Three-dimensional airway changes after adenotonsillectomy in children with obstructive apnea: Do expectations meet reality?

Changes in behavioral and cognitive abilities after rapid maxillary expansion in children affected by persistent snoring after long-term adenotonsillectomy: A noncontrolled study

INTRODUCTION

The objective of this study was to verify changes in behavioral abilities and cognitive functions after rapid maxillary expansion (RME) in children with refractory sleep-disordered breathing (SDB) in the long term after adenotonsillectomy.

METHODS

A prospective clinical trial study using RME therapy was conducted. Participant inclusion criteria were children who had adenotonsillectomy with maxillary transverse deficiency and persistent SDB (obstructive apnea-hypopnea index ≥1). The study included 24 children aged 5-12 years, and of these 24 children, 13 had primary snoring and 11 had obstructive sleep apnea. The patients underwent laryngeal nasofibroscopy and a complete polysomnography. In addition, patients completed the Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire. Behavioral and neurocognitive tests were also completed before and after RME.

RESULTS

The Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life scores showed a statistically significant decrease in both groups (P <0.001) after RME. The results showed that neurocognitive and behavioral parameters (Child Behavior Checklist scale) were similar in primary snoring and obstructive sleep apnea (OSA) groups before RME. In the OSA group, the mean scores of the "Somatic" and "Aggressiveness" domains decreased significantly (P <0.05). The cognitive functions did not register significant differences pre- and post-RME in any of the cognitive functions, except for visuospatial function in the OSA group.

CONCLUSIONS

The noncontrolled design was a major limitation of our study. The need for treatment for SDB should consider the association of symptoms and behavioral disturbances with the child's obstructive apnea-hypopnea index. RME might prove to be an alternative treatment for children with SDB refractory to adenotonsillectomy, improving quality of life and behavioral aspects. However, a larger sample size with a control group is needed to substantiate these claims.

Effectiveness and safety of (adeno) tonsillectomy for pediatric obstructive sleep apnea in different age groups: A systematic review and meta-analysis

This meta-analysis aimed to assess the effectiveness and safety of (adeno)tonsillectomy (AT) for uncomplicated pediatric obstructive sleep apnea (OSA) across different age groups. Four electronic databases were searched until April 2022, and 93 studies (9087 participants) were selected, including before-after studies, cohort studies, and randomized controlled trials. It has been suggested that age, disease severity, and length of follow-up are associated with surgical effects. Compared with older children (>7 years), patients receiving AT surgery before the age of 7 exhibited a significantly greater release of disease severity, as well as a greater decrease in hypoxemic burden, improvement in sleep quality, and better cardiovascular function. Cognitive/behavioral performance also improved after AT, although it was more related to the length of follow-up than the age at surgery. Notably, the surgical complication rate was considerably higher in patients younger than 3 years old. Overall, we suggest that the age of 3-7 years might be optimal for AT in polysomnography-diagnosed uncomplicated OSA to maximize potential benefits for both disease and comorbidities and balance the risks of surgery.

Evaluation of Pharyngeal Airway Dimensions and Hyoid Bone Position in Children After Adenoidectomy or Adenotonsillectomy: A Cephalometric Study

Background. The study aimed to compare the airway morphology and hyoid bone position in children undergoing adenoidectomy or adenotonsillectomy with healthy individuals with no skeletal problems in similar age and development period. Methods. The subjects in the study were divided into three groups. These groups were defined as those having undergone adenoidectomy (53 children), those having undergone adenotonsillectomy (48 children), and the systemically healthy control group (63 children). Seventeen pharyngeal airway, nine hyoid, and four area measurements were used in the cephalometric radiographs of the children in all the groups. One-way analysis of variance was used to evaluate the children in each group. In addition, Tukey tests were used for a bilateral comparison of significant parameters. The results were considered statistically significant at P<0.05. Results. The mean age of 164 patients in the study group was 12.76±2.85 years. The vertical airway length significantly decreased in the adenotonsillectomy group compared to other groups, while the epiglottic pharyngeal length significantly increased in the former than in the latter (P<0.05). The area measurements showed that although the oropharynx area significantly increased in the adenotonsillectomy group compared to other groups, the hypopharynx and total area measurements were significantly different compared with the control group (P<0.05). No statistically significant difference was found between the three groups in all measurements of the hyoid bone position (P>0.05). Conclusion. The study showed that adenotonsillectomy operations caused more increases in the oropharynx and hypopharynx parts of the pharyngeal airway. Adenoidectomy and adenotonsillectomy operations did not contribute significantly to the hyoid bone position.

