Published online January 4, 2006
PEDIATRICS Vol. 117 No. 1 January 2006, pp. e61-e66 (doi:10.1542/10.1542/peds.2005-0795)
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ARTICLE

Intranasal Steroids and Oral Leukotriene Modifier Therapy in Residual Sleep-Disordered Breathing After Tonsillectomy and Adenoidectomy in Children

Leila Kheirandish, MD, Aviv D. Goldbart, MD and David Gozal, MD

Kosair Children's Hospital Research Institute and Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, Kentucky

OBJECTIVE. Tonsillectomy and adenoidectomy (T&A) is the primary therapeutic approach for sleep-disordered breathing (SDB) in children. However, residual mild SDB will be found in more than one third of these patients after T&A. We hypothesized that combined therapy with the leukotriene receptor antagonist montelukast and intranasal budesonide would result in normalization of residual SDB after T&A.

METHODS. During the period of October 2002 to February 2005, children who underwent T&A for SDB underwent a routine postoperative (second) overnight polysomnographic evaluation (PSG) 10 to 14 weeks after T&A surgery. In children with residual apnea hypopnea index (AHI) >1 and <5/hour of total sleep time (TST), treatment with montelukast and intranasal budesonide aqueous solution was administered for a period of 12 weeks (M/B group), at which time a third PSG was performed. Children who had residual SDB and did not receive M/B therapy from their treating physicians were recruited as control subjects.

RESULTS. Twenty-two children received M/B, and 14 children served as control subjects. Mean age, gender distribution, ethnicity, and BMI were similar in the 2 treatment groups. The mean AHI at the second PSG was 3.9 ± 1.2/hour of TST and 3.6 ± 1.4/hour of TST in M/B-treated and control patients, respectively. Similar nadir arterial oxygen saturation (87.3 ± 1.2%) and respiratory arousal index (4.6 ± 0.7/hour of TST) were recorded for both groups. However, the M/B group demonstrated significant improvements in AHI (0.3 ± 0.3/hour of TST), in nadir arterial oxygen saturation (92.5 ± 3.0%), and in respiratory arousal index (0.8 ± 0.7/hour of TST) on the third PSG, whereas no significant changes occurred over time in control subjects.

CONCLUSIONS. Combined anti-inflammatory therapy that consists of oral montelukast and intranasal budesonide effectively improves and/or normalizes respiratory and sleep disturbances in children with residual SDB after T&A.

Key Words: leukotriene receptors • glucocorticoid receptors • sleep apnea • lymphoid hyperplasia • tonsils • adenoids • tonsillectomy and adenoidectomy • montelukast • sleep disordered breathing • budesonide

Abbreviations: SDB—sleep-disordered breathing • T&A—tonsillectomy and adenoidectomy • CPAP—continuous positive airway pressure • AHI—apnea hypopnea index • PSG—overnight polysomnographic evaluation • TST—total sleep time • M/B—oral montelukast and intranasal budesonide therapy • SpO2—arterial oxygen saturation • ARtotI—total number of arousals per hour of sleep time • SPS—sleep pressure score

Accepted Jul 8, 2005.


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