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Al-Naimi AR, Abu-Hasan M, Belavendra A, Janahi I. Prevalence, Severity, and Treatment of Obstructive Sleep Apnea in Children with Down Syndrome in Qatar. Cureus 2024; 16:e61777. [PMID: 38975488 PMCID: PMC11227032 DOI: 10.7759/cureus.61777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
INTRODUCTION Patients with Down syndrome (DS) are at risk for sleep disorder breathing (SDB) due to their abnormal craniofacial anatomy, hypotonia, and propensity for obesity. The prevalence and severity of SDB in this population vary between different cohorts due to the multifactorial nature of these patients and the different diagnostic criteria used. We aim to report the prevalence and severity of SDB in the DS population in Qatar. METHODS This study is a retrospective review of all patients with genetically confirmed DS who completed a diagnostic polysomnography (PSG) study at Sidra Medicine in Doha, Qatar, which is the only pediatric sleep center in the country, between September 2019 and July 2022. Clinical and PSG data were collected from the patients' electronic medical records. Central and obstructive events were scored according to the American Academy of Sleep Medicine (AASM) criteria. Obstructive sleep apnea (OSA) diagnosis was made based on apnea-hypopnea index (AHI) and defined as AHI >1.5 events/hour. OSA was considered mild if AHI was ≥ 1.5 but < 5, moderate if AHI was ≥ 5 but < 10, and severe if AHI was ≥ 10 events/hour. Diagnosis with central apnea was considered if the central apnea index was > 5 events/hour. Hypoventilation was considered present if end-tidal/transcutaneous carbon dioxide gas was more than 50 mmHg for more than 25% of total sleep time. Multiple regression analysis was performed to evaluate predictors of high AHI and rapid eye movement (REM)-AHI. RESULTS A total of 80 patients (49 males and 31 females) were included. Median (range) age was 7.3 years (0.9, 21). The mean (range) BMI z-score was 1.7 (-1.3, 4.3). Sixty-five patients were diagnosed with OSA, with a prevalence rate of 81%. OSA was mild in 25 (38.5%) patients, moderate in 15 (23.1%) patients, and severe in 25 (38.5%) patients. Only one patient was diagnosed with central apnea and five patients (6.9%) with alveolar hypoventilation. Multiple regression analysis showed BMI (P = 0.007) and snoring/apnea symptoms (P=0.023) to be predictive of high AHI. No correlation was found between the same variables and REM-AHI. Treatments used for OSA included anti-inflammatory medications in 37 (46%) patients, tonsillectomy/adenoidectomy in 13 (16.5%) patients, and positive airway pressure support in 10 (15%) patients. CONCLUSION Our patient population with DS had a high prevalence of OSA comparable to other reported cohorts. High BMI and symptoms of snoring are predictive of OSA.
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Ulualp SO, Kezirian EJ. Advanced Diagnostic Techniques in Obstructive Sleep Apnea. Otolaryngol Clin North Am 2024; 57:371-383. [PMID: 38485538 DOI: 10.1016/j.otc.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
Optimal surgical and medical management of obstructive sleep apnea requires clinically reliable identification of patterns and sites of upper airway obstruction. A wide variety of modalities have been used to evaluate upper airway obstruction. Drug-induced sleep endoscopy (DISE) and cine MRI are increasingly used to identify upper airway obstruction sites, to characterize airway obstruction patterns, to determine optimum medical and surgical treatment, and to plan individualized surgical management. Here, we provide an overview of the applications of DISE and cine MRI in assessing upper airway obstruction in children and adults with obstructive sleep apnea.
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Affiliation(s)
- Seckin O Ulualp
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Division of Pediatric Otolaryngology, Children's Health, 2360 North Stemmons Freeway, F6.215, Dallas, TX 75207, USA.
| | - Eric J Kezirian
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Head and Neck Surgery, 1131 Wilshire Boulevard, Suite 302, Santa Monica, CA 90401, USA
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Ulualp SO, Kezirian EJ. Advanced Diagnostic Techniques in Obstructive Sleep Apnea. Otolaryngol Clin North Am 2024:S0030-6665(24)00033-1. [PMID: 38519293 DOI: 10.1016/j.otc.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
Optimal surgical and medical management of obstructive sleep apnea (OSA) requires clinically reliable identification of patterns and sites of upper airway obstruction. A wide variety of modalities has been used to evaluate upper airway obstruction. Drug-induced sleep endoscopy (DISE) and cine MRI are increasingly used to identify upper airway obstruction sites, to characterize airway obstruction patterns, to determine optimum medical and surgical treatment, and to plan individualized surgical management. Here, the authors provide an overview of the applications of DISE and cine MRI in assessing upper airway obstruction in children and adults with OSA.
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Affiliation(s)
- Seckin O Ulualp
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Division of Pediatric Otolaryngology, Children's Health, 2360 North Stemmons Freeway, F6.215, Dallas, TX 75207, USA.
| | - Eric J Kezirian
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Head and Neck Surgery, 1131 Wilshire Boulevard, Suite 302, Santa Monica, CA 90401, USA
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Wolter NE, Scheffler P, Li C, End C, McKinnon NK, Narang I, Amin R, Chiang J, Matava C, Propst EJ. Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits. Int J Pediatr Otorhinolaryngol 2023; 174:111743. [PMID: 37748322 DOI: 10.1016/j.ijporl.2023.111743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/24/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVES To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP). METHODS A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions. RESULTS Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p < 0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p = 0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p = 0.002) and EDACS<3 (p = 0.031). CONCLUSION Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.
