Predictors of Obstructive Sleep Apnea Severity in Adolescents

Ethnic/racial and sex disparities in obstructive sleep apnea among adolescents in southern California

STUDY OBJECTIVES

Pediatric obstructive sleep apnea (OSA) is common; however, inclusion of adolescents and especially those of ethnic/racial minorities in research is scarce. We hypothesized that ethnic/racial minority adolescents undergoing polysomnography have higher prevalence and more severe OSA compared to those who are non-Hispanic (NH) White.

METHODS

Retrospective review of 1,745 adolescents undergoing diagnostic polysomnography. Demographic characteristics, age, body mass index percentile, and polysomnography parameters were obtained. Descriptive statistics comparing race/ethnicity were analyzed. Linear regression of log-transformed obstructive apnea-hypopnea index, and logistic regression of moderate-severe OSA (obstructive apnea-hypopnea index ≥ 5 events/h) adjusting for covariates were analyzed.

RESULTS

A total of 58.2% adolescents were Hispanic, 24.1% NH-White, 4.3% NH-Asian/Pacific Islander, 4.2% NH-Black/African American, and 6.6% NH-other. Compared to the NH-White group, the Hispanic group had higher obstructive apnea-hypopnea index and any level of OSA severity, the Black/African American group had higher any level of OSA, and the NH-Asian group had higher moderate-severe OSA. Multiple linear regression of log-obstructive apnea-hypopnea index identified a positive association with Hispanic ethnicity (β: 0.25, P value < .05). Compared to the NH-White group, the Hispanic and the Asian/Pacific Islander groups were 1.45 (95% confidence interval: 1.10, 1.93) and 1.81 (95% confidence interval: 1.05, 3.10) times more likely to have moderate-severe OSA, respectively, after adjusting for relevant covariates. Stratified analysis by sex identified an association only among males between Hispanic ethnicity (odds ratio: 1.85, 95% confidence interval: 1.27, 2.70) and Asian/Pacific Islander ethnicity (odds ratio: 2.62, 95% confidence interval: 1.35, 5.11) and moderate-severe OSA, compared to the NH-White group.

CONCLUSIONS

Among adolescents undergoing polysomnography evaluation, we identified OSA racial/ethnic and sex disparities in Hispanic and NH-Asian adolescents. Community level studies with adequate representation of these minority groups are needed to identify factors associated with the reported increased susceptibility.

CITATION

Landeo-Gutierrez J, Ryu J, Tantisira K, Bhattacharjee R. Ethnic/racial and sex disparities in obstructive sleep apnea among adolescents in southern California. J Clin Sleep Med. 2024;20(10):1637-1645.

Correlations between clinical parameters and PSQ in children with suspected OSA

The aim of this study was to measure tonsils and adenoid vegetations, investigate the modified Mallampati score, determine BMI according to body mass and corresponding percentile, and compare these data with the results of the Pediatric Sleep Questionnaire (PSQ). The subjects were children aged 2 to 18 who were indicated for adenotonsillectomy at the Clinic for Otorhinolaryngology and Head and Neck Surgery. A doctor specialist conducted the clinical examinations. According to the PSQ, 75 subjects were divided into two groups: those at high risk and those at low risk for developing obstructive sleep apnea (OSA). The PSQ results showed that 45 subjects (60 %) were at high risk for OSA, and these subjects had significantly lower weight and BMI. Although a higher number of subjects had grade 4 tonsils and grade 3 and 4 adenoids, this distribution was not statistically significant. There was no statistically significant difference in the distribution of the modified Mallampati score when compared with the PSQ results. Lower body mass and BMI were statistically significant risk factors for OSA, while the size of the tonsils and adenoids, as well as the modified Mallampati score, did not show any statistically significant difference in comparison with the PSQ results.

