Polysomnography outcomes of sleep endoscopy–directed intervention in surgically naïve children at risk for persistent obstructive sleep apnea

  • Erin KirkhamEmail author
  • Cheng-Cheng Ma
  • Natalia Filipek
  • David L. Horn
  • Kaalan Johnson
  • Maida L. Chen
  • Sanjay R. Parikh
ENT • Original Article



Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naïve children is unclear. We report polysomnography outcomes of surgically naïve children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy.


This study is a case series of 62 surgically naïve children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test.


Children were on average 5.9 (± 5.5, 0.2–18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7 years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p < 0.01) and oxygen nadir (82 to 87, p < 0.01). Thirty-eight (61%) had a postoperative oAHI < 5; 16 (21%) had a postoperative oAHI < 2.


DISE resulted in intervention other than AT in 58% of surgically naïve children at high risk for persistent OSA after AT. DISE-directed intervention resulted in significant mean improvement in postoperative OSA.


Sleep endoscopy DISE Pediatric Sleep apnea 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

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


  1. 1.
    Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D (2008) Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proc Am Thorac Soc 5(2):274–282. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Imanguli M, Ulualp SO (2016) Risk factors for residual obstructive sleep apnea after adenotonsillectomy in children. Laryngoscope 126(11):2624–2629. CrossRefPubMedGoogle Scholar
  3. 3.
    Bixler EO, Vgontzas AN, Lin HM, Liao D, Calhoun S, Fedok F, Vlasic V, Graff G (2008) Blood pressure associated with sleep-disordered breathing in a population sample of children. Hypertension 52(5):841–846CrossRefGoogle Scholar
  4. 4.
    Galland BC, Tripp EG, Gray A, Taylor BJ (2011) Apnea-hypopnea indices and snoring in children diagnosed with ADHD: a matched case-control study. Sleep Breath 15(3):455–462. CrossRefPubMedGoogle Scholar
  5. 5.
    Stillwell PC, Chapman DL, Ward SLD, Howenstine M, Light MJ, McColley SA, Schaeffer DA, Wagener JS (2002) Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 109(4):704–712CrossRefGoogle Scholar
  6. 6.
    Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, Mitchell RB, Amin R, Katz ES, Arens R, Paruthi S, Muzumdar H, Gozal D, Thomas NH, Ware J, Beebe D, Snyder K, Elden L, Sprecher RC, Willging P, Jones D, Bent JP, Hoban T, Chervin RD, Ellenberg SS, Redline S, Childhood Adenotonsillectomy T (2013) A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 368(25):2366–2376. CrossRefPubMedPubMedCentralGoogle 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. CrossRefPubMedGoogle Scholar
  8. 8.
    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. CrossRefPubMedGoogle Scholar
  9. 9.
    Mitchell RB (2007) Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope 117(10):1844–1854. CrossRefPubMedGoogle 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. CrossRefPubMedGoogle Scholar
  11. 11.
    Mitchell RB, Kelly J (2004) Adenotonsillectomy for obstructive sleep apnea in obese children. Otolaryngol Head Neck Surg 131(1):104–108. CrossRefPubMedGoogle Scholar
  12. 12.
    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. CrossRefPubMedGoogle Scholar
  13. 13.
    Mitchell RB, Boss EF (2009) Pediatric obstructive sleep apnea in obese and normal-weight children: impact of adenotonsillectomy on quality-of-life and behavior. Dev Neuropsychol 34(5):650–661. CrossRefPubMedGoogle Scholar
  14. 14.