Morphofunctional changes following adenotonsillectomy of obstructive sleep apnea children: a case series analysis

Objective

To perform a case series analysis of the changes in the pulmonary artery systolic pressure (PASP), nasal inspiratory flow (NIF), upper airway volume, obstructive apnea/hypopnea index (OAHI), and the maxillomandibular three-dimensional (3D) morphology after adenotonsillectomy (T&A) of obstructive sleep apnea children (OSA).

Materials and methods

Retrospective assessment of files from 1002 children screened between 2012 and 2020 in a hospital-based mouth-breather referral center. From this universe, 15 obstructive sleep apnea children (7 females; 8 males), ages 4.1 to 8.9 years old (mean age of 5.4 years ± 1.3), who presented indications of tonsillectomy and/or adenoidectomy were selected. The complete baseline examination (T0) was carried out before T&A and a second complete examination (T1) was made 18.7-month follow-up after T&A (ranging from 12 to 30 months). Eleven patients were submitted to T&A, and four patients had indications but did not receive authorization for surgery from the public health system. According to the protocol of the outpatient clinic for OSA patients, Doppler echocardiography, polysomnography, rhinomanometry, and computed tomography imaging was performed at (T0) and (T1).

Results

PASP decreased 16.6% after T&A. NIF increased more in T&A children (40.3%) than in non-T&A children (16.8%). The upper airway volume increased in T&A and non-T&A children, but greater volumetric gain (45.6%) was found in the nasopharynx of T&A patients. OAHI did not change in six T&A children (55%) and three non-T&A children (75%). The maxilla displaced downward and backward relative to the cranial base in six T&A children (55%) and two untreated children (50%). Nine of the T&A children (85%) and three untreated children (75%) presented extensive condylar growth and increased mandibular length. The qualitative 3D assessment showed similar morphological 3D changes in T&A and non-T&A patients.

Conclusion

Pulmonary artery systolic pressure decreased, nasal inspiratory flow increased, and nasopharynx volume increased following adenotonsillectomy, but obstructive apnea/hypopnea index and maxillomandibular morphology were similar in surgical and non-surgical patients.

AI-based automatic segmentation of craniomaxillofacial anatomy from CBCT scans for automatic detection of pharyngeal airway evaluations in OSA patients

This study aims to generate and also validate an automatic detection algorithm for pharyngeal airway on CBCT data using an AI software (Diagnocat) which will procure a measurement method. The second aim is to validate the newly developed artificial intelligence system in comparison to commercially available software for 3D CBCT evaluation. A Convolutional Neural Network-based machine learning algorithm was used for the segmentation of the pharyngeal airways in OSA and non-OSA patients. Radiologists used semi-automatic software to manually determine the airway and their measurements were compared with the AI. OSA patients were classified as minimal, mild, moderate, and severe groups, and the mean airway volumes of the groups were compared. The narrowest points of the airway (mm), the field of the airway (mm²), and volume of the airway (cc) of both OSA and non-OSA patients were also compared. There was no statistically significant difference between the manual technique and Diagnocat measurements in all groups (p > 0.05). Inter-class correlation coefficients were 0.954 for manual and automatic segmentation, 0.956 for Diagnocat and automatic segmentation, 0.972 for Diagnocat and manual segmentation. Although there was no statistically significant difference in total airway volume measurements between the manual measurements, automatic measurements, and DC measurements in non-OSA and OSA patients, we evaluated the output images to understand why the mean value for the total airway was higher in DC measurement. It was seen that the DC algorithm also measures the epiglottis volume and the posterior nasal aperture volume due to the low soft-tissue contrast in CBCT images and that leads to higher values in airway volume measurement.

Changes in Cone-Beam Computed Tomography Pediatric Airway Measurements After Adenotonsillectomy in Patients With OSA

Importance

Early intervention using cone-beam computed tomography (CBCT) and adenotonsillectomy for children with obstructive sleep apnea (OSA) may prevent impaired growth, adverse cardiovascular consequences, learning deficits, and poor quality of life.

Objective

To assess changes in CBCT airway measurements and polysomnography (PSG) parameters that occur after adenotonsillectomy in children with OSA and to determine whether CBCT changes are correlated with apnea-hypopnea index (AHI) reduction.

Design, Setting, and Participants

This prospective cohort study was conducted at a tertiary medical center from 2013 to 2016. Children aged 7 to 13 years with PSG-confirmed OSA (ie, AHI ≥1) were recruited. Data analysis was performed from March to July 2021.

Exposures

All participants underwent CBCT and PSG before and after adenotonsillectomy.

Main Outcomes and Measures

Changes in PSG and CBCT parameters after adenotonsillectomy were analyzed.

