Cine Magnetic Resonance Imaging: Evaluation of Persistent Airway Obstruction after Tonsil and Adenoidectomy in Children with Down Syndrome

Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management

This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h(-1), those with an AHI of 1-5 episodes·h(-1) and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).

Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

Although adenotonsillectomy is accepted as a first-line therapy for pediatric obstructive sleep apnea (OSA), there is currently no consensus regarding optimal methods for identifying the sites of obstruction or treatment of children with persistent disease after surgery. With this in mind, our aim was to systematically review the English-language literature pertaining to these issues.

STUDY DESIGN

Systematic review.

METHODS

We searched all indexed years of Pubmed, Cochrane CENTRAL, DynaMed, UpToDate, CINAHL, and Scopus for English-language articles containing original human data, with ≥ 7 participants, all < 18 years old. Data regarding study design, demographics, clinical characteristics/outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by two investigators.

RESULTS

Of 758 identified abstracts, 24 articles (combined population = 960) were ultimately included. Seventeen (71%) described methods to identify site(s) of obstruction: drug-induced sleep endoscopy (11/24), cine magnetic resonance imaging (MRI) (3/24), and alternative imaging (3/24). Treatment options included lingual tonsillectomy (n = 6), with success rates of 57% to 88% (Cohen's effect size d = 1.38), as well as supraglottoplasty (n = 4), with success rates of 58% to 72% (d = 0.64). Additional treatments included medications and surgery (e.g., partial midline glossectomy and tongue suspension).

CONCLUSIONS

Drug-induced sleep endoscopy and cine MRI are the most commonly reported tools to identify sites of obstruction for children with persistent OSA; however, these techniques have not yet been clearly linked to outcomes. Evidence for treatment is extremely limited and focuses primarily on lingual tonsillectomy and supraglottoplasty. Also, reports regarding appropriate patient selection and outcomes in obese or otherwise healthy children are scant.

Sleep profiles in children with Down syndrome

Down syndrome (DS) is the most common genetic cause of intellectual disability and results from an extra chromosome 21 (Trisomy 21). Sleep issues and/or obstructive sleep apnea (OSA) are assumed to be part of the DS phenotype with a high prevalence but are often under recognized. This cross-sectional study of children with DS examines the caregiver-reported sleep behaviors of 108 children with DS, ranging in age from 1.50 to 13.40 years (mean = 5.18 years) utilizing a standardized assessment tool, the Children's Sleep Habit Questionnaire (CSHQ). The CSHQ revealed 76% of children with DS had sleep problems, which began at a young age, and continue to persist and may recur with increasing age. Furthermore, children with DS who undergone adenoidectomy and tonsillectomy for OSA continued to have sleep problems suggesting that ongoing monitoring of sleep issues is needed in this population. Implications of sleep problems and recommended anticipatory guidance and intervention are discussed.

Optical coherence tomography and autofluorescence imaging of human tonsil

For the first time, we present co-registered autofluorescence imaging and optical coherence tomography (AF/OCT) of excised human palatine tonsils to evaluate the capabilities of OCT to visualize tonsil tissue components. Despite limited penetration depth, OCT can provide detailed structural information about tonsil tissue with much higher resolution than that of computed tomography, magnetic resonance imaging, and Ultrasound. Different tonsil tissue components such as epithelium, dense connective tissue, lymphoid nodules, and crypts can be visualized by OCT. The co-registered AF imaging can provide matching biochemical information. AF/OCT scans may provide a non-invasive tool for detecting tonsillar cancers and for studying the natural history of their development.

MRI sleep studies: use of positive airway pressure support in patients with severe obstructive sleep apnea

Maintaining the patency of the upper airway during MRI sleep studies, without an artificial airway placement in sedated or anesthetized patients with severe obstructive sleep apnea (OSA) is a major challenge. We report two cases in which a continuous positive airway pressure (CPAP) was used instead of artificial airway to allow interpretation of the dynamic component of the study.

Obstructive sleep apnea syndrome and cognition in Down syndrome

AIM

Good-quality sleep is essential for normal learning and memory. Sleep fragmentation and disrupted sleep architecture are commonly observed throughout the lifespan of individuals with Down syndrome, a condition marked by cognitive deficits emerging within the first few months of life. While obstructive sleep apnea syndrome (OSAS) is known to contribute to the loss of sleep quality in Down syndrome, its relation to cognitive and behavioral impairment remains poorly understood.

