Treatment outcomes of supraglottoplasty for pediatric obstructive sleep apnea: A meta-analysis

Persistent Obstructive Sleep Apnea Post-adenotonsillectomy in Children

Background Childhood obstructive sleep apnea (OSA) is a common disorder in children mostly due to adenotonsillar hypertrophy. Therefore, adenotonsillectomy is the mainstay of treatment. However, the outcome of adenotonsillectomy is limited in some patients who develop persistent OSA (POSA). We aim to evaluate the prevalence, risk factors, and treatments of POSA in the pediatric population in Qatar. Methodology This is a retrospective review of medical electronic records of patients aged 1-18 years, who underwent adenoidectomy and/or tonsillectomy at Sidra Medicine (Doha, Qatar) between June 2017 and September 2022. Demographic, clinical, and polysomnography (PSG) data were collected. POSA was defined as the persistence of at least one of the following OSA symptoms: snoring, gasping, mouth breathing or witnessed sleep apnea during post-surgery clinic visits, and/or post-surgical diagnosis of OSA by PSG. The prevalence of POSA was defined as the number of patients who had persistent symptoms divided by patients who were followed at outpatient clinics (ENT/pulmonology) post-surgery. Risk factors for POSA were evaluated using multivariate regression analysis. Results A total of 410 patients (259 males and 151 females) underwent adenotonsillectomy during the study period. The average age at surgery was 3.6 ± 2.5 years. The majority of patients (85.9%) had no history of underlying medical conditions. The rest of the patients (14.1%) were diagnosed with chromosomal abnormalities or neuromuscular disorders. All patients (100%) had a history of snoring before surgery, and 32.4% of patients had a history of witnessed sleep apnea. A total of 52 patients had persistent symptoms four months post-surgery. POSA prevalence was estimated at 15.4%. Univariate analysis showed young age at the time of surgery (p = 0.015), history of asthma (23%, 12/52) (p = 0.002), allergic rhinitis (13%, 7/52) (p = 0.001), gastroesophageal reflux disease ((11%, 6/52) (p < 0.001), and genetic syndromes (17%, 9/52) (p < 0.005) as significant risk factors for POSA. Multiple regression analysis showed that syndromic disorders and allergic rhinitis were significantly correlated with persistent OSA (p = 0.021 and p = 0.000, respectively). Conclusions POSA is prevalent in children post-tonsillectomy and adenoidectomy, especially in patients with genetic syndromes and those with symptoms of allergic rhinitis. Future studies are needed to better define the condition and provide evidence-based diagnostic and therapeutic approaches.

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Tonsillectomy & Adenoidectomy: Tongue Base and Larynx

Pediatric patients with persistent obstructive sleep apnea (OSA) after adenotonsillectomy often have additional sites of upper airway obstruction such as the tongue base or larynx. Sleep endoscopy and cross-sectional, dynamic imaging can be used to direct surgical management of persistent OSA. The tongue base is one of the most common sites of obstruction in children with persistent OSA, especially for patients with Trisomy 21. Lingual tonsillectomy, tongue suspension, and/or posterior midline glossectomy may be used to address lingual tonsil hypertrophy and tongue base obstruction. Epiglottopexy and/or supraglottoplasty may be used to address laryngomalacia and epiglottic prolapse resulting in OSA.

The role of rigid laryngo-tracheo-bronchoscopy in children with obstructive sleep apnoea: a case series of 65 children

OBJECTIVE

To assess the role of laryngo-tracheo-bronchoscopy in children with obstructive sleep apnoea by identifying airway abnormalities at surgery, that occur separately or in addition to adenotonsillar hypertrophy, and examining the correlation with respiratory parameters.

METHODS

A retrospective study was conducted of children with obstructive sleep apnoea who underwent laryngo-tracheo-bronchoscopy intra-operatively, performed by a single ENT surgeon from February 2016 to July 2019. Pre- and post-operative minimum oxygen saturation, apnoea-hypopnoea index, and oxygen desaturation index were recorded.