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Affiliation(s)
- Nikolaus E Wolter
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Patrick Scheffler
- Phoenix Children's Hospital, Division of Otolaryngology - Head and Neck Surgery, Phoenix, AZ, USA
| | - Chantal Li
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher End
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nicole K McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evan J Propst
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Savoldi F, Fung KKF, Mak WS, Kan EYL, Yang Y, Kwok KL, Gu M. Are the severity of obstruction and the apnea-hypopnea index related to orofacial anatomy in children with obstructive sleep apnea? a kinetic MRI study. Dentomaxillofac Radiol 2023; 52:20220422. [PMID: 37192022 PMCID: PMC10304841 DOI: 10.1259/dmfr.20220422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES The proportionality between anatomical characteristics and disease severity in children and adolescents with obstructive sleep apnea (OSA) has not been well characterized. The present study investigated the relationship between the dentoskeletal and oropharyngeal features of young patients with OSA and either the apnea-hypopnea index (AHI) or the amount of upper airway obstruction. METHODS MRI of 25 patients (8- to 18-year-old) with OSA (mean AHI = 4.3 events/h) was retrospectively analyzed. Sleep kinetic MRI (kMRI) was used to assess airway obstruction, and static MRI (sMRI) was used to assess dentoskeletal, soft tissue, and airway parameters. Factors related to AHI and obstruction severity were identified with multiple linear regression (significance level α = 0.05). RESULTS As evidenced by kMRI, circumferential obstruction was present in 44% of patients, while laterolateral and anteroposterior was present in 28%; as evidenced by kMRI, obstructions were retropalatal in 64% of cases and retroglossal in 36% (no nasopharyngeal obstructions); kMRI showed a higher prevalence of retroglossal obstructions compared to sMRI(p = 0.037); the main obstruction airway area was not related to AHI; the maxillary skeletal width was related to AHI (β = -0.512, p = 0.007) and obstruction severity (β = 0.625, p = 0.002); and the retropalatal width was related to AHI (β = -0.384, p = 0.024) and obstruction severity (β = 0.519, p = 0.006). CONCLUSIONS In children and adolescents, the severity of OSA and obstruction were inversely proportional to the maxillary basal width and retropalatal airway width. Further studies are needed to assess the benefits of targeted clinical treatments widening the transverse dimension of these structures.
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Affiliation(s)
- Fabio Savoldi
- Orthodontics, Division of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong, Hong Kong, Hong Kong SAR, PRC
| | - Kevin KF Fung
- Department of Radiology, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, PRC
| | - Wing-Sze Mak
- Department of Diagnostic and Interventional Radiology, Kwong Wah Hospital, Hong Kong, Hong Kong SAR, PRC
| | - Elaine YL Kan
- Department of Radiology, Hong Kong Children’s Hospital, Hong Kong, Hong Kong SAR, PRC
| | - Yanqi Yang
- Orthodontics, Division of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong, Hong Kong, Hong Kong SAR, PRC
| | - Ka-Li Kwok
- Department of Paediatrics, Kwong Wah Hospital, Hong Kong, Hong Kong SAR, PRC
| | - Min Gu
- Orthodontics, Division of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong, Hong Kong, Hong Kong SAR, PRC
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Li C, Kou YF, DeMarcantonio MA, Heubi CH, Fleck R, Kandil A, Smith DF, Ishman SL. Sleep Endoscopy and Cine Magnetic Resonance Imaging Evaluation of Children With Persistent Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2023; 168:848-855. [PMID: 35608914 PMCID: PMC10127993 DOI: 10.1177/01945998221097659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare findings of same-day cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) and examine how each technique uniquely contributes to the evaluation of persistent obstructive sleep apnea following adenotonsillectomy. STUDY DESIGN Retrospective cohort study. SETTING Quaternary care center. METHODS Chart review was performed for consecutive patients who underwent same-day cine MRI and DISE between 2015 and 2020. Descriptive statistics are reported, and Cohen kappa coefficients were calculated to evaluate the agreement between cine MRI and DISE for obstruction at the adenoids, lingual tonsils, and tongue base. RESULTS There were 137 patients, the mean age was 10.4 years (95% CI, 3.2-16.7), and 62.8% were male. The most common sites of obstruction on DISE were the tongue base (86.9%), velum (78.7%), epiglottis (74.5%), inferior turbinate (68.6%), and lingual tonsil (61.3%). The most common sites of obstruction on cine MRI were the hypopharynx (56.3%), tongue base (44.8%), lingual tonsil (38.0%), and macroglossia (37.6%). There was moderate agreement for adenoid hypertrophy (κ = 0.53) and poor agreement for lingual tonsil hypertrophy (κ = 0.15) and tongue base obstruction (κ = 0.09). DISE identified more instances of multilevel obstruction when compared with cine MRI (94.9% vs 48.2%). CONCLUSION DISE offered a better examination of nasal and supraglottic obstruction and is sensitive to partial vs complete collapse, while cine MRI offered better soft tissue resolution for lymphoid tissue hypertrophy and provided a global view of primary and secondary airway obstruction. Cine MRI and DISE are complementary modalities in the evaluation of children with persistent obstructive sleep apnea.
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Affiliation(s)
- Carol Li
- Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Yann-Fuu Kou
- Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael A. DeMarcantonio
- Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christine H. Heubi
- Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Robert Fleck
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Radiology, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ali Kandil
- Division of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - David F. Smith
- Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Circadian Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stacey L. Ishman
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of HeathVine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Mothersole K, Ulualp SO, Szmuk P, Liu C. The Effect of Tonsillectomy and Adenoidectomy on Upper Airway Obstruction Patterns in Children with Obstructive Sleep Apnea. Int Arch Otorhinolaryngol 2023; 27:e211-e217. [PMID: 37125372 PMCID: PMC10147455 DOI: 10.1055/s-0043-1768207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/24/2021] [Indexed: 05/02/2023] Open
Abstract
Introduction Alterations in upper airway flow dynamics and sites of airway obstruction immediately after tonsillectomy and adenoidectomy (TA) have not been assessed. Identification of the changes in airway obstruction patterns after TA potentially improves the surgical management of children with obstructive sleep apnea (OSA). Objective To evaluate the effect of TA on upper airway obstruction patterns detected with drug-induced sleep endoscopy (DISE). Methods The medical records of patients who underwent pre-TA DISE during the induction of anesthesia and post-TA DISE at the end of TA were reviewed. Data pertaining to polysomnography and DISE findings were analyzed. Results Twenty-seven patients (15 male and 12 females aged between 2 and 18 years old) were identified. All patients had obstruction at multiple sites of the upper airway. Prior to TA, airway obstruction was at the level of the velum in 27 patients, of the oropharynx/lateral walls in 27, of the tongue in 7, and of the epiglottis in 4. After TA, airway obstruction was at the level of the velum in 24 patients, of the oropharynx/lateral walls in 16, of the tongue in 6, and of the epiglottis in 4. The degree of obstruction at the levels of the velum and oropharynx/lateral walls after TA was significantly decreased. Conclusions Drug-induced sleep endoscopy performed prior to TA revealed that most of the sites of airway obstruction persisted after TA in OSA children with multiple sites of airway obstruction. Further studies in larger group of children with OSA are needed to establish the value of DISE findings in predicting residual OSA after TA, surgical planning, determining the need for post TA sleep study, and counseling caregivers.
