European Archives of Oto-Rhino-Laryngology

, Volume 276, Issue 7, pp 2097–2104 | Cite as

Obstructive sleep apnea in 2–6 year old children referred for adenotonsillectomy

  • Britt ØverlandEmail author
  • Hanne Berdal
  • Harriet Akre



Adenotonsillectomy is one of the most common surgical procedures performed in children. The indications for surgery are either frequent recurrent throat infections or hypertrophy of the tonsils/adenoid vegetation, which can cause obstructive sleep apnea (OSA). There is disagreement regarding the need for sleep studies before adenotonsillectomy to confirm a diagnosis of OSA. Several studies have evaluated questionnaires and physical examination as tools to identify OSA, with conflicting results. The aim of this study was to evaluate the prevalence of OSA among children referred for adenotonsillectomy and whether questionnaires or physical examination can help identify OSA.


This is a prospective cohort study of children aged 2–6 years, referred for adenotonsillectomy. Polysomnography and an otorhinological examination were performed. Tonsillar size and the oral cavity were graded using Friedman’s classification and Mallampati score, respectively. The Pediatric Sleep Questionnaire (PSQ) and OSA-18 were also completed.


100 children were included. The prevalence of OSA was 87%, with 52% having moderate to severe OSA. The usefulness of the PSQ and OSA-18 for detecting OSA was evaluated using multiple cutoff points, but none yielded acceptable values for both sensitivity and specificity. In logistic regression analyses predicting different levels of OSA severity, age, Friedman tonsillar size and Mallampati score were weakly associated with OSA.


The prevalence of OSA is high among children referred for adenotonsillectomy and questionnaires and clinical characteristics are not sensitive enough to detect the presence or severity of OSA.


Obstructive sleep apnea Pediatrics Adenotonsillectomy 


Compliance with ethical standards

Conflict of interest

Author B. Ø.: declares that se has no conflict of interest. Author H.B.: declares that se has no conflict of interest. Author H. A.: declares that se has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the national research committee and with the 1964 Helsinki declaration and is later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all participants included in the study.


