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Laryngoscope. 2013 Jul;123(7):1817-22. doi: 10.1002/lary.23925. Epub 2013 Mar 27.

A pilot staging system to predict persistent obstructive sleep apnea in children following adenotonsillectomy.

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Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.



A recent meta-analysis by Friedman et al. found that 66% of children have resolution of obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy (TA). However, accurate predictors of persistent OSA in children despite surgery are difficult to identify. We evaluate the utility of staging children with OSA using characteristics predictive of adult palatoplasty success.


A retrospective analysis of children who underwent sleep studies before and after TA in a tertiary care center from 2008 through 2011.


Tonsil size (TS)/modified Mallampati position score (MMP)/body mass index (BMI) z Score were used to categorize patients into a three- and four-stage tonsillectomy staging system. Stage 1 included patients with low MMP scores/large tonsils; stage 2 with low MMP scores/small tonsils or high MMP scores/large tonsils. Stage 3 included patients with high MMP scores/small tonsils. For the four-stage system, any patient with a BMI z Score ≥2.0 was stage 4.


Thirty-five patients (14 females) were included (mean age, 6.8 years; range, 1.0-18.6 years). OSA severity ranged from mild (n = 6), moderate (n = 10), to severe (n = 19), with a mean respiratory disturbance index (RDI) of 20.9 before surgery and 2.4 after. Similar to results seen for adult palatoplasty, staging by TS/MMP/BMI corresponded with response to surgery. In stage 1 to 2, 11/17 (64.7%) children had RDI <1.5 postoperatively, with decreasing TA success rates in stages 3 to 4 at 10/18 (55.5%). Although these results were not statistically significant (P = .14), the trend was similar to the adult analysis.


A trend toward a dose-response relationship was seen between physical exam staging and persistent OSA after TA. Further data collection and analysis with a larger sample size are warranted.

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