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Affiliation(s)
- Kelsey Mothersole
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Seckin Omer Ulualp
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Divisions of Pediatric Otolaryngology, Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, TX, United States
- Address for correspondence Seckin Omer Ulualp, MD Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center5323 Harry Hines Blvd, Dallas, TX 75390-9035United States
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Department of Anesthesiology, Children's Health Medical Center, Dallas, TX, United States
- Outcome Research Consortium, Cleveland, OH, United States
| | - Christopher Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Divisions of Pediatric Otolaryngology, Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, TX, United States
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Sharma AV, Padhya T, Nallu S. Management of Pediatric Obstructive Sleep Apnea After Failed Tonsillectomy and Adenoidectomy. Adv Pediatr 2022; 69:95-105. [PMID: 35985719 DOI: 10.1016/j.yapd.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pediatric obstructive sleep apnea (OSA) represents a different entity from its adult counterpart and therefore requires a different therapeutic approach. Adenotonsillectomy (AT) is the primary treatment of pediatric OSA, and evidence shows it is very effective. However, there is a growing understanding that residual OSA is common, and next steps for patients who fail primary AT are less certain. This article reviews current methods of evaluating and treating these complex patients.
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Affiliation(s)
- Abhay Varun Sharma
- Department of Otolaryngology Head and Neck Surgery, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, MDC 73 Tampa, FL 33612, USA.
| | - Tapan Padhya
- Department of Otolaryngology Head and Neck Surgery, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, MDC 73 Tampa, FL 33612, USA
| | - Sagarika Nallu
- USF Health Department of Pediatrics, Division of Neurology, 13101 Bruce B Downs Boulevard, Tampa, FL 33612, USA
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Persistent Obstructive Sleep Apnea in Children with Down Syndrome After Adenotonsillectomy: Drug Induced Sleep Endoscopy-Directed Treatment. J Craniofac Surg 2022; 33:e185-e187. [PMID: 35385239 DOI: 10.1097/scs.0000000000008246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Children with down syndrome (DS) are more liable to develop obstructive sleep apnea (OSA) which is usually treated with adenotonsillectomy. However, OSA may persist in many of those patients after the procedure. The aim of this study was to assess the efficacy of drug-induced sleep endoscopy (DISE)-directed treatment in management of DS children with persistent OSA after adenotonsillectomy. Sixteen DS children with persistent OSA after adenotonsillectomy were evaluated. DISE was done in the operating theatre to identify the site of obstruction, and surgical intervention was performed according to the finding. Polysomnographic study was used pre- and post-operatively to measure the outcome. DISE revealed obstruction in different sites of the airway. DISE-directed treatment was done according to the site of obstruction. Polysomnographic study showed postoperative significant changes for all parameters. The authors achieved improvement of overall apnea-hypopnea index which was normalized in seven patients (44%). In conclusion, DISE-directed treatment is an effective procedure for persistent OSA in DS children who underwent adenotonsillectomy. However, residual obstruction in those children may be due to many characteristic features that cause narrowing of the airway.
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Much Ado about Sleep: Current Concepts on Mechanisms and Predisposition to Pediatric Obstructive Sleep Apnea. CHILDREN 2021; 8:children8111032. [PMID: 34828745 PMCID: PMC8623682 DOI: 10.3390/children8111032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 12/22/2022]
Abstract
Obstructive Sleep Apnea (OSA) is a form of sleep-disordered breathing characterized by upper airway collapse during sleep resulting in recurring arousals and desaturations. However, many aspects of this syndrome in children remain unclear. Understanding underlying pathogenic mechanisms of OSA is critical for the development of therapeutic strategies. In this article, we review current concepts surrounding the mechanism, pathogenesis, and predisposing factors of pediatric OSA. Specifically, we discuss the biomechanical properties of the upper airway that contribute to its primary role in OSA pathogenesis and examine the anatomical and neuromuscular factors that predispose to upper airway narrowing and collapsibility.
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Arganbright JM, Lee JC, Weatherly RA. Pediatric drug-induced sleep endoscopy: An updated review of the literature. World J Otorhinolaryngol Head Neck Surg 2021; 7:221-227. [PMID: 34430829 PMCID: PMC8356111 DOI: 10.1016/j.wjorl.2021.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The field of drug-induced sleep endoscopy (DISE) has grown considerably over the last 10∼15 years, to now include its use in pediatric patients. In this review article, we outline our approach to the use of this technology in Children with Airway Obstruction, most specifically in the management of children with airway obstruction and known or suspected adenotonsillar enlargement.
