TABLE 1:

Evaluation of the Child with Suspected OSAS or Residual OSAS following AT

Otherwise healthy children

Clinical evaluation: history and physical exam (recommended by AAP [1], AASM [114], AAO-HNS [10], and ERS [115]) Diagnostic polysomnogram (recommended by AAP [1], AASM [26, 114], and ERS [115]) AAO-HNS recommends polysomnography if the need for surgery is unclear or if there is discordance between the clinical history and the tonsillar size on physical exam [28] Alternative testing when polysomnography is not available AAP: options include nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, or ambulatory polysomnography [1] ERS: options include ambulatory polysomnography or polygraphy, nocturnal oximetry, Pediatric Sleep Questionnaire, or Sleep Clinical Record [115] AASM: does not recommend home sleep apnea testing for OSAS diagnosis in children [37] AAO-HNS: home-based studies may be considered but are not recommended for routine use [28] Consider endocrinology/weight management referral for obese children Consider cardiology referral for children with severe sleep apnea or cardiometabolic risk factors

Children with complex comorbidities

Includes children with obesity, neuromuscular disorders, craniofacial abnormalities, genetic syndromes, sickle cell disease, etc. Clinical evaluation: history & physical exam (recommended by AAP [1], AASM [114] AAO-HNS [10], and ERS [115]) Diagnostic polysomnogram (recommended by AAP [1], AASM [114], AAO-HNS [10], and ERS [115]) Expert evaluation (e.g. pediatric pulmonology, pediatric otolaryngology, sleep medicine, craniofacial team) Consider endocrinology/weight management referral for obese children Consider cardiology referral for children with severe sleep apnea or cardiometabolic risk factors

Children with residual OSAS following AT

Post-treatment reevaluation of high-risk patients AAP: High-risk children (defined as those with significantly abnormal baseline polysomnogram, sequelae of OSAS, obesity, or continued symptoms following treatment) should be reevaluated with objective testing or referred to a sleep specialist [1] AASM: Polysomnography should be repeated following adenotonsillectomy in children at risk of recurrence: mild preoperative OSAS with residual symptoms following surgery, pre-operative evidence of moderate-severe OSAS, obesity, craniofacial abnormalities, or neurologic disorders [114] ERS: Patients at risk of persistent OSAS or with persistent symptoms should be reevaluated with polysomnography or polygraphy [115] Expert evaluation (pediatric pulmonology, sleep medicine, pediatric otolaryngology, endocrinology) Polysomnography titration for positive airway pressure therapy (AAP [1]) Nasopharyngoscopy or drug-induced sleep endoscopy Imaging (computed tomography, dynamic magnetic resonance imaging) Cardiology referral for persistent, untreated OSAS

AAO-HNS American Academy of Otolaryngology—Head & Neck Surgery, AAP American Academy of Pediatrics, AASM American Academy of Sleep Medicine, ERS European Respiratory Society, OSAS obstructive sleep apnea syndrome