RESULTS

Sixty-five children were identified; 34 were aged less than three years and 31 were aged three years or more. 77 per cent and 13 per cent respectively had an airway abnormality; the t-test showed a significantly higher mean oxygen desaturation index and lower mean minimum oxygen saturation pre-operatively compared to children without an airway abnormality.

CONCLUSION

An update of the surgical pathway for children aged less than three years with obstructive sleep apnoea is required to include laryngo-tracheo-bronchoscopy intra-operatively. A t-test analysis of the pre-operative respiratory parameters suggests that airway abnormalities contribute to obstructive sleep apnoea severity.

A Comparison of Drug-Induced Sleep Endoscopy Findings in Infants and Toddlers

OBJECTIVE

To compare patterns of obstruction in infants and toddlers with obstructive sleep apnea (OSA) by analyzing drug-induced sleep endoscopy (DISE) examinations.

STUDY DESIGN

Retrospective chart review.

SETTING

An academic tertiary care pediatric hospital at a single institution.

METHODS

Children aged ≤3 years who underwent DISE with propofol titration from 2020 to 2022 were included in the study. Data extracted included age, body mass index, comorbidities, and polysomnography parameters. The sites of anatomic obstruction during DISE were recorded using a validated 10-site scoring system.

RESULTS

A total of 86 children underwent DISE, including 15 infants (<1 year) and 71 toddlers (>1≤3 years). Sixty-two percent were male and 37% were female. The mean age of the infant group was 9.6 months (95% confidence interval [CI]: 7.92, 11.28 months), and the mean age of the toddler group was 2.3 years (95% CI: 2.06, 2.50 years). The mean total number of sites of obstruction was not significantly different between infants (N = 2.5) and toddlers (N = 3.2, P = .086). The most common subsite of significant obstruction in both infants and toddlers was the aryepiglottic folds (46.7% and 36.8%, respectively; P = .578). The sites of obstruction and frequency of their occurrence were not significantly different between the 2 groups.

CONCLUSION

Multisite airway obstruction is common among children with OSA, especially at the epiglottis, aryepiglottic folds, and tongue base. There is no difference in sites of obstruction and their frequency between toddlers and infants.

Polysomnogram outcomes in patients with laryngomalacia and obstructive sleep apnoea treated surgically versus non-surgically

OBJECTIVE

To compare supraglottoplasty versus non-surgical treatment in children with laryngomalacia and mild, moderate and severe obstructive sleep apnoea.

METHODS

Patients were classified based on their obstructive apnoea hypopnoea index on initial polysomnogram, which was compared to their post-treatment polysomnogram.

RESULTS

Eighteen patients underwent supraglottoplasty, and 12 patients had non-surgical treatment. The average obstructive apnoea hypopnoea index after supraglottoplasty fell by 12.68 events per hour (p = 0.0039) in the supraglottoplasty group and 3.3 events per hour (p = 0.3) in the non-surgical treatment group. Comparison of the change in obstructive apnoea hypopnoea index in the surgical versus non-surgical groups did not meet statistical significance (p = 0.09).

CONCLUSION

All patients with laryngomalacia and obstructive sleep apnoea had a statistically significant improvement in obstructive apnoea hypopnoea index after supraglottoplasty irrespective of obstructive sleep apnoea severity, whereas patients who received non-surgical treatment had more variable and unpredictable results. Direct comparison of the change between the two groups did not find supraglottoplasty to be superior to non-surgical treatment. Larger prospective studies are recommended.

Characteristics and outcomes of interventions for pediatric laryngomalacia: A systematic review with meta-analysis

OBJECTIVES

To analyze characteristics of children treated for laryngomalacia to determine predictive factors and provide an updated meta-analysis on outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines from inception to May 2, 2023, using CINAHL, PubMed, and Scopus databases. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Data were meta-analyzed using fixed-/random-effects model to derive continuous measures (mean), proportions (%), and mean difference (Δ) with 95% confidence interval (CI).

