Adenoid removal for sleep apnea is almost always done together with the tonsils (adenotonsillectomy). In the CHAT trial of 464 children aged 5 to 9, sleep studies normalized in 79% after early surgery versus 46% with watchful waiting, although attention scores did not differ. In a review of 578 children only 27.2% were completely free of apnea afterwards, and older or obese children did worse. In adults, a meta-analysis of 216 patients found the apnea-hypopnea index fell by 65% after tonsillectomy, with the best results in people with large tonsils and milder apnea. Whether surgery is right for a particular child or adult is a decision for an ear, nose and throat specialist after a sleep study.
The conversation tends to start the same way. A child snores, pauses, sleeps restlessly and is tired or hyperactive by day, and an ear, nose and throat doctor says the adenoids and tonsils are large. Surgery is the usual suggestion, and parents reasonably want to know how well it works. Adults with big tonsils get a shorter version of the same talk. Randomized trials and large reviews answer it, including the part that leaflets skip: surgery helps most patients and cures fewer than people expect.
A child who stops breathing for long stretches, turns blue around the lips, or is very hard to wake needs urgent medical care. Call your local emergency number. The rest is background for planned decisions with a doctor.
What the Childhood Adenotonsillectomy Trial showed about adenoid removal for sleep apnea
In practice the adenoids are rarely removed alone. They sit behind the nose and the tonsils sit on both sides of the back of the throat, and in children the two tend to be taken out in one operation, called adenotonsillectomy. The strongest evidence comes from the Childhood Adenotonsillectomy Trial, known as CHAT. It randomly assigned 464 children aged 5 to 9 with obstructive sleep apnea to early surgery or to watchful waiting with supportive care, and measured outcomes seven months later.
The headline outcome did not move much. Attention and executive function scores improved by 7.1 points in the surgery group and 5.1 in the waiting group, a difference that was not statistically significant (P=0.16). Everything else favored surgery: behavior, quality of life, symptoms and the sleep study itself. Sleep studies returned to normal in 79% of the surgery group and 46% of the waiting group. Almost half of the children who simply waited had a normal study seven months later, so some apnea in children gets better without an operation.
Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, Mitchell RB, Amin R, Katz ES, Arens R, Paruthi S, Muzumdar H, Gozal D, Thomas NH, Ware J, Beebe D, Snyder K, Elden L, Sprecher RC, Willging P, Jones D, Bent JP, Hoban T, Chervin RD, Ellenberg SS, Redline S, Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013. PMID 23692173
An older prospective study looked at the same question from the angle of behavior. It followed 105 children aged 5 to 12.9, of whom 78 were scheduled for adenotonsillectomy, mostly for suspected sleep-disordered breathing. Before surgery the children were more hyperactive, less attentive and sleepier than controls, and more of them met criteria for attention-deficit/hyperactivity disorder. A year later the groups no longer differed. The sleep recordings, however, did not predict who improved, except for sleepiness, which led the authors to ask for better measures of how nighttime breathing affects children.
Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 2006. PMID 16585288
Why a normal sleep study is not guaranteed
A multicenter review pulled the before and after sleep studies of 578 otherwise healthy children (average age 6.9 years) from eight sleep centers, six in the United States and two in Europe. About half of the children were obese. Surgery brought the obstructive apnea-hypopnea index down from 18.2 to 4.1 events per hour on average, a large and statistically clear improvement. But only 157 children, 27.2%, ended up with an index below 1 event per hour, which the review used as the mark of complete resolution.
Two factors stood out as the main reasons for leftovers: age and body mass index. Children older than 7 and obese children had more apnea after surgery. Asthma and the severity of apnea before surgery played smaller parts in non-obese children. The authors suggested that non-obese children with severe apnea and children with chronic asthma should have a repeat overnight study, because their risk of residual apnea is higher.
Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 2010. PMID 20448096
The index dropped by about three quarters on average, which is a big change in how often the airway closes. What it leaves is a question about follow-up. Obesity was one of the strongest predictors of leftover apnea in that review, so it is fair to ask what it means for your child (Sleep apnea risk factors covers the adult picture).
Snoring and mild apnea: the PATS trial
The harder question is the child who snores loudly but has few breathing events. The Pediatric Adenotonsillectomy Trial for Snoring, PATS, enrolled 459 children aged 3 to 12.9 whose obstructive apnea-hypopnea index was below 3. Half had early adenotonsillectomy and half had watchful waiting, and 86% of them completed follow-up at 12 months.
Neither of the two primary outcomes differed between groups: a parent-rated executive function score and a computerized attention test. Behavior problems, sleepiness, symptoms and quality of life improved more with surgery, and so did blood pressure: the systolic and diastolic percentile levels fell more in the surgery group. And progression of the apnea-hypopnea index to above 3 happened in 1.3% of the operated children and 13.2% of the waiting children. The trial leaves a real choice between operating and waiting while keeping an eye on the child, and the authors do not pretend otherwise.
Redline S, Cook K, Chervin RD, Ishman S, Baldassari CM, Mitchell RB, Tapia IE, Amin R, Hassan F, Ibrahim S, Ross K, Elden LM, Kirkham EM, Zopf D, Shah J, Otteson T, Naqvi K, Owens J, Young L, Furth S, Connolly H, Clark CAC, Bakker JP, Garetz S, Radcliffe J, Taylor HG, Rosen CL, Wang R, Pediatric Adenotonsillectomy Trial for Snoring (PATS) Study Team. Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial. JAMA 2023. PMID 38051326
A practical point follows from both trials: children who wait are not left alone. In CHAT and PATS "watchful waiting" came with supportive care and was not a way of ignoring the problem. A child whose snoring is getting louder or who starts having pauses between snores is a child who should be seen again.