METHOD

Using ambulatory polysomnography, we measured sleep in an unreferred community-based sample of 38 individuals with Down syndrome (15 males, 23 females; mean age 9y 7mo (SD 1y 9mo), range 7-12y). Cognitive outcomes were assessed with the Arizona Cognitive Test Battery, a set of psychometric measures designed and validated for this population.

RESULTS

Among children with Down syndrome, mean Verbal IQ score (p=0.006) was 9 points lower in those with comorbid OSAS (apnea-hypopnea index >1.5) than in those without OSAS, and performance on measures of cognitive flexibility was poorer (p=0.03). In addition, those with OSAS showed increased light-stage sleep (p=0.009) at the expense of slow-wave sleep (p=0.04).

INTERPRETATION

These findings demonstrate a relation between OSAS and cognitive outcomes in Down syndrome. More work is required to fully understand the mechanisms underlying the links between poor sleep and impaired cognitive function. Overall, these findings highlight the importance of adequate sleep in typically and atypically developing populations.

A general review of the otolaryngologic manifestations of Down Syndrome

OBJECTIVE

Down Syndrome (DS) is the most common chromosome abnormality in liveborn children. Otolaryngologists frequently encounter these patients in their practice; in one survey, 50% of DS patients had been seen by Otolaryngology at least once. As such, it is essential that the practicing Otolaryngologist is aware of the otologic, rhinologic, and laryngologic manifestations of this complex disease and comfortable in the management and treatment of these unique patients. Our goal was to provide this information in a concise and definitive document.

METHODS

A comprehensive literature review using PubMed was completed. The terms "Otolaryngology", "Head and neck", "Ear, nose, throat", "Down Syndrome", and "Trisomy 21" were searched in various combinations. Applicable articles that discussed the Otolaryngologic manifestations of Down Syndrome were included.

RESULTS

In total, fifty articles were included for review. The Down Syndrome child tends to have smaller external ear canals, have higher rates of chronic ear disease, and may present with conductive, sensorineural, or mixed hearing loss. As such, DS patients should receive behaviouralaudiological testing every 6 monthsand annually after the age of three in addition to closer follow-up by an Otolaryngologist if tympanic membranes cannot be visualized or if the external auditory canals are significantly stenosed. Management should involve close follow-up and a low threshold for PE tube placement to reduce the risks for speech and language delay. Chronic rhinitis in the Down Syndrome patient is common. Retrognathia, hypotonia, and macroglossia can all cause obstructive sleep apnea (OSA) in this population and therefore each DS patient should get an overnight polysomnograph. Subglottic stenosis, vocal cord paralysis and laryngomalacia are not infrequently seen in the Down Syndrome patient. To reduce acquired subglottic stenosis, endotracheal tubes that are at least two sizes smaller than what is appropriate for the patient's age should be used.

CONCLUSION

Down Syndrome is common and there are many Otolaryngologic manifestations. We recommend that this patient population visit an Otolaryngologist on a regular basis and that the practicing Otolaryngologist is comfortable with the management and treatment of the unique challenges faced with these children.

Epidemiology of respiratory symptoms in children with Down syndrome: a nationwide prospective web-based parent-reported study

Background

Children with Down syndrome suffer from recurrent respiratory tract and ear-nose-throat complaints that influence daily life. Little is known about the frequency of these complaints, as well as their relation to co-morbidity and ageing.

Methods/design

A prospective web-based parent-reported observational study was designed for parents having a child with Down syndrome (age 0 to 18 years). Upon registration, parents receive an email containing a link to a weekly questionnaire regarding respiratory symptoms during two consecutive years. Additionally, at the beginning, after one year and at the end of the study they receive an extended questionnaire concerning baseline data, daily activities and medical history. The data will be compared to the ongoing “child-is-ill” study, which collects weekly data in an identical fashion in children that are considered to be “normal as to being ill” by their parents.

Discussion

This study will provide important data on the epidemiology of respiratory symptoms in children with Down syndrome, which will be useful for further studies on treatment options. Also, this study will gain insight in healthcare usage and work absence due to the child’s illnesses.

Pediatric sleep surgery

Adenotonsillectomy is the most common surgery performed for sleep disordered breathing with good outcomes. Children with obesity, craniofacial disorders, and neurologic impairment are at risk for persistent sleep apnea after adenotonsillectomy. Techniques exist to address obstructive lesions of the palate, tongue base, or craniofacial skeleton in children with persistent sleep apnea. Children with obstructive sleep apnea have a higher rate of peri-operative complications.