RESULTS

100 articles were identified with information on outcomes of pediatric patients with laryngomalacia (N = 18,317). The mean age was 10.6 months (range: 0 to 252, 95%CI: 9.6 to 11.6, p = 0.00) with a 1.4:1 male to female ratio. Many patients presented with stridor (87.9%, 95% CI: 69.8 to 98.4), and the most common comorbidity at time of diagnosis was gastroesophageal reflux disease (48.8%, 95%CI: 40.9 to 56.8). Based on the patient population included in our analysis, 86.1% received supraglottoplasty (95% CI: 78.7 to 92.1). A total of 73.6% (95% CI: 65.5 to 81.0) had reported complete resolution of symptoms. For patients with a concurrent diagnosis of sleep disordered breathing receiving supraglottoplasty, the apnea-hypopnea index improved with a mean difference of -10.0 (95%CI: 15.6 to -4.5) events per hour post-treatment.

CONCLUSIONS

Laryngomalacia continues to be a common problem in the pediatric population. Supraglottoplasty remains an effective treatment option leading to symptomatic improvement in many cases. For those with concurrent sleep disordered breathing, supraglottoplasty lowers the apnea-hypopnea index.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

An update on diagnosis and management of obstructive sleep apnoea in the first 2 years of life

The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.

Clinical Application of Pediatric Sleep Endoscopy: An International Survey

OBJECTIVES

To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE.

METHODS

A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations.

RESULTS

A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral.

CONCLUSION

Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

Management and outcomes of obstructive sleep apnea in infants

OBJECTIVE

To characterize the clinical characteristics of infants with obstructive sleep apnea (OSA), define the resolution rate of infant OSA, and identify factors associated with OSA resolution.

METHODS

We identified infants diagnosed with OSA via retrospective chart review at less than one year of age at a tertiary care center. We identified patient comorbidities, flexible or rigid airway evaluations, surgical procedures, and oxygen/other respiratory support administration. We identified infants as having resolved OSA based on clinical or polysomnogram resolution. We compared the frequency of comorbid diagnoses and receipt of interventions in infants with resolved versus non-resolved OSA by χ² analysis.

RESULTS

83 patients were included. Prematurity was found in 35/83 (42%), hypotonia-related diagnoses in 31/83 (37%), and craniofacial abnormalities in 34/83 (41%). Resolution was observed in 61/83 (74%), either clinically or by polysomnogram, during follow up. On χ² analysis, surgical intervention was not associated with likelihood of resolution (73% versus 74% in those without surgical intervention, p = 0.98). Patients with airway abnormalities on flexible or rigid evaluation were less likely to have OSA resolution than those without (63% versus 100%, p = 0.010), as were patients with hypotonia-related diagnoses (58% versus 83%, p = 0.014). In patients with laryngomalacia, there was no association of supraglottoplasty with increased resolution (88% with supraglottoplasty versus 80% without, p = 1.00).

CONCLUSIONS

We identified a group of infants with OSA with diverse comorbidities. There was a high rate of resolution. This data can assist with treatment planning and family counselling for infants with OSA. A prospective clinical trial is needed to better assess consequences of OSA in this age.

Persistent obstructive sleep apnoea in children: treatment options and management considerations

Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.

Optimal laser usage improves surgical efficiency in pediatric supraglottoplasty

OBJECTIVES

To compare patient specific and surgical efficiency outcomes in children undergoing supraglottoplasty (SGP) with flexible fiber CO2 laser in Ultrapulse mode versus cold steel at a tertiary care center.

METHODS

A single surgeon retrospective cohort study of pediatric patients with laryngomalacia undergoing SGP without concomitant or prior airway surgery. We reviewed perioperative complications, total hospital stay including intensive care admission, symptom resolution and the need for revision surgery. Surgical efficiency was measured as the mean total operative time and laryngeal suspension time.