Tonsillectomy in adults: size and severity decide
Studies of tonsillectomy for sleep apnea in adults are a different kind of evidence, because surgery was reserved for adults whose tonsils were clearly enlarged. A systematic review and meta-analysis gathered 17 studies of isolated tonsillectomy in 216 adults (average age 34.4, average body mass index 29.0). Their tonsils were enlarged (graded 2 to 4 or described as large). The apnea-hypopnea index fell by 65.2%, from 40.5 to 14.1 events per hour. The lowest oxygen level during sleep rose from 77.7% to 85.5%, and the Epworth Sleepiness Scale score dropped from 11.6 to 6.1.
The finding most readers want is in the subgroup data. Among 54 patients with individual results, patients whose index was below 30 before surgery all succeeded (25 of 25) and 84% were cured, with an average index of 2.4 afterwards. Those with an index of 30 or more succeeded in 72.4% (21 of 29) and were cured in 34.4%, with an average of 14.3 afterwards. The authors concluded that tonsillectomy can work for adult sleep apnea, especially with large tonsils and mild to moderate apnea.
Camacho M, Li D, Kawai M, Zaghi S, Teixeira J, Senchak AJ, Brietzke SE, Frasier S, Certal V. Tonsillectomy for adult obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope 2016. PMID 27005314
The limits are as important as the numbers. The 17 studies were small, 216 adults in total, and the participants were young (average 34.4) with enlarged tonsils, so the results do not transfer to every adult with apnea. As for adenoids on their own in adults, none of these studies covers it. An adult who has been told their adenoids are the problem should ask which exam or scan showed it, and whether a sleep study confirmed the apnea.
Questions worth asking before surgery
Reading across the trials, a few questions come up again and again. They are things to bring to the consultation, not instructions:
- Was the diagnosis made with an overnight study, or from history and examination alone? The trials selected children by sleep study, and the numbers here only apply to people like them.
- How large is the apnea-hypopnea index, and how do the tonsils look? Severity and size were the predictors in the adult review.
- Is weight part of the story? Obesity was one of the two strongest predictors of leftover apnea in the review of 578 children.
- Is a repeat sleep study planned after healing, and when?
- What is the plan if breathing at night is not normal afterwards? Options exist, and the surgeon should be able to name them.
For context on how seriously untreated apnea needs to be taken, Is sleep apnea dangerous? collects the long-term data, and Types of sleep apnea explains why some breathing pauses have nothing to do with the throat.
Tracking snoring and pauses at home, before and after
A sleep study is the measurement doctors rely on, and nothing at home replaces it. What home recordings can do is show change over several weeks in things a parent or partner would otherwise judge by ear: how many nights have snoring, how loud, and whether gaps appear. That helps when someone is deciding between operating and waiting, and it gives the follow-up appointment something concrete to look at.
SleepTrace listens through the phone's microphone and estimates sleep phases from sound. It recognizes snoring, talking and coughing and keeps short clips for those (the free plan plays back 3 clips a month, Premium has no limit), and it shows a sleep apnea indicator as a screening, not a diagnosis. Keep the app open overnight and the phone charging; the screen dims on its own. It is not a medical device.
Frequently asked questions
It cures some children and helps most. In the CHAT trial, which randomized 464 children aged 5 to 9, 79% of those who had early surgery had a normal sleep study seven months later, against 46% of those who waited. In a multicenter review of 578 children, the apnea-hypopnea index fell from 18.2 to 4.1 events per hour on average, but only 27.2% reached an index below 1. Children who were older than 7 or obese were more likely to have apnea left over.
The adult evidence is about the tonsils. A meta-analysis of 17 studies with 216 adults found that tonsillectomy alone lowered the apnea-hypopnea index by 65.2%, from 40.5 to 14.1 events per hour. Those patients had enlarged tonsils and were on average 34 years old. Adenoid-only surgery in adults is not covered by those studies, so an adult asking about it should get the answer from an ear, nose and throat specialist who has looked at their airway.
Large tonsils and adenoids narrow the airway behind the nose and mouth, and they are the usual reason surgery is offered. The trials enrolled children whose sleep studies showed obstructive sleep apnea or snoring. Size is only part of the picture: weight, age and asthma also predicted whether apnea persisted after surgery in the multicenter review.
In the PATS trial, 459 children aged 3 to 12.9 with snoring and a low apnea-hypopnea index (under 3) were randomized to early surgery or watchful waiting. After 12 months, attention and executive function did not differ. Behavior, sleepiness, symptoms and quality of life improved more after surgery, and only 1.3% of the operated children progressed to an index above 3, against 13.2% of those who waited. Parents and surgeons weigh those results differently, which is a normal reason to ask for a second opinion.
The authors of the multicenter review recommended a repeat overnight study after surgery for children with severe apnea who were not obese and for those with chronic asthma, because both groups had a higher risk of apnea remaining. Ask the surgeon whether a repeat study is planned for your child's situation.
SleepTrace is a wellness app, not a medical device. This article is general information, not medical advice. If your symptoms are frequent, severe or worrying, please talk to a doctor.
Whether surgery is right is a decision for a specialist and a sleep study. SleepTrace can show the sound side before and after: how often snoring or possible breathing pauses show up, and when, so you compare nights instead of memories. It is a screening aid, not a diagnosis, and it does not measure oxygen.
Hear your own night. SleepTrace turns a night of audio into your sleep phases, the sounds you made, and how it all trends. Works without a wearable, better with one. Your phone on the nightstand is enough to start. Get it for iPhone or Android →