  1. 1.
    Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM (2011) Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 144(1 Suppl):S1–S30. CrossRefGoogle Scholar
  2. 2.
    Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130(3):576–584. CrossRefGoogle Scholar
  3. 3.
    Brietzke SE, Katz ES, Roberson DW (2004) Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/hypopnea syndrome? A systematic review of the literature. Otolaryngol Head Neck Surg 131(6):827–832. CrossRefGoogle Scholar
  4. 4.
    Rosen CL (1999) Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children. Pediatr Pulmonol 27(6):403–409CrossRefGoogle Scholar
  5. 5.
    Suen JS, Arnold JE, Brooks LJ (1995) Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg 121(5):525–530CrossRefGoogle Scholar
  6. 6.
    Brietzke SE, Gallagher D (2006) The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg 134(6):979–984. CrossRefGoogle Scholar
  7. 7.
    Friedman M, Wilson M, Lin HC, Chang HW (2009) Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140(6):800–808. CrossRefGoogle Scholar
  8. 8.
    Amin R, Anthony L, Somers V, Fenchel M, McConnell K, Jefferies J, Willging P, Kalra M, Daniels S (2008) Growth velocity predicts recurrence of sleep-disordered breathing 1 year after adenotonsillectomy. Am J Respir Crit Care Med 177(6):654–659. CrossRefGoogle Scholar
  9. 9.
    Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D (2010) Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 182(5):676–683. CrossRefGoogle Scholar
  10. 10.
    Mitchell RB, Kelly J (2004) Outcome of adenotonsillectomy for severe obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol 68(11):1375–1379. CrossRefGoogle Scholar
  11. 11.
    Mitchell RB, Kelly J (2007) Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children. Otolaryngol Head Neck Surg 137(1):43–48. CrossRefGoogle Scholar
  12. 12.
    Brown KA, Morin I, Hickey C, Manoukian JJ, Nixon GM, Brouillette RT (2003) Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative respiratory morbidity. Anesthesiology 99(3):586–595CrossRefGoogle Scholar
  13. 13.
    Gerber ME, O’Connor DM, Adler E, Myer CM 3rd (1996) Selected risk factors in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg 122(8):811–814CrossRefGoogle Scholar
  14. 14.
    Lalakea ML, Marquez-Biggs I, Messner AH (1999) Safety of pediatric short-stay tonsillectomy. Arch Otolaryngol Head Neck Surg 125(7):749–752CrossRefGoogle Scholar
  15. 15.
    McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM (1992) Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 118(9):940–943CrossRefGoogle Scholar
  16. 16.
    Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C (1994) Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated? Pediatrics 93(5):784–788Google Scholar
  17. 17.
    Mitchell RB, Pereira KD, Friedman NR (2006) Sleep-disordered breathing in children: survey of current practice. Laryngoscope 116(6):956–958. CrossRefGoogle Scholar
  18. 18.
    Weatherly RA, Mai EF, Ruzicka DL, Chervin RD (2003) Identification and evaluation of obstructive sleep apnea prior to adenotonsillectomy in children: a survey of practice patterns. Sleep Med 4(4):297–307CrossRefGoogle Scholar
  19. 19.
    American Thoracic Society (1996) Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med 153(2):866–878. CrossRefGoogle Scholar
  20. 20.
    Clinical Practice Guideline (2002) Diagnosis and management of childhood obstructive sleep apnea syndrome Pediatrics 109(4):704–712CrossRefGoogle Scholar
  21. 21.
    Nath Zallek S, Chervin RD (2000) Improvement in cluster headache after treatment for obstructive sleep apnea. Sleep Med 1(2):135–138CrossRefGoogle Scholar
  22. 22.
    Paradise JL (1996) Tonsillectomy and adenoidectomy. Pediatric otolaryngology, 4th edn. Saunders, PhiladelphiaGoogle Scholar
  23. 23.
    World Health Organization WHO Global Database on Child Growth and Malnutrition. Accessed 27 May 2018
  24. 24.
    Friedman M, Ibrahim H, Joseph NJ (2004) Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 114(3):454–459. CrossRefGoogle Scholar
  25. 25.
    Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL (1985) A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 32(4):429–434CrossRefGoogle Scholar
  26. 26.
    Chervin RD, Hedger K, Dillon JE, Pituch KJ (2000) Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med 1(1):21–32CrossRefGoogle Scholar
  27. 27.
    Franco RA Jr, Rosenfeld RM, Rao M (2000) First place–resident clinical science award 1999. Quality of life for children with obstructive sleep apnea. Otolaryngol Head Neck Surg 123(1 Pt 1):9–16. CrossRefGoogle Scholar
  28. 28.
    Berry RBBR, Gamaldo CE, Harding SM, Marcus CL, Vaughn BV (eds) (2012) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, version 2.0. American Academy of Sleep Medicine, DarienGoogle Scholar
  29. 29.
    American Academy of Sleep Medicine (2014) International classification of sleep disorders, 3rd edn. American Acedemy of Sleep Medicine, DarienGoogle Scholar
  30. 30.
    Redline S, Amin R, Beebe D, Chervin RD, Garetz SL, Giordani B, Marcus CL, Moore RH, Rosen CL, Arens R, Gozal D, Katz ES, Mitchell RB, Muzumdar H, Taylor HG, Thomas N, Ellenberg S (2011) The childhood adenotonsillectomy trial (CHAT): rationale, design, and challenges of a randomized controlled trial evaluating a standard surgical procedure in a pediatric population. Sleep 34(11):1509–1517. CrossRefGoogle Scholar
  31. 31.