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Affiliation(s)
- Jill M Arganbright
- Children's Mercy Kansas City, Division of Otolaryngology, Kansas City, MO, USA.,University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
| | - Jason C Lee
- University of Kansas Medical Center, Department of Otolaryngology, Kansas City, KS, USA
| | - Robert A Weatherly
- Children's Mercy Kansas City, Division of Otolaryngology, Kansas City, MO, USA.,University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
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End C, Propst EJ, Cushing SL, McKinnon NK, Narang I, Amin R, Chiang J, Al-Saleh S, Matava C, Wolter NE. Risks and Benefits of Adenotonsillectomy in Children With Cerebral Palsy With Obstructive Sleep Apnea: A Systematic Review. Laryngoscope 2021; 132:687-694. [PMID: 34032299 DOI: 10.1002/lary.29625] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/24/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS Assess the risks and benefits of adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in children with cerebral palsy (CP). STUDY DESIGN Systematic review. METHODS We conducted a systematic review of Medline, Embase, and Cochrane Central Registry from 1946 to 2021. Broad search concepts included cerebral palsy, pediatric, tonsillectomy/adenoidectomy, and sleep. Additional articles were identified by searching reference lists. Studies on the safety and efficacy of AT for OSA management in children with CP were included. RESULTS Fifteen articles met inclusion criteria. Articles were classified into one or more of four themes: intraoperative risk (n = 1), postoperative risk (n = 3), postoperative care requirements (n = 6), and surgical outcomes (n = 7). No intraoperative anesthetic complications were reported. Postoperatively, respiratory complications including pneumonia were common and necessitated additional airway management. Following AT, children with CP required close postoperative observation, experienced increased lengths of stay, and had increased odds of unplanned intensive care unit (ICU) admission. Benefits following AT were improvement in OSA as measured by a reduction in obstructive apnea-hypopnea index (OAHI) as well as improved quality of life in some; however, many patients went on to require tracheostomy due to persistent OSA. CONCLUSIONS Children with CP who undergo AT have a significant risk of developing a postoperative respiratory complication. Realistic counseling of families around increased perioperative risks in this population is imperative and close postoperative monitoring is critical. Many children will obtain a reduction in OAHI, but additional surgical management is often required, including tracheostomy. Further research is needed to determine the best management strategy for OSA in children with CP. Laryngoscope, 2021.
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Affiliation(s)
- Christopher End
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sharon L Cushing
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole K McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, Department of Anesthesia, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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13
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14
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Baldassari CM, Lam DJ, Ishman SL, Chernobilsky B, Friedman NR, Giordano T, Lawlor C, Mitchell RB, Nardone H, Ruda J, Zalzal H, Deneal A, Dhepyasuwan N, Rosenfeld RM. Expert Consensus Statement: Pediatric Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg 2021; 165:578-591. [PMID: 33400611 DOI: 10.1177/0194599820985000] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep. METHODS Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized. RESULTS The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research. CONCLUSION Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.
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Affiliation(s)
- Cristina M Baldassari
- Eastern Virginia Medical School / Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
| | - Derek J Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center / University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Norman R Friedman
- Children's Hospital Colorado / University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Terri Giordano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Claire Lawlor
- Children's National Medical Center / George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Heather Nardone
- Nemours / Alfred I. duPont Hospital for Children, New Castle County, Delaware, USA
| | - James Ruda
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Habib Zalzal
- West Virginia University, Morgantown, West Virginia, USA
| | - Adrienne Deneal
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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15
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Elders B, Ciet P, Tiddens H, van den Bosch W, Wielopolski P, Pullens B. MRI of the upper airways in children and young adults: the MUSIC study. Thorax 2020; 76:44-52. [PMID: 33122446 PMCID: PMC7803889 DOI: 10.1136/thoraxjnl-2020-214921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/24/2020] [Accepted: 09/11/2020] [Indexed: 11/03/2022]
Abstract
RATIONALE Paediatric laryngotracheal stenosis (LTS) is often successfully corrected with open airway surgery. However, respiratory and vocal sequelae frequently remain. Clinical care and surgical interventions could be improved with better understanding of these sequelae. OBJECTIVE The objective of this cross-sectional study was to develop an upper airway MRI protocol to obtain information on anatomical and functional sequelae post-LTS repair. METHODS Forty-eight patients (age 14.4 (range 7.5-30.7) years) and 11 healthy volunteers (15.9 (8.2-28.8) years) were included. Spirometry and static and dynamic upper airway MRI (3.0 T, 30 min protocol) were conducted. Analysis included assessment of postoperative anatomy and airway lumen measurements during static and dynamic (inspiration and phonation) acquisitions. MAIN RESULTS Good image quality without artefacts was achieved for static and dynamic images in the majority of MRIs. MRI showed vocal cord thickening in 80.9% of patients and compared with volunteers, a significant decrease in vocal cord lumen area (22.0 (IQR 17.7-30.3) mm2 vs 35.1 (21.2-54.7) mm2, p=0.03) but not cricoid lumen area (62.3±27.0 mm2 vs 66.2±34.8 mm2, p=0.70). Furthermore, 53.2% of patients had an A-frame deformation at site of previous tracheal cannula, showing lumen collapse during inspiration. Dynamic imaging showed incomplete vocal cord abduction during inspiration in 42.6% and incomplete adduction during phonation in 61.7% of patients. CONCLUSIONS Static and dynamic MRI is an excellent modality to non-invasively image anatomy, tissue characteristics and vocal cord dynamics of the upper airways. MRI-derived knowledge on postsurgical LTS sequelae might be used to improve surgery.