Comparative Study of Myofascial Exercise and the Voluntary Breathing Technique on the Apnea-Hypopnea Index Among Adolescents

Background Myofunctional therapy has shown promise in addressing sleep-disordered breathing. This study aimed to investigate the efficacy of myofascial exercise and voluntary breathing techniques in reducing the apnea-hypopnea index (AHI) among adolescents. Methodology In this randomized controlled study, adolescents aged 13-18 with sleep-disordered breathing were randomly assigned to one of three groups (n=40 per group): myofascial exercise, voluntary breathing techniques, and a standard care control group. Baseline assessments, including the AHI and sleep quality, were conducted before the interventions. A polysomnography (PSG) sleep study was performed in a sleep laboratory, with recordings conducted over six to eight hours during the night to calculate the AHI. The myofascial exercise and voluntary breathing technique groups received their respective interventions, while the control group received standard care. Post-intervention assessments were conducted to measure changes in AHI and other outcomes. Results The study found no significant differences in age, BMI, and gender among the three groups. However, significant differences were observed in AHI and sleep quality measures. The control group's AHI was 8.72 ± 1.78, whereas the myofascial exercise group (4.82 ± 1.42) and the voluntary breathing group (6.81 ± 1.83) exhibited more substantial reductions (p < 0.001). Similarly, while baseline sleep quality scores did not differ, significant improvements were observed in all groups post-intervention, with more substantial enhancements in the myofascial exercise (4.38 ± 1.19) and voluntary breathing (7.23 ± 1.76) groups. The analysis of baseline AHI categories revealed no significant differences, but at follow-up, significant variations emerged among the groups, indicating greater reductions in AHI categories in the myofascial exercise and voluntary breathing groups compared to the control group. Conclusion These findings indicate that incorporating myofascial exercises or voluntary breathing techniques into treatment plans for adolescents with sleep-disordered breathing can result in significant improvements in AHI and overall sleep quality.

Fibromyalgia in obstructive sleep apnea-hypopnea syndrome: a systematic review and meta-analysis

Introduction: Fibromyalgia (FM) is a common condition in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). This meta-analysis aimed to evaluate differences in sleep monitoring indicators between patients with OSAHS and positive FM and patients with OSAHS and negative FM and to determine the incidence of FM in patients with OSAHS. Methods: An exhaustive literature review was conducted to analyze the incidence of FM in patients with OSAHS, using online databases, including PubMed, EMBASE, Web of Science, CNKI, and Wanfang, both in English and Chinese. The quality of the included studies was assessed by two researchers using the Newcastle-Ottawa Scale scores. The acquired data were analyzed using Stata 11.0 software. Continuous variables were combined and analyzed using the weighted mean difference as the effect size. Conjoint analyses were performed using random-effects (I2 > 50%) or fixed-effect (I2 ≤ 50%) models based on I2 values. Results: Fourteen studies met the inclusion criteria. This study showed that 21% of patients with OSAHS experienced FM. Subgroup analyses were performed based on race, age, sex, body mass index, and diagnostic criteria for patients with OSAHS. These findings indicate that obese patients with OSAHS have a higher risk of FM, similar to females with OSAHS. Regarding most sleep monitoring indicators, there were no discernible differences between patients with OSAHS with positive FM and those with negative FM. However, patients with positive FM had marginally lower minimum arterial oxygen saturation levels than those with negative FM. The current literature suggests that patients with OSAHS have a high incidence of FM (21%), and FM has little effect on polysomnographic indicators of OSAHS. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024510786, identifier CRD42024510786.

The Effects of Adenotonsillectomy for Obstructive Sleep Apnea on Growth Trajectory in Children With Obesity

OBJECTIVE

To analyze the growth trajectory of children with obesity before and after adenotonsillectomy (T&A). We hypothesize that T&A will not affect the growth trajectory but children in a multidisciplinary weight management program (MWMP) will have a healthier growth trajectory.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary Children's Hospital.

