Current Sleep Medicine Reports

, Volume 4, Issue 3, pp 243–253 | Cite as

Adenotonsillectomy in Pediatric OSA: Time to Look Elsewhere

  • Hui-Leng TanEmail author
  • Leila Kheirandish-Gozal
  • David Gozal
Sleep Related Breathing Disorders (L Kheirandish-Gozal, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Sleep Related Breathing Disorders


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.


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.


Pediatric obstructive sleep apnea Adenotonsillectomy Anti-inflammatory therapy Myofunctional therapy Intra-oral appliances CPAP High flow oxygen 


Compliance with Ethical Standards

Conflict of Interest

Hui-Leng Tan declares no conflicts of interest. Leila Kheirandish-Gozal is a section editor for Current Sleep Medicine Reports. David Gozal is a section editor for Current Sleep Medicine Reports.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance

  1. 1.
    •• Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576–84. AAP Consensus Guidelines. CrossRefPubMedGoogle Scholar
  2. 2.
    Pringle MB, Natesh BG, Buchanan EM. National UK survey on the assessment and surgical management of suspected pediatric obstructive sleep apnoea syndrome. Int J Pediatr Otorhinolaryngol. 2013;77(10):1689–96.CrossRefPubMedGoogle Scholar
  3. 3.
    Chen JW, Liao PW, Hsieh CJ, Chen CC, Chiou SJ. Factors associated with changing indications for adenotonsillectomy: a population-based longitudinal study. PLoS One. 2018;13(5):e0193317.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Tauman R, Gulliver TE, Krishna J, Montgomery-Downs HE, O’Brien LM, Ivanenko A, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 2006;149(6):803–808.Google Scholar
  5. 5.
    Venekamp RP, Hearne BJ, Chandrasekharan D, Blackshaw H, Lim J, Schilder AG. Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev. 2015;10:CD011165.Google Scholar
  6. 6.
    Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010;182(5):676–83.CrossRefPubMedGoogle Scholar
  7. 7.
    Cote CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem! Anesth Analg. 2014;118(6):1276–83.CrossRefPubMedGoogle Scholar
  8. 8.
    Goldman JL, Baugh RF, Davies L, Skinner ML, Stachler RJ, Brereton J, et al. Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope. 2013;123(10):2544–53.PubMedGoogle Scholar
  9. 9.
    De Luca CG, Pacheco-Pereira C, Aydinoz S, Bhattacharjee R, Tan HL, Kheirandish-Gozal L, et al. Adenotonsillectomy complications: a meta-analysis. Pediatrics. 2015;136(4):702–18.CrossRefGoogle Scholar
  10. 10.
    Nixon GM, Kermack AS, McGregor CD, Davis GM, Manoukian JJ, Brown KA, et al. Sleep and breathing on the first night after adenotonsillectomy for obstructive sleep apnea. Pediatr Pulmonol. 2005;39(4):332–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Gozal D, Burnside MM. Increased upper airway collapsibility in children with obstructive sleep apnea during wakefulness. Am J Respir Crit Care Med. 2004;169(2):163–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Marcus CL, McColley SA, Carroll JL, Loughlin GM, Smith PL, Schwartz AR. Upper airway collapsibility in children with obstructive sleep apnea syndrome. J Appl Physiol (1985). 1994;77(2):918–24.CrossRefGoogle Scholar
  13. 13.
    Brown KA, Laferriere A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology. 2004;100(4):806–10. discussion 5ACrossRefPubMedGoogle Scholar
  14. 14.
    Waters KA, McBrien F, Stewart P, Hinder M, Wharton S. Effects of OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children. J Appl Physiol (1985). 2002;92(5):1987–94.CrossRefGoogle Scholar
  15. 15.
    Marcus CL, Lutz J, Carroll JL, Bamford O. Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. J Appl Physiol (1985). 1998;84(6):1926–36.CrossRefGoogle Scholar
  16. 16.
    Brooks D, Horner RL, Kimoff RJ, Kozar LF, Render-Teixeira CL, Phillipson EA. Effect of obstructive sleep apnea versus sleep fragmentation on responses to airway occlusion. Am J Respir Crit Care Med. 1997;155(5):1609–17.CrossRefPubMedGoogle Scholar
