Mina Chung DDS, BDS, MS
There was inconclusive evidence on the efficacy of different medical, surgical, and mechanical interventions for obstructive sleep apnea (OSA).
Evidence reviewed was based on five parallel-arm randomized controlled trials comparing seven different interventions. Further research would require comparing interventions against placebo groups using overnight polysomnography (PSG) and apnea/hypopnea index (AHI) as a measure of severity of OSA .
Are medical, behavioral, mechanical, and surgical interventions efficacious in improving OSA in children?
A comprehensive search on MEDLINE (1950-August 2007), EMBASE (OVID) (1988- August 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (1964-August 2007), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982-August 2007), Web of Science (1900-August 2007), and Literatura Latino-Americana e do Caribe de Informação em Ciências da Saúde (LILACS) (1982-August 2007). Ongoing clinical trials were searched at controlled-trials.com, the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) Clinical Trials Register, and the National Research Register (UK). A grey literature search was performed using SCOPUS and hand search of conference proceedings from 2002-2007 of the American Thoracic Society, Associated Professional Sleep Societies, European Sleep Research Society and European Respiratory Society. Both English and non-English studies were included in the search. The initial search resulted in 1690 abstracts being identified of which 86 full papers were reviewed. 81 studies were excluded because they were not RCTs, studied adults or infants only, did not diagnose OSA or included children with an AHI
The 5 studies that were included in the review investigated 7 different interventions. Medical intervention of intranasal steroids resulted in improvement of the AHI post-treatment; there was no change in nadir SpO2. Surgical intervention compared temperature-controlled radiofrequency ablation of tonsils and conventional adenotonsillectomy (ATE), which showed no statistically significant difference in post-treatment respiratory disturbance index (RDI), snoring score, or tonsillar size. A study comparing ATE or maxillary distraction in children with OSA or narrow maxilla showed residual events enough to warrant complementary intervention in all of the patients. Mechanical interventions of using a personalized jaw-positioning oral appliance for 6 months showed AHI decreased in the intervention group and lower risk for tonsillar hyperplasia. The study on an oral appliance was of low methodological quality and made an invalid statistical comparison for the main outcome, resulting in an unjustified conclusion of a benefit of the device. Continuous and bi-level positive airway pressure therapy was compared which showed no difference in either of the groups. No behavioral intervention was investigated.
There is no conclusive evidence on the efficacy of differing interventions for OSA. Studies showed little data supporting the use of ATE.
Source of Funding:
American Dental Association Foundation
Importance and Context:
Obstructive sleep apnea (OSA) is a common childhood condition that is defined as a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns”. OSA can affect children of all ages, although preschool-aged children are the most affected. If left untreated, children are at risk of neurocognitive deficits and can result in serious morbidity. Nocturnal polysomnography (sleep study) is the standard for diagnosis to quantitate ventilatory and sleep abnormalities. Currently, adenotonsillectomy is the first line of treatment for most children.1
1 American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2002; 109(4):704-712.
Strengths and Weaknesses of the Systematic Review:
The review used accepted methods to identify and select RCT studies. There were no language restrictions, however, inclusion was limited to children from age 1-16. No single ‘a priory’ outcome was measured. Outcomes varied between the studies using AHI as the primary quantifier and RDI if there was no report of AHI. Due to the variability of outcomes in the studies, result pooling was not attempted.
Strengths and Weaknesses of the Evidence:
The review recognized the low number of studies; therefore publication bias was not examined. Also, the studies were parallel-arm RCT studies in which 3 of the studies compared different interventions to each other and 2 studies were compared to controls. The quality of trials was high in one study and medium to low in the other studies. The trial suffers significant methodological shortcomings such as inappropriate randomization and lack of an intention to treat analysis (nine out of 32 patients withdrew from the study). Further, the authors failed to compare the post-treatment AHIs in the two groups and incorrectly concluded (based on their before and after analysis of the treatment group) that an oral appliance is more effective than no intervention in reducing the AHI. Another significant problem is the high frequency of non-compliance with the intervention; five out of 19 children in the treatment group dropped out because they refused to wear the appliance. The review recognized its limitations basing conclusions on varying outcome measurements.
Implications for Dental Practice:
The etiology of OSA is thought to be a combination of adenotonsillar hypertrophy and poor neuromuscular tone of the upper airway. Particularly for preschool-aged children, the size of the adenoids and tonsils are largest according to airway size, therefore the first line therapy for OSA is ATE. Two studies in the review demonstrated limited data on the efficacy of ATE.
However, the review provides no definite conclusion on the efficacy of different OSA interventions. Further studies need to be performed in order to determine efficacy by comparing interventions and controls.