In Reference to “The Effect of Montelukast on Mild Persistent OSA after Adenotonsillectomy in Children: A Preliminary Study”

Recently, we experienced a pediatric patient who complained of severe snoring and sleep apnea that was refractory to 3 surgical treatments including adenotonsillectomy. As a result, we have read the article entitled “The Effects of Montelukast on Mild Persistent OSA after Adenotonsillectomy in Children: A Preliminary Study,” published by Wang et al, ¹ with great interest. They concluded that montelukast as a complementary therapy can improve sleep disturbances in children with obstructive sleep apnea (OSA) after adenotonsillectomy. It is well known that montelukast as a first-line therapy can be used to treat mild to moderate OSA in children through a prospective double-blind randomized trial and large retrospective cohort study. However, this is a very interesting article as it is the first study of patients with recurrent sleep apnea after surgery. On the other hand, we want to make some comments about this study.

First, montelukast can be used to treat mild to moderate OSA because montelukast has an anti-inflammatory effect that helps to reduce adenotonsillar inflammation. ² Tubal and lingual tonsillar hypertrophy, as well as recurrent/residual adenoid and chronic rhinosinusitis, have been known to be the main causes. ³ Were the causes for the recurrence considered in each patient? We suggest it is necessary to describe the treatment group in more detail according to the cause for recurrences. Also, on the basis of our experiences, residual and recurrent adenoid hypertrophy are rarely seen after microdebriber-assisted adenoidectomy. Which surgical method was used in adenoidectomy?

Second, as shown in Table 2, significant improvement in the apnea-hypopnea index (AHI) and nadir SpO₂ was seen in the treatment group. We wonder how the arousal index (AI) changed. In Table 1, the authors described AI before montelukast treatment, but they did not describe it after treatment in Table 2. That is why recent recommendations suggest the inclusion of respiratory event–related arousals, in addition to apneas and hypopneas, in a respiratory disturbance index.

Third, we want to point out 2 minor points. In the third line of the Results section, we think “1<AHI<5” is correctly described. The authors state that polysomnography (PSG) was performed at 6 months after tonsillectomy and adenoidectomy (T&A) but Figure 1 indicates that they performed a 3-month observation. Which is correct?