Intracapsular tonsillectomy/tonsillotomy for severe pediatric obstructive sleep apnea A PRISMA-based systematic review and exploratory meta-analytic synthesis of full-text articles.

BACKGROUND: Intracapsular tonsillectomy/tonsillotomy combined with adenoidectomy has been increasingly adopted for pediatric obstructive sleep apnea (OSA) because it reduces postoperative pain, dysphagia, and hemorrhage while preserving respiratory efficacy. However, its role in severe pediatric OSA remains debated. OBJECTIVE: To evaluate the effectiveness and safety of intracapsular tonsillectomy/tonsillotomy combined with adenoidectomy in children with severe OSA, focusing on polysomnographic (PSG) improvement, residual disease, need for additional treatment, revision/completion tonsillectomy, nocturnal ventilation, and postoperative complications. METHODS: A PRISMA 2020-compliant, PICO-based systematic review was conducted. Thirty-six records were identified through title and abstract screening. After the initial screening, 11 studies were excluded and 25 full-text articles were assessed for eligibility. Studies involving syndromic or cleft populations, procedures other than intracapsular tonsil surgery, or lacking PSG-based outcomes were excluded. Fourteen studies were included in the qualitative synthesis, and 11 provided extractable pre- and postoperative apnea-hypopnea index/obstructive apnea-hypopnea index (AHI/OAHI) data for quantitative analysis. RESULTS: Intracapsular or partial tonsil surgery consistently reduced respiratory event burden (p < 0.001). In children with severe OSA, the sample-size-weighted reduction in AHI/OAHI was 16.5 events/hour (95% confidence interval [CI], 14.2-18.8). The weighted mean preoperative AHI/OAHI was 19.6 events/hour (95% CI, 18.7-20.5), decreasing to 3.0 events/hour (95% CI, 2.6-3.4) postoperatively. Reported postoperative bleeding rates were very low in intracapsular cohorts. Rates of tonsillar regrowth and revision surgery ranged from approximately 2% to 15%, depending on follow-up duration and surgical technique. CONCLUSIONS: In appropriately selected children with severe OSA, intracapsular tonsillectomy/tonsillotomy combined with adenoidectomy provides substantial PSG improvement while maintaining a favorable postoperative morbidity profile. The principal trade-off is the need for long-term surveillance for residual OSA and tonsillar regrowth. No intracapsular surgical technique or instrument has demonstrated clear superiority, although all commonly used approaches achieved clinically meaningful improvements.