Arytenoid obstruction in children with Down's syndrome tied to adenotonsillectomy failure: JAMA

Persistent obstructive sleep apnea after adenotonsillectomy is common in children with Down syndrome or obesity. Arytenoid obstruction may contribute to the higher rate of failure of adenotonsillectomy in children with DS, suggests a study, published in the JAMA Otolaryngology-Head & Neck Surgery on December 03, 2020. 

Persistent obstructive sleep apnea after adenotonsillectomy is common in children with Down syndrome or obesity. Drug-induced sleep endoscopy could help to identify anatomic differences in these patients that might affect surgical decision-making. However, the patterns of collapse during drug-induced sleep endoscopy, differ in children with obesity or children with Down syndrome (DS) compared with children without obesity and DS. For further analysis, researchers of America conducted a study, and assessed drug-induced sleep endoscopy findings in surgically naive children with obstructive sleep apnea with obesity or Down syndrome and compare these findings with children without obesity or Down syndrome.

It was a cross-sectional analysis of data from a prospective cohort study of patients enrolled between May 1, 2015, and December 31, 2019, in an academic tertiary care children's hospital and included a consecutive sample of surgically naive children (age 2-18 years) who underwent drug-induced sleep endoscopy at the time of adenotonsillectomy for sleep-disordered breathing. Researchers included a total of 317 children among which 115 (36%) were controls without obesity or Down syndrome, 179 (56%) had obesity without Down syndrome, and 23 (7%) had Down syndrome. They scored sleep endoscopy findings using the Sleep Endoscopy Rating Scale. They compared ratings at 6 anatomic levels for children with obesity or Down syndrome with controls without obesity or Down syndrome using several measures of effect size (Cohen d, Cramer V, and η2).

Key findings of the study were:

♦ On comparing with controls without obesity or Down syndrome, the researchers found that the children with Down syndrome demonstrated 

∗ Greater overall obstruction (mean sleep endoscopy rating scale total score of 5.6 vs 4.8; Cohen d, 0.46), and 

∗ Greater tonsillar (percentage of complete obstruction: 65% vs 54%), 

∗ Tongue base (percentage of complete obstruction: 26% vs 12%), and 

∗ Arytenoid obstruction (percentage of at least partial obstruction, 35% vs 6%). 

♦They also found that children with obesity had greater tonsillar (percentage of complete obstruction, 74% vs 54%) and less base of tongue obstruction (percentage of complete obstruction, 2% vs 12%) compared with controls.

The authors concluded, " In this cohort study, surgically naive children with obesity with obstructive sleep apnea had predominantly tonsillar obstruction, whereas children with Down syndrome demonstrated greater obstruction of the tonsils, tongue base, and arytenoids compared with controls. Routine drug-induced sleep endoscopy should be considered in surgically naive children with Down syndrome to help inform the surgical plan."

For further information:

https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2773738