Study setting {9}
Participants will be recruited at Shanghai Stomatological Hospital, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University and Shanghai Children's Hospital, which are all located in Shanghai, China, from May 2018 to December 2021 (anticipated). These hospitals comprise all diagnostic and treatment departments, including E.N.T. and stomatological departments. Notification of subject recruitment will be published in these three hospitals and their official websites.
Eligibility criteria {10}
All participants will be assessed by a treatment group consisting of more than three experienced pediatric physicians, otolaryngologists and orthodontists.
Inclusion criteria
(1) Patients aged 7~10 years;
(2) Patients diagnosed with mild OSAHS (an apnea index 1~5 events per hour according to PSG);
(3) Patients with hypertrophy of tonsil or adenoid;
(4) Patients with mouth breathing;
(5) Patients with constricted dental arch or mandibular retraction (ANB≥4.5);
(6) Patients whose guardians agreed to enter this trial and signed the relevant informed consent.
Exclusion criteria
- Patients diagnosed with central sleep apnea/hypopnea syndrome;
- Patients with concurrent systemic diseases;
- Patients with rhinostegnosis;
- Patients with a z score equals to or greater than 3 based on the body-mass index (BMI).
Who will take informed consent? {26a}
A qualified clinical research assistant who is blinded to the patients’ group will obtained the written informed consent from guardians of participants after fully explanation of this study.
Additional consent provisions for collection and use of participant data and biological specimens {26b}
Not applicable.
Interventions
Explanation for the choice of comparators {6b}
All subjects will receive different treatments-- drug treatment, surgical treatment, orthodontic treatment and surgery and postoperative orthodontic treatment within 4 weeks after randomization. The practitioners will be doctors who has a minimum of 5 years work experience in their hospital and have gone through a training of trial protocol prior to the study.
Intervention description {11a}
Drug treatment group: Patients in this group will receive mometasone furoate aqueous nasal spray once a day (0.1mg) in the morning for 2 months. The research assistants will interview participants’ parents by telephone to remind the patients of treatment stage.
Surgical treatment group: Patients in this group will receive adenotonsillectomy under general anesthesia. Routine follow-up was conducted 2 weeks after surgery to evaluate the security.
Orthodontic treatment group: Patients in this group will receive orthodontic treatments. They will receive orthodontic treatment according to a consistent comprehensive protocol, which mainly contains the use of a removable Twin-block appliance combined with RME (figure 3).
Surgery and postoperative orthodontic group: Patients in this group will receive adenotonsillectomy under general anesthesia and the subsequent orthodontic treatment after surgery. The orthodontic treatment appliance will be also a removable Twin-block combined with RME.
Criteria for discontinuing or modifying allocated interventions {11b}
Participants may quit the study at their guardians’ discretion or defer to the supervisory team. Circumstances that suspended participants from study include adverse events and detection of evidence that may influence the outcomes of research. Subjects who leave the study will be followed up until they are in stable status.
Strategies to improve adherence to interventions {11c}
Additional services will be provided for participants through the Wechat or phone to arrange the treatment time to enhance their adherence. The monitor or principle researcher will visit every study site monthly to ascertain that all aspects of the program are being followed and that the trial is being carried out in accordance with the provisions of the drug clinical trial quality management practices (GCP). During monitoring visit, the monitor will check the case report form (CRF) for subjects in the trial to confirm that all items have been completed and the data are obtained according to the protocol. The monitor will also check that the CRF data is consistent with the clinical record or the original data.
Relevant concomitant care permitted or prohibited during the trial {11d}
Other treatments that may affect the outcomes of the study, such as traditional Chinese medicine, acupuncture and massage, are prohibited during the trial.
Provisions for post-trial care {30}
Participants may quit the study at their guardians’ discretion or defer to the supervisory team if they are not responding well to treatment. They will be followed up and get corresponding therapy for free after they leave the study.
