The first line treatment for obstructive sleep apnea (OSA) in children is adenotonsillectomy (AT). Persistent OSA occurs in 30% of otherwise healthy children after AT. In children who are obese, or have craniofacial, genetic or neuromuscular disorders, persistent OSA after AT is as high as 70%. Thus, otolaryngologists are increasingly managing this challenging patient population. Despite this, there are no guidelines regarding the optimal management of children with persistent OSA after AT. The role of observation, drug induced sleep endoscopy (DISE), cine MRI, allergy evaluation, CPAP, and turbinate, palatal and tongue base surgeries will be discussed.