METHODS

Body mass index (BMI) trajectories of nonsyndromic children with obesity and obstructive sleep apnea (OSA) who underwent T&A were analyzed. A linear mixed effects model was fit to the BMI expressed as a percentage of the 95th percentile (%BMIp95 ) data. Covariates included demographic variables, pre- and postoperative participation in an MWMP, baseline obesity class, and time. We explored clinically meaningful interactions. BMI slope estimates before and after surgery were calculated and compared for baseline obesity classification and postoperative MWMP visits.

RESULTS

A total of 177 patients, 58% male with a mean age of 9.7 years at the time of surgery, were studied. Higher baseline obesity class (II and III), time, the interaction between obesity class III and elapsed time relative to surgical date, and the interaction between obesity class III and the postsurgical period were all significantly associated with the outcome of %BMIp95 (P < .05). There was a significantly higher %BMIp95 trajectory following surgery in patients with baseline obesity class III who did not have any postoperative MWMP visits (P < .001). Preoperative obesity visits, however, were not significantly associated with postoperative growth.

CONCLUSION

The association between T&A and weight trajectory depends upon obesity class and participation in a MWMP. Coordinated care of children with obesity between otolaryngologists and an MWMP may improve OSA and obesity outcomes.

LEVEL OF EVIDENCE

The level of evidence: 3.

Retrospective Analysis of the Airway Space Changes in Dentofacial Deformity after Two-Jaw Orthognathic Surgery Using Cone Beam Computed Tomography

Orthognathic surgery is used to modify anomalies in maxillomandibular position; this process can significantly affect the anatomy of the airway and cause functional changes. This study aims to define the impact of mandibular maxillary movement on the airway of subjects with dentofacial deformity. A retrospective study was conducted on subjects with Angle class II (CII group) and Angle class III (CIII group) dentofacial deformities. The subjects were treated via bimaxillary surgery; for all of them, planning was performed with software and 3D printing. Cone beam computed tomography (CBCT) was obtained 21 days before surgery and 6 months after surgery and was used for planning and follow-up with the same conditions and equipment. Was used the superimposition technique to obtain the maximum and minimum airway areas and total airway volume. The data were analyzed with the Shapiro-Wilk test and Student's t-test, while Spearman's test was used to correlate the variables, considering a value of p < 0.05. Thus, 76 subjects aged 18 to 55 years (32.38 ± 10.91) were included: 46 subjects were in CII group, treated with a maxillo-mandibular advancement, and 30 subjects were in the CIII group, treated with a maxillary advancement and a mandibular setback. In the CII group, a maxillary advancement of +2.45 mm (±0.88) and a mandibular advancement of +4.25 mm (±1.25) were observed, with a significant increase in all the airway records. In the CIII group, a maxillary advancement of +3.42 mm (±1.25) and a mandibular setback of -3.62 mm (±1.18) were noted, with no significant changes in the variables measured for the airway (p > 0.05). It may be concluded that maxillo-mandibular advancement is an effective procedure to augment the airway area and volume in the CII group. On the other hand, in subjects with mandibular prognathism and Angle class III operated with the maxillary advancement and mandibular setback lower than 4 mm, it is possible to not reduce the areas and volume in the airway.

Assessment of neighborhood-level disadvantage and pediatric obstructive sleep apnea severity

Objectives

To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children.

Methods

A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy.

Results

Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38).

Conclusions

The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study.

Level of Evidence

Level 4.

