Multi-level surgery for obstructive sleep apnoea in syndromic and non-syndromic paediatric patients – A systematic review and meta-analysis

Abstract

Study objectives

Multilevel surgery for obstructive sleep apnoea treatment is a well-accepted option for adult patients. However, in paediatric populations, it is less established. This study evaluates the efficacy of multi-level airway surgery in treating both non-syndromic and syndromic paediatric obstructive sleep apnoea.

Methods

PubMed, Embase and The Cochrane Library databases were searched from inception to November 30, 2025. Two independent authors performed screening and extraction of studies according to PRISMA guidelines. Observational and randomised studies pertaining to sleep outcomes of various multi-level sleep surgeries in syndromic and non-syndromic children were selected. Pooled analyses were performed for post-operative improvements in Apnoea-Hypopnea Index (AHI) and SpO₂ Sleep Nadir. Quality of evidence assessment was assessed with respective risk of bias appraisal tools.

Results

From 2925 initial non-duplicate studies, 17 studies were included for analysis, comprising 338 children (228 non-syndromic children, 80 children with Down Syndrome and 30 children with other syndromes). In non-syndromic children, AHI improved by −10.13 (95%CI -13.30 to −6.97; I² = 71.7%) and SpO₂ sleep nadir by 4.39 (95%CI 1.68–7.11; I² = 79.5%), with AHI normalisation rate at 66.4%. In children with Down syndrome, AHI improved by −14.58 (95%CI [-16.23, −12.93], I² = 0%) and SpO₂ nadir by +3.75 (95%CI [1.72, 5.78], I² = 0%).

Conclusion

Multi-level airway surgery presents a valuable adjunct to adenotonsillectomy in addressing paediatric OSA, particularly for selected syndromic and refractory cases. Future research should identify specific syndromic subgroups that would benefit most from multi-level surgery, to better inform individualised treatment strategies.