Adolescents and young adults with Down syndrome presenting to a medical clinic with depression: co-morbid obstructive sleep apnea

Adolescents and young adults with Down syndrome (DS) sometimes experience new-onset mood disorder and decline in adaptive skills. The clinical phenomenon is poorly characterized and its pathogenesis is not understood. The possible contribution of obstructive sleep apnea syndrome (OSAS) to this phenomenon has not been studied. Subjects were ascertained as a convenience sample through our clinic for persons with DS and medical or mental health concerns between 2004 and 2009. When mood symptoms were present an axis I diagnosis was made using DSM-IV-R criteria. Subjects without an axis I diagnosis served as controls. The Reiss scales for children's dual diagnosis and the aberrant behavior checklist (ABC) were completed by caretakers. Twenty-eight cases meeting criteria for major depressive episode (MDE) and nine controls without psychopathology were referred for overnight polysomnography (PSG). Functional decline was reported in 19 (68%) of cases with MDE, but none of the controls. Twenty-four (86%) cases had OSAS compared with only 4 (44%) of controls. Moderate-severe OSAS was present in 15 (54%) of cases compared to only 1 (11%) of controls. Intermittent sleep-associated hypoxia and REM sleep deficits were also more frequent in cases. Across all subjects, prior tonsillectomy was not related to the presence or absence of OSAS. Our findings suggest that OSAS may be a common co-morbidity in adolescents and younger adults with DS and depression. Recognition of this association maybe critical to understanding the pathogenesis and management of mood-related disorders, and functional decline in affected individuals.

Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy

PURPOSE OF REVIEW

There is an increasing percentage of children with persistent obstructive sleep apnea (OSA) after removal of the tonsils and adenoids (T&A). Although sleep apnea has been an active area of research and treatment in the adult population, our awareness of this problem in children is still in its initial stages. In addition, therapies to successfully treat this residual OSA are still not fully established. It is important to develop evaluation and management protocols for these children.

RECENT FINDINGS

This review will discuss risk factors associated with persistent OSA after T&A and techniques to evaluate the pediatric airway in order to identify the site, or sites, of obstruction. Various medical and surgical options are presented.

SUMMARY

Clinicians need to be aware of the potential for persistent sleep disordered breathing and OSA in children, despite previous T&A. Evaluation protocols and techniques will differ in children, due to limitations in their cooperation during the physical examination. Alternative methods, such as airway endoscopy and cine MRI, are presented. Medical and surgical options are presented. Outcomes data for pediatric populations are rare. Multilevel, single stage surgery has a higher risk for oropharyngeal stenosis in children compared with adults and conservative, multistage approaches may be more appropriate.

Some infants with Down syndrome spontaneously outgrow their obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is commonly seen in children with Down syndrome (DS). Though some infants with DS spontaneously outgrow their OSA, it is not clear how often this occurs or how this should affect the choice between surgical and nonsurgical treatment.

METHODS

Retrospective chart review of all infants with DS younger than 2 years referred over a 66-month period to Children's Hospital Boston for sleep study because of suspected OSA.

RESULTS

A total of 16 of 29 children studied were diagnosed with OSA; 6 were treated with continuous positive airway pressure (CPAP), 3 of whom were found 5, 5, and 10 months later on repeat sleep study to have no further evidence of OSA.

CONCLUSION

A significant number of infants with DS and OSA may outgrow it within several months. This has implications for treatment choice, especially between CPAP and tracheostomy, because it may only be needed for a short time.

Severe hypothyroidism presenting as obstructive sleep apnea

A 5-year-old child with Down syndrome (DS) diagnosed with mild to moderate obstructive sleep apnea (OSA) and subsequently found to have severe hypothyroidism is presented. Following 3 months of treatment with levothyroxine, she had full resolution of her OSA. This case underscores the importance of routine thyroid function screening in children with DS and demonstrates that OSA in children with DS can be caused by other underlying medical issues that themselves require therapy, such as the hypothyroidism in this child. Although empiric testing of thyroid function is not recommended as part of the routine workup of patients with OSA, when caring for children at higher risk for thyroid dysfunction, such as those with DS, it is important to establish whether or not it is present, as treating it may bring about partial or full resolution of the OSA, as was shown to occur in this patient.

