Awake vs Sleep Endoscopy for Refractory Pediatric Sleep Apnea

Introduction: We aimed to assess the utility of awake endoscopy (AE) for surgical planning for refractory (post-adenotonsillectomy) pediatric obstructive sleep apnea (OSA). We hypothesized that AE would be associated with subsequent sleep endoscopy (SE) findings and surgical intervention at the adenoid and lingual tonsils. We hypothesized no significant association between AE and SE scores or intervention at the more dynamic levels of the airway (palate, lateral wall, tongue base, and supraglottis).

Methods: This was a retrospective analysis of prospectively collected data on patients seen in a multidisciplinary refractory OSA clinic (from 2018-2022) who were assessed with AE scored in clinic with a standardized rubric and then underwent SE-directed surgery within one year scored with the Chan-Parikh scale. AE and SE scores were dichotomized into obstructive and non-obstructive at each level. Lingual tonsil size was graded using the pediatric Friedman scale on AE and SE. Associations between AE and SE scores, and surgical intervention at each site were assessed with the χ2 test and Spearman correlation.

Results: Thirty-three of 211 children in the clinic database underwent complete scored AE followed by SE-direct surgery for sleep apnea within one year. They were on average 9.0 (+/-4.6) years old, 27% female, 82% white, 36% syndromic and 39% obese. Obstruction on AE was significantly associated with obstruction on SE at the level of the adenoids (p < 0.01), but not at the dynamic levels (all p>0.05). There was a significant correlation between lingual tonsil size on AE and SE (ρ=0.57, p< 0.01). Obstructive AE scores were significantly associated with surgery at the level of the adenoids (p < 0.01) and lingual tonsils (p < 0.01), but not with intervention at other anatomic levels.

Conclusions: Obstruction on AE predicts obstruction on SE and an increased likelihood of surgery at the level of the adenoids and lingual tonsils, but not at other anatomic levels. Awake and sleep endoscopy may provide complimentary diagnostic information for surgical planning for refractory pediatric OSA.