Response to the Polysomnography Commentary by Tunkel

We thank Dr Tunkel for his commentary on the guideline for polysomnography prior to tonsillectomy in children. Dr Tunkel’s commentary includes useful historical observations that help set the context for the guideline. He correctly mentions that the debate over the need for polysomnography prior to tonsillectomy in children with sleep-disordered breathing is at least 2 decades old. ¹ Dr Tunkel also emphasizes an important concept: that obstructive sleep apnea is but one form of sleep-disordered breathing. In addition, as stated in the commentary, during the past decade, it has become clear that some children with snoring and normal polysomnography (PSG) had neurocognitive and physiologic consequences that showed improvement after tonsillectomy. ² Furthermore, most tonsillectomies are currently performed without prior PSG. ³

We find 3 distinct concerns in Dr Tunkel’s commentary on the guideline for polysomnography prior to tonsillectomy in children:

We agree with Dr Tunkel that a child younger than 2 years should undergo preoperative PSG given the increased risks of postoperative respiratory complications, the likelihood of more severe OSA, and the uncertainties of diagnosis at this young age. ⁴ However, the guideline targeted children 2 to 18 years old and, as noted by Dr Tunkel, such a recommendation would be outside the scope of the guideline.

A lower limit of 2 years was selected because (1) tonsillectomies in children younger than 2 years are uncommon and (2) there is little published evidence regarding PSG in children scheduled for tonsillectomy younger than 2 years.

With respect to Action Statement 2, the committee agrees that the “need for surgery” will be different, depending on whether a surgeon believes that OSAS is a requirement for tonsillectomy or if he or she believes sleep-disordered breathing without OSAS is a sufficient reason to proceed with tonsillectomy. The guideline does not address the indications for tonsillectomy. The guideline simply states that when clinicians or parents are uncertain about the need for surgery (whatever the reason), the clinician should advocate for PSG since the presence or absence of OSAS is likely to be relevant in the final decision to proceed with tonsillectomy. Similarly, members of the guideline development group agree that the literature shows that the measures of tonsil size do not necessarily correlate with the severity of OSAS on PSG. However, if the tonsils are very small and not likely to obstruct the upper airway and if PSG is either normal or shows central apnea, this information will be helpful in deciding whether to proceed with tonsillectomy.

With respect to Action Statement 3, while Dr Tunkel’s suggestion that anesthesiologists be appraised of the absence of PSG data prior to surgery might, in some selected circumstance, be useful, notifying other physicians that a test has not been ordered would be a significant departure from current practice. It could suggest that a test was not requested by error and may lead to delays or confusion. The peer-reviewed literature simply lacks information that could support such a recommendation. It is unknown if anesthesiologists will modify their practice based on this information, but this could be a subject of future research.