Effects of adeno-tonsillectomy on polysomnography patterns in Down syndrome children with obstructive sleep apnea: a comparative study with children without Down syndrome

OBJECTIVE

To determine if adeno-tonsillectomy (T&A) in children with Down syndrome (DS) improves breathing, measured by apnea hypopnea index (AHI), rapid eye movement AHI (REM-AHI) and the lowest oxygen desaturation (SaO2), and sleep disruption, measured by arousal index (ArI) and time spent in stages 1-4 and rapid eye movement (REM) sleep and compare these results with a group of non-DS children with obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective chart review at pediatric sleep center.

PATIENTS

Eleven DS and nine non-DS children underwent pre- and post-T&A polysomnography between 1997 and 2005.

OUTCOME MEASURES

Pre- and post-T&A polysomnography parameters were compared using paired t-test and independent samples test.

RESULTS

Mean age in DS group was 101 months and non-DS group was 80 months (64% males in DS and 88% in non-DS group). The average BMI was 29.8 and 27.6 for DS and non-DS group. The total AHI showed significant improvement after T&A but this was not as marked as the non-DS group. REM-AHI and lowest SaO2 did not show significant change in the DS children. The non-DS group showed significant improvement in all respiratory parameters. Both groups showed mild improvement in sleep parameters. With the modest overall improvement, 27% of the DS children required no further treatment. However, 73% required CPAP, BiPAP or oxygen for persistent OSA.

CONCLUSION

This study supports the fact that T&A in DS children improves some parameters of OSA, however not as markedly as in non-DS children.

Magnetic Resonance Scanning of the Upper Airway following Difficult Intubation Reveals an Unexpected Lingual Tonsil

We present a case of a 40-year-old woman requiring elective surgery who had an unexpected Grade 4 Cormack and Lehane laryngoscopy view. Both curved and straight laryngoscope blades in the sniffing and hyperextended head and neck positions were used. Endotracheal intubation was accomplished with some difficulty using a No. 3 Macintosh blade and Frova intubating catheter in the sniffing position. The cause of the difficult laryngoscopy was a lingual tonsil as shown in postoperative magnetic resonance scans.

We feel that a comprehensive postoperative evaluation should be conducted after every difficult laryngoscopy (Cormack and Lehane Grade 3b and 4). The use of magnetic resonance imaging may provide important objective information for both the anaesthetist and the patient, allowing a better understanding of causes and possible solutions for future airway management.

Cine-MRI swallowing evaluation after tongue reconstruction

OBJECTIVE

To determine the feasibility of cine-MRI for non-invasive swallowing evaluation after surgery for lingual carcinoma with reconstruction using microvascular free flaps.

METHODS

Ten patients with stage IV carcinoma of the mobile tongue and/or tongue base treated by surgical resection and reconstruction with a free flap were evaluated after an average of 4.3 years (range: 1.5-11 years), using cine-MRI in "single-shot fast spin echo" (SSFSE) mode. Fiberoptic laryngoscopy of swallowing was performed before MRI to detect aspiration. The tolerance and ability to complete the exam were noted. The mobilities of the oral and pharyngeal structures visualized were evaluated as normal, reduced or increased.

RESULTS

Cine-MRI was well tolerated in all cases; "dry" swallow was performed for the 2 patients with clinical aspiration. Tongue base-pharyngeal wall contact was observed in 5 cases. An increased anterior tongue recoil, increased mandibular recoil, increased posterior oropharyngeal wall advancement and an increased laryngeal elevation were observed in 4 cases. One case of a passive "slide" mechanism was observed.

CONCLUSIONS

Cine-MRI is a safe, non-invasive technique for the evaluation of the mobility of oral and oropharyngeal structures after free-flap reconstruction of the tongue. For selected cases, it may be complementary to clinical examination for evaluation of dysphagia after surgery and free-flap reconstruction. Further technical advances will be necessary before cine-MRI can replace videofluoroscopy, however.

Morphologic and histologic outcomes of tongue reduction surgery in an animal model

OBJECTIVE

To describe the effect of anterior tongue reduction surgery on tongue size, morphology, and histology.

DESIGN

Prospective experiment.

MATERIALS

Twenty-two 12-week-old Yucatan minipigs.

METHODS

Six sibling pairs had tongue reduction (Group B) or sham surgery (Group A), and underwent euthanasia the day of surgery. Five sibling pairs had tongue reduction (Group D) or sham surgery (Group C), and were raised for four weeks. Data collected included changes in tongue morphology, histology, and animal response to surgery.

RESULTS

All animals tolerated surgery and maintained their weight. Tongue size was uniformly reduced in all animals as compared to sham surgery. Tongue reduction was stable long term in Group D. All animals had normal wound healing and neurovascular structure preservation. Fibrosis occurred at the repair site.