Outcomes {12}
Endpoint measurements will be performed before the treatment (baseline survey; month 0) and 7 months (M 7) and 12 months (M 12) and 24 months (M 24) after the starting point.
Primary endpoint
The primary endpoint of the trial is the mean change of AHI from the baseline (M 0) to the primary endpoint (M 7), because PSG is still the gold criterion for diagnosing OSAHS. All subjects will undergo attended overnight PSG in hospitalized ward. They will go to bed at their usual sleeping time and sleep for at least 6 hours to ensure PSG monitoring time. A reduction in airflow of more than 90% compared to preceding sleep breathing is considered to be an obstructive apnea. A hypopnea is defined as a reduction in airflow of more than 30%, accompany with an oxygen desaturation of ≥3% and/or an arousal. The duration of obstructive apneas or hypopnea equal to or greater than 2 respiratory cycles is defined as an obstructive event. The definition of AHI is the number of obstructive events per hour. The analysis will include the mixed events but not central events.
Secondary endpoints
The secondary endpoints will consist of the lowest oxyhemoglobin saturation (LSaO2), apnea index, and hypopnea index assessed by PSG, subjective symptoms (assessed by questionnaire OSA-20), Cephalometric measurements and Morphologic analysis of upper airway.
Subjective symptoms
Subjective symptoms will be assessed according to questionnaire, OSA-20. OSA-20 includes 20 questions divided to five domains, sleep interference, physical suffering, emotional disorder, diurnal problems, and guardian concern. These questions are graded on a scale of 1 to 7 applying an ordinal Likert scoring system. Guardians will complete the questionnaire without help to ensure its reliability and validity. A total of score ranged from 20 to 140 points will be associated with quality of life.
LSaO2
The lowest oxyhemoglobin saturation will be assessed according to PSG.
Cephalometric measurements
Lateral cephalometric radiographs will be taken for all the subjects at intercuspal occlusion, then traced and digitized in the software Dolphin. The cephalometric measurements are presented in Fig. 4. The measurement items are as follows. SNA: angular indicator for assessment of maxillary protrusion; SNB: angular indicator for assessment of mandibular protrusion; ANB: angular indicator for assessment of the sagittal relationship between the jaws; MP-FH: angular between the mandibular plane and Frankfort plane; MP-SN: angular between the mandibular plane and SN plane; UI-SN: angular indicator for assessment of upper anterior teeth protrusion; LI-MP: angular indicator for assessment of upper anterior teeth protrusion; UL-Ep: distance between upper lip and the aesthetic plane; LL-Ep: distance between lower lip and the aesthetic plane.
Morphologic analysis of UA
Cone-bean computed tomography (CBCT) of subjects will be taken at the Radiology Department of Shanghai Stomatological Hospital according to the standard protocol. During the scaning, subjects will be positioned in the orthostatism, with the Frankfort plane parallel to the floor. The images will be digitized in medicine (DICOM) files, and then imported into Dolphin software for anatomic landmark localization and UA measurements. Two orthodontists will be trained as analyst and perform the localization and UA measurements as presented in figure 5. The analyst will be blinded to patients’ information during the measurements.
Participant timeline {13}
Schedule of enrollment, interventions and outcome assessment.
Action/Timepoint
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Enrolment
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Baseline survey
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Randomization
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Follow-up (M 7)
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Follow-up (M 12)
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Follow-up (M 24)
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Informed consent
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Demographic characteristics
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Medical history
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Orthodontic treatment
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Assessment
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Sample size {14}
In this study, our expectation hypothesis is that the intervention may decrease subjects’ AHI. In a study reported in 2016, that AHI score decreased by 0.8 in children with mild OSAHS who received adenotonsillectomy, while increased by 2.1 in watchful waiting group(P<0.05)[44]. Another non-randomized study reported that average AHI of children decreased by 2.0, 1.5 and 3.7, respectively, after medical therapy, adenotonsillectomy and orthodontic treatment[45]. If 80 eligible subjects in each group were expected, we were allowed to detect the effect value of 0.4 (the average decreasing of AHI among groups was 2.9) at a power of 80% and a 5% significance level. In consideration of a potential dropout rate of approximately 10%, a total sample size of 352 subjects will be required in this study.
