Intracapsular Adenotonsillotomy May Be Effective for Pediatric OSA

A boy sleeping alone in his parent’s bed with his teddy bear.
Is intracapsular adenotonsillotomy a viable alternative to adenotonsillectomy — a more common procedure for obstructive sleep apnea — in children who are otherwise healthy?

Intracapsular adenotonsillotomy (ATO) may be an effective treatment for children with obstructive sleep apnea (OSA) who are otherwise healthy, according to results of a 5-year follow-up study published in Sleep Medicine: X.

Adenotonsillotomy, which removes only the tonsillar tissue protruding from the anterior tonsillar pillar, preserving the capsule, is less invasive and is associated with less postoperative morbidity than adenotonsillectomy (ATE), which is a common treatment for pediatric OSA. However, the less invasive ATO procedure also leaves tonsillar tissue that may grow back, which means those undergoing the procedure for OSA could potentially require reoperation for recurrent OSA.

To determine the viability of ATO as an alternative to ATE, investigators evaluated the long-term follow-up results of a randomized controlled trial (RCT) comparing ATE with ATO in young children with moderate to severe OSA. The follow-up study compared 5-year changes in Obstructive Apnea/Hypopnea Index (OAHI) in ATE vs ATO and reported on the risk of reoperation after ATO.

The initial prospective RCT comparing ATE and ATO was conducted at a university in Sweden from 2011 to 2021 and included 79 children aged 2 to 6 years. All children attended overnight in-laboratory polysomnography (PSG) before surgical treatment and had a PSG follow-up at 1 year after surgical intervention. The current follow-up study assessed data collected at a 5-year PSG follow-up. As with the 1-year follow-up, the participants’ parent or caregiver was asked to complete the OSA-18 questionnaire for the 5-year follow-up on the same evening as each PSG procedure.

A total of 45 children —17 of 40 patients (43%) from the ATE group and 28 of 39 (72%) from the ATO group — underwent PSG at 5 years along with the per protocol analysis. Those who participated in this 5-year follow-up had a median age of 9 years and 6 months (interquartile range [IQR], 107-120 months).

In the ATE group, the mean OAHI decreased from 12.3 (SD 8.0) at baseline to 0.6 (0.7) at 5 years, a 95% mean reduction. In the ATO group, the mean OAHI decreased from 12.6 (7.4) at baseline to 0.5 (0.6) at 5 years, a 96% mean reduction. The mean difference between the groups postoperatively was 0.1 (95% CI, -0.3 to 0.5). Each group had 5 children with mild OSA (OAHI ≥1 to <5), and the others had OAHI of less than 1.

The median OSA-18 was reduced in the ATE group from 57 (IQR, 47-79) to 27 (IQR, 22-36) and in the ATO group from 67 (IQR, 53-79) to 32 (IQR, 25-44). No differences were found between the groups for postoperative values of total OSA-18 score (P =.10), sleep disturbance (P =.18), or health-related quality of life (P =.17).

The need for repeated tonsil surgery was also assessed. The investigators found that 15% of children from the initial study’s ATO group had reoperation with ATE, yielding a relapse rate of 30.7 per 1000 person and year. These children were excluded from the 5-year follow-up per protocol analysis.

Study limitations include the small population and the dropout rate of 35%. In addition, the study may not be generalizable to the overall population of children with OSA because it excluded those with obesity and other comorbidities and risk factors for OSA. Also, the researchers only evaluated 1 tonsillotomy technique (coblation).

“This long-term follow-up study of our previous RCT indicates that [adenotonsillotomy] could be effective in treating pediatric OSA after 5 years in young otherwise healthy children,” stated the investigators. “The risk of relapse after [adenotonsillotomy] is notable, so information should be provided to caregivers, and follow-ups are necessary.” The investigators further noted that “In clinical practice, follow-ups and PSGs are rarely used, so there is a risk of missing the need for second surgery because of residual/recurrent OSA.”


Sjölander I, Borgström A, Nerfeldt P, Friberg D. Adenotonsillotomy versus adenotonsillectomy in pediatric obstructive sleep apnea: a 5-year RCT. Sleep Med X. Published online September 8, 2022. doi:10.1016/j.sleepx.2022.100055