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The Laryngoscope
V
C
2016 The American Laryngological,
Rhinological and Otological Society, Inc.
Polysomnographic Outcomes Following Lingual Tonsillectomy for
Persistent Obstructive Sleep Apnea in Down Syndrome
J. Drew Prosser, MD; Sally R. Shott, MD; Oscar Rodriguez, MD; Narong Simakajornboon, MD;
Jareen Meinzen-Derr, PhD; Stacey L. Ishman, MD, MPH
Objectives/Hypothesis:
Lingual tonsil hypertrophy is a common cause of persistent airway obstruction in patients with
Down syndrome (DS) following adenotonsillectomy (T&A); however, little is known about the effect of lingual tonsillectomy
(LT) on polysomnographic outcomes in these patients. Our objective was to describe changes in sleep-related respiratory out-
comes following LT in children with DS and persistent obstructive sleep apnea (OSA) following T&A.
Study Design:
Retrospective case series.
Methods:
We included all children with DS who underwent polysomnography before and after LT at a tertiary care cen-
ter from 2003 to 2013. Nonparametric analysis of variables was performed.
Results:
Forty patients with DS underwent LT; 21 met inclusion criteria. The mean age at surgery was 9.3
6
4.3 years
and 47.6% were female. The median apnea-hypopnea index (AHI) was 9.1 events/hour (range, 3.8 to 43.8 events/hour)
before surgery and 3.7 events/hour (range, 0.5 to 24.4 events/hour) after surgery. The median improvement in overall AHI
and the obstructive AHI (oAHI) were 5.1 events/hour (range,
2
2.9 to 41) and 5.3 events/hour (range,
2
2.9 to 41), respec-
tively (
P
<
.0001). The mean oxygen saturation nadir improved from 84% to 89% (
P
5
.004). The mean time with CO
2
>
50
mm Hg, central index, and percentage of rapid eye movement sleep were not significantly different. After surgery, the oAHI
was
<
5 events/hour in 61.9% and 1 in 19% of patients.
Conclusions:
In children with DS, persistent OSA after T&A and lingual tonsil hypertrophy, LT significantly improved
AHI, oAHI, and O
2
saturation nadir. We recommend that children with DS should be evaluated for lingual tonsil hypertrophy
if found to have persistent OSA following T&A.
Key Words:
Obstructive sleep apnea, Down syndrome, lingual tonsil hypertrophy, lingual tonsillectomy.
Level of Evidence:
4
Laryngoscope
, 00:000–000, 2016
INTRODUCTION
Obstructive sleep apnea (OSA) is a sleep-related
breathing disorder associated with significant morbidity
in children, including impaired memory, behavioral dis-
turbances, attention deficit and hyperactivity disorder,
and cardiovascular disease.
1,2
Althoughe the prevalence
of OSA in the general pediatric population is low
(approximately 1%–2%), the prevalence is much higher
in children with Down syndrome (DS), where an esti-
mated 40% to 80% are affected.
3,4
Adenotonsillectomy
(T&A) is the first-line treatment in children with OSA;
however, persistent OSA is common after surgery in
children with DS. Studies have shown that in children
with DS, T&A results in resolution of OSA, with an
obstructive AHI 1 event/hour, in only 16% to 33% of
those treated.
5,6
Several factors have been implicated in the patho-
genesis of persistent OSA in patients with DS. These
include muscular hypotonia as well as anatomic features
such as macroglossia, relative glossoptosis, midface
hypoplasia, hypopharyngeal collapse, and lingual tonsil
hypertrophy.
7
Anatomic studies have shown lingual ton-
sil hypertrophy to be significantly more common in chil-
dren with DS than in controls, with almost 35% of
children with persistent OSA and DS reported to have
lingual tonsil hypertrophy, compared to 3% of the gener-
al pediatric population.
8,9
Lingual tonsillectomy (LT) has been shown to
improve OSA in patients with lingual tonsil hypertrophy
and persistent OSA after T&A.
10
Despite evidence that
lingual tonsil hypertrophy plays a significant role in the
persistence or recurrent of pediatric OSA, and the recog-
nition that this finding is more prevalent in patients
with DS than in children without comorbidities, no
Additional Supporting Information may be found in the online
version of this article.
From the Department of Otolaryngology–Head and Neck Surgery
(
J
.
D
.
P
.), Georgia Regents University, Augusta, Georgia; Division of Pediat-
ric Otolaryngology–Head and Neck Surgery (
S
.
R
.
S
.,
S
.
L
.
I
.), Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio; Department of
Otolaryngology–Head and Neck Surgery (
S
.
R
.
S
.,
S
.
L
.
I
.), University of Cin-
cinnati College of Medicine, Cincinnati, Ohio; Department of Pediatric
Pulmonary and Sleep Medicine (
O
.
R
.), University of Mississippi Medical
Center, Jackson, Mississippi; Division of Pulmonary and Sleep Medicine
(
N
.
S
.,
S
.
L
.
I
.), Cincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio; Division of Biostatistics and Epidemiology (
J
.
M
.-
D
.), Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio, U.S.A.
Editor’s Note: This Manuscript was accepted for publication June
28, 2016.
Presented at the Triological Society Combined Sections Meeting,
Miami, Florida, U.S.A., January 22–24, 2016.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Stacey L. Ishman, MD, Cincinnati Child-
ren’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2018, Cincin-
nati, Ohio 45229. E-mail:
stacey.ishman@cchmc.orgDOI: 10.1002/lary.26202
Prosser et al.: PSG Outcomes of Lingual Tonsillectomy in DS
Reprinted by permission of Laryngoscope. 2017; 127(2):520-524.
78