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This article reviews the management of children with persistent obstructive sleep apnoea (OSA) following adenotonsillectomy (AT). Risk factors for patients to have persistent disease include obesity, being Afro-Caribbean and existing co-morbidities such as craniofacial and neuromuscular disorders. Initial assessment of patients would include a full assessment and examination of the patient including severity, impact of quality of life and fibreoptic laryngoscopy to assess for turbinate hypertrophy, adenoidal regrowth, laryngomalacia or lingual tonsil hypertrophy. For children with persistent OSA following AT, the authors suggest further investigation in the form of drug-induced sleep endoscopy (DISE) or cine-MRI for dynamic assessment of the airway during sleep. However, there are still challenges with performing DISE and cine-MRI routinely. There is a lack of evidence showing improved outcomes in children following DISE. Cine-MRI is still not routine practice, probably due to ongoing concerns of sedating a child with severe OSA for MRI imaging without securing the airway. Children with severe OSA will often have multi-level obstruction and each level will need to be individually managed. There is some evidence for using anti-inflammatory medications such as nasal steroids and leukotriene modifiers such as montelukast for children with persistent mild OSA. CPAP could be used as well although compliance with CPAP is a challenge in the paediatric population. The most common source of obstruction in children with persistent OSA is the tongue base. Lingual tonsillectomy is the most commonly described procedure with success rate of up to 60%. Uvulopalatopharyngoplasty (UPPP) in children is not routinely recommended. The supraglottis is another common area for persistent obstruction and supraglottoplasty has been shown to significantly improve outcomes. Oral appliances for children need to be used cautiously due to the risk of adverse effects on developing dentition. In summary, a systematic approach in managing children with persistent OSA following AT may help improve outcomes although parents should be counselled that there is a risk of persistent disease despite further treatments. 

Managing the child with persistent sleep apnea.
AE Bluher, SL Ishman, CM Baldassari.
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Wai Sum Cho

Queens Medical Centre, Nottingham, UK.

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