Adenotonsillectomy improves behavior in childhood obstructive sleep apnea (CHAT Trial)

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1. Early adenotonsillectomy for children with obstructive sleep apnea was associated with improvements in symptoms, polysomnographic tests, behavior, and quality of life. 

2. Black and obese children treated with adenotonsillectomy showed lower rates of normalization of polysomnographic findings, but still had greater improvement compared to the watchful waiting group. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Adenotonsillar hypertrophy is one of the major risk factors for childhood obstructive sleep apnea, which is associated with numerous adverse health outcomes later in life. The primary treatment is adenotonsillectomy, but the outcomes of this procedure compared to conservative treatment (watchful waiting) have not been clearly evaluated. This study demonstrated that early adenotonsillectomy in school aged children with obstructive sleep apnea is associated with improvements in symptoms, polysomnographic findings, behavior, and quality of life. Because of the higher prevalence in these groups, subgroup analysis was conducted with black and obese children, demonstrating lower polysomnographic normalization. The study was limited by its numerous exclusion criteria, which prevents these results from being generalized to a wider population. Many of the secondary outcomes measures relied on the caretakers’ and teachers’ subjective assessment of behavior and quality of life, which could potentially introduce a source of bias. Finally, the follow-up period was 7 months, which could be too short to fully evaluate a response to the surgery.

Click to read the study in the New England Journal of Medicine

Click to read an accompanying editorial

Relevant Reading: Outcome of Adenotonsillectomy for Obstructive Sleep Apnea in Obese and Normal-Weight Children

In-Depth [randomized controlled trial]: This multicenter study examined 464 children between 5 and 9 years of age with obstructive sleep apnea. Exclusion criteria included prolonged hemoglobin desaturation, treatment with ADHD medication, BMI z-score greater than 3, and coexisting conditions that could exacerbate the obstructive sleep apnea. Eligible patients were randomized to either receive early adenotonsillectomy, or watchful waiting.  Baseline characteristics were similar between both groups. Follow-up evaluation was performed at 7 months. 

There was no significant improvement in attention and executive function from baseline, as measured by Developmental Neuropsychological Assessment. However, secondary measures of behavior and quality of life, as measured by the Conners’ Rating Scale and BRIEF score, were significantly improved in the adenotonsillectomy group, as were reduction of symptoms. Polysomnographic findings were normalized in 79% of children in the adenotonsillectomy group, compared to 46% in the watchful waiting group. In a subgroup analysis of black children and obese children, symptoms and behavior were improved more in the adenotonsillectomy group than the watchful waiting group, but both populations showed lower rates of polysomnographic normalization compared to nonobese children and children of other races (79% and 39% in black children; 67% and 29% in obese children).

By James Jiang and Allen Ho

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