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Affiliation(s)
- Bernadette Elders
- Department of Pediatric Pulmonology, Erasmus MC Sophia, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Pierluigi Ciet
- Department of Pediatric Pulmonology, Erasmus MC Sophia, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Harm Tiddens
- Department of Pediatric Pulmonology, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Wytse van den Bosch
- Department of Pediatric Pulmonology, Erasmus MC Sophia, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Piotr Wielopolski
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Bas Pullens
- Department of Pediatric Othorhinolaryngology, Erasmus MC Sophia, Rotterdam, The Netherlands
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16
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Raposo D, Menezes M, Rito J, Trindade-Soares M, Adónis C, Loureiro HC, Freire F. Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2020; 164:414-421. [PMID: 32777981 DOI: 10.1177/0194599820947666] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea and to differentiate them between surgically naïve children and children who had adenotonsillectomy performed. STUDY DESIGN Retrospective case series with chart review. SETTING Secondary care hospital. SUBJECTS AND METHODS A cohort of 56 children with the diagnosis of obstructive sleep apnea was submitted to DISE and subsequent upper airway surgery: 23 were surgically naïve, and 33 had persistent obstructive sleep apnea after adenotonsillectomy. Comparisons between groups were calculated with chi-square test and Student's t test. Simple linear regression was used to model polysomnographic indices. RESULTS In surgically naïve children, the most common sites of obstruction were the adenoids (78.2%) and the lateral pharyngeal walls/tonsils (82.6%). In children with persistent obstructive sleep apnea after adenotonsillectomy, the most common sites of obstruction were the adenoids (54.5%), followed by the supraglottis (48.5%) and the tongue base (45.5%). No correlation was found between obstructive apnea-hypopnea index and DISE findings. Simple linear regression revealed that the degree of obstruction at the tongue base (β = -0.73; 95% CI, -1.22 to -0.25; P = .004) and the presence of multilevel obstruction (β = -1.75; 95% CI, -3.20 to -0.30; P = .02) predicted saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy. CONCLUSION DISE findings differed between surgically naïve children and children with persistent obstructive sleep apnea after adenotonsillectomy. Increased obstruction at the level of the tongue base and the presence of multilevel obstruction predicted a lower saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy.
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Affiliation(s)
- Diogo Raposo
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | - Marco Menezes
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | - João Rito
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | | | - Cristina Adónis
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | | | - Filipe Freire
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
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17
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Ohn M, Eastwood P, von Ungern-Sternberg BS. Preoperative identification of children at high risk of obstructive sleep apnea. Paediatr Anaesth 2020; 30:221-231. [PMID: 31841240 DOI: 10.1111/pan.13788] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/08/2019] [Accepted: 12/10/2019] [Indexed: 12/24/2022]
Abstract
Obstructive sleep apnea is a common childhood disorder which can lead to serious health problems if left untreated. Enlarged adenoid and tonsils are the commonest causes, and adenotonsillectomy is the recommended first line of treatment. Obstructive sleep apnea poses as an anesthetic challenge, and it is a well-known risk factor for perioperative adverse events. The presence and severity of an obstructive sleep apnea diagnosis will influence anesthesia, pain management, and level of monitoring in recovery period. Preoperative obstructive sleep apnea assessment is necessary, and anesthetists are ideally placed to do so. Currently, there is no standardized approach to the best method of preoperative screening for obstructive sleep apnea. Focused history, clinical assessments, and knowledge regarding the strengths and limitations of available obstructive sleep apnea assessment tools will help recognize a child with obstructive sleep apnea in the preoperative setting.
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Affiliation(s)
- Mon Ohn
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia.,Medical School, The University of Western Australia, Crawley, WA, Australia.,Telethon Kids Institute, Nedlands, WA, Australia
| | - Peter Eastwood
- Centre for Sleep Science, School of Human Sciences, The University of Western Australia, Crawley, WA, Australia.,West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Britta S von Ungern-Sternberg
- Medical School, The University of Western Australia, Crawley, WA, Australia.,Telethon Kids Institute, Nedlands, WA, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia
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18
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Quinlan CM, Otero H, Tapia IE. Upper airway visualization in pediatric obstructive sleep apnea. Paediatr Respir Rev 2019; 32:48-54. [PMID: 31076378 PMCID: PMC6776720 DOI: 10.1016/j.prrv.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/28/2019] [Indexed: 10/27/2022]
Abstract
Pediatric Obstructive Sleep Apnea (OSA) is a condition that may lead to a variety of comorbidities in adolescence and adulthood. The gold standard of diagnosing OSA is polysomnography (PSG). Over the past fifteen years numerous publications have explored how to better visualize the upper airway to further assess OSA in the pediatric population, and eventually institute personalized treatment. Lateral neck radiograph, cephalometry, computed axial tomography, and magnetic resonance imaging are all unique imaging techniques that are used in the diagnosis of OSA. Drug Induced Sleep Endoscopy is a direct visualization technique that is gathering momentum in pediatrics. Each approach has respective benefits and weaknesses. However, none of them at this time can replace PSG. They are a helpful supplement in those patients with complicated upper airway anatomy and in those with residual OSA.
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Affiliation(s)
- Courtney M Quinlan
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hansel Otero
- Division of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ignacio E Tapia
- Sleep Center, Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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19
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Nehme J, LaBerge R, Pothos M, Barrowman N, Hoey L, Kukko M, Monsour A, Katz SL. Treatment and persistence/recurrence of sleep-disordered breathing in children with Down syndrome. Pediatr Pulmonol 2019; 54:1291-1296. [PMID: 31172656 DOI: 10.1002/ppul.24380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/10/2019] [Accepted: 05/01/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Sleep-disordered breathing (SDB) is common in children with Down syndrome, but the trajectory and long-term outcomes are not well-described. In a retrospective longitudinal cohort of children with Down syndrome, study objectives were to (1) characterize polysomnography (PSG), treatments received, and persistence/recurrence of SDB and (2) explore predictors of SDB persistence/recurrence. METHODS A retrospective cohort study was conducted of children who underwent PSGs between 2004 and 2014. SDB was defined as obstructive sleep apnea (OSA)-mixed (apnea-hypopnea index [AHI] >5 events/hour), central sleep apnea or hypoventilation. PSGs, interventions, and trajectory of SDB were described. Age, body mass index (BMI) Z-score and AHI at first SDB diagnosis were evaluated as predictors of persistent/recurrent SDB. RESULTS Of 506 children, 120 had ≥1 PSG; 54 had subsequent PSGs. Children with ≥2 PSGs were more likely to have higher total AHI (P = .02) and obstructive-mixed AHI (P = .01). Thirty-five of fifty-four (65%) were initially diagnosed with OSA-mixed SDB. After first PSG, 67 of 120 had OSA-mixed SDB, of whom 25 (37.3%) underwent adenotonsillectomy (T&A), 13 (19.4%) received positive airway pressure (PAP). Those who underwent T&A after PSG were significantly younger than those who received PAP (median age 6.2 vs 12.5 years; P = .005). OSA-mixed SDB persisted/recurred in 33 of 54 (73.3%) with ≥2 PSGs. Persistence/recurrence was not associated with age, AHI or BMI Z-score at first SDB. CONCLUSION Children with Down syndrome undergoing T&A for SDB were significantly younger than those treated with PAP. SDB persisted/recurred in three of four and was not predicted by age, SDB severity or BMI Z-score. Longitudinal PSG assessment for persistence/recurrence of SDB is required in this population.
