By Earl Gage, MD
Kids Plastic Surgery, Mercy Children’s Hospital – St Louis, MO
CCA posts a monthly blog series called, "Ask the Doctor." You can submit your questions to Annie Reeves ([email protected]) and we will ask Dr. Earl Gage of Kids' Plastic Surgery in St. Louis to answer them. Thanks Dr.
Gage for helping spread information and resources for our cranio families!
Question: I have seen a few children with sleep apnea that improved after tonsil and adenoid removal. I know of one child that the surgery made their sleep apnea worse. Do you recommend this procedure? Do you do a sleep study first? It seems to be a “trend” with doctors right now.
Answer: When a child has a craniofacial condition, particularly one that results in undergrowth of the midface, sleep apnea is common. If obstructive sleep apnea is severe, this can result in significant sleep disturbances and low oxygen levels, which can have a negative impact on development. In some instances, severe apnea can even be life threatening.
If a child has mild to moderate sleep apnea and large tonsils, I believe it makes sense to consider tonsillectomy. Many times, this results in substantial improvement in nighttime breathing and quality of sleep. In more severe cases of obstructive sleep apnea, additional treatment beyond tonsillectomy may be required, depending on the age of the child. These might include midface distraction, LeFort advacement or tracheostomy. The goal with any intervention is to improve breathing, improve sleep quality and help your child develop normally.
Regarding need for a sleep study, I would say it largely depends on the reason for the tonsillectomy. There are multiple reasons that an ENT surgeon may recommend tonsillectomy, including frequent infections, tonsillar abscesses, diseases of the tonsillar tissue or obstructive apnea, to name some of the most common. Where tonsillectomy is done for infection or disease related reasons, a sleep study is probably not necessary. However, when tonsillectomy is being considered to address sleep apnea, as is more commonly the case in children with craniofacial disorders, then it probably is a good idea to obtain a sleep study. The sleep study can help you clarify how bad the sleep apnea is and whether it is obstructive (due to a mechanical blockage) or central (where the brain “forgets” to breathe). If severe obstructive sleep apnea is seen in a child with both big tonsils and midface undergrowth, then the study may help predict whether tonsillectomy alone is likely to help. For instance, if apnea is severe, the tonsils large and the midface severely retruded, it may be that tonsillectomy will help some but not enough. Recognizing this before tonsillectomy can lead to a larger team discussion about what other interventions may be required and how these should be sequenced and timed. Finally, when compared to a post-operative sleep study, the pre-operative sleep study serves as a useful baseline to determine if surgery was successful and helps your team decide if something else needs to be done.
I hope this helps. As always, please don’t hesitate to raise your concerns and your questions with your team.
Very helpful and succinctly done, Earl. - Deji Fashemo, DDS, MPH
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