Obstructive sleep apnea in young Asian adults with sleep-related complaints

This study aimed to investigate the proportion of young OSA adults with sleep-related complaints in a sleep center, affiliated with a tertiary medical center for over a decade. This study presents a chronicle change in the numbers of young adults receiving polysomnography (PSG) and young patients with OSA from 2000 to 2017. We further analyzed 371 young patients with OSA among 2378 patients receiving PSG in our sleep center from 2016 to 2017 to capture their characteristics. Young adults constituted a substantial and relatively steady portion of examinees of PSG (25.1% ± 2.8%) and confirmed OSA cases (19.8 ± 2.4%) even though the total numbers increased with the years. Young adults with OSA tend to be sleepier, have a greater body mass index, and have a higher percentage of cigarette smoking and alcohol consumption. They also complained more about snoring and daytime sleepiness. They had a higher apnea-hypopnea index on average and experienced more hypoxemia during their sleep, both in terms of duration and the extent of desaturation. Even though the prevalence of comorbidities increased with age, hypertension in young male adults carried higher risks for OSA. Young adults with OSA have constituted a relatively constant portion of all confirmed OSA cases across time. The young adults with OSA were heavier, more symptomatic, and with more severe severity.Clinical trial: The Institutional Review Board of Taipei Veterans General Hospital approved the study (VGHIRB No. 2018-10-002CC). The study is registered with ClinicalTrials.gov, number NCT03885440.

Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea

OBJECTIVES/HYPOTHESIS

To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA).

METHODS

Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared.

RESULTS

There were 887 patients included in this study. 14.8% (n = 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O₂  < 90% (tb90) (95% CI = 1.07-1.14, OR = 1.10, p < 0.001), Black race (95% CI = 1.53-3.58, OR = 2.34, p < 0.001), primary neurologic co-morbidity (1.67-6.32, OR = 3.27, p < 0.001), Down syndrome (1.25-5.94, OR = 2.72, p = 0.01), and age (0.84-0.94, OR = 0.88, p < 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90.

CONCLUSIONS

Our results demonstrate that there are other potential risk factors outside of AHI and O₂ nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

The 3% Oxygen Desaturation Index is an Independent Risk Factor for Hypertension Among Children with Obstructive Sleep Apnea

BACKGROUND

Obstructive sleep apnea (OSA) and obesity are both directional risk factors of hypertension. Chronic intermittent hypoxemia (IH) is a commonly observed pathophysiological mechanism involved in multiple comorbidities of OSA. However, their interactions are not well understood in children. This study aimed to investigate the associations of IH indexes (oxygen desaturation index 3% [ODI3], mean peripheral oxygen saturation [SpO₂], least SpO₂, and time with SpO₂ < 85%), apnea-hypopnea index, and weight status with hypertension in a sample of pediatric OSA patients.

METHODS

The medical records of 365 pediatric OSA patients were retrospectively reviewed in this cross-sectional study. Demographics, anthropometrics, standard in-laboratory polysomnography, and nocturnal blood pressure were collected. Multivariate logistic regression with forward selection was used to identify independent predictors of hypertension.

RESULTS

Multivariate logistic regression analysis showed that ODI3 (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01-1.03) and body mass index z-score (OR = 1.34, 95% CI = 1.12-1.60) were independent continuous predictors of pediatric hypertension, whilst severe OSA (OR = 2.62, 95% CI = 1.60-4.29) and overweight/obesity (OR = 2.63, 95% CI = 1.59-4.34) were independent categorical predictors. Traditional risk factors including male sex (OR = 2.33, 95% CI = 1.02-5.33), late childhood/adolescence (OR = 1.98, 95% CI = 1.01-3.88), and overweight/obesity (OR = 2.97, 95% CI = 1.56-5.67) combined with sleep hypoxemia (least SpO₂ ≤ 95%) (OR = 2.24, 95% CI = 1.16-4.04) predicted hypertension (R ² = 0.21) in the severe IH subgroup (n = 205), while the no/mild IH subgroup (n = 160) had an entirely different predictor, severe OSA (OR = 3.81, 95% CI = 1.49-9.74) (R ² = 0.07).

CONCLUSION

The close relationships among IH, overweight/obesity, and hypertension highlight the importance of reducing IH and body weight in children with OSA.

Tissue Doppler echocardiography in children with OSA before and after tonsillectomy and adenoidectomy: A systematic review and meta-analysis

BACKGROUND

When to order an echocardiogram in children with obstructive sleep apnea (OSA) is debated. Studies evaluating the utility of pre-operative standard echocardiography are inconsistent. Tissue Doppler imaging (TDI) is an additional technique that quantifies the velocity of myocardial motion to assess cardiac function. The utility of TDI in pediatric OSA remains unclear.

