Comparative outcomes of intracapsular and total tonsillectomy for obstructive sleep apnea in children with Trisomy 21.

INTRODUCTION

Children with Trisomy 21 (T21) are at high risk for obstructive sleep apnea (OSA) and perioperative complications. Intracapsular tonsillectomy (IT) is associated with reduced postoperative morbidity, but its long-term efficacy compared to total tonsillectomy (TT) remains debated.

OBJECTIVES

To compare the safety and efficacy of IT versus TT for OSA in children with T21.

METHODS

A retrospective cohort study was conducted of patients aged 2-18 years with T21 who underwent tonsillectomies with/without adenoidectomy between 2005 and 2025 at a tertiary center. Patients undergoing concurrent airway procedures were excluded. Outcomes included postoperative complications, polysomnography (PSG) changes, symptom recurrence, and OSA-symptom-free survival.

RESULTS

Among 176 patients (mean age 5.9 years; 54.0% female), 109 underwent TT and 67 IT. Preoperative OSA severity and tonsil size did not differ. Postoperative return visits were significantly higher after TT (17.4% vs 1.5%, p = 0.001) for poor oral intake (12.8% vs 1.5%, p = 0.010) and bleeding (6.4% vs 0.0%, p = 0.045). Improvements in AHI (53.4% TT vs 53.1% IT, p = 1.00) and OSA resolution (19.0% vs 21.9%, p = 0.787) were comparable. Unadjusted OSA recurrence was higher after TT, but this difference was not significant after adjusting for surgery year and follow-up duration (HR 1.10, 95% CI 0.54-2.25, p = 0.785). No patient undergoing IT required completion tonsillectomy despite tonsillar regrowth being observed in 5 patients (7.5%), all of whom were managed conservatively.

CONCLUSION

Intracapsular tonsillectomy provides equivalent OSA control with lower perioperative morbidity compared with total tonsillectomy, supporting IT as a safe and effective first-line surgical approach for children with T21.