Recruitment {15}
Participants will be recruited at Shanghai Stomatological Hospital, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University and Shanghai Children's Hospital, which are all located in Shanghai, China, from May 2018 to December 2021 (anticipated). These hospitals comprise all diagnostic and treatment departments, including E.N.T. and stomatological departments. Notification of subject recruitment will be published in these three hospitals and their official websites.c
Assignment of interventions: allocation
Sequence generation {16a}
A Central Randomization System was designed with the help of Shanghai KNOWLANDS MedPharm Consulting Co. Ltd, and then installed in researchers’ phone in every study site.
Concealment mechanism {16b}
The Central Randomization System can be used for management of participants information and randomization. Before signing an informed consent form, subjects and their guardians will be fully explained about this study by researchers in every study site. The basic information of patients will be registered into the Central Randomization System by research assistants. After the baseline survey, the eligible participants will be divided into four groups at random with a ratio of 1:1:1:1.
Implementation {16c}
Randomization will be implemented by a data analyst from Shanghai KNOWLANDS MedPharm Consulting Co. Ltd using the minimization method with 80% allocation probability according to the following stratification factors: (1) Male/female patient; (2) fat or not based on BMI. Then an email will be submitted automatically to the project coordinator with the ID numbers and groups of participants to be randomized. The project coordinator will then contact participants to inform them about the initiation of treatment.
Assignment of interventions: Blinding
Who will be blinded {17a}
When analyse the outcomes, the analyst will be blinded to patients’ information during the measurements.
Procedure for unblinding if needed {17b}
Not applicable, the analysts are not allowed to be unblinded at any circumstances.
Data collection and management
Plans for assessment and collection of outcomes {18a}
Case report form (CRF) specially designed by coordinator investigators and Shanghai KNOWLANDS MedPharm Consulting Co. Ltd are used for documentation. The trainings related with recruitment, screening, randomization, evaluation, instructions for CRF will be organized before the study for researchers in order to conducting a high-quality clinical trial. A CRF must be filled out for every subject by investigators. All data and information in the CRF must be clear. Changes in the CRF must be marked with a line across the incorrect data. Both of incorrect data and corrections must be kept legible and the signature of researcher and time must be marked next to corrected data. A qualified clinical research assistant who is blinded to the patients’ group will supervise the study process at fixed period, including the completion of informed consent, the screening process, the intervention treatment, the recording of adverse events, and the filling out of CRF. The original CRFs will be used by the data management center and then return to the sponsor center, Shanghai Stomatological Hospital.
Plans to promote participant retention and complete follow-up {18b}
Clinical research assistants from every study site will contact participants monthly to promote their retention and complete follow-up. Additional services will be provided for participants through the Wechat or phone to arrange the treatment time to enhance their adherence.
Data management {19}
The original CRFs will be used by the data management center and then return to the sponsor center, Shanghai Stomatological Hospital. All the questionnaires, PSG data and image measurement data will be collected, stored into separate folders and regularly checked. The outcomes will be encoded and entered in a timely manner using the EpiData 3.1 double-entry test results
Confidentiality {27}
Subject will be informed that the data will be stored and analysed on the computer, but only the researcher team members can get the information associated with each subject. In addition, subjects will be informed of the possibility that their clinical records will be reviewed by representatives of the sponsor and/or regulatory authority. All unpublished information, including patent applications, production processes, and basic data will be deemed confidential. Any public report of the results of this study will not disclose personal identity of the participants. The trial data will be available for public inquiry and sharing, which will be limited to web-based electronic databases to ensure that no personal privacy information is disclosed.
Plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/future use {33}
Not applicable, no samples collected.
