title: Gaps in evidence: Management of pediatric obstructive sleep apnea without tonsillar hypertrophy.
abstract: OBJECTIVE
  Persistent obstructive sleep apnea (OSA) is demonstrated in 40% of children after adenotonsillectomy. We previously evaluated the basis of management decisions in children with OSA without tonsillar hypertrophy and found that 61% of decisions were non-evidence based. The aim of this study was to identify gaps in evidence for the management of children with OSA without tonsillar hypertrophy.
  
  
  METHODS
  Case series.
  
  
  METHODS
  We recorded all real-time decisions made by pediatric subspecialists from eight disciplines that participated in an upper airway clinic and management conferences. Practitioners were immediately queried regarding the basis of their decisions, and non-evidence-based decisions were categorized.
  
  
  RESULTS
  During 10 case conferences and five clinics, 507 decisions were made for 63 children (43% with Down syndrome, 20% with Pierre Robin sequence). The 309 non-evidence-based decisions most commonly pertained to follow-up timing and appropriate subspecialty clinic location (116/309, 38%) as well as timing for repeat polysomnography (35/309, 11%), especially in children at high risk for persistent OSA after treatment. Additional gaps identified included the likelihood of OSA improvement from weight loss, and effectiveness of sleep surgical procedures (i.e., lingual tonsillectomy, posterior midline glossectomy, and craniofacial surgery) alone or in combination.
  
  
  CONCLUSIONS
  Identified gaps in evidence included timing and location of follow-up, appropriate use of polysomnography for surveillance, effectiveness of specific surgical procedures performed alone and in combination, and the use of oral appliances and continuous positive airway pressure therapy in children with Down syndrome. We also found a need for studies to compare the effectiveness of these treatment options in diverse patient populations.
  
  
  METHODS
  4 Laryngoscope, 126:758-762, 2016.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors.forename: Alice
authors.initials: A
authors.lastname: Tang
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors.forename: Matthew
authors.initials: M
authors.lastname: Gropler
authors.affiliation: Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Angela L
authors.initials: AL
authors.lastname: Duggins
authors.affiliation: Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.|Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, U.S.A.
authors.forename: Raouf S
authors.initials: RS
authors.lastname: Amin
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.|Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Sally R
authors.initials: SR
authors.lastname: Shott
authors.affiliation: Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.|Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, U.S.A.
authors.forename: Barbara
authors.initials: B
authors.lastname: Chini
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.|Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.|Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Ishman
mesh_terms: D000233:Adenoidectomy / Q000379:methods*; D000293:Adolescent; D058109:Airway Management / Q000379:methods; D001291:Attitude of Health Personnel; D002648:Child; D002675:Child, Preschool; D045422:Continuous Positive Airway Pressure / Q000379:methods; D003657:Decision Making; D019317:Evidence-Based Medicine; D005260:Female; D005927:Glossectomy / Q000379:methods; D006801:Humans; D006984:Hypertrophy / Q000473:pathology / Q000601:surgery; D008297:Male; D014066:Palatine Tonsil / Q000473:pathology / Q000601:surgery; D017286:Polysomnography / Q000379:methods; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D018570:Risk Assessment; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis* / Q000601:surgery / Q000628:therapy; D014068:Tonsillectomy / Q000379:methods*; D016896:Treatment Outcome
keywords: Evidence-based decisions; decision making; obstructive sleep apnea; pediatric; persistent pediatric obstructive sleep apnea