Synchronous airway lesions in children with obstructive sleep apnea.

OBJECTIVE: Drug-induced sleep endoscopy is established for evaluating the upper airway in pediatric obstructive sleep apnea (OSA), but the role of comprehensive lower airway assessment remains uncertain. We aimed to determine whether synchronous airway lesions identified during microlaryngoscopy and bronchoscopy (MLB) are associated with OSA severity in children undergoing adenotonsillectomy (AT). STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care academic children's hospital. METHODS: We reviewed MLB findings documented by three fellowship-trained pediatric otolaryngologists during ATs for OSA between January 2019 and December 2023. Children with craniofacial abnormalities, genetic syndromes, or tracheostomy dependence were excluded. Associations between airway findings, demographics, polysomnography, and surgical management were analyzed. RESULTS: Among 117 children (mean age 3.5 years, SD 2.2), 63.2 % were male, 54.7 % were Black, and 76.1 % had Medicaid insurance. Synchronous airway lesions were present in 44 (37.6 %). Laryngomalacia-related abnormalities were most common (19.7 %), followed by mucosal cobblestoning (5.1 %). Children with synchronous airway lesions were more likely to have asthma (P = 0.02), but no associations were observed with age, race, insurance status, or prematurity. Notably, no patient required intervention based on MLB findings, and surgical management was unchanged. Preoperative polysomnographic parameters-including apnea-hypopnea index (30.0 vs. 26.7 events/hour, P = 0.39), oxygen saturation nadir (81.0 % vs. 78.6 %, P = 0.22), and sleep efficiency (77.5 % vs. 74.5 %, P = 0.32)-did not differ between groups. CONCLUSION: Synchronous airway lesions were common but did not correlate with OSA severity or alter management. These findings suggest many are incidental, supporting a selective, individualized approach to MLB use in pediatric OSA pending evidence-based guidelines.