METHODS

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines using PubMed, Scopus, CINAHL, and Cochrane Library databases. Studies of echocardiographic findings using TDI in children with polysomnogram confirmed OSA before and after tonsillectomy and adenoidectomy (T&A) were included. 1,423 studies were screened, and 4 studies met inclusion criteria. Meta-analysis of echocardiographic findings was performed.

RESULTS

Data from 560 children were analyzed. Study groups included pre- and post-T&A children with OSA and non OSA controls. Pre-T&A S' wave at the tricuspid annulus (S' RV) was decreased with a mean difference of -1.04 [95% CI -1.57, -0.52, p < 0.001] and E'/A' ratio at the mitral annulus (E'/A' LV) was decreased with a mean difference of -0.74 [95% CI -0.85, -0.64, p < 0.001] when compared to controls. These variables were not statistically different when comparing post-T&A to controls.

CONCLUSIONS

TDI appears to successfully detect subclinical changes in cardiac function in children with OSA. However, echocardiography parameters of post-T&A and non OSA control children were similar. Further prospective studies stratified by OSA severity are needed with both TDI and standard echocardiography to define the utility of pre-operative cardiac imaging.

A contemporary review of obstructive sleep apnea

PURPOSE OF REVIEW

This review provides a contemporary review of sleep apnea with emphasis on definitions, epidemiology, and consequences.

RECENT FINDINGS

Amyloid β-42 is one of the main peptides forming amyloid plaques in the brains of Alzheimer patients. Poorer sleep quality and shorter sleep duration have been associated with a higher amyloid burden. Decreased sleep time in the elderly is a precipitating factor in amyloid retention. Studies have shown that the dysregulation of the homeostatic balance of the major inhibitory and excitatory amino acid neurotransmitter systems of gamma-aminobutyric acid (GABA) and glutamate play a role in sleep disordered breathing (SDB).

SUMMARY

Untreated sleep disordered breathing (obstructive sleep apnea and/or central sleep apnea) are an important cause of medical mortality and morbidity. OSA is characterized by recurrent episodes of partial or complete collapse of the upper airway during sleep followed by hypoxia and sympathetic activation. Apneic events are terminated by arousal, followed by increases in pulse and blood pressure, and re-oxygenation and the release of inflammatory factors. Individuals with OSA have an increased risk of developing atrial fibrillation. Hypoxemia and poor sleep quality because of OSA increase the risk of cognitive decline in the elderly.

Shared and unique individual risk factors and clinical biomarkers in children with allergic rhinitis and obstructive sleep apnea syndrome

INTRODUCTION

Rhinitis and obstructive sleep apnea syndrome (OSAS) are different diseases, but have some similar risk factors.

OBJECTIVE

The aims of this study were to compare the risk factors and clinical biomarkers for rhinitis and OSAS in children.

METHODS

We examined 3917 children (age 4-13 years) who were enrolled in a cross-sectional study conducted in Seongnam, Korea. Their parents completed the Pediatric Sleep Questionnaire (PSQ) for evaluation of OSAS and the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire for evaluation of rhinitis. Clinical biomarkers, including total eosinophil count and neutrophil-lymphocyte ratio (NLR), were measured in a subset of these children.

RESULTS

OSAS and rhinitis had prevalences of 4.0% and 43.5%, respectively. Body mass index (P < 0.001) and prematurity (P = 0.016) were significantly associated with OSAS, but not with rhinitis. Higher parental education and income increased the risk for rhinitis, but decreased the risk for OSAS. Having more siblings and birth by Cesarean delivery decreased the risk for rhinitis, but living in a new household increased the risk for rhinitis. A short distance of the residence to a main road during pregnancy significantly increased the risk of OSAS. Males, increased exposure to mould, and firstborns had increased risk of OSAS and rhinitis. The NLR was higher in OSAS patients than in those with allergic rhinitis (P = 0.001).

