Adenotonsillectomy in Pediatric OSA: Time to Look Elsewhere

Abstract

Purpose of Review: The treatment options for pediatric OSA have expanded significantly over the past decade. While adenotonsillectomy (T&A) remains the first line of treatment and the intervention of choice for many patients, this review aims to highlight the limitations of T&A and reposition its role in the therapeutic schema by examining the increasing range of alternative options that have become available. Recent Findings: Among the alternative treatment options of pediatric OSA, we should include anti-inflammatory medical therapy (montelukast and nasal steroids), respiratory support such as continuous positive airway pressure (CPAP) therapy or high flow nasal cannula therapy, newer complementary therapies, such as myofunctional re-education, and anatomically site-specific therapy, such as orthodontic treatment and intra-oral appliances. In addition, beneficial lifestyle interventions, such as weight loss in obese children, also need to be addressed. Summary: There is no doubt that the definitive nature of T&A surgery still makes it the intervention of choice for many children with OSA, but not all. In addition, T&A is fraught with a relatively high risk of residual OSA, such that a more nuanced approach, better tailored to individual needs, should be contemplated in the context of the emerging options. We propose an algorithm on when to consider the use of alternative therapies to T&A, and which therapies to trial and when.