Cognitive Effects of Adenotonsillectomy for Obstructive Sleep Apnea

Abstract

OBJECTIVE: Research reveals mixed evidence for the effects of adenotonsillectomy (AT) on cognitive tests in children with obstructive sleep apnea syndrome (OSAS). The primary aim of the study was to investigate effects of AT on cognitive test scores in the randomized Childhood Adenotonsillectomy Trial. METHODS:Children ages 5 to 9 years with OSAS without prolonged oxyhemoglobin desaturation were randomly assigned to watchful waiting with supportive care (n = 227) or early AT (eAT, n = 226). Neuropsychological tests were administered before the intervention and 7 months after the intervention. Mixed model analysis compared the groups on changes in test scores across follow-up, and regression analysis examined associations of these changes in the eAT group with changes in sleep measures. RESULTS:Mean test scores were within the average range for both groups. Scores improved significantly (P < .05) more across follow-up for the eAT group than for the watchful waiting group. These differences were found only on measures of nonverbal reasoning, fine motor skills, and selective attention and had small effects sizes (Cohen's d,. As additional evidence for AT-related effects on scores, gains in test scores for the eAT group were associated with improvements in sleep measures. CONCLUSIONS:Small and selective effects of AT were observed on cognitive tests in children with OSAS without prolonged desaturation. Relative to evidence from Childhood Adenotonsillectomy Trial for larger effects of surgery on sleep, behavior, and quality of life, AT may have limited benefits in reversing any cognitive effects of OSAS, or these benefits may require more extended follow-up to become manifest. 1 The prevalence of OSAS is ~1% to 6%, with higher rates in African Americans and children from families of lower socioeconomic status. 2 -4 Children with untreated OSAS are at risk for adverse outcomes ranging from daytime sleepiness and compromised cardiovascular health to behavior problems and impairments in cognition and academic performance. 5 -11 Problems in behavior and emotional regulation are common in children with OSAS compared with healthy controls, but evidence for adverse effects of OSAS on children's cognitive abilities is more mixed. 6 Some studies fail to find differences between children with OSAS and healthy controls, 12,13 and those that do report variable associations of measures of sleep disturbance with cognitive test scores. 7, 14 -18 Similarly, studies of outcomes of adenotonsillectomy (AT) in children with OSAS indicate variable benefits on such tests, with little evidence for associations of these effects with the severity of OSAS and sleep disruption. 8, 13, 14, 16, 19 -26 In the recently completed multicenter Childhood Adenotonsillectomy Trial (CHAT), children with OSAS without prolonged oxyhemoglobin desaturation assigned to early AT (eAT) improved more than those assigned to watchful waiting with supportive care (WWSC) on key secondary outcomes. 27 -29 Specifically, the eAT group improved more tha...

Sleep Disturbances and Neurobehavioral Performance in Juvenile Idiopathic Arthritis

“…We anticipated that a breathing abnormality during sleep could be related to difficulty in responding to multiple stimuli (e.g., making slower responses), but this was not observed. Nevertheless, our finding of slower simple reaction time is similar to previous studies in children with OSA that showed negative associations between OSA and tests of speed and accuracy (5, 14–16, 23). We had anticipated finding significant differences in sustained visual attention and simple reaction time between JIA with and without OSA, but this was not observed.…”

Frequency of snoring, rather than apnea–hypopnea index, predicts both cognitive and behavioral problems in young children

“…However, demonstrations of cognitive impairments have often been less robust than those reported when assessing behavioral outcomes, with some studies failing to detect significant differences between children with and without SDB [29]. For example, the only randomized clinical trial to date that examined the effects of adenotonsillectomy (T&A) treatment for SDB found significant improvements in behavioral functioning after seven months compared to children assigned to a watchful waiting treatment arm, but cognitive/executive-functioning changes were small and less consistent [30,31]. …”

Pediatric OSA Syndrome Morbidity Biomarkers

“…38 However, even though the long-term implications of cognitive losses are obviously of great concern, relatively fewer studies have attempted to identify markers of cognitive susceptibility, [88][89][90] most likely because of the labor-intensive nature of psychometric testing and the relatively large number of children required for such endeavors. 2,4 Taken together, it appears that the presence of morbidities that have been thus far associated with pediatric OSAS illustrates the complex interactions between biologic pathways activated by the presence of the disease (eg, inflammation, oxidative stress), environmental factors (eg, diet, physical activity, pollution), and genetic determinants (ie, singlenucleotide polymorphisms in relevant genes involved in the pathophysiology of end-organ dysfunction). 91 On the basis of such a conceptual framework, the vast array of novel technologies that allow for unbiased exploration of an exceedingly large number of prospective biomarkers in relatively small biologic samples should encourage researchers and funding agencies alike to invest in prospective real-life studies aimed at discovering, validating, and implementing biomarkers that reliably detect at-risk pediatric OSAS populations and enable timely and effective interventions.…”

“…[2][3][4] Furthermore, evidence of cardiovascular involvement manifesting as endothelial dysfunction, systemic and pulmonary hypertension, and alterations in left ventricular geometry and contractility has been reported, [5][6][7][8][9] along with heightened risk for metabolic perturbations such as insulin resistance, and dyslipidemias, nocturnal enuresis, and excessive daytime sleepiness. [10][11][12][13][14] As a result of OSAS, increases in health-care use and costs have been reported, 15,16 while effective treatment exerts obvious quality-of-life improvements.…”