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Affiliation(s)
- Joy Nehme
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Robert LaBerge
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Mary Pothos
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Nicholas Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Lynda Hoey
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Madelaine Kukko
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Sherri L Katz
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.,Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
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20
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Nguyen XL, Briffod J, Couloigner V, Darqué F, Kerbrat JB, Vecchierini MF. [Adolescent obstructive sleep apnoea syndrome: Characteristics and treatment]. Rev Mal Respir 2019; 36:697-706. [PMID: 31255317 DOI: 10.1016/j.rmr.2018.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022]
Abstract
Although the prevalence of the obstructive sleep apnoea syndrome (OSAS) is high in adolescents, studies pertaining to adolescent OSAS are less numerous than childhood studies. Cases of adolescent OSAS may consist of residual OSAS after adenotonsillectomy, but most often are de novo cases. Major pathophysiological factors are weight excess or even high-grade obesity, and the association of upper airway narrowing and tonsillar hypertrophy (pharyngeal, palatal or even lingual). ENT and systematic orthodontic assessments are the main points. In case of predisposing factors such as dental, occlusal or dento-facial abnormalities, a specific orthodontic treatment can be discussed. First line treatment is surgical adenotonsillectomy; surgical reduction of the lingual tonsils is seldom required. CPAP treatment may be indicated in the case of severe comorbidities (craniofacial malformations, neuromuscular diseases…) or in obese adolescents with severe residual OSAS. Treatment of adolescent OSAS has to be comprehensive and multidisciplinary, taking into account the specific treatments of obesity and abnormal sleep/wake rhythms.
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Affiliation(s)
- X-L Nguyen
- Unité somnologie et fonction respiratoire, hôpital St-Antoine, 75012 Paris, France
| | - J Briffod
- Centre médical spécialisé de l'enfant et de l'adolescent, 17, rue Froment, 75011 Paris, France
| | - V Couloigner
- Service d'ORL pédiatrique, hôpital Necker-Enfants Malades, université Paris Descartes, AP-HP, 75015 Paris, France
| | - F Darqué
- Unité d'orthopédie dento-faciale, hôpital Pellegrin, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - J-B Kerbrat
- Pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France
| | - M-F Vecchierini
- Centre du sommeil et de la vigilance, Hôtel-Dieu, 1, place du Parvis Notre-Dame, 75181 Paris cedex 04, France.
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21
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Guidelines of the French Society of Otorhinolaryngology. Role of the ENT specialist in the diagnosis of obstructive sleep apnea-hypopnea syndrome (OSAHS) in children. Part 2: Diagnostic investigations apart from sleep studies. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:295-299. [PMID: 31202665 DOI: 10.1016/j.anorl.2019.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This manuscript specifically focuses on diagnostic investigations apart from sleep studies. METHODS A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group. RESULTS At the end of the process, guidelines were established and graded regarding diagnostic investigations apart from sleep studies, in particular respiratory functional tests, biological markers, and morphologic assessment under induced sleep (drug-induced sleep endoscopy (DISE) and cine-MRI).
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22
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Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2019; 121:179-187. [PMID: 30925395 DOI: 10.1016/j.ijporl.2019.02.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the efficacy of upper airway surgery for children with persistent obstructive sleep apnea after adenotonsillectomy and to assess sleep study outcomes when Drug Induced Sleep Endoscopy, Cine MRI, or other imaging procedure is performed to assist in identifying the location of obstruction and planning surgery. METHODS Systematic review and meta-analysis was performed. Inclusion criteria was English-language studies with original data including pediatric patients with persistent OSA after T&A. Exclusion criteria included case reports and lack of pre and post-operative sleep study data. Data Sources were PubMed, Cochrane Central, and Embase from 2000 to 2018. PRISMA standards were followed for the selection and review of articles. The Newcastle-Ottawa Quality Assessment scale was used to score the quality of evidence of the studies. All manuscripts were reviewed independently by two investigators. Primary outcome measures were apnea-hypopnea index and minimum oxygen saturation. Data was pooled using a random-effects model. RESULTS Of the 1902 abstracts identified, 11 studies (214 patients) met inclusion criteria for systematic review, 5 with Drug Induced Sleep Endoscopy as the diagnostic technique, 4 with Cine MRI, and 2 with MRI/CT. All studies were case series. Most subjects had syndromic comorbidities and/or obesity. Ten studies (198 patients) were included in the meta-analysis. Overall, there was a change in apnea hypopnea index of -6.51 (95% CI, -8.17 to - 4.85; p < 0.001) and an increase in minimum oxygen saturation by 3.24% (95% CI, 1.49%-4.98%; p < 0.001) following surgical intervention. Both Drug Induced Sleep Endoscopy and Cine MRI directed surgeries resulted in significant improvement in sleep study parameters. The two techniques could not be directly compared due to significant differences in co-morbidity rates between patients. CONCLUSIONS Surgery for pediatric persistent obstructive sleep apnea improves apnea hypopnea index and minimum oxygen saturation but does not resolve the disease. This is true when both Drug Induced Sleep Endoscopy and Cine MRI findings were used to direct surgery.
