Article Image

AAO-HNSF 2022: The Great Debate Preview: Should Adenotonsillectomy be the First-Line Treatment for Pediatric OSA?

Op-Med is a collection of original articles contributed by Doximity members.

At this year’s annual meeting, I will be moderating a debate between Dr. Derek Lam and Dr. Stacey Ishman on management of mild obstructive sleep apnea in the pediatric population. I expect a riveting discourse, as new research has emerged on options for management.

What are the highlights that attendees should take away from this presentation?

While adenotonsillectomy has traditionally been the first-line treatment for obstructive sleep apnea in children, research over the past 10 years has demonstrated that there are other options for management, including medical management and observation. When deciding whether or not to operate, several factors should be considered beyond the sleep study findings, including the impact on quality of life and parental input. This is truly a diagnosis that requires shared-decision making when deciding on treatment.

What is the central question that your presentation tries to answer?

Should adenotonsillectomy be the first-line treatment for pediatric obstructive sleep apnea?

How do these findings and/or conclusions potentially impact clinical practice?

I think traditional management has consisted of recommending adenotonsillectomy in children with mild OSA. We have found that some kids get better with time, and some may benefit from anti-inflammatory medications. These findings can affect clinical practice as we now have options to offer families that can meet them where they need us. Not all caregivers are ready to jump into an operation immediately, and being able to present the risks and benefits of the various options with actual evidence allows families to make an informed decision and potentially reduce the number of patients who undergo surgery.

The most recent impactful studies that are critical when discussing with families are the CHAT, or Childhood Adenotonsillectomy Trial, and all the post-hoc analyses that came from that study, the POSTA, or Pre-school OSA Tonsillectomy Adenoidectomy, study, and the study evaluating oral leukotriene use for mild OSA from Goldbart et al. There have been systemic and narrative reviews that have been published following these initial studies that confirm that the findings are valid and non-surgical options are also viable for mild OSA. Often symptom burden and quality of life are the fork in the road as to which path to go down, as opposed to polysomnographic findings.

What are 3-5 questions you would ask attendees about the topic of your presentation to spark an engaging conversation?

-What do you typically recommend for your patients in clinical practice?

-What biases do you bring to shared-decision making when presenting management options for mild OSA in the pediatric population?

-How often do you see patients who receive non-surgical management who later return to you for surgery?

Dr. Raol is employed by the Emory School of Medicine. She has no conflicts of interest to report.

Image by Vector Juice / Shutterstock

All opinions published on Op-Med are the author’s and do not reflect the official position of Doximity or its editors. Op-Med is a safe space for free expression and diverse perspectives. For more information, or to submit your own opinion, please see our submission guidelines or email

More from Op-Med