  17. 17.
    Wang H, Fu Y, Feng Y, Guan J, Yin S. Tonsillectomy versus tonsillotomy for sleep-disordered breathing in children: a meta analysis. PLoS One. 2015;10(3):e0121500.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Ericsson E, Graf J, Lundeborg-Hammarstrom I, Hultcrantz E. Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up. J Otolaryngol Head Neck Surg. 2014;43(1):26.CrossRefPubMedGoogle Scholar
  19. 19.
    Odhagen E, Sunnergren O, Hemlin C, Hessen Soderman AC, Ericsson E, Stalfors J. Risk of reoperation after tonsillotomy versus tonsillectomy: a population-based cohort study. Eur Arch Otorhinolaryngol. 2016;273(10):3263–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Scott JP, Peters-Golden M. Antileukotriene agents for the treatment of lung disease. Am J Respir Crit Care Med. 2013;188(5):538–44.CrossRefPubMedGoogle Scholar
  21. 21.
    Goldbart AD, Goldman JL, Li RC, Brittian KR, Tauman R, Gozal D. Differential expression of cysteinyl leukotriene receptors 1 and 2 in tonsils of children with obstructive sleep apnea syndrome or recurrent infection. Chest. 2004;126(1):13–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Dayyat E, Serpero LD, Kheirandish-Gozal L, Goldman JL, Snow A, Bhattacharjee R, et al. Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009;135(5):1142–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Goldbart AD, Goldman JL, Veling MC, Gozal D. Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005;172(3):364–70.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    •• Kheirandish-Gozal L, Bandla HP, Gozal D. Montelukast for children with obstructive sleep apnea: results of a double-blind, randomized. Placebo-Controlled Trial. Ann Am Thorac Soc. 2016;13(10):1736–41. Randomised double blind, placebo controlled trial of montelukast in the treatment of pediatric OSA. PubMedGoogle Scholar
  25. 25.
    Goldbart AD, Greenberg-Dotan S, Tal A. Montelukast for children with obstructive sleep apnea: a double-blind, placebo-controlled study. Pediatrics. 2012;130(3):e575–80.CrossRefPubMedGoogle Scholar
  26. 26.
    Kheirandish-Gozal L, Serpero LD, Dayyat E, Kim J, Goldman JL, Snow A, et al. Corticosteroids suppress in vitro tonsillar proliferation in children with obstructive sleep apnoea. Eur Respir J. 2009;33(5):1077–84.CrossRefPubMedGoogle Scholar
  27. 27.
    Esteitie R, Emani J, Sharma S, Suskind DL, Baroody FM. Effect of fluticasone furoate on interleukin 6 secretion from adenoid tissues in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2011;137(6):576–82.CrossRefPubMedGoogle Scholar
  28. 28.
    Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics. 2008;122(1):e149–55.CrossRefPubMedGoogle Scholar
  29. 29.
    Gudnadottir G, Ellegard E, Hellgren J. Intranasal budesonide and quality of life in pediatric sleep-disordered breathing: a randomized controlled trial. Otolaryngol Head Neck Surg. 2018;158(4):752–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Chan CC, Au CT, Lam HS, Lee DL, Wing YK, Li AM. Intranasal corticosteroids for mild childhood obstructive sleep apnea--a randomized, placebo-controlled study. Sleep Med. 2015;16(3):358–63.CrossRefPubMedGoogle Scholar
  31. 31.
    Brouillette RT, Manoukian JJ, Ducharme FM, Oudjhane K, Earle LG, Ladan S, et al. Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. J Pediatr. 2001;138(6):838–44.CrossRefPubMedGoogle Scholar
  32. 32.
    •• Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. 2006;117(1):e61–6. Combinational therapy of intranasal steroids and oral leukotriene modifier therapy in the treatment of residual sleep-disordered breathing after adenotonsillectomy. CrossRefPubMedGoogle Scholar
  33. 33.
