A new study published in Laryngoscope Investigative Otolaryngology shows a disconnect between respiratory improvement and recovery of sleep quality following adenotonsillectomy outcomes in pediatric OSA.1 According to the study, the procedure was found to improve sleep efficiency, defined as the proportion of time spent asleep relative to time spent in bed. However, the study’s authors said clinicians should anticipate variable outcomes, particularly in patients with comorbid conditions such as Down syndrome.
Anne C. Coates, MD, a pediatric pulmonologist at Maine Medical Center and Associate Professor of Pediatrics at Tufts University School of Medicine, said sleep efficiency is a blunt metric for OSA outcomes, particularly in children with Down syndrome, a subset of the study population highlighted.
“There can be a significant reduction in [apnea-hypopnea index] with improved gas exchange, less respiratory effort, and fewer arousals from airway obstruction,” she said. “But many factors that can impact sleep efficiency have nothing to do with underlying airway obstruction or impaired gas exchange, such as behavioral issues or altered sleep architecture.”
Indeed, the researchers, led by Basir S. Mansoor of the Department of Otolaryngology-Head and Neck Surgery at UT Southwestern Medical Center in Dallas, concluded that the findings demonstrate that respiratory improvement does not guarantee recovery of sleep quality, and that benefits may require months to manifest.
Thus, clinicians may need to look beyond traditional outcome measures to determine what constitutes surgical success for individual children.
Dr. Coates said she agreed and suggested that multidisciplinary care teams work with families and patients to ensure everyone is on the same page.
“For some patients, it may take longer to see a benefit, especially when there are nonrespiratory factors such as behavioral issues or an underlying intellectual disability that may be impacting sleep efficiency,” she said.
The retrospective cohort study of 139 children undergoing adenotonsillectomy with preoperative and postoperative polysomnography confirmed the procedure’s well-established benefit in reducing respiratory burden. Median apnea-hypopnea index dropped from 17.3 to 6.0 events per hour, a significant reduction consistent with effective resolution of upper airway obstruction.
Changes in sleep efficiency were inconsistent, however. The proportion of children achieving normal sleep efficiency (≥85%) increased modestly from 42.4% preoperatively to 48.9% postoperatively, and the proportion of children with severely reduced sleep efficiency (<70%) nearly doubled from 9.4% to 18.0%.
The study found that postoperative patients with poor sleep efficiency did not exhibit major distortions in the proportions of their sleep architecture (REM vs non-REM). Instead, deficits were driven by reduced absolute sleep time, suggesting persistent difficulties with sleep consolidation rather than structural abnormalities.
According to the investigators, one of the most clinically relevant findings was the strong association between comorbid conditions and postoperative sleep inefficiency. Children with Down syndrome were significantly overrepresented among those with persistent or worsening sleep efficiency, accounting for up to 19.6% of the mild to moderate sleep efficiency group and 16.0% of the severe sleep efficiency group postoperatively. As shown in this and previous studies, craniofacial anatomy, hypotonia, and airway collapsibility in Down syndrome may limit the effectiveness of adenotonsillectomy alone.
The investigators also observed a time-dependent pattern in the recovery of sleep efficiency. Children evaluated more than six months following surgery demonstrated an average improvement in sleep efficiency, whereas those assessed within six months showed slight declines. This finding suggests that early postoperative polysomnography may underestimate long-term benefits, and it may explain some of the variability reported in prior studies.
Clinically, the data support delaying definitive postoperative sleep quality assessments when feasible, and the research team suggested that sleep efficiency should be considered alongside traditional respiratory metrics when evaluating treatment success in pediatric OSA.
Alternatively, future studies could examine sleep fragmentation—which may be a better measure of treatment success—instead of sleep efficiency, Dr. Coates said.
References
1. Mansoor BS, Zhang M, Mohamed A, Abdi A, Johnson RF. The effect of adenotonsillectomy on sleep efficiency in pediatric patients. Laryngoscope Investig Otolaryngol. 2026;11(2):e70404. doi:10.1002/lio2.70404