RESULTS

Among 63 patients, 32 cold steel SGPs were compared with 31 flexible fiber CO2 Ultrapulse laser SGPs. There was no statistical difference in the demographic profile. There was no statistical difference in need for intraoperative resuscitation (1 [3.0%] vs 0 [0%] cases) or perioperative intubation (4 [12.1%] vs 2 [6.3%] cases), mean total days in ICU (1.09 [0.51] vs 1.06 [0.44] [p = 0.38]) or days hospitalized (1.73 [1.67] vs 1.62 [2.27] [p = 0.42]), symptom resolution, need for revision surgery (2 [6.3%] vs 0 [0%] [p = 0.49] patients) or mean operative time (29.0 [14.19] vs. 32.2 [22.71] [p = 0.95] minutes). There was a statistically significant decreased time in laryngeal suspension in the laser group versus cold steel group (5.9 [1.80] vs 7.9 [2.19] [p = 0.006] minutes).

CONCLUSION

For pediatric SGPs, optimal flexible fiber CO2 laser usage can improve surgical efficiency in comparison to cold steel, with no differences in postoperative outcomes or complications. Both the flexible fiber CO2 laser and cold steel SGPs are safe and effective methods for treatment of laryngomalacia.

Ambulatory Blood Pressure Variability after Adenotonsillectomy in Childhood Sleep Apnea

OBJECTIVE

To investigate the influence of adenotonsillectomy (T&A) on ambulatory blood pressure (BP) variability in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective, interventional study.

METHODS

Children with OSA symptoms were recruited from a tertiary center. After OSA diagnosis was confirmed (ie, apnea-hypopnea index [AHI] > 1), these children underwent T&A for treatment. We performed polysomnography and 24-hour recordings of ambulatory BP before and 3 to 6 months postoperatively. Ambulatory BP variability was presented as the standard deviation of mean blood pressure in the 24-hour monitoring of ambulatory BP. Differences in BP variability among different subgroups were tested using a multivariable linear mixed model.

RESULTS

A total of 190 children were enrolled (mean age: 7.8 ± 3.3 years; 73% were boys; 34% were obese). The AHI significantly decreased from 12.3 ± 17.0 to 2.7 ± 5.5 events/hr after T&A. Overall, daytime, and nighttime ambulatory BP did not significantly change postoperatively, and overall, daytime, and nighttime ambulatory BP variability did not differ significantly preoperatively and postoperatively. In the subgroup analysis, children aged <6 years demonstrated a significantly greater decrease in ambulatory BP variability postoperatively than those aged >6 years (nighttime diastolic BP variability: 9.9 to 7.7 vs. 8.9 to 9.4). Children with hypertension also showed a significantly greater decrease in ambulatory BP variability than those without hypertension.

CONCLUSIONS

We concluded that overall ambulatory BP variability does not significantly change after T&A in children with OSA. Moreover, young-aged and hypertensive children demonstrate a significant decrease in BP variability after T&A.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2491-2497, 2022.

A novel sleep oximetry scoring tool for pediatric laryngomalacia

OBJECTIVE

Despite being a more accessible and less resource intensive modality than polysomnography, the utility of sleep oximetry (SO) in pediatric laryngomalacia (LM) is not well understood or validated. We aimed to retrospectively evaluate the utility of overnight home based SO in children with LM by developing and internally validating the Modified Laryngomalacia Oximetry Score (MLOS) scoring system to triage severity and guide clinical decision making.

METHODS

We evaluated pediatric patients with a diagnosis of LM at our tertiary referral centre. Data from initial and post-treatment SO including mean oxygen saturation (spO2) nadir and mean oxygen desaturation index (ODI) were aggregated. The MLOS ranging from I-VI (inconclusive to severe) was created by two otolaryngologists to incorporate bradycardia associated desaturation events during SO. Corresponding McGill Oximetry Score (MOS) was also determined.