CONCLUSION

OSAS and rhinitis shared some risk factors, whereas other factors had inverse association with the two disorders. These results imply that different strategies might be used for prevention of rhinitis and OSAS.

Clinical Practice Guideline: Tonsillectomy in Children (Update)

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

(1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.

Pilot study of the potential of 3D ultrasound to measure tonsillar volume and hypertrophy

OBJECTIVE

Obstructive sleep apnea (OSA), results in approximately 4-5 million outpatient visits per year in the United States. In pediatric patients, OSA is primarily caused by adenotonsillar hypertrophy, and therefore, adenotonsillectomy remains an effective surgical treatment. We investigate whether 3D ultrasound (3DUS) imaging can accurately and objectively assess tonsillar hypertrophy for the potential identification and stratification of candidates for adenotonsillectomy.

METHODS

A prospective study was performed evaluating pediatric patients (N = 17) between the ages of 4-14 years who were undergoing adenotonsillectomy for OSA symptoms. On the day of surgery, tonsillar ultrasound was performed by a single attending radiologist. Tonsillectomy was performed and each tonsils' principal axes and physical volume by water submergence were measured. The findings were compared using paired T-test, Pearson correlation coefficient and Bland-Altman analysis.

RESULTS

The average tonsillar physical measurements of length, width and height were 1.54 ± 0.28, 2.0 ± 0.31 cm and 2.72 ± 0.41 cm, and 1.73 ± 0.17, 1.61 ± 0.21 mm and 2.98 ± 0.28 mm from physical and 3DUS estimations, respectively (P < 0.001 for all measurements). The average tonsillar volume was 3.84 ± 1.23 ml and 4.30 ± 1.15 ml from physical and 3DUS measurements, respectively (p = 0.04). The Bland-Altman mean difference ± 95% limit of agreement between length, width, height, and volume results from the two measurements were -0.186 ± 2.01 cm, -0.393 ± 6.33 cm, 0.25 ± 7.71 cm, and 0.45 ± 2.32 ml, respectively.

CONCLUSION

While 3DUS is feasible, it may not be an accurate estimate of tonsillar volume for assessing hypertrophy. A larger study will be required to establish the accuracy of 3DUS measurements of tonsillar volume.

Obstructive Sleep Apnea in Children With Autism

STUDY OBJECTIVES

To describe the demographic and clinical characteristics of children with autism spectrum disorder (ASD) referred for polysomnography (PSG) and to look for predictors of obstructive sleep apnea (OSA) and severe OSA in these children.

METHODS

This is a retrospective case series of children ages 2 to 18 years who underwent PSG between January 2009 and February 2015. Children were excluded if they had major comorbidities, prior tonsillectomy, or missing data. The following information was collected: age, sex, race, height, weight, tonsil size, and prior diagnosis of allergies, asthma, gastroesophageal reflux disease, seizure disorder, developmental delay, cerebral palsy, or attention deficit hyperactivity disorder. Predictors of OSA were evaluated.

RESULTS

A total of 45 children were included with a mean (standard deviation [SD]) age of 6.1 years (2.8). The patients were 80% male, 49% Hispanic, 27% African American, 22% Caucasian, and 2.2% other. Of these children 26 (58%) had OSA (apnea-hypopnea index [AHI] > 1 event/h) and 15 (33%) were obese (body mass index, body mass index z-score ≥ 95th percentile). The mean (SD) AHI was 7.7 (15.0) events/h (range 1.0-76.6). A total of 9 (20%) had severe OSA (AHI ≥  10 events/h). There were no demographic or clinical predictors of OSA in this group. However, increasing weight served as a predictor of severe OSA and African American or Hispanic children were more likely obese.

CONCLUSIONS

The absence of demographic or clinical predictors of OSA supports using general indications for PSG in children with ASD.