    Lennon CJ, Wang RY, Wallace A, Chinnadurai S (2017) Risk of failure of adenotonsillectomy for obstructive sleep apnea in obese pediatric patients. Int J Pediatr Otorhinolaryngol 92:7–10. CrossRefPubMedGoogle Scholar
  15. 15.
    Nino G, Gutierrez MJ, Ravindra A, Nino CL, Rodriguez-Martinez CE (2012) Abdominal adiposity correlates with adenotonsillectomy outcome in obese adolescents with severe obstructive sleep apnea. Pulm Med 2012:351037. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Thottam PJ, Trivedi S, Siegel B, Williams K, Mehta D (2015) Comparative outcomes of severe obstructive sleep apnea in pediatric patients with trisomy 21. Int J Pediatr Otorhinolaryngol 79(7):1013–1016. CrossRefPubMedGoogle Scholar
  17. 17.
    Maris M, Verhulst S, Wojciechowski M, Van de Heyning P, Boudewyns A (2017) Outcome of adenotonsillectomy in children with Down syndrome and obstructive sleep apnoea. Arch Dis Child 102(4):331–336.,351 CrossRefPubMedGoogle Scholar
  18. 18.
    Shete MM, Stocks RM, Sebelik ME, Schoumacher RA (2010) Effects of adeno-tonsillectomy on polysomnography patterns in Down syndrome children with obstructive sleep apnea: a comparative study with children without Down syndrome. Int J Pediatr Otorhinolaryngol 74(3):241–244. CrossRefPubMedGoogle Scholar
  19. 19.
    Amonoo-Kuofi K, Phillips SP, Randhawa PS, Lane R, Wyatt ME, Leighton SE (2009) Adenotonsillectomy for sleep-disordered breathing in children with syndromic craniosynostosis. J Craniofac Surg 20(6):1978–1980. CrossRefPubMedGoogle Scholar
  20. 20.
    Mitchell RB, Kelly J (2005) Outcome of adenotonsillectomy for obstructive sleep apnea in children under 3 years. Otolaryngol Head Neck Surg 132(5):681–684. CrossRefPubMedGoogle Scholar
  21. 21.
    Willington AJ, Ramsden JD (2012) Adenotonsillectomy for the management of obstructive sleep apnea in children with congenital craniosynostosis syndromes. J Craniofac Surg 23(4):1020–1022. CrossRefPubMedGoogle Scholar
  22. 22.
    Lin AC, Koltai PJ (2009) Persistent pediatric obstructive sleep apnea and lingual tonsillectomy. Otolaryngol Head Neck Surg 141(1):81–85. CrossRefPubMedGoogle Scholar
  23. 23.
    Mase CA, Chen ML, Horn DL, Parikh SR (2015) Supraglottoplasty for sleep endoscopy diagnosed sleep dependent laryngomalacia. Int J Pediatr Otorhinolaryngol 79(4):511–515. CrossRefPubMedGoogle Scholar
  24. 24.
    Fishman G, Zemel M, DeRowe A, Sadot E, Sivan Y, Koltai PJ (2013) Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: inter-observer correlation and comparison with awake endoscopy. Int J Pediatr Otorhinolaryngol 77(5):752–755. CrossRefPubMedGoogle Scholar
  25. 25.
    Ulualp SO, Szmuk P (2013) Drug-induced sleep endoscopy for upper airway evaluation in children with obstructive sleep apnea. Laryngoscope 123(1):292–297. CrossRefPubMedGoogle Scholar
  26. 26.
    Gazzaz MJ, Isaac A, Anderson S, Alsufyani N, Alrajhi Y, El-Hakim H (2017) Does drug-induced sleep endoscopy change the surgical decision in surgically naive non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study. J Otolaryngol Head Neck Surg 46(1):12. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Galluzzi F, Pignataro L, Gaini RM, Garavello W (2015) Drug induced sleep endoscopy in the decision-making process of children with obstructive sleep apnea. Sleep Med 16(3):331–335. CrossRefPubMedGoogle Scholar
  28. 28.
    Boudewyns A, Saldien V, Van de Heyning P, Verhulst S (2018) Drug-induced sedation endoscopy in surgically naive infants and children with obstructive sleep apnea: impact on treatment decision and outcome. Sleep Breath 22(2):503–510. CrossRefPubMedGoogle Scholar
  29. 29.
    Boudewyns A, Van de Heyning P, Verhulst S (2017) Drug-induced sedation endoscopy in children < 2 years with obstructive sleep apnea syndrome: upper airway findings and treatment outcomes. Eur Arch Otorhinolaryngol 274(5):2319–2325. CrossRefPubMedGoogle Scholar
