title: Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea.
abstract: OBJECTIVE
  Although adenotonsillectomy is accepted as a first-line therapy for pediatric obstructive sleep apnea (OSA), there is currently no consensus regarding optimal methods for identifying the sites of obstruction or treatment of children with persistent disease after surgery. With this in mind, our aim was to systematically review the English-language literature pertaining to these issues.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  We searched all indexed years of Pubmed, Cochrane CENTRAL, DynaMed, UpToDate, CINAHL, and Scopus for English-language articles containing original human data, with ≥ 7 participants, all < 18 years old. Data regarding study design, demographics, clinical characteristics/outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by two investigators.
  
  
  RESULTS
  Of 758 identified abstracts, 24 articles (combined population = 960) were ultimately included. Seventeen (71%) described methods to identify site(s) of obstruction: drug-induced sleep endoscopy (11/24), cine magnetic resonance imaging (MRI) (3/24), and alternative imaging (3/24). Treatment options included lingual tonsillectomy (n = 6), with success rates of 57% to 88% (Cohen's effect size d = 1.38), as well as supraglottoplasty (n = 4), with success rates of 58% to 72% (d = 0.64). Additional treatments included medications and surgery (e.g., partial midline glossectomy and tongue suspension).
  
  
  CONCLUSIONS
  Drug-induced sleep endoscopy and cine MRI are the most commonly reported tools to identify sites of obstruction for children with persistent OSA; however, these techniques have not yet been clearly linked to outcomes. Evidence for treatment is extremely limited and focuses primarily on lingual tonsillectomy and supraglottoplasty. Also, reports regarding appropriate patient selection and outcomes in obese or otherwise healthy children are scant.
authors.affiliation: Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.|University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.
authors.forename: P Vairavan
authors.initials: PV
authors.lastname: Manickam
authors.affiliation: Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.|University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.
authors.forename: Sally R
authors.initials: SR
authors.lastname: Shott
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.
authors.forename: Emily F
authors.initials: EF
authors.lastname: Boss
authors.affiliation: Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.
authors.forename: Aliza P
authors.initials: AP
authors.lastname: Cohen
authors.affiliation: Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.
authors.forename: Jareen K
authors.initials: JK
authors.lastname: Meinzen-Derr
authors.affiliation: Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.|University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.
authors.forename: Raouf S
authors.initials: RS
authors.lastname: Amin
authors.affiliation: Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.|Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.|University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Ishman
mesh_terms: D000233:Adenoidectomy / Q000379:methods*; D002648:Child; D045422:Continuous Positive Airway Pressure; D006801:Humans; D017286:Polysomnography; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D014068:Tonsillectomy / Q000379:methods*
keywords: Diagnosis; cine MRI; drug-induced sleep endoscopy; lingual tonsillectomy; pediatric; persistent obstructive sleep apnea; sleep state-dependent laryngomalacia; supraglottoplasty; treatment