Pediatric Sleep-Disordered Breathing and Obstructive Sleep Apnea After 2020: Is Adenotonsillectomy Still Enough?

Obstructive sleep apnea (OSA) affects roughly 1–5% of children and is linked to neurocognitive impairment, behavioral problems, metabolic dysfunction, and cardiovascular risk. Adenotonsillectomy (AT) has long served as the first-line treatment, yet a substantial proportion of children go on to develop persistent or recurrent disease after surgery, according to a growing body of evidence. This review summarizes developments published after 2020 in the diagnosis, treatment, and follow-up of pediatric OSA, focusing on the evolving role of AT and on multimodal management strategies. The review synthesizes current literature, clinical practice guidelines, and expert consensus statements, among them the 2023/2024 American Thoracic Society (ATS) Clinical Practice Guideline on persistent post-adenotonsillectomy OSA and the 2024 Year in Review summaries on sleep-disordered breathing research. AT significantly lowers the apnea-hypopnea index (AHI) and improves quality of life, but persistent OSA still occurs in 15–40% of operated children, climbing to roughly 50% in high-risk groups such as those with obesity, Down syndrome, or neuromuscular disorders. Home sleep apnea testing (HSAT) and nocturnal oximetry are gaining acceptance as alternatives to polysomnography (PSG). Intranasal corticosteroids and montelukast lower AHI in mild-to-moderate OSA, and weight loss remains a mandatory pillar of management in obese children. When OSA persists after AT, the ATS guideline supports individualized CPAP/BiPAP, pharmacotherapy, or additional surgery. Drug-induced sleep endoscopy has emerged as the reference technique for localising the site of obstruction, allowing targeted, potentially single-session multilevel surgery. Anti-inflammatory therapy works best as a defined six- to twelve-week trial with structured reassessment rather than open-ended treatment, and orthodontic or dentofacial orthopedic treatment, delivered jointly with dental surgeons, along with orofacial myofunctional therapy, are reasonable supportive options in appropriately selected children, though both rest on low-certainty evidence. AT is best regarded as the first step of a broader, multidisciplinary pathway rather than a definitive cure. Clinicians need to identify which high-risk children require post-operative PSG and to put combined therapeutic strategies in place. The otolaryngologist’s role is expanding to include pharmacological management and coordinated care with sleep medicine specialists. This narrative review is intended to complement, not replace, the graded recommendations of the 2024 ATS Clinical Practice Guideline; the correspondence between the two is set out explicitly in a table.