CONCLUSION

Midline tongue reduction resulted in uniform tongue reduction in all dimensions and volume, without damaging neurovascular structures. Localized fibrosis is a sequela of healing.

The frequency of lingual tonsil enlargement in obese children

OBJECTIVE

Enlargement of the lingual tonsils is being increasingly recognized as a not uncommon and treatable cause of obstructive sleep apnea, particularly in patients with Down syndrome who have undergone palatine tonsillectomy and adenoidectomy. We have recognized an increasing number of patients who are obese and have obstructive sleep apnea with enlarged lingual tonsils. The purpose of this study was to evaluate the frequency of enlarged lingual tonsils in obese children.

SUBJECTS AND METHODS

Seventy-one obese children (mean body mass index = 41.6 kg/m(2)) underwent sagittal fast spin-echo inversion recovery imaging. Lingual tonsils were identified and measured in the greatest anteroposterior diameter. Lingual tonsils > 10 mm were considered markedly enlarged. The subgroup with absent palatine tonsils (previous tonsillectomy) (n = 41) were compared with those with palatine tonsils present (n = 30).

RESULTS

Forty-four (62%) of the obese children had measurable lingual tonsils, which is greater than the frequency previously reported in normal subjects (0%), subjects with obstructive sleep apnea (33%), or subjects with Down syndrome and obstructive sleep apnea (50%). Ten (14%) had lingual tonsils > 10 mm. Obese subjects with absent palatine tonsils (previous tonsillectomy) had a higher prevalence of measurable lingual tonsils than those with palatine tonsils (78% vs 22%, respectively; p < 0.001) and a higher prevalence of lingual tonsils > 10 mm (90% vs 10%, p < 0.001).

CONCLUSION

Obese children have a high frequency of enlargement of the lingual tonsils with a significantly higher prevalence in those with previous tonsillectomy. Enlarged lingual tonsils may play a role in the pathogenesis of obstructive sleep apnea in obese children.

OSAS in Down syndrome: T&A versus T&A plus lateral pharyngoplasty

OBJECTIVE

Obstructive Sleep Apnea Syndrome (OSAS) is common in children with Down syndrome (DS). Adenotonsillectomy (T&A) has traditionally been the initial surgical treatment. More aggressive surgery has also been recommended. Previous studies have used parental reporting and not objective data to assess treatment outcomes. Polysomnography (PSG) is used to objectively evaluate the results of T&A versus T&A plus lateral pharyngoplasty in the initial treatment of OSAS in children with DS.

METHODS

This is a retrospective study of children with OSAS and DS. Group 1 consisted of 21 children with DS who underwent T&A. Group 2 consisted of 16 children of similar age who had T&A plus lateral pharyngoplasty as initial surgical treatment. Post-operative PSG's were available for all patients. Apnea/hypopnea index (AHI), presence of hypoxemia and hypercarbia, and arousal index were measured and compared.

RESULTS

In group 1, after T&A, 48% continued to have an elevated AHI. If hypercarbia and hypoxemia are included in the result analysis, 67% continued to have abnormal PSG's after their surgery. In group 2, 63% had an elevated AHI post-operatively. When hypercarbia and hypoxemia are included in the analysis, 75% continued to have abnormal PSG's after surgery. There was no statistically significant difference in the outcome of the two groups.

CONCLUSIONS

Pediatric patients with OSAS and DS may show improvement after T&A, however only about one third will have a normal post-operative sleep study. Adding a lateral pharyngoplasty does not improve these results. Further study with objective outcome data is needed to determine a better first line surgical treatment for these patients.

Cine magnetic resonance imaging with single-shot fast spin echo for evaluation of dysphagia and aspiration

The aim of this study was to determine the feasibility of and interest in evaluation of swallowing using dynamic magnetic resonance imaging (cine-MRI) in patients with dysphagia and aspiration caused by an abnormal pharyngeal phase of swallow. A cohort of six patients previously treated for head and neck cancer with persistent dysphagia and/or aspiration were evaluated an average of 47 months after treatment. The morphology and mobility of the oral, oropharyngeal, and laryngeal structures were analyzed using cine-MRI using single-shot fast spin echo technology. The qualitative observations were compared with a clinical fiberoptic swallowing evaluation. Swallowing physiology was analyzable for dry (saliva) swallow in all patients. MRI was well-tolerated by all six patients and no clinical aspiration occurred during the MRI. In five of six cases, further information on the cause of dysphagia was obtained using cine-MRI compared with the clinical evaluation alone. In the remaining case, cine-MRI confirmed the clinical evaluation. Cine-MRI using the dry swallow technique is feasible and without risk in patients with clinical aspiration. Cine-MRI is complementary to clinical evaluation of swallowing in patients with an abnormal pharyngeal phase of swallowing resulting from treatment of cancer.