Results

A total of 49 children (mean [SD] age, 9.5 [1.8] years; 34 boys [69.4%]) were recruited. Eighteen participants (36.7%) had obesity. After adenotonsillectomy, AHI significantly decreased from 11.4 to 1.2 events per hour (mean difference, -10.24 events per hour; 95% CI, -13.84 to -6.64 events per hour). The following CBCT parameters significantly increased: total airway volume (from 11 265 to 15 161 mm3; mean difference, 3896.6 mm3; 95% CI, 2788.0 to 5005.2 mm3), nasopharyngeal volume (from 2366 to 3826 mm3; mean difference, 1459.7 mm3; 95% CI, 1122.9 to 1796.5 mm3), minimal nasopharyngeal airway area (from 128 to 191 mm2; mean difference, 63.1 mm2; 95% CI, 47.4 to 78.8 mm2), mean nasopharyngeal airway area (from 144 to 231 mm2; mean difference, 86.8 mm2; 95% CI, 67.0 to 106.5 mm2), oropharyngeal volume (from 8898 to 11 335 mm3; mean difference, 2436.9 mm3; 95% CI, 1477.0 to 3396.8 mm3), minimal oropharyngeal airway area (from 82 to 158 mm2; mean difference, 76.2 mm2; 95% CI, 57.0 to 95.4 mm2), and mean oropharyngeal airway area (from 182 to 234 mm2; mean difference, 52.5 mm2; 95% CI, 33.6 to 71.4 mm2). Among all parameters, only body mass index percentile showed large effect size between the group with residual OSA (postoperative AHI ≥1) and the group with resolved disease, with the residual OSA group having a higher body mass index percentile (87.8 vs 61.4; mean difference, 26.33; 95% CI, 10.00 to 42.66). A quantile regression model revealed that total airway volume and minimal oropharyngeal airway area were significantly correlated with reductions in AHI.

Conclusions and Relevance

These findings suggest that in children undergoing adenotonsillectomy, improvements in total airway volume and oropharyngeal minimal airway area were correlated with reduction of AHI. Future studies are needed to assess whether CBCT has a role in the evaluation of children with OSA who are being considered for adenotonsillectomy.

Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review

INTRODUCTION

Obstructive sleep apnea syndrome is a common condition in childhood and if left untreated can result in many health problems. An accurate diagnosis of the etiology is crucial for obstructive sleep apnea treatment success. Functional orthodontic appliances that stimulate mandibular growth by forward mandibular positioning are an alternative therapeutic option in growing patients.

OBJECTIVE

To perform a literature review about the effects of functional orthodontic appliances used to correct the mandibular deficiency in obstructive sleep apnea treatment.

METHODS

The literature search was conducted in June 2020 using Cochrane Library; PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS Ovid; SciELO Web of Science; EMBASE Bireme and BBO Bireme electronic databases. The search included papers published in English, until June 2020, whose methodology referred to the types and effects of functional orthopedic appliances on obstructive sleep apnea treatment in children.

RESULTS

The search strategy identified thirteen articles; only four articles were randomized clinical studies. All studies using the oral appliances or functional orthopedic appliances for obstructive sleep apnea in children resulted in improvements in the apnea-hypopnea index score. The cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace, improving the respiratory function in the short term.

CONCLUSION

Functional appliances may be an alternative treatment for obstructive sleep apnea, but it cannot be concluded that they are effective in treating pediatric obstructive sleep apnea. There are significant deficiencies in the existing evidence, mainly due to absence of control groups, small sample sizes, lack of randomization and no long-term results.

Sleep Bruxism and SDB in Albanian Growing Subjects: A Cross-Sectional Study

Background: The aim of this study was to evaluate a possible correlation between sleep bruxism and risk factors of developing obstructive sleep apnea syndrome (OSAS) in a sample of growing subjects and to assess parental awareness about sleep bruxism in their children. Methods: The sample was composed of 310 subjects (173 females and 137 males), with a mean age of 8.9 years, attending "Ndre Mjeda" school of Tirana (Albania). All parents of the children participating in the study were asked to fill in a questionnaire manually or via a digital version. The questionnaire was composed of three sections: personal data, sleep quality data, and OSAS risk factors, and it was filled out by both parents. Results: Of our samples, 41.3% presented with bruxism, and 16.5% of the parents ground their teeth. Oral breathing was reported in 11.9% of the subjects, and among these, 40% of the subjects were affected by bruxism (p > 0.05). Of the subjects, 18.7% snore overnight. Comparing it with sleep bruxism, the two phenomena are often related (p = 0.00). Conclusions: Heredity, night-sweating, nycturia, oral breathing, and snoring seem to have a significant correlation with bruxism.