Diagnostic Accuracy of the Thai SRBD-PSQ Combined with Adenotonsillar Hypertrophy Assessment for Moderate-toSevere Pediatric Obstructive Sleep Apnea

Abstract

Background: Obstructive sleep apnea (OSA) is a common sleep disorder in children and is associated with significant neurocognitive, cardiovascular, and metabolic consequences if left untreated. Although polysomnography (PSG) is the gold standard for diagnosing pediatric OSA, its use is limited in many settings. The Pediatric Sleep Questionnaire (PSQ) is a validated screening tool for sleep-related breathing disorders in children; however, its diagnostic accuracy varies. Combining questionnaire results with clinical evaluation of adenotonsillar hypertrophy may improve diagnostic performance. Objective: To evaluate the diagnostic accuracy of the Thai Sleep-Related Breathing Disorder–Pediatric Sleep Questionnaire (Thai SRBD-PSQ) combined with adenotonsillar hypertrophy assessment for identifying moderateto-severe pediatric OSA. Materials and methods: This diagnostic accuracy study included children aged 2–12 years with suspected sleep-related breathing disorders who underwent standard PSG at the Phramongkutklao Hospital Sleep Disorder Center between 2018 and 2024. The Thai SRBD-PSQ was completed prior to PSG. Tonsillar size was graded using the Brodsky scale, and adenoid hypertrophy was determined using the adenoid–nasopharynx ratio on lateral neck radiography. Moderate-to-severe OSA was defined as an apnea– hypopnea index (AHI) ≥ 5 events/h. Diagnostic performance was analyzed for the questionnaire alone and in combination with adenotonsillar hypertrophy assessment. Results: Fifty-seven children were included (61.4% male; mean age 7.79 ± 2.53 years), of whom 23 (40.4%) had moderate-to-severe OSA. A positive Thai SRBD-PSQ result (score ≥ 8) was observed in 32 participants (56.1%). The questionnaire alone demonstrated a sensitivity of 52.2% (95% CI: 30.6-73.2%), specificity of 41.2% (95% CI: 24.6-59.3%), PPV of 37.5% (95% CI: 21.1-56.3%), NPV of 56.0% (95% CI: 34.9-75.6%), and accuracy of 45.6% (95% CI: 32.4- 59.3%). When combined with tonsillar hypertrophy, specificity increased to 85.3% (95% CI: 68.9-95%) and accuracy to 66.7% (95% CI: 52.9-78.6%). The combination of both adenoid and tonsillar hypertrophy yielded the highest specificity of 97.1% (95% CI: 84.7-99.9%) and PPV of 75.0% (95% CI: 19.4-99.4%), with an accuracy of 63.2% (95% CI: 49.3-75.6%), although sensitivity decreased to 13.0% (95% CI: 2.78-33.6%). Conclusions: The combination of adenotonsillar hypertrophy assessment with the Thai SRBD-PSQ improved diagnostic specificity and overall accuracy for identifying moderate-to-severe pediatric OSA. This combined approach may serve as a practical prioritization tool for PSG referral or treatment planning in settings with limited access to PSG, although its reduced sensitivity limits its use as a standalone screening method for excluding disease.