Strong evidence supports tonsil and
adenoidectomy in the context of obstructive sleep apnea (OSA) in children.
However, whether a polysomnogram (PSG) is indicated for either preoperative or
postoperative evaluation of OSA is not yet established. Although expert opinion
suggests that a PSG study is needed to justify the need for tonsil and
adenoidectomy, the expert opinion exists in the absence of controlled,
randomized studies. Moreover, some experts opine that PSG is indicated both
before and after tonsil and adenoidectomy. Certainly, greater clarity surrounding
the indications for obtaining PSG studies is needed…
In most sleep laboratories, the cost
of an overnight study, including professional fees, exceeds 3000 US dollars.
Charges to the patient or the payer are generally well in excess of costs.
Thus, there ought to be clear justification to undertake a relatively costly,
and inconvenient, diagnostic study. Certainly, in the presence of concerns such
as central hypoventilation syndrome or recurrent airway obstruction that does
not lead to overt hypoxemia, a PSG may be both instructive and justified. However,
when clinical outcomes are apparent and the results of the PSG are largely
confirmatory, obtaining the test might not be completely justified…
Given the broad distribution of the
PSG testing, it might be time for a well designed trial that can effectively
test the hypothesis that PSG testing improves specific, well defined, outcomes
in the context of children with OSA, the most common indication for procuring a
study. A trial wherein children with clinical evidence of OSA are randomly
assigned to either empiric treatment or to undergo PSG testing would provide
significant information surrounding the value and utility of PSG. Such data
would meaningfully inform the management of many children worldwide.
See: Cornfield DN, Bhargava S. Sleep medicine: pediatric polysomnography revisited.
Curr Opin Pediatr. 2015 Jun;27(3):325-8.
From a sleep medicine colleague: Thank you for forwarding this to me. It is, at least in part, in alignment with my practice. For children with moderate or severe symptoms of OSA a polysomnogram is often not necessary. Sometimes I can even convince the parents of this. The test is useful in those with mild symptoms in which case the PSG often dispels the feared diagnosis and prevents a needless and costly surgery as well as the associated morbidity. Here we do less pre-T/A evaluations since a solid portion of our work is in the evaluation of children with neuromuscular disorders and scoliosis for sleep related hypoventilation leading to bilevel therapy. Positive airway pressure used in this context has been shown to increase quality of life 20% and extend life 10 years.
ReplyDeleteThere are 2 limitations of this opinion article. First, it is unbalanced; a “pro/con” approach offers a fairer opportunity for evaluation and leaves some of the thinking to the reader. Second, although it mentions some problems with current practice it does not offer solutions. In fact, alternative questionnaires and measurements have been unable to improve on the PSG’s predictive ability, limited though it is.