Statistical methods
Statistical methods for primary and secondary outcomes {20a}
Statistical analysis will be conducted using IBM SPSS Statistics (version 22.0). Descriptive analysis will be performed for all of our variates. The analysis set will consist of the Intent-to-treat (ITT) set, Per-protocol (PP) set and Safety set. All subjects will be included in the ITT set after randomization regardless of whether they received the treatment or not. Subjects who completed treatment sessions (M0 to M7) without any major violation to the trial procedure will be included in the PP set. Participants who receives treatment will be included in the Safety set for safety analysis. The significance level will be set at P< 0.05 will be considered significant.
The primary endpoint of this study is the change of AHI from M0 to M7. Intergroup comparisons will be performed using a covariance analysis (ANCOVA) to adjust for gender, obesity status and baseline AHI. The outcomes will be mainly analyzed using the PP set. Linear regression will be used to evaluate the correlation between observed differences of AHI and the potential prognostic factors, such as gender, BMI, neck size and research site.
Interim analyses {21b}
Not applicable. No interim analysis is planned in the study
Methods for additional analyses (e.g. subgroup analyses) {20b}
The analysis of LSaO2, the volume of upper airway and the total score of OSA-20 in secondary points will use similar statistical methods with AHI. Descriptive statistical analysis will be used for the measurements of lateral cephalometric film and UA.
Methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c}
Missing data will be disposed with the last-observation-carried-forward (LOCF) method.
Plans to give access to the full protocol, participant level-data and statistical code {31c}
Not applicable.
Oversight and monitoring
Composition of the coordinating centre and trial steering committee {5d}
The monitor team will visit every study site biannually to ascertain that all aspects of the program are being followed and that the trial is being carried out in accordance with the provisions of the drug clinical trial quality management practices (GCP). There are three research centers in the study. Each research center includes at least three main investigator and one coordinator. Clinical research coordinators will be responsible to register information, get informed consent, keep contact with participants to inform them about treatment procedures. Investigators are experienced doctors who will perform examination and intervention for patients. A supervisory team of three experienced doctor will be established to assess and manage the adverse events. Data processing team includes two orthodontists who will perform the localization and UA measurements and three statistician.
Composition of the data monitoring committee, its role and reporting structure {21a}
Not applicable. Intervention measures in the study are mature and commonly used treatment methods, with almost no safety problems.
Adverse event reporting and harms {22}
Adverse events will be recorded and reported by researchers within 24 hrs. A supervisory team of three experienced doctor from every research site will be established to assess and manage the adverse events. Serious adverse events will be reported to the Ethics Committee. For subjects in drug treatment group and surgical treatment group, the observation time for reporting adverse events will be from M0 to M7. While for subjects who will receive orthodontic treatment, the observation time will be from M0 to the end of orthodontic treatment. Participants may quit the study at their guardians’ discretion or defer to the supervisory team. Circumstances that suspended participants from study include adverse events and detection of evidence that may influence the outcomes of research. Furthermore, subjects who leave the study will be followed up until they are in stable status.
Frequency and plans for auditing trial conduct {23}
The monitor team consisting of people from the sponsor Shanghai Hospital Development Center will visit every study site biannually to ascertain that all aspects of the program are being followed and that the trial is being carried out in accordance with the provisions of the drug clinical trial quality management practices (GCP). During monitoring visit, the monitor will check the case report form (CRF) for subjects in the trial to confirm that all items have been completed and the data are obtained according to the protocol. The monitor will also check that the CRF data is consistent with the clinical record or the original data.
Plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25}
During the study, there may be program modifications that may affect the study or patient safety. Any modifications shall be agreed upon by the sponsor/researcher and the Ethics Committee prior to their implementation. Revisions shall be recorded in written new version and must be signed by the same parties that signed the final draft of the pilot protocol.
Dissemination plans {31a}
The final clinical report will be the basis for the study to be published in a medical journal or reported at meeting. A formal report or publication of the data from the study will be jointly published by a person appointed by principle investigators.