Tonsil size, a factor in pediatric sleep apnea triage algorithm, Study says

As a result, children may be referred to multiple specialties, such as pediatric sleep medicine and pediatric otolaryngology, resulting in long waitlists.

Hence, a recent study published by D. S. Heath et al in the Journal of Otolaryngology - Head & Neck Surgery have found out that tonsil size was the strongest predictor of adenoidectomy (AT), while oximetry helped stratify individual risk for AT and this can help in triaging the pediatric patients.

The authors further highlighted that children with 2+ tonsil sizes should be triaged to otolaryngology, while the remainder should be referred to a pediatric sleep specialist.

The study used the data from the pediatric OSA clinic to identify predictors of tonsillectomy and/or adenoidectomy (AT). Before being seen in the clinic, parents completed the Pediatric Sleep Questionnaire (PSQ) and screening questionnaires for restless leg syndrome (RLS), nasal rhinitis, and gastroesophageal reflux disease (GERD).

Tonsil size data were obtained from patient charts and graded using the Brodsky-five grade scale. Children completed an overnight oximetry study before being seen in the clinic, and a McGill oximetry score (MOS) was assigned based on the number and depth of oxygen desaturations.

Logistic regression, controlling for otolaryngology physician, was used to identify significant predictors of AT. Three triage algorithms were subsequently generated based on the univariate and multivariate results to predict AT.

From the OSA cohort, there were 469 eligible children, 47% female with a mean age = 8.19 years, out of which 89% of children reported snoring. Significant predictors of AT in univariate analysis included tonsil size and four PSQ questions, (1) struggles to breathe at night, (2) apneas, (3) daytime mouth breathing, and (4) AM dry mouth.

The first triage algorithm, only using the four PSQ questions, had an odds ratio (OR) of 4.02 for predicting AT (sensitivity = 0.28, specificity = 0.91).

Using only tonsil size, the second algorithm had an OR to predict AT of 9.11 (sensitivity = 0.72, specificity = 0.78).

The third algorithm, where MOS was used to stratify risk for AT among those children with 2+ tonsils, had the same OR, sensitivity, and specificity as the tonsil-only algorithm.

As a result, it was concluded that tonsil size was the strongest predictor of AT, while oximetry helped stratify individual risk for AT. The researchers recommend that referral letters for snoring children include graded tonsil size to aid in the triage based on the findings. Furthermore, children with 2+ tonsil sizes should be triaged to otolaryngology, while the remainder should be referred to a pediatric sleep specialist.