Utility of brain MRI in children with sleep-disordered breathing

Type one chiari malformation as a cause of central sleep apnea and hypoventilation in children

OBJECTIVES

Chiari type 1 malformation (CM1) may occasionally lead to central sleep apnea (CSA). We studied, in a large clinical cohort of pediatric CM1 patients, the effect of CM1 on breathing during sleep.

METHODS

This is a retrospective single pediatric pulmonology center study with a systematic evaluation of pediatric CM1 patients under age 18 with polysomnography (PSG) during 2008-2020. Children with syndromes were excluded. All patients had undergone head and spine magnetic resonance imaging.

RESULTS

We included 104 children with CM1 with a median age of 7 (interquartile range (IQR) 5-13) years. The median extent of tonsillar descent (TD) was 13 (IQR 10-18) mm. Syringomyelia was present in 19 children (18%). Of all children, 53 (51%) had normal PSG, 35 (34%) showed periodic breathing or central apnea and hypopnea index ≥5 h-1, and 16 (15%) displayed features of compensated central hypoventilation and end-tidal or transcutaneous carbon dioxide 99th percentile level above 50 mmHg. TD had the best predictive value for central breathing disorders. In a linear model, both age (61%) and TD (39%) predicted median breathing frequency (R = 0.33, p < 0.001).

CONCLUSIONS

Although severe CSA is a rare complication of brainstem compression in pediatric patients with CM1, short arousal-triggered episodes of periodic breathing and mild compensated central hypoventilation are common. TD shows the best but still poor prediction of the presence of a central breathing disorder. This highlights the use of PSG in patient evaluation. Posterior fossa decompression surgery effectively treats central breathing disorders.

Obstructive sleep apnea syndrome as a rare presentation in a young girl with a central nervous system tumor

Sleep-related breathing disorders (SRBDs) are a common problem in infancy and childhood. The most common type of SRBD in this age group is obstructive sleep apnea syndrome (OSAS), generally caused by factors affecting airway patency, such as tonsillar hypertrophy or obesity. However, in adults OSAS can also be caused by processes affecting the brainstem, such as central nervous system tumors. This report describes a 2-year-old girl who presented with symptoms of snoring, restless sleep, repeated night-time waking, and apneic events whilst asleep. She had no co-morbidities, and examination revealed normal sized tonsils. A sleep study demonstrated severe OSAS with an obstructive apnea/hypopnea index of 34. Her OSAS completely resolved on excision of the tumor. The case highlights the importance of neurological examination as part of evaluation of OSAS, especially in cases where tonsils are not enlarged and there are no other risk factors for OSAS.

Evaluation of endoscopic assisted suction coagulation adenoidectomy versus traditional curettage technique

Background

Adenoidal hypertrophy is a common condition in children and can cause symptoms such as mouth breathing, nasal discharge, snoring, sleep apnea, and hyponasal speech. The curettage adenoidectomy has some disadvantages, especially the intranasal extension of the adenoid tissue that makes this technique inadequate. This study is conducted to evaluate and compare between assisted suction coagulation adenoidectomy and traditional curettage techniques.

Results

One hundred twenty-two patients with symptomatic adenoid hypertrophy such as nasal obstruction, snoring, and mouth breathing were included in our study. Patients underwent adenoidectomy either traditional curettage adenoidectomy (60 patients as group A) or endoscopic assisted suction coagulation adenoidectomy (62 patients as group B). Patients were scheduled for follow-up visits with respect to operative time, operative and postoperative complications. The mean age of groups A and B were 6.57+2.8 and 7+2.8 ranging from 3 to12 years. There was a statistically significant difference between groups as regard intraoperative blood loss, trauma, postoperative complications as neck stiffness and bad odor plus postoperative endoscopic and radiological grading after the operation.

Conclusions

Suction coagulation diathermy adenoidectomy is alternative to cold adenoidectomy with significantly fewer intraoperative complications such as blood loss and trauma of prevertebral muscle plus post-operative complications such as primary or secondary bleeding and rhinolalia aperta.