The relationship between risk of obstructive sleep apnea and other sleep problems, depression, and anxiety in adolescents from a community sample

Obstructive sleep apnea (OSA) is highly related to mental health problems, such as depression and anxiety. However, previous studies on OSA and depression and anxiety have mostly been conducted in the adult population. We aimed to (1) screen for risk of OSA in a sample of adolescents from the general population using self-report questionnaires and (2) examine whether there are differences between the high- and low-risk groups for OSA in depressive and anxiety symptoms, self-esteem, and sleep-related variables. The data of 793 students (age range: 12-17 years old) were analyzed. The participants were assigned to the high-risk (n = 202, 25.5%) or the low-risk group (n = 591, 74.5%) of OSA. The participants in the high-risk group had more severe anxiety symptoms, lower self-esteem, insomnia, excessive daytime sleepiness, and higher BMI compared those in the low-risk group. This study shows that it is possible to efficiently screen for risks of various problems associated with OSA in adolescents using an easy and simple screening tool.

The Feasibility and Utility of Level III Portable Sleep Studies in the Pediatric Inpatient Setting

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) may significantly impact the course of medical illness in hospitalized children. Polysomnography (PSG) is the gold standard for establishing diagnosis of SDB, but its availability is limited. The aim of this study was to explore the feasibility and utility of level III portable sleep studies in hospitalized children with SDB.

METHODS

A retrospective study was conducted at a tertiary hospital over the preceding 2 years in hospitalized children < 18 years who had undergone a level III sleep study using the Nox T3 system. The information obtained included demographic data, comorbidities, indication for admission and sleep study, time interval between the study ordered and done, adequacy of technical data from sleep study, study diagnosis, and subsequent management interventions for SDB.

RESULTS

A total of 51 hospitalized children had these studies; 32 were female and mean age was 4.3 years. Approximately 90% of children had significant comorbidities, including neurological and craniofacial abnormalities. The majority (80%) of studies were conducted within 24 hours of the time requested and 92.1% studies had technically adequate data for analysis. Thirty-nine (76.5%) children were identified with SDB; all but one patient underwent therapy for SDB during that same hospitalization, including supplemental oxygen (48.7%), positive airway pressure therapy (23%), surgical intervention (38.2%) or caffeine (10.2%). Twelve percent of children had more than one intervention done.

CONCLUSIONS

The level III portable sleep study is readily available, sufficient to diagnose SDB, and help to provide appropriate medical and/or surgical therapies in hospitalized children with complex medical conditions.

Asthma and obesity as predictors of severe obstructive sleep apnea in an adolescent pediatric population

OBJECTIVE

To study a cohort of children referred for full-night polysomnography (PSG) due to suspicion of obstructive sleep apnea (OSA). We examined the relationship between asthma, obesity, and severe OSA (sOSA).

METHODS

We performed a retrospective case control analysis of children, ages 9 to 17 years, who underwent full-night PSG. The primary goal was to determine the association between asthma, obesity, and sOSA (apnea-hypopnea index ≥10). We used multiple logistic regression analysis to estimate these associations after controlling for covariates. A P value of ≤.05 was considered significant.

RESULTS

The study included 367 children (mean [standard deviation] age 14 years (1.7), 56% male, 43% Hispanic). The prevalence of asthma was 188 of 367 (52%); obesity was 197 of 367 (54%); and sOSA was 109 of 367 (30%). sOSA was less likely in asthmatics (coefficient = -0.59; standard error [SE] = 0.23; P = .01; odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.34 to 0.88) and more likely with obesity (coefficient = 0.89; SE = 0.24; P < .001; OR = 2.4; 95% CI = 1.5 to 3.9). The presence of asthma reduced the likelihood of sOSA by an average of 14% among obese patients and 9% among nonobese patients. These associations held even after controlling for age, sex, race, income, and tonsillar hypertrophy.

CONCLUSION

The presence of asthma reduced, whereas obesity increased the likelihood of sOSA among a large cohort of older children referred for PSG. These relationships were additive. Further research is indicated regarding these relationships.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:812-817, 2020.