    Kheirandish-Gozal L, Bhattacharjee R, Bandla HPR, Gozal D. Antiinflammatory therapy outcomes for mild OSA in children. Chest. 2014;146(1):88–95.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    •• Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366–76. The main results of the CHAT study. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Garetz SL, Mitchell RB, Parker PD, Moore RH, Rosen CL, Giordani B, et al. Quality of life and obstructive sleep apnea symptoms after pediatric adenotonsillectomy. Pediatrics. 2015;135(2):e477–86.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Thomas NH, Xanthopoulos MS, Kim JY, Shults J, Escobar E, Giordani B, et al. Effects of adenotonsillectomy on parent-reported behavior in children with obstructive sleep apnea. Sleep. 2017;40(4)Google Scholar
  37. 37.
    Taylor HG, Bowen SR, Beebe DW, Hodges E, Amin R, Arens R, et al. Cognitive effects of adenotonsillectomy for obstructive sleep apnea. Pediatrics. 2016;138(2)Google Scholar
  38. 38.
    Chervin RD, Ellenberg SS, Hou X, Marcus CL, Garetz SL, Katz ES, et al. Prognosis for spontaneous resolution of OSA in children. Chest. 2015;148(5):1204–13.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Marcus CL, Rosen G, Ward SL, Halbower AC, Sterni L, Lutz J, et al. Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea. Pediatrics. 2006;117(3):e442–51.CrossRefPubMedGoogle Scholar
  40. 40.
    Ramirez A, Khirani S, Aloui S, Delord V, Borel JC, Pepin JL, et al. Continuous positive airway pressure and noninvasive ventilation adherence in children. Sleep Med. 2013;14(12):1290–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Riley EB, Fieldston ES, Xanthopoulos MS, Beck SE, Menello MK, Matthews E, et al. Financial analysis of an intensive pediatric continuous positive airway pressure program. Sleep. 2017;40(2)Google Scholar
  42. 42.
    Prashad PS, Marcus CL, Maggs J, Stettler N, Cornaglia MA, Costa P, et al. Investigating reasons for CPAP adherence in adolescents: a qualitative approach. J Clin Sleep Med. 2013;9(12):1303–13.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Xanthopoulos MS, Kim JY, Blechner M, Chang MY, Menello MK, Brown C, et al. Self-efficacy and short-term adherence to continuous positive airway pressure treatment in children. Sleep. 2017;40(7)Google Scholar
  44. 44.
    Marcus CL, Radcliffe J, Konstantinopoulou S, Beck SE, Cornaglia MA, Traylor J, et al. Effects of positive airway pressure therapy on neurobehavioral outcomes in children with obstructive sleep apnea. Am J Respir Crit Care Med. 2012;185(9):998–1003.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Overbergh C, Installe S, Boudewyns A, Van Hoorenbeeck K, Verhulst SL. The Optiflow interface for chronic CPAP use in children. Sleep Med. 2018;44:1–3.CrossRefPubMedGoogle Scholar
  46. 46.
    Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT. Nasal pillows as an alternative interface in patients with obstructive sleep apnoea syndrome initiating continuous positive airway pressure therapy. J Sleep Res. 2011;20(2):367–73.CrossRefPubMedGoogle Scholar
  47. 47.
    Verhulst SL, Franckx H, Van Gaal L, De Backer W, Desager K. The effect of weight loss on sleep-disordered breathing in obese teenagers. Obesity (Silver Spring). 2009;17(6):1178–83.Google Scholar
  48. 48.
    Van Eyck A, De Guchtenaere A, Van Gaal L, De Backer W, Verhulst SL, Van Hoorenbeeck K. Clinical predictors of residual sleep apnea after weight loss therapy in obese adolescents. J Pediatr. 2018;196:189–93 e1.CrossRefPubMedGoogle Scholar
  49. 49.
    Boudewyns A, Abel F, Alexopoulos E, Evangelisti M, Kaditis A, Miano S, et al. Adenotonsillectomy to treat obstructive sleep apnea: Is it enough? Pediatr Pulmonol. 2017;52(5):699–709.CrossRefPubMedGoogle Scholar
  50. 50.
    Kalra M, Inge T, Garcia V, Daniels S, Lawson L, Curti R, et al. Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res. 2005;13(7):1175–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Alqahtani AR, Elahmedi MO, Al Qahtani A. Co-morbidity resolution in morbidly obese children and adolescents undergoing sleeve gastrectomy. Surg Obes Relat Dis. 2014;10(5):842–50.CrossRefPubMedGoogle Scholar
  52. 52.