  30. 30.
    Boudewyns A, Verhulst S, Maris M, Saldien V, Van de Heyning P (2014) Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome. Sleep Med 15(12):1526–1531. CrossRefPubMedGoogle Scholar
  31. 31.
    Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J (2009) Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381CrossRefGoogle Scholar
  32. 32.
    Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM, American Academy of Sleep M (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 8(5):597–619. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Sheldon SH, Ferber R, Kryger MH (2014) Principles and practice of pediatric sleep medicine. Second edition. Elsevier Saunders, LondonGoogle Scholar
  34. 34.
    Chan DK, Liming BJ, Horn DL, Parikh SR (2014) A new scoring system for upper airway pediatric sleep endoscopy. JAMA Otolaryngol Head Neck Surg 140(7):595–602. CrossRefPubMedGoogle Scholar
  35. 35.
    Maris M, Verhulst S, Saldien V, Van de Heyning P, Wojciechowski M, Boudewyns A (2016) Drug-induced sedation endoscopy in surgically naive children with Down syndrome and obstructive sleep apnea. Sleep Med 24:63–70. CrossRefPubMedGoogle Scholar
  36. 36.
    Truong MT, Woo VG, Koltai PJ (2012) Sleep endoscopy as a diagnostic tool in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 76(5):722–727. CrossRefPubMedGoogle Scholar
  37. 37.
    He S, Peddireddy NS, Smith DF, Duggins AL, Heubi C, Shott SR, Ishman SL (2018) Outcomes of drug-induced sleep endoscopy-directed surgery for pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg 158(3):559–565. CrossRefPubMedGoogle Scholar
  38. 38.
    Bhushan B, Schroeder JW Jr, Billings KR, Giancola N, Thompson DM (2019) Polysomnography outcomes after supraglottoplasty in children with obstructive sleep apnea. Otolaryngol Head Neck Surg 161(4):694–698. CrossRefPubMedGoogle Scholar
  39. 39.
    Farhood Z, Ong AA, Nguyen SA, Gillespie MB, Discolo CM, White DR (2016) Objective outcomes of supraglottoplasty for children with laryngomalacia and obstructive sleep apnea: a meta-analysis. JAMA Otolaryngol Head Neck Surg 142(7):665–671. CrossRefPubMedGoogle Scholar
  40. 40.
    Amin MR, Isaacson G (1997) State-dependent laryngomalacia. Ann Otol Rhinol Laryngol 106(11):887–890. CrossRefPubMedGoogle Scholar
  41. 41.
    Digoy GP, Shukry M, Stoner JA (2012) Sleep apnea in children with laryngomalacia: diagnosis via sedated endoscopy and objective outcomes after supraglottoplasty. Otolaryngol Head Neck Surg 147(3):544–550. CrossRefPubMedGoogle Scholar
  42. 42.
    Camacho M, Dunn B, Torre C, Sasaki J, Gonzales R, Liu SY, Chan DK, Certal V, Cable BB (2016) Supraglottoplasty for laryngomalacia with obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 126(5):1246–1255. CrossRefPubMedGoogle Scholar
  43. 43.
    Bliss M, Yanamadala S, Koltai P (2018) Utility of concurrent direct laryngoscopy and bronchoscopy with drug induced sleep endoscopy in pediatric patients with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 110:34–36. CrossRefPubMedGoogle Scholar
  44. 44.
    Baldassari CM, Mitchell RB, Schubert C, Rudnick EF (2008) Pediatric obstructive sleep apnea and quality of life: a meta-analysis. Otolaryngol Head Neck Surg 138(3):265–273. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Otolaryngology: Head and Neck SurgeryThe University of MichiganAnn ArborUSA
  2. 2.Mott Children’s HospitalUniversity of Michigan Medical CenterAnn ArborUSA
  3. 3.Department of Otolaryngology: Head and Neck SurgeryThe University of Washington School of MedicineSeattleUSA
  4. 4.Seattle Children’s HospitalSeattleUSA
  5. 5.Department of Pulmonary and Sleep MedicineSeattle Children’s HospitalSeattleUSA

Personalised recommendations