RESULTS

172 patients were included in final analysis. The average age was 9.2 ± 14.3 months. 98 (57%) of patients were identified as Thompson severity score 1, and 87 (50.6%) of patients underwent supraglottoplasty. The surgical cohort had a significantly higher MLOS and MOS scores of 4 and 2 respectively, and higher mean ODI and spO2 nadir metrics. When evaluating post-supraglottoplasty SO tracings, all parameters improved significantly, including median MLOS score from 4 to 1. Only the mean ODI improved in the non-surgical cohort. Patients with Thompson severity score 2/3 had significantly higher MLOS.

CONCLUSION

We present a simple scoring system based on overnight SO, the MLOS, to help triage severity of pediatric LM and guide decision-making. MLOS is associated with worse clinical severity and a need for surgery, and shows significant improvement after surgery.

Sleep Endoscopy Findings in Children With Obstructive Sleep Apnea and Small Tonsils

OBJECTIVE

Obstructive Sleep Apnea (OSA) in children is treated primarily with adenotonsillectomy (AT). When clinical exam demonstrates small tonsils, the success of AT in resolving OSA is uncertain. The purpose of this study is to determine the utility of Drug induced Sleep Endoscopy (DISE) for children with OSA and small tonsils (Brodsky scale 1+) and to identify what obstructive trends exist in this subset of patients and to determine the utility of DISE-directed surgical intervention in patients with small tonsils.

METHODS

A retrospective chart review was performed for patients who underwent DISE at a tertiary care center over a 2-year period. Inclusion criteria were 1+ tonsils and a positive sleep study. Data collected included DISE findings, BMI, comorbid conditions, and pre-op PSG data.

RESULTS

Forty children were included with a mean age of 5.0 years (range 8 months-16 years). Mean preoperative AHI was 5.46 and mean oxygen saturation nadir was 87.1%. The most common contributor to airway obstruction was the adenoid (29 patients, 72.5%), followed by the tongue base or lingual tonsil (21 patients, 52.5%). The palatine tonsils (10 patients, 25.0%), epiglottis (10.0%), or obstruction intrinsic to the larynx (10.0%) were significantly less frequently identified as contributors to OSA when compared to the adenoid (P < .001). The majority of patients had multilevel obstruction (25 patients, 62.5%). Adenoidectomy (27 patients, 67.5%) was the most commonly performed procedure, followed by tonsillectomy (10 patients, 25.0%, P < .001) and tongue base surgery (9 patient 22.5%, P < .001).

CONCLUSION

In this group, small palatine tonsils were infrequently identified as a contributor to airway obstruction and tonsillectomy was avoided in most cases. This study illustrates the utility of DISE as a tool to personalize the surgical management of pediatric patients with OSA and small tonsils on physical exam.

C-reactive protein in children with obstructive sleep apnea and effects of adenotonsillectomy

OBJECTIVE

C-reactive protein (CRP) is an important serum marker of inflammation associated with cardiovascular outcomes. This study aims to evaluate the association between CRP and childhood obstructive sleep apnea (OSA) and clarify the effects of adenotonsillectomy on serum CRP levels in children with OSA.

METHODS

Children with symptoms suggestive of OSA who underwent an overnight polysomnography were recruited from a tertiary medical center. Their serum CRP levels were measured. For children who underwent adenotonsillectomy for OSA treatment, polysomnography and serum high-sensitivity CRP (hs-CRP) level measurement were conducted after surgery.

