Adenotonsillectomy Versus Watchful Waiting for Children with Obstructive Sleep Apnea Syndrome: A Systematic Review with Meta-Analysis

The treatment of children with Obstructive Sleep Apnea Syndrome (OSAS) remains a point of debate among otorhinolaryngologists worldwide. This study aims to comparatively assess the clinical outcomes of adenotonsillectomy (ATE) and watchful waiting in children with OSAS. We searched the databases of PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL), until the 1st of October 2023. Comparative trials assessing the efficacy of adenotonsillectomy and watchful waiting in children with OSAS were considered. The primary outcome measure was the apnea-hypopnea index (AHI), and secondary outcomes included quality of life as measured by OSA-18 score, and mean SpO2 levels. A subgroup analysis evaluating the changes in AHI depending on the severity of the initial disease was also executed. We conducted a random-effects pairwise meta-analysis of change scores to include randomized and non-randomized controlled trials. The quality assessment was carried out by using the Cochrane risk of bias tool for randomized and the ROBINS-I tool for non-randomized trials, respectively. Two randomized and five non-randomized trials were included. There was a statistically significant difference regarding AHI in favor of the ATE group compared to the watchful waiting group (Standardized mean difference [SMD] was - 0.60, 95%CI -0.79 to -0.41, p < 0.001). Likewise, a statistically significant decrease in change scores for OSA-18 between ATE and watchful waiting was noted (SMD was - 0.79, 95%CI -0.97 to -0.61, p < 0.001). On the other hand, there was no significant difference when ATE and watchful waiting groups were compared for SpO2 levels between each other (SMD was 0.52, 95%CI -1.53 to 2.56, p < 0.62). In the subgroup analysis assessing mild OSAS, there was a significant difference in favor of ATE compared to watchful waiting (SMD was -0.91, 95%CI -1.35 to -0.47, p < 0.0001). For mild to moderate OSAS, similar results were noted favoring ATE as well (SMD was - 0.53, 95%CI -0.87 to -0.19, p < 0.003). This study provides evidence of moderate strength supporting the superiority of ATE over the watchful waiting approach in terms of AHI and OSA-18. This also appears to be the case for AHI in children with mild and mild to moderate OSAS.