    Alonso-Alvarez ML, Teran-Santos J, Navazo-Eguia AI, Martinez MG, Jurado-Luque MJ, Corral-Penafiel J, et al. Treatment outcomes of obstructive sleep apnoea in obese community-dwelling children: the NANOS study. Eur Respir J. 2015;46(3):717–27.CrossRefPubMedGoogle Scholar
  53. 53.
    Lee M Jr, Nagler J. High-flow nasal cannula therapy beyond the perinatal period. Curr Opin Pediatr. 2017;29(3):291–6.CrossRefPubMedGoogle Scholar
  54. 54.
    Shetty S, Hickey A, Rafferty GF, Peacock JL, Greenough A. Work of breathing during CPAP and heated humidified high-flow nasal cannula. Arch Dis Child Fetal Neonatal Ed. 2016;101(5):F404–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Wilkinson D, Andersen C, O’Donnell CP, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2016;2:CD006405.PubMedGoogle Scholar
  56. 56.
    Hawkins S, Huston S, Campbell K, Halbower A. High-flow, heated, humidified air via nasal cannula treats cpap-intolerant children with obstructive sleep apnea. J Clin Sleep Med. 2017;13(8):981–9.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    McGinley B, Halbower A, Schwartz AR, Smith PL, Patil SP, Schneider H. Effect of a high-flow open nasal cannula system on obstructive sleep apnea in children. Pediatrics. 2009;124(1):179–88.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Joseph L, Goldberg S, Shitrit M, Picard E. High-flow nasal cannula therapy for obstructive sleep apnea in children. J Clin Sleep Med. 2015;11(9):1007–10.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Roberts SD, Kapadia H, Greenlee G, Chen ML. Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions. J Clin Sleep Med. 2016;12(4):469–75.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018;103(1):F29–35.CrossRefPubMedGoogle Scholar
  61. 61.
    Hegde S, Prodhan P. Serious air leak syndrome complicating high-flow nasal cannula therapy: a report of 3 cases. Pediatrics. 2013;131(3):e939–44.CrossRefPubMedGoogle Scholar
  62. 62.
    Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med. 2013;14(6):518–25.CrossRefPubMedGoogle Scholar
  63. 63.
    Villa MP, Brasili L, Ferretti A, Vitelli O, Rabasco J, Mazzotta AR, et al. Oropharyngeal exercises to reduce symptoms of OSA after AT. Sleep Breath. 2015;19(1):281–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Villa MP, Evangelisti M, Martella S, Barreto M, Del Pozzo M. Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing? Sleep Breath. 2017;21(4):1025–32.CrossRefPubMedGoogle Scholar
  65. 65.
    Huynh NT, Desplats E, Almeida FR. Orthodontics treatments for managing obstructive sleep apnea syndrome in children: a systematic review and meta-analysis. Sleep Med Rev. 2016;25:84–94.CrossRefPubMedGoogle Scholar
  66. 66.
    Guilleminault C, Monteyrol PJ, Huynh NT, Pirelli P, Quo S, Li K. Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study. Sleep Breath. 2011;15(2):173–7.CrossRefPubMedGoogle Scholar
  67. 67.
    Villa MP, Castaldo R, Miano S, Paolino MC, Vitelli O, Tabarrini A, et al. Adenotonsillectomy and orthodontic therapy in pediatric obstructive sleep apnea. Sleep Breath. 2014;18(3):533–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Villa MP, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, et al. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128–34.CrossRefPubMedGoogle Scholar
  69. 69.
    Cozza P, Gatto R, Ballanti F, Prete L. Management of obstructive sleep apnoea in children with modified monobloc appliances. Eur J Paediatr Dent. 2004;5(1):24–9.PubMedGoogle Scholar
  70. 70.
    Hoxha S, Kaya-Sezginer E, Bakar-Ates F, Kokturk O, Toygar-Memikoglu U. Effect of semi-rapid maxillary expansion in children with obstructive sleep apnea syndrome: 5-month follow-up study. Sleep Breath 2018.Google Scholar
  71. 71.
    Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761–6.CrossRefPubMedGoogle Scholar
  72. 72.
    Boudewyns A, Van de Heyning P, Verhulst S. Drug-induced sedation endoscopy in children <2 years with obstructive sleep apnea syndrome: upper airway findings and treatment outcomes. Eur Arch Otorhinolaryngol. 2017;274(5):2319–25.CrossRefPubMedGoogle Scholar