Comparison of lingual tonsil size as depicted on MR imaging between children with obstructive sleep apnea despite previous tonsillectomy and adenoidectomy and normal controls

BACKGROUND

Cine MRI has become a useful tool in the evaluation of patients with persistent obstructive sleep apnea (OSA) despite previous surgical intervention and in patients with underlying conditions that render them susceptible to multilevel airway obstruction. Findings on cine MRI studies have also increased our understanding of the mechanisms and anatomic causes of OSA in children.

OBJECTIVE

To compare lingual tonsil size between children with OSA and a group of normal controls. In addition, a subanalysis was made of the group of children with OSA comparing lingual tonsils between children with and without underlying Down syndrome.

MATERIALS AND METHODS

Children with persistent OSA despite previous palatine tonsillectomy and adenoidectomy and controls without OSA underwent MR imaging with sagittal fast spin echo inversion-recovery images, and lingual tonsils were categorized as nonperceptible at imaging or present and measurable. When present, lingual tonsils were measured in the maximum anterior-posterior diameter. If lingual tonsils were greater than 10 mm in diameter and abutting both the posterior border of the tongue and the posterior pharyngeal wall, they were considered markedly enlarged.

RESULTS

There were statistically significant differences between the OSA and control groups for the presence vs. nonvisualization of lingual tonsils (OSA 33% vs. control 0%, P=0.0001) and mean diameter of the lingual tonsils (OSA 9.50 mm vs. control 0.0 mm, P=0.00001). Within the OSA group, there were statistically significant differences between children with and without Down syndrome for the three lingual tonsil width categories (P=0.0070) and occurrence of markedly enlarged lingual tonsils (with Down syndrome 35% vs. without Down syndrome 3%, P=0.0035).

CONCLUSIONS

Enlargement of the lingual tonsils is relatively common in children with persistent obstructive sleep apnea after palatine tonsillectomy and adenoidectomy. This is particularly true in patients with Down syndrome.

Trisomy 21 and the pediatric surgeon

PURPOSE OF REVIEW

Trisomy 21 (Down syndrome) is a common condition encountered by the pediatric surgeon. The surgical anomalies associated with Down syndrome now have treatment options that were previously considered futile. An effective surgical team approach to these children involves knowledge of the unique pathophysiology of trisomy 21 and an appreciation for the desires of the family and the needs of the child.

RECENT FINDINGS

Surgical techniques benefit children with Down syndrome equally as typical children. Pessimism regarding the outcome of surgical treatment of colorectal anomalies is fading, with evidence of nearly equivalent outcomes. Several autoimmune disorders impact children with Down syndrome. Idiosyncratic susceptibility to infections and malignancy is noted. Unique anesthetic complications and aerodigestive tract disorders have been identified. Many anomalies have surgical options that enhance the quality of life.

SUMMARY

There is optimism in the surgical treatment of children with Down syndrome. Improved operations, better anesthetic management and recognition of problems specific to the child with trisomy 21 make it safer and ethical to offer surgical solutions. Societal acceptance and mainstream participation are on the rise. The astute, compassionate pediatric surgeon does much to enhance the quality of life of these children and of the families who love them.

Down syndrome: Common otolaryngologic manifestations

Otolaryngologic or ear, nose, and throat (ENT) problems are common in children with Down Syndrome (DS). This includes problems with chronic ear infections and chronic middle ear effusions with associated hearing loss, airway obstruction, and sleep apnea, as well as problems with chronic rhinitis and sinusitis. In addition, many of these ENT problems require surgical interventions, and there are special anesthesia considerations that need to be addressed in children with DS. These include subglottic stenosis, post-operative airway obstruction, and cervical spine concerns. As the care of children with DS has become more consistent and proactive, outcomes from the treatment of these ENT manifestations have improved. Aggressive interventions, both medical and surgical, have led to a decreased incidence of hearing loss, good control of the chronic rhinitis, and a better awareness of the incidence of sleep apnea and sleep-disordered breathing in individuals with DS. These common otolaryngologic manifestations of DS are reviewed with recommendations for ongoing care and monitoring.