Surgery May Improve Dysphagia Outcomes in Kids With Sleep Apnea

Undergoing adenotonsillectomy may improve dysphagia outcomes in children with obstructive sleep apnea (OSA) and tonsil hypertrophy compared with watchful waiting with supportive care (WWSC), a secondary analysis of the randomized CHAT trial suggested.

After 7 months, the prevalence of dysphagia — difficulty in swallowing — decreased by 21.3% (95% CI 13.5-28.9) in patients who underwent the surgery compared with 1% (95% CI -7.6 to 9.6) for those in the WWSC group, reported Zhenkun Yu, MD, PhD, of the School of Medicine at Southeast University in Jiangsu, China, and co-authors.

Those who underwent adenotonsillectomy were more likely to have a resolution of dysphagia versus those in the WWSC group (adjusted OR 4.84, 95% CI 1.91-12.25), they noted in JAMA Otolaryngology–Head & Neck Surgery.

“The pathophysiology of dysphagia in OSA is not entirely understood, but it has been suggested that dysphagia in OSA may result from 3 main mechanisms: sensory alteration, motor changes, and impaired swallowing-breathing integration,” Yu and team wrote, noting that adenotonsillar hypertrophy is considered to be the most prominent cause of OSA in kids.

“Parents of children with adenotonsillar hypertrophy have reported their children eating in small amounts, consuming food slowly, choking frequently, demonstrating a preference for pasty foods, and having difficulty in both chewing and swallowing,” they explained. “Adenotonsillectomy is the first-line treatment for pediatric OSA and results in improvements in both polysomnographic parameters and quality of life.”

The primary purpose of the multicenter Childhood Adenotonsillectomy Trial (CHAT) was to assess whether early adenotonsillectomy improved attention and executive-function scores on the Developmental Neuropsychological Assessment compared with watchful waiting among school-age children with OSA. Researchers found that the surgery did not significantly improve attention or executive function, but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings.

In this analysis, the odds of persistent dysphagia at follow-up were higher in the WWSC group compared with the surgery group (aOR 2.18, 95% CI 1.06-4.49), and kids in the WWSC group were almost 7.5 times more likely to develop new difficulty in swallowing versus kids who underwent surgery (aOR 7.47, 95% CI 2.57-21.75).

There was also a 12% difference (95% CI 6.8-17.7) between the surgery and WWSC groups in newly developed dysphagia at 7-month follow-up.

Overall, patients who had a higher Apnea-Hypopnea Index (AHI) at baseline were less likely to see resolution of dysphagia (aOR 0.91, 95% CI 0.83-0.98).

This secondary analysis of CHAT was conducted at tertiary children’s hospitals from December 2022 to January 2023.

A total of 386 participants with OSA and tonsil hypertrophy ages 5 to 9.9 years (median age 6) were included in the analysis; 51.6% were girls, 47.7% were Black, and 36.4% were white.

They were randomized to adenotonsillectomy or WWSC (defined as “conservative medical management, with treatment or referral for treatment of comorbidities (e.g., asthma, allergic rhinitis), education regarding general sleep hygiene and healthy behaviors, and use of nasal saline spray as needed for nasal mucosal crusting or dryness”) and underwent polysomnography at baseline and 7 months. Parents/caregivers completed the OSA-18 questionnaire, including an item on difficulty in swallowing at baseline and 7 months.

At baseline, the number of children with dysphagia was similar between groups (29.8% of the surgery group and 25.8% of the WWSC group).

There were no significant differences in dysphagia prevalence based on race, ethnicity, age, sex, AHI score, oxygen nadir, and tonsillar size.

The multifactorial nature of dysphagia is complex, Yu and team acknowledged. “Strictly speaking, it is difficult to identify the specific location of swallowing difficulties due to the lack of additional swallowing-related information from CHAT,” they wrote.

Furthermore, while the survey used in the study is a validated quality-of-life measure, it was not designed to assess swallowing difficulties specifically, they said.

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