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Ulualp S. Outcomes of Tongue Base Reduction and Lingual Tonsillectomy for Residual Pediatric Obstructive Sleep Apnea after Adenotonsillectomy. Int Arch Otorhinolaryngol 2019; 23:e415-e421. [PMID: 31649761 PMCID: PMC6805200 DOI: 10.1055/s-0039-1685156] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 02/17/2019] [Indexed: 10/27/2022] Open
Abstract
Introduction Upper airway obstruction at multiple sites, including the velum, the oropharynx, the tongue base, the lingual tonsils, or the supraglottis, has been resulting in residual obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy (TA). The role of combined lingual tonsillectomy and tongue base volume reduction for treatment of OSA has not been studied in nonsyndromic children with residual OSA after TA. Objective To evaluate the outcomes of tongue base volume reduction and lingual tonsillectomy in children with residual OSA after TA. Methods A retrospective chart review was conducted to obtain information on history and physical examination, past medical history, findings of drug-induced sleep endoscopy (DISE), of polysomnography (PSG), and surgical management. Pre- and postoperative PSGs were evaluated to assess the resolution of OSA and to determine the improvement in the obstructive apnea-hypopnea index (oAHI) before and after the surgery. Results A total of 10 children (5 male, 5 female, age range: 10-17 years old, mean age: 14.5 ± 2.6 years old) underwent tongue base reduction and lingual tonsillectomy. Drug-induced sleep endoscopy (DISE) revealed airway obstruction due to posterior displacement of the tongue and to the hypertrophy of the lingual tonsils. All of the patients reported subjective improvement in the OSA symptoms. All of the patients had improvement in the oAHI. The postoperative oAHI was lower than the preoperative oAHI ( p < 0.002). The postoperative apnea-hypopnea index during rapid eye movement sleep (REM-AHI) was lower than the preoperative REM-AHI ( p = 0.004). Obstructive sleep apnea was resolved in children with normal weight. Overweight and obese children had residual OSA. Nonsyndromic children had resolution of OSA or mild OSA after the surgery. Conclusions Tongue base reduction and lingual tonsillectomy resulted in subjective and objective improvement of OSA in children with airway obstruction due to posterior displacement of the tongue and to hypertrophy of the lingual tonsils.
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Affiliation(s)
- Seckin Ulualp
- Department of Otolaryngology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, United States
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24
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Lu CT, Li HY, Lee GS, Huang YS, Huang CG, Chen NH, Lee LA. Snoring sound energy as a potential biomarker for disease severity and surgical response in childhood obstructive sleep apnoea: A pilot study. Clin Otolaryngol 2018; 44:47-52. [PMID: 30260574 DOI: 10.1111/coa.13231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 09/07/2018] [Accepted: 09/23/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the relationship between baseline snoring sound energy (SSE) and disease severity, changes in SSE after adenotonsillectomy, and the predictors of surgical success in children with obstructive sleep apnoea (OSA). DESIGN Prospective cohort study. SETTING Tertiary referral medical centre. PARTICIPANTS Thirty-two children with OSA whose apnoea-hypopnoea index ≥5 or apnoea-hypopnoea index ≥1.5 with OSA comorbidities were recruited. Patients with complicated OSA were excluded. All participants underwent snoring sound analysis, polysomnography, and adenotonsillectomy. MAIN OUTCOME MEASURES Snoring sound energy and apnoea-hypopnoea index were assessed at baseline and 6 months after adenotonsillectomy. Surgical success was defined as a postoperative apnoea-hypopnoea index <1.5. RESULTS The median age, body mass index, and apnoea-hypopnoea index was 9 years, 19.0 kg/m2 , and 13.2 events/h, respectively. Multivariate logistic regression showed that a baseline tonsil size of IV (odds ratio 15.7 [95% CI: 1.5-166.3]) and SSE of 801-1000 Hz > 21.9 dB (odds ratio 32.3 [95% CI: 2.6-396.6]) were significantly related to severe OSA. Following adenotonsillectomy, apnoea-hypopnoea index decreased significantly (P < 0.001). SSE of 41-200 Hz, 201-400 Hz and 801-1000 Hz also decreased significantly (P = 0.04, 0.01 and 0.006, respectively). Baseline SSE of 801-1000 Hz < 8.5 dB significantly predicted surgical success (odds ratio 11.0 [95% CI: 1.4-85.2]). CONCLUSIONS Our findings suggest the potential utility of SSE of 801-1000 Hz to screen for severe OSA, predict surgical success and assess therapeutic outcomes. Specific baseline SSE may represent a potential biomarker for childhood OSA.
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Affiliation(s)
- Chun-Ting Lu
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsueh-Yu Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Faculty of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Guo-She Lee
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Otolaryngology, Taipei City Hospital, Taipei, Taiwan
| | - Yu-Shu Huang
- Faculty of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Child Psychiatry, Sleep Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chung-Guei Huang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medical Biotechnology and Laboratory Science, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Ning-Hung Chen
- Faculty of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Internal Medicine, Sleep Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Li-Ang Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Faculty of Medicine, Chang Gung University, Taoyuan, Taiwan
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Sleep endoscopy findings in children with persistent obstructive sleep apnea after adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2018; 107:190-193. [PMID: 29501304 DOI: 10.1016/j.ijporl.2018.01.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/19/2018] [Accepted: 01/20/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Describe the patterns of obstruction in persistent pediatric OSA and their relationship with patient weight. STUDY DESIGN Retrospective review. METHODS All pediatric DISE procedures performed at a tertiary care hospital between October 2010 and October 2015 were reviewed. Patients had polysomnography after adenotonsillectomy that confirmed persistent obstructive sleep apnea (OSA). Variables included age, gender, co-morbidities, and AHI. DISE findings focused on inferior turbinates, adenoid, tongue base, epiglottis, aryepiglottic (AE) folds, arytenoids, lingual tonsil and their contributions to obstruction. RESULTS 34 patients were included with mean age of 7.85 (2-16) years, mean BMI of 23.15 (13.6-44.8) and mean AHI of 6.34 (1.5-25.2) events per hour. Obstruction occurred at the level of the epiglottis in 97%, with retropositioning by tongue base (73.6%) or lingual tonsil enlargement (70.5%). Obstruction occurred at the inferior turbinates in 76.5%, the adenoid in 64.7% and the palate in 58.8%. Shortened AE folds were less often identified (15%). Multiple sites of partial or complete obstruction were found in 97% of patients. Overweight or obese patients had a mean of 3 sites of complete obstruction and 4.69 sites of partial or complete obstruction as compared to 2.33 and 4.52 in underweight or normal weight children. Overweight or obese children were more likely to have obstruction at the lingual tonsil or adenoid than normal/underweight children. CONCLUSION Multiple sites of obstruction in persistent pediatric OSA were found. Children with higher BMIs had slightly different findings, suggesting that attention to adenoid regrowth and lingual tonsil hypertrophy is important.