RESULTS

This study included 326 children (mean age: 7.2 ± 3.0 years; boys: 67%). Children with apnea-hypopnea index (AHI) > 5 events/h had significantly higher hs-CRP levels than children with AHI of 1-5 events/h and AHI < 1 event/h [median (interquartile range): 0.08 (0.03-0.25) vs 0.03 (0.02-0.14) vs 0.04 (0.01-0.10), P < 0.001]. Log-transformed hs-CRP levels were positively associated with log AHI values (r = 0.2, P < 0.001). In multiple linear regression analysis, hs-CRP levels were independently associated with AHI; 101 children with OSA (ie, AHI > 1) underwent adenotonsillectomy. In children with OSA in the study cohort, a significant reduction of hs-CRP levels did not occur after surgery [from 0.07 (0.02-0.22) to 0.08 (0.03-0.17), P = 0.716]. In children with OSA having abnormal hs-CRP levels (ie, CRP > 1 mg/dL), hs-CRP levels significantly decreased after surgery [from 1.87 (1.11-2.78) to 0.20 (0.07-1.04), P = 0.043].

CONCLUSION

Children with OSA had increased hs-CRP levels. Children with OSA and abnormal hs-CRP levels exhibited significantly reduced hs-CRP levels following adenotonsillectomy.

Effect of adenotonsillectomy on blood pressure in children with obstructive sleep apnea: a meta-analysis

BACKGROUND

While adenotonsillectomy (T&A) is widely recognized as the first-line therapy for pediatric obstructive sleep apnea (OSA), effects of T&A on blood pressure (BP) remain unclear. This meta-analysis evaluates the associations between T&A and BP in children with OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42020154425). Two authors independently searched the PubMed, Medline, EMBASE, and Cochrane databases. The keywords used were "sleep apnea syndromes," "adenotonsillectomy," and "child." A random-effects model was applied to determine office systolic BP (SBP), diastolic BP (DBP), and ambulatory BP changes.

RESULT

Twelve studies with 1193 children were analyzed (mean age: 7.6 y; 54% boys). The apnea-hypopnea index significantly reduced of 9.4 events/h (95% CI, -12.0 to -6.8) after T&A. Office SBP (-0.24 mmHg; 95% CI, -1.64 to 1.16) and DBP (-1.65 mmHg; 95% CI, -3.47 to 0.17) did not decrease significantly after surgery. No significant decreases were observed in 24-h ambulatory BP after T&A. Subgroup analysis showed a significant postoperative decrease in office SBP (-6.23 mmHg; 95% CI, -7.78 to -4.67) and DBP (-7.93 mmHg; 95% CI, -10.37 to -5.48) among children with hypertension but a slight increase in office SBP (2.50 mmHg; 95% CI, 1.14 to 3.86) and DBP (1.98 mmHg; 95% CI, -0.02 to 3.98) in those without (P for heterogeneity < 0.001).

CONCLUSION

This meta-analysis suggests the office and ambulatory BP changes after T&A in children with OSA are trivial. Moreover, children with hypertension experience a significantly greater decrease in office BP than children without hypertension.

24-Hour Ambulatory Blood Pressure Variability in Children with Obstructive Sleep Apnea

OBJECTIVE

To evaluate blood pressure (BP) variability in 24-hour ambulatory BP monitoring in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Case series study.

METHODS

Children aged 4 to 16 years with clinical symptoms were recruited in a tertiary medical center. Overnight polysomnography and 24-hour recordings of ambulatory BP were performed for each child. The severity of OSA was classified as primary snoring (apnea-hypopnea index [AHI] < 1), mild OSA (1 ≤ AHI < 5), moderate OSA (10 > AHI ≥ 5), and severe OSA (AHI ≥ 10). The standard deviation of mean BP was used as an indicator of BP variability.

RESULTS

A total of 550 children were included (mean age: 7.6 years; 70% were boys; 20% were obese). Compared with the children with primary snoring, children with severe OSA exhibited significantly higher nighttime systolic BP (108.0 vs. 100.5 mmHg, P < .001), nighttime diastolic BP (58.9 vs 55.6 mmHg, P = .002), nighttime mean arterial pressure (75.3 vs. 70.5 mmHg, P < .001), nighttime systolic BP load (40.5% vs. 25.0%, P < .001), nighttime diastolic BP load (25.3% vs. 12.9%, P < .001), and nighttime systolic BP variability (11.4 vs. 9.6, P = .001). Multiple linear regression analyses revealed an independent association between AHI and nighttime systolic BP variability (regression coefficient = 0.31, 95% CI = 0.06-0.56, P = .015) after adjustment for age, gender, adiposity, and hypertensive status.

