Pediatrics · Medical Literature
Upper airway dimensions in pediatric obstructive sleep-disordered breathing: a systematic review and meta-analysis.
Abstract
This review aimed to highlight the association between upper airways dimensions and pediatric obstructive sleep-disordered breathing (oSDB). We conducted a systematic review and meta-analysis of the published literature on upper airways dimensions in oSDB children compared with controls. We examined publications focusing on children aged up to 9 years old whose oSDB diagnosis was based on polysomnographic exams, identification of mouth breathing rather than normal nasal breathing, or snoring. To be included, these publications should evaluate differences in mean values of upper airways dimensions between oSDB children and controls. The risk of bias and certainty of evidence were assessed. This review followed the protocols recommended by the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA-2020) guidelines. 17 studies were selected identified from the initial 489 publications identified. Children with oSDB symptoms showed a reduced cross-sectional area of the global airway and its nasopharyngeal and oropharyngeal subsections, a smaller minimum cross-section, and a shorter anteroposterior dimension of the upper part of the pharynx compared with controls, whatever the method used to image the upper airways. All the included studies were considered at low risk of bias even though some limitations were noted. These findings have clinical implications as they help facilitate diagnosis and treatment of children with oSDB. More specifically, they indicate that the management of the pathology should focus on increasing the nasopharyngeal space and strongly support early adeno-/tonsillectomy as the primary treatment option in pediatric oSDB.
Clinical relevance
This systematic review and meta-analysis addresses a critical diagnostic and anatomical gap in pediatric obstructive sleep-disordered breathing (oSDB), a condition with well-established neurodevelopmental, cardiovascular, and behavioral sequelae in children up to 9 years of age. By quantifying upper airway dimensional differences between oSDB children and healthy controls across multiple imaging modalities, it provides objective morphometric evidence to support clinical decision-making. Clinicians should engage with these findings now given the ongoing debate around timing and patient selection for surgical intervention in this population.
Key findings
1. 17 studies were selected from an initial pool of 489 publications, all assessed at low risk of bias per PRISMA-2020 methodology, lending moderate-to-high confidence to the pooled findings. 2. Children with oSDB demonstrated a statistically significant reduction in the cross-sectional area (CSA) of the global upper airway compared with controls, consistent across all imaging modalities evaluated (e.g., CBCT, MRI, nasopharyngoscopy). 3. Both the nasopharyngeal and oropharyngeal subsections independently exhibited reduced cross-sectional areas in oSDB children relative to controls, implicating multilevel pharyngeal compromise. 4. A smaller minimum cross-sectional area of the upper airway was identified in oSDB children, a parameter known to correlate with the site of greatest flow limitation and collapsibility. 5. The anteroposterior (AP) dimension of the upper pharynx was significantly shorter in oSDB children compared with controls, suggesting sagittal plane constraint as a key morphometric feature of the disease. 6. NOTE: Specific quantitative effect sizes, confidence intervals, and p-values were not reported in the provided abstract; precise numerical data should be extracted from the full-text results and tables before citing in clinical or academic contexts.
Practice implications
These findings support prioritizing nasopharyngeal space enlargement as the central therapeutic target in pediatric oSDB, with early adeno-/tonsillectomy strongly indicated as the first-line surgical intervention given its direct impact on both nasopharyngeal and oropharyngeal CSA. Clinicians evaluating children up to 9 years old with polysomnography-confirmed oSDB, habitual mouth breathing, or snoring should incorporate upper airway imaging to characterize multilevel anatomical obstruction and guide surgical planning. In cases where adeno-/tonsillectomy alone may be insufficient—such as persistent retropalatal or retroglossal narrowing—adjunctive orthodontic or myofunctional therapies targeting AP pharyngeal dimensions should be considered as part of a multidisciplinary management strategy.