. OSA and snoring can be related, but are different entities.
Most otolaryngologists or ear/nose/throat surgeons (“ENTs”), by the way, including me, are not sleep experts. Most ENTs offer some treatments for apnea, though, including tonsil and adenoid surgery.
I recently spoke by phone with Dr. Stacy Ishman, a pediatric otolaryngologist at Johns Hopkins. In addition to being an ENT surgeon, she is also board certified in sleep medicine. She is a bona fide sleep expert, in other words, having passed a rigorous test on the subject, after extensive training in that area of medicine.
In a recent article written for other physicians, she wrote, in reviewing many detailed studies, that “untreated OSA is associated with a number of [problems],” including trouble thinking clearly, hyperactivity, and heart problems, among other issues.
What sleep experts term “sleep disordered breathing” (SDB) includes both OSA and snoring. Dr. Ishman noted a study that found that “school performance has been shown to improve after treatment of SDB” with surgery. In our phone conversation, she noted that she does recommend surgery for some children who have snoring, without frank apnea, if they have other significant symptoms.
Sometimes parents give me the impression that they definitely know their child is pausing in their breathing for significant periods — they have no doubt. Parents may report that these pauses alarm other caregivers (grandparents, child care providers, etc.). In that case, after an exam and discussion, I sometimes recommend considering “partial” tonsillotomy, and adenoidectomy.
Other times, a parent is aware of loud snoring, but isn’t sure a child is actually pausing. I then usually recommend a formal sleep study. The child spends the night in a nice hotel-like room, with a parent, with stickers on their head and chest, to monitor their breathing.
A primary care doctor can order a sleep study, or I can. Then we can discuss whether a child has measurable OSA or SDB. One of the best places in our region for a child sleep study, I’ve found, is in Springfield, Massachusetts, at Baystate.
An overnight sleep study is what experts call the “gold standard.” There is no better test to evaluate for OSA. Specifically, sleep studies are more accurate at diagnosing OSA than just a verbal history and physical exam, performed by a physician like myself.
ENTs generally perform two types of tonsil surgery for OSA in kids: total tonsillectomy and partial tonsillotomy. The AAP published its treatment guideline (noted above) in 2002, before many ENTs offered partial tonsil surgery. Hence, the guideline refers to tonsil-lectomy – removing all of the tonsil tissue, on both sides of the throat.
The partial tonsil-lotomy procedure creates space in the back of the throat, without removing the whole tonsil. This generally causes much less post-operative pain than a total tonsillectomy. The obstructive sleeping pauses usually disappear.
When the whole tonsil is removed, the muscles with which you swallow are raw and exposed. Every swallow hurts, like pushing on a severe bruise, until the mouth lining (pink mucus membrane) regrows over the wound. That usually takes about two weeks.
When I leave part of the tonsil in place, the swallowing muscles aren’t directly exposed. The partial procedure does pose a small risk of tonsil re-growth. In my view, this risk is worth the benefit of greatly reduced pain, for most patients.
Partial tonsillotomy doesn’t yet have as many studies to support it as traditional tonsillectomy, because it is a relatively new procedure. I believe that with time, evidence will show that it provides a better surgical option for many, and perhaps most, kids with OSA.
William Wood, MD is a board-certified Otolaryngologist practicing at Southern Vermont Ear, Nose & Throat Associates, a member of the BMH Physician Group. He can be reached at 802-257-8355.