Central sleep apnea and Chiari 1 malformation in a pediatric patient with Klippel-Feil syndrome

None

Klippel-Feil sequence (KFS) is a rare congenital condition that presents with congenital cervical spine fusion, reduced cervical spine flexion, and low posterior hairline. Chiari malformation type 1 and sleep-disordered breathing (SDB) are frequent comorbidities of KFS. The pathologic basis of the connection between Chiari malformation type 1 and SDB in the setting of KFS is not clearly understood. Here we report a pediatric patient with KFS, SDB, and drooling who also had Chiari malformation type 1. Posterior fossa decompression of this patient significantly improved most symptoms including sleep disturbances. Repeat polysomnogram 8 weeks after posterior fossa decompression revealed worsening central sleep apnea despite the patient being clinically asymptomatic. Taken together, this case highlights the point that, although it is critical to recognize the association of SDB in the setting of KFS, decompression alone may not be sufficient to completely alleviate SDB and certain neurologic symptoms.

A Conditional Inference Tree Model for Predicting Sleep-Related Breathing Disorders in Patients With Chiari Malformation Type 1: Description and External Validation

STUDY OBJECTIVES

The aim of this study is to generate and validate supervised machine learning algorithms to detect patients with Chiari malformation (CM) 1 or 1.5 at high risk of the development of sleep-related breathing disorders (SRBD) using clinical and neuroradiological parameters.

METHODS

We prospectively included two independent datasets. A training dataset (n = 90) was used to obtain the best model, whereas a second dataset was used to validate it (n = 74). In both cohorts, the same clinical, neuroradiological, and sleep studies were carried out. We used two supervised machine learning approaches, multiple logistic regression (MLR) and the unbiased recursive partitioning technique conditional inference tree (URP-CTREE), to detect patients at high risk of SRBD. We then compared the accuracy, sensitivity, and specificity of the two prediction models.

RESULTS

Age (odds ratio [OR] 1.1 95% confidence interval [CI] 1.05-1.17), sex (OR 0.19 95% CI 0.05-0.67), CM type (OR 4.36 95% CI 1.14-18.5), and clivus length (OR 1.14 95% CI 1.01-1.31) were the significant predictor variables for a respiratory disturbance index (RDI) cutoff that was ≥ 10 events/h using MLR. The URP-CTREE model predicted that patients with CM-1 who were age 52 years or older and males with CM-1 who were older than 29 years had a high risk of SRBD. The accuracy of predicting patients with an RDI ≥ 10 events/h was similar in the two cohorts but in the URP-CTREE model, specificity was significantly greater when compared to MLR in both study groups.

CONCLUSIONS

Both MLR and URP-CTREE predictive models are useful for the diagnosis of SRBD in patients with CM. However, URP-CTREE is easier to apply and interpret in clinical practice.

Polysomnography in Pediatric Otolaryngology: If Not Obstructive Sleep Apnea, What Is It?

Objective

To determine common polysomnographic (PSG) diagnoses for children referred by otolaryngologists.

Study Design

Retrospective case series with chart review.

Setting

Single tertiary pediatric hospital (2010-2015).

Subjects and Methods

Review of the medical records of 1258 patients undergoing PSG by otolaryngology referral. Patients who underwent previous otolaryngologic surgery were excluded. Data distributions were evaluated using means with standard deviations for continuous variables and frequencies with percentages for categorical variables.

Results

A total of 1258 patients were included; 55.9% were male, 64.5% were Caucasian, 16.6% had Down syndrome, and 48% had public insurance. The median age at the time of PSG was 5.2 years (range = 0.2-18.94). Indications for PSG were sleep-disordered breathing (SDB; 69.4%), restless sleep (12.7%), airway anomalies (7.5%), and laryngomalacia (7.2%). SDB was seen in 73.4%, obstructive sleep apnea (OSA) in 53.2%, OSA + central sleep apnea (CSA) in 4.5%, CSA in 0.9%, and non-OSA snoring in 15%. Other diagnoses included periodic limb movements of sleep (PLMS; 7.4%), hypoventilation (6.8%), and nonapneic hypoxemia (2.6%). SDB was more common in younger children and seen in 91.4% of children <12 months and in 69.2% of children ≥24 months, while non-OSA snoring was more common with increasing age (3.7% in children <12 months, 17.7% of children ≥24 months). PLMS were seen in 8.9% of children ≥24 months and in no children <12 months.

Conclusion

While OSA and snoring were the most common diagnoses reported, PLMS, alveolar hypoventilation, and CSA occurred in 7.4%, 6.8%, and 5.4%, respectively. These findings indicate that additional diagnoses other than OSA should be considered for children seen in an otolaryngology clinic setting who undergo PSG for sleep disturbances.