    Rosen CL, Larkin EK, Kirchner HL, Emancipator JL, Bivins SF, Surovec SA, Martin RJ, Redline S (2003) Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. J Pediatr 142(4):383–389. CrossRefGoogle Scholar
  32. 32.
    Tamanyan K, Walter LM, Davey MJ, Nixon GM, Horne RS, Biggs SN (2016) Risk factors for obstructive sleep apnoea in Australian children. J Paediatr Child Health 52(5):512–517. CrossRefGoogle Scholar
  33. 33.
    Certal V, Catumbela E, Winck JC, Azevedo I, Teixeira-Pinto A, Costa-Pereira A (2012) Clinical assessment of pediatric obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 122(9):2105–2114. CrossRefGoogle Scholar
  34. 34.
    Mitchell RB, Garetz S, Moore RH, Rosen CL, Marcus CL, Katz ES, Arens R, Chervin RD, Paruthi S, Amin R, Elden L, Ellenberg SS, Redline S (2015) The use of clinical parameters to predict obstructive sleep apnea syndrome severity in children: the Childhood Adenotonsillectomy (CHAT) study randomized clinical trial. JAMA Otolaryngol Head Neck Surg 141(2):130–136. CrossRefGoogle Scholar
  35. 35.
    Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G (1999) Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med 159(5 Pt 1):1527–1532. CrossRefGoogle Scholar
  36. 36.
    Goodwin JL, Kaemingk KL, Fregosi RF, Rosen GM, Morgan WJ, Sherrill DL, Quan SF (2003) Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children—the Tucson Children’s Assessment of Sleep Apnea study (TuCASA). Sleep 26(5):587–591CrossRefGoogle Scholar
  37. 37.
    Jeans WD, Fernando DC, Maw AR, Leighton BC (1981) A longitudinal study of the growth of the nasopharynx and its contents in normal children. Br J Radiol 54(638):117–121. CrossRefGoogle Scholar
  38. 38.
    Howard NS, Brietzke SE (2009) Pediatric tonsil size: objective vs subjective measurements correlated to overnight polysomnogram. Otolaryngol Head Neck Surg 140(5):675–681. CrossRefGoogle Scholar
  39. 39.
    Nolan J, Brietzke SE (2011) Systematic review of pediatric tonsil size and polysomnogram-measured obstructive sleep apnea severity. Otolaryngol Head Neck Surg 144(6):844–850. CrossRefGoogle Scholar
  40. 40.
    Tang A, Benke JR, Cohen AP, Ishman SL (2015) Influence of tonsillar size on OSA improvement in children undergoing adenotonsillectomy. Otolaryngol Head Neck Surg 153(2):281–285. CrossRefGoogle Scholar
  41. 41.
    Bixler EO, Vgontzas AN, Lin HM, Liao D, Calhoun S, Vela-Bueno A, Fedok F, Vlasic V, Graff G (2009) Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep 32(6):731–736CrossRefGoogle Scholar
  42. 42.
    Guilleminault C, Huang YS, Glamann C, Li K, Chan A (2007) Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey. Otolaryngol Head Neck Surg 136(2):169–175. CrossRefGoogle Scholar
  43. 43.
    Kumar HV, Schroeder JW, Gang Z, Sheldon SH (2014) Mallampati score and pediatric obstructive sleep apnea. J Clin Sleep Med 10(9):985–990. Google Scholar
  44. 44.
    Kohler M, Lushington K, Couper R, Martin J, van den Heuvel C, Pamula Y, Kennedy D (2008) Obesity and risk of sleep related upper airway obstruction in Caucasian children. J Clin Sleep Med 4(2):129–136Google Scholar
  45. 45.
    Weinstock TG, Rosen CL, Marcus CL, Garetz S, Mitchell RB, Amin R, Paruthi S, Katz E, Arens R, Weng J, Ross K, Chervin RD, Ellenberg S, Wang R, Redline S (2014) Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates. Sleep 37(2):261–269. CrossRefGoogle Scholar
  46. 46.
    Hrubos-Strom H, Randby A, Namtvedt SK, Kristiansen HA, Einvik G, Benth J, Somers VK, Nordhus IH, Russell MB, Dammen T, Omland T, Kvaerner KJ (2011) A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP). J Sleep Res 20(1 Pt 2):162–170. CrossRefGoogle Scholar
  47. 47.
    Baldassari CM, Alam L, Vigilar M, Benke J, Martin C, Ishman S (2014) Correlation between REM AHI and quality-of-life scores in children with sleep-disordered breathing. Otolaryngol Head Neck Surg 151(4):687–691. CrossRefGoogle Scholar
  48. 48.
    Ishman SL, Yang CJ, Cohen AP, Benke JR, Meinzen-Derr JK, Anderson RM, Madden ME, Tabangin ME (2015) Is the OSA-18 predictive of obstructive sleep apnea: comparison to polysomnography. Laryngoscope 125(6):1491–1495. CrossRefGoogle Scholar
  49. 49.
    Kobayashi R, Miyazaki S, Karaki M, Hoshikawa H, Nakata S, Hara H, Kodama S, Kikuchi A, Kitamura T, Mori N (2014) Evaluation of adenotonsillectomy and tonsillectomy for pediatric obstructive sleep apnea by rhinomanometry and the OSA-18 questionnaire. Acta Otolaryngol 134(8):818–823. CrossRefGoogle Scholar
  50. 50.
    Bertran K, Mesa T, Rosso K, Krakowiak MJ, Pincheira E, Brockmann PE (2015) Diagnostic accuracy of the Spanish version of the pediatric sleep questionnaire for screening of obstructive sleep apnea in habitually snoring children. Sleep Med 16(5):631–636. CrossRefGoogle Scholar
  51. 51.
    Certal V, Silva H, Carvalho C, Costa-Pereira A, Azevedo I, Winck J, Capasso R, Camacho M (2015) Model for prediction of pediatric OSA: proposal for a clinical decision rule. Laryngoscope 125(12):2823–2827. CrossRefGoogle Scholar
  52. 52.
    Pena-Zarza JA, Osona-Rodriguez de Torres B, Gil-Sanchez JA, Figuerola-Mulet J (2012) Utility of the pediatric sleep questionnaire and pulse oximetry as screening tools in pediatric patients with suspected obstructive sleep apnea syndrome. Sleep Disord 2012:819035. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Pediatric and Adult Sleep Disorder ClinicLovisenberg Diaconal HospitalOsloNorway
  2. 2.Department of Otorhinolaryngology/Head and Neck SurgeryOslo University HospitalOsloNorway
  3. 3.Institute of Clinical MedicineUniversity of OsloOsloNorway

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