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Wilcox LJ, Bergeron M, Reghunathan S, Ishman SL. An updated review of pediatric drug-induced sleep endoscopy. Laryngoscope Investig Otolaryngol 2017; 2:423-431. [PMID: 29299518 PMCID: PMC5743164 DOI: 10.1002/lio2.118] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/06/2017] [Indexed: 01/22/2023] Open
Abstract
Objectives Drug-induced sleep endoscopy (DISE) involves assessment of the upper airway using a flexible endoscope while patients are in a pharmacologically-induced sleep-like state. The aim of this article is to review the current literature regarding the role of DISE in children with obstructive sleep apnea (OSA). The indications, typical anesthetic protocol, comparison to other diagnostic modalities, scoring systems, and outcomes are discussed. Methods A comprehensive review of literature regarding pediatric DISE up through May 2017 was performed. Results DISE provides a thorough evaluation of sites of obstruction during sedation. It is typically indicated for children with persistent OSA after tonsillectomy, those with OSA without tonsillar hypertrophy, children with risk factors predisposing then to multiple sites of obstruction, or when sleep-state dependent laryngomalacia is suspected. The dexmedotomidine and ketamine protocol, which replicates non-REM sleep, appears to be safe and is often used for pediatric DISE, although propofol is the most commonly employed agent for DISE in adults. Six different scoring systems (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) have been used to report pediatric DISE findings, but none is universally accepted. Conclusions DISE is a safe and useful technique to assess levels of obstruction in children. There is currently no universally-accepted anesthetic protocol or scoring system for pediatric DISE, but both will be necessary in order to provide a consistent method to report findings, enhance communication among providers and optimize surgical outcomes. Level of Evidence N/A.
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Affiliation(s)
- Lyndy J. Wilcox
- Division of Pediatric Otolaryngology–Head and Neck SurgeryCincinnati Children's Hospital Medical CenterCincinnatiOhioU.S.A
| | - Mathieu Bergeron
- Division of Pediatric Otolaryngology–Head and Neck SurgeryCincinnati Children's Hospital Medical CenterCincinnatiOhioU.S.A
| | - Saranya Reghunathan
- Department of Otolaryngology–Head & Neck Surgery , University of Arizona College of Medicine–TucsonTucsonArizonaU.S.A.
| | - Stacey L. Ishman
- Division of Pediatric Otolaryngology–Head and Neck SurgeryCincinnati Children's Hospital Medical CenterCincinnatiOhioU.S.A
- Division of Pulmonary and Sleep MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioU.S.A
- Department of Otolaryngology–Head & Neck Surgery , University of Cincinnati College of MedicineCincinnatiOhioU.S.A.
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Management of Pediatric OSA Beyond Adeno-Tonsillectomy. CURRENT SLEEP MEDICINE REPORTS 2017. [DOI: 10.1007/s40675-017-0083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Oh MS, Dedhia RC. Current Techniques and Role of Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea. CURRENT SLEEP MEDICINE REPORTS 2017. [DOI: 10.1007/s40675-017-0082-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Joosten KF, Larramona H, Miano S, Van Waardenburg D, Kaditis AG, Vandenbussche N, Ersu R. How do we recognize the child with OSAS? Pediatr Pulmonol 2017; 52:260-271. [PMID: 27865065 DOI: 10.1002/ppul.23639] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 10/12/2016] [Accepted: 10/30/2016] [Indexed: 12/29/2022]
Abstract
Obstructive sleep-disordered breathing includes a spectrum of clinical entities with variable severity ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). The clinical suspicion for OSAS is most often raised by parental report of specific symptoms and/or abnormalities identified by the physical examination which predispose to upper airway obstruction (e.g., adenotonsillar hypertrophy, obesity, craniofacial abnormalities, neuromuscular disorders). Symptoms and signs of OSAS are classified into those directly related to the intermittent pharyngeal airway obstruction (e.g., parental report of snoring, apneic events) and into morbidity resulting from the upper airway obstruction (e.g., increased daytime sleepiness, hyperactivity, poor school performance, inadequate somatic growth rate or enuresis). History of premature birth and a family history of OSAS as well as obesity and African American ethnicity are associated with increased risk of sleep-disordered breathing in childhood. Polysomnography is the gold standard method for the diagnosis of OSAS but may not be always feasible, especially in low-income countries or non-tertiary hospitals. Nocturnal oximetry and/or sleep questionnaires may be used to identify the child at high risk of OSAS when polysomnography is not an option. Endoscopy and MRI of the upper airway may help to identify the level(s) of upper airway obstruction and to evaluate the dynamic mechanics of the upper airway, especially in children with combined abnormalities. Pediatr Pulmonol. 2017;52:260-271. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Koen F Joosten
- Erasmus MC, Pediatric Intensive Care, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Helena Larramona
- Paediatric Pulmonology Unit, Department of Pediatrics, University Autonoma of Barcelona, Corporacio Sanitaria Parc Tauli, Hospital of Sabadell, Barcelona, Spain
| | - Silvia Miano
- Sleep and Epilepsy Centre, Neurocentre of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - Dick Van Waardenburg
- Pediatric Intensive Care Unit, Department of Pediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Athanasios G Kaditis
- Pediatric Pulmonology Unit, First Department of Paediatrics, National and Kapodistrian University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
| | | | - Refika Ersu
- Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
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