  73. 73.
    Boudewyns A, Saldien V, Van de Heyning P, Verhulst S. Drug-induced sedation endoscopy in surgically naive infants and children with obstructive sleep apnea: impact on treatment decision and outcome. Sleep Breath. 2018;22(2):503–10.CrossRefPubMedGoogle Scholar
  74. 74.
    Amos JM, Durr ML, Nardone HC, Baldassari CM, Duggins A, Ishman SL. Systematic review of drug-induced sleep endoscopy scoring systems. Otolaryngol Head Neck Surg. 2018;158(2):240–8.CrossRefPubMedGoogle Scholar
  75. 75.
    Wilcox LJ, Bergeron M, Reghunathan S, Ishman SL. An updated review of pediatric drug-induced sleep endoscopy. Laryngoscope Investig Otolaryngol. 2017;2(6):423–31.CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    Van Holsbeke C, Vos W, Van Hoorenbeeck K, Boudewyns A, Salgado R, Verdonck PR, et al. Functional respiratory imaging as a tool to assess upper airway patency in children with obstructive sleep apnea. Sleep Med. 2013;14(5):433–9.CrossRefPubMedGoogle Scholar
  77. 77.
    Slaats M, Loterman D, van Holsbeke C, Vos W, Van Hoorenbeeck K, de Backer J, et al. The role of functional respiratory imaging in treatment selection of children with obstructive sleep apnea and down syndrome. J Clin Sleep Med. 2018;14(4):651–9.CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Zeng G, Teng Y, Zhu J, Zhu D, Yang B, Hu L, et al. Clinical application of MRI-respiratory gating technology in the evaluation of children with obstructive sleep apnea hypopnea syndrome. Medicine (Baltimore). 2018;97(4):e9680.CrossRefGoogle Scholar
  79. 79.
    Mahmoud M, Gunter J, Sadhasivam S. Cine MRI airway studies in children with sleep apnea: optimal images and anesthetic challenges. Pediatr Radiol. 2009;39(10):1034–7.CrossRefPubMedGoogle Scholar
  80. 80.
    Shott SR, Donnelly LF. Cine magnetic resonance imaging: evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with Down syndrome. Laryngoscope. 2004;114(10):1724–9.CrossRefPubMedGoogle Scholar
  81. 81.
    Donnelly LF, Shott SR, LaRose CR, Chini BA, Amin RS. Causes of persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy in children with down syndrome as depicted on static and dynamic cine MRI. AJR Am J Roentgenol. 2004;183(1):175–81.CrossRefPubMedGoogle Scholar
  82. 82.
    Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 Suppl):S1–15.CrossRefPubMedGoogle Scholar
  83. 83.
    Pateron B, Marianowski R, Monteyrol PJ, Couloigner V, Akkari M, Chalumeau F et al. French Society of ENT (SFORL) guidelines (short version) on the roles of the various treatment options in childhood obstructive sleep apnea-hypopnea syndrome. Eur Ann Otorhinolaryngol Head Neck Dis 2018.Google Scholar
  84. 84.
    Luz Alonso-Alvarez M, Canet T, Cubell-Alarco M, Estivill E, Fernandez-Julian E, Gozal D, et al. Consensus document on sleep apnea-hypopnea syndrome in children (full version). Sociedad Espanola de Sueno. El Area de Sueno de la Sociedad Espanola de Neumologia y Cirugia Toracica(SEPAR). Arch Bronconeumol. 2011;47(Suppl 5):0, 2–18.CrossRefGoogle Scholar
  85. 85.
    •• Kaditis AG, Alonso Alvarez ML, Boudewyns A, Abel F, Alexopoulos EI, Ersu R, et al. ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children. Eur Respir J. 2017;50(6) ERS consensus guidelines. Google Scholar
  86. 86.
    •• Kaditis AG, Alonso Alvarez ML, Boudewyns A, Alexopoulos EI, Ersu R, Joosten K, et al. Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J. 2016;47(1):69–94. ERS consensus guidelines. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Hui-Leng Tan
    • 1
    Email author
  • Leila Kheirandish-Gozal
    • 2
  • David Gozal
    • 2
  1. 1.Department of Paediatric Respiratory MedicineRoyal Brompton HospitalLondonUK
  2. 2.Sections of Pediatric Sleep Medicine and Pediatric Pulmonology, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences DivisionThe University of ChicagoChicagoUSA

Personalised recommendations