Upper airway dimensions in pediatric obstructive sleep-disordered breathing: a systematic review and meta-analysis
Clinical Snapshot
PICO Framework
| P — Population | Children aged up to 9 years with obstructive sleep-disordered breathing (oSDB), diagnosed via polysomnography, identification of mouth breathing, or snoring |
| I — Intervention | Measurement of upper airway dimensions (cross-sectional area, minimum cross-section, anteroposterior dimensions) using imaging modalities |
| C — Comparator | Age-matched healthy controls without oSDB |
| O — Outcomes | Differences in mean values of upper airway dimensions between oSDB children and controls, including global airway cross-sectional area, nasopharyngeal and oropharyngeal subsection areas, minimum cross-section, and anteroposterior pharyngeal dimensions |
Bottom Line
This systematic review and meta-analysis of 17 studies confirms that children aged up to 9 years with obstructive sleep-disordered breathing have measurably smaller upper airway dimensions — including reduced nasopharyngeal and oropharyngeal cross-sectional areas and shorter anteroposterior pharyngeal dimensions — compared with healthy controls. Findings were consistent regardless of imaging modality used. All included studies were rated at low risk of bias, and PRISMA-2020 guidelines were followed. However, the clinical utility of this review is constrained by several important limitations: diagnostic criteria for oSDB were heterogeneous (ranging from polysomnography to snoring alone), pooled effect sizes and confidence intervals are not reported in the abstract, and outcomes are restricted to anatomical surrogates without addressing patient-important endpoints such as apnoea-hypopnoea index, neurocognitive function, or quality of life. The authors' conclusion supporting early adenotonsillectomy as primary treatment is clinically reasonable and consistent with existing guidelines, but is not directly derived from the data presented. For Australian clinicians, these findings reinforce current RACGP and Australasian Sleep Association guidance on surgical management of paediatric oSDB with adenotonsillar hypertrophy, while highlighting the value of upper airway imaging in complex or atypical presentations.
Key Findings
P Value: Not reported in abstract
Effect Size: Not reported in abstract; specific pooled effect sizes (e.g., mean differences in mm² or mm) are not provided
Primary Outcome: Children with oSDB symptoms demonstrated reduced cross-sectional area of the global upper airway and its nasopharyngeal and oropharyngeal subsections, a smaller minimum cross-section, and a shorter anteroposterior dimension of the upper pharynx compared with controls
Nnt Or Sensitivity: Not applicable to this anatomical observational meta-analysis; no NNT, sensitivity, specificity, or hazard ratio data reported
Confidence Interval: Not reported in abstract
Clinical Application
Upper airway imaging (MRI, CT, acoustic rhinometry, nasopharyngoscopy) is available in tertiary paediatric centres but not universally accessible in primary or community care settings. Radiation-free modalities (MRI, acoustic rhinometry) are preferable in children. The findings support clinical assessment of nasopharyngeal and oropharyngeal dimensions as part of oSDB workup, which is feasible in specialist practice. In Australia, adenotonsillectomy for paediatric obstructive sleep apnoea is supported by RACGP and Australasian Sleep Association guidelines as first-line surgical treatment when adenotonsillar hypertrophy is confirmed. The findings of this review are consistent with this approach. Polysomnography for children is available through accredited sleep laboratories and is Medicare-rebatable under specific criteria (MBS item numbers apply for diagnostic PSG in children with suspected OSA). Myofunctional therapy and orthodontic expansion (e.g., rapid maxillary expansion) are increasingly recognised adjuncts in Australian paediatric sleep medicine, consistent with the review's emphasis on nasopharyngeal space augmentation. TGA-approved CPAP devices remain an option for children unsuitable for or awaiting surgery. The PBS does not currently list pharmacological agents specifically for paediatric oSDB. Children aged up to 9 years presenting with symptoms of obstructive sleep-disordered breathing, including habitual snoring, observed mouth breathing, or polysomnographically confirmed obstructive sleep apnoea. Most applicable to ENT, paediatric respiratory, and paediatric dentistry/orthodontic settings.
Abstract
PURPOSE: This review aimed to highlight the association between upper airways dimensions and pediatric obstructive sleep-disordered breathing (oSDB). METHODS: 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. RESULTS: 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. CONCLUSION: 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.
References
- 1.Remy, F., & Gillot, A. (2026). Upper airway dimensions in pediatric obstructive sleep-disordered breathing: a systematic review and meta-analysis. Sleep & Breathing. https://doi.org/10.1007/s11325-025-03342-2
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