ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Adenotonsillectomy Remains the Treatment of Choice for Children with Obstructive Sleep Apnea but Multiple Non-surgical Options Exist for Select Cases
Clinical Question Are nonsurgical treatments, such as leukotriene receptor antagonists (Montelukast) and continuous positive airway pressure (CPAP) therapy, as effective in improving sleep apnea in children as surgical options?
Clinical Bottom Line For children with mild obstructive sleep apnea due to enlarged adenotonsillar hypertrophy, leukotriene receptor antagonists can be considered as a nonsurgical alternative treatment.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 26788489Shokouhi/201560 children with sleep apnea due to adenotonsillar hypertrophyRandomized Controlled Trial
Key resultsSixty children with healthy weights between the ages of 4 and 12 years displaying habitual snoring and grade 3 or greater nasopharynx obstruction upon endoscopy examination and enlarged adenoids as seen on radiographs were chosen. The 60 children were randomly assigned to treatment with Montelukast, a cysteinyl-leukotriene receptor antagonist (n=30), or placebo (n=30) for 12-week treatment. Upon completion of treatment, snoring, mouth breathing, and sleep discomfort were re-measured. Before treatment, all children had snoring most times or always. Posttreatment, 80% of children treated with Montelukast only snored sometimes or never. Sleep discomfort and mouth breathing studies showed statistically significant improvement (P<.0001). Radiographic studies showed a 76% reduction in adenoid size for the Montelukast treatment, but only a 3% reduction in the placebo group. The authors conclude that this treatment should be considered instead of surgery.
#2) 26465274Venekamp/2016Three studies on children with obstructive sleep disordersMeta-Analysis
Key resultsThe authors examined three different studies. The risk of bias was low in one and moderate-to-high in the two others. These studies examined the effectiveness of adenotonsillectomy, positive airway pressure, leukotriene antagonist, orthodontic therapy, myofunctional therapy, position therapy, and lifestyle changes in treatment of obstructive sleep apnea in children. Adenotonsillectomy remains the standard of care for children with obstructive sleep apnea due to adenotonsillar hypertrophy. However, "watchful waiting" should be considered since the tonsils and adenoids of half of the patients without surgery normalized after 7 months. If nonsurgical methods are desired, surgery cannot be performed, or if symptoms persist after adenotonsillectomy, CPAP treatment should be used. Orthodontic therapy can be used if an upper airway is obstructed by the maxilla or when mandibular retrusion is believed to contribute. Nasal steroids can be used for certain etiologies of obstructive sleep apnea, but were found to have minimal effect. There were too few studies on oropharyngeal exercise and leukotriene antagonists to support their use for OSA in children; however, some evidence existed. Due to the correlation of obesity with OSA, lifestyle changes in overweight children are believed to be effective. Position therapy is not recommended due to conflicting studies and questionable feasibility.
#3) 18680183Praud/2008Children with sleep disordered breathingNarrative review
Key resultsAlthough adenotonsillectomy (AT) has been the treatment of choice for many children with obstructive sleep apnea (OSA), there has been a considerable mortality associated with the procedure, especially in children less than 2 years old. Also, OSA has been found to recur in up to 75% of children who have undergone AT. Therefore, CPAP has been recommended as an alternative, but patient compliance with the mask can be poor. In attempts to find alternate treatments for these children, medications such as nasal steroids and leukotriene inhibitors have been found to be effective in mild cases when administered over a prolonged period of time (6 weeks or more). However, the authors caution that this treatment cannot be firmly recommended until more scientific studies are done. The authors also recommend orthodontic evaluation of all children. Maxillary expansion is one orthodontic treatment that has been found to help children with OSA.
Evidence Search “nonsurgical treatment sleep apnea children” “montelukast treatment sleep apnea children” “cpap children sleep apnea”
Comments on
The Evidence
Validity: Shokouhi/2015 is a limited example of the effectiveness of leukotriene receptor antagonist in children with obstructive sleep apnea. Few studies exist to confirm their findings. The most valid source, Venekamp/2016, did not find sufficient evidence to support the use of leukotriene receptor antagonist in children for treatment of obstructive sleep apnea. The effectivness of CPAP has been confirmed by multiple studies, as has as the use of bi-level positive airway pressure treatment, for children with OSA. Perspective: Additional studies should be performed with both leukotriene receptor antagonists and continuous positive airway pressure therapy to determine their effectiveness. However, both leukotriene receptor antagonists and continuous positive airway pressure therapy have shown promise in treatment of children.
Applicability For children suffering from obstructive sleep apnea, adenotonsillectomy is considered the standard for care if the OSA is caused by adenotonsillar hypertrophy unless the child is less than 2 years old. Other options exist for children who did not respond to adenotonsillectomy, if their sleep apnea is caused by an airway blocked due to their jaw’s skeletal anatomy, prefer to avoid surgery, or who are unable to undergo surgery. With the increase in childhood obesity, the prevalence of OSA in children is likely to increase. In some cases, lifestyle changes may be an appropriate therapy.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Orthodontics) (Pediatric Dentistry)
Keywords Obstructive sleep apnea, children, CPAP, nonsurgical treatment, adenotonsillectomy, montelukast, leukotriene antagonist
ID# 3217
Date of submission: 04/13/2017spacer
E-mail GUESSN@livemail.uthscsa.edu
Author Nathan Guess
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Ann Larsen DDS, MS
Faculty mentor/Co-author e-mail larsena@uthscsa.edu
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