CONCLUSIONS

OSA in children is associated with increased BP and BP variability.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2126-2132, 2021.

Outcomes of OSA in surgically naïve young children with and without DISE identified laryngomalacia

INTRODUCTION

Obstructive sleep apnea (OSA) in young children is caused by upper airway obstruction and is associated with changes in cognitive development, temperament and behavior. Adenotonsillectomy (AT) is often utilized as first line therapy for pediatric OSA. Children with laryngomalacia (LM) have a high chance of residual OSA after AT. There is paucity of literature regarding surgically naïve young children with OSA and laryngomalacia. Our study aimed to compare demographics, comorbidities and outcomes associated with OSA in surgically naïve young children with and without laryngomalacia.

METHODS

Retrospective chart review of surgically naïve young children (<2-year-old) with polysomnogram (PSG) diagnosed OSA. All young children underwent pre-operative PSG followed by drug-induced sleep endoscopy (DISE) directed intervention. Variables documented included demographics, comorbidities, history of adenotonsillectomy, DISE directed surgical interventions and pre and post PSG findings. Laryngomalacia was defined as presence of obstruction (Chan Parikh score ≥ 2) at the supraglottic level on DISE evaluation. Demographics and prevalence of comorbidities of those with and without LM were compared using t-test (continuous) and Chi Square (categorical). P value is significant for <0.05.

RESULTS

79 surgically naïve young children with PSG diagnosed OSA performed between 2015 and 2019 were included in the study. Children with LM were younger in age (11 months) and had a higher OSA-18 score (35) compared to children without LM (17 months) (OSA-18 score: 5). No significant difference was noted in the pre-DISE PSG parameters in the 2 groups. 56.1% of children with OSA and laryngomalacia did not need AT. Both children with and without laryngomalacia showed improvement in AHI on post-DISE PSG. Higher baseline AHI was associated with greater improvement in AHI.

CONCLUSION

Surgically naïve young children with OSA and LM present earlier than those without LM and report a significantly worse quality of life Young children with a higher baseline AHI were found to have greater improvement in severity of OSA post-DISE and surgical intervention. Majority of children with OSA and laryngomalacia did not need adenotonsillectomy after a preprocedural DISE assessment yet showed similar improvement in AHI. More studies are needed to determine which patients with OSA and laryngomalacia will need multilevel interventions.

Management of obstructive sleep apnea in children with achondroplasia: Outcomes of surgical interventions

INTRODUCTION

Children with achondroplasia are predisposed to obstructive sleep apnea (OSA), however little is known regarding surgical interventions and outcomes for this condition. The aim of this study was to evaluate the severity of OSA in children with achondroplasia and report outcomes of surgical interventions using polysomnography (PSG) parameters.

METHODS

Retrospective chart review of children with achondroplasia with documented OSA from 2002 to 2018 that had pre- and post-operative PSG results. Additional data extracted included age, gender, and type of surgical interventions. The primary outcome was change in postoperative obstructive apnea hypopnea index (OAHI).

RESULTS

Twenty-two children with achondroplasia were identified that underwent formal PSG before and after confirmed OSA. The median age was 12 months (range 4 days-15.3 years, IQR 2 years) at time of initial PSG evaluation. The majority (72.7%) of patients had severe OSA with a median preoperative OAHI of 14.25 (IQR 9.4). The most common surgical intervention was adenotonsillectomy (n = 15). Multilevel surgical intervention was required in 9 (41.0%) patients. Post-operatively, 16 (72.7%) children experienced a reduction in OAHI, of which four (18.2%) had complete OSA resolution. OAHI scores increased in six (27.3%) children. Patients with the most severe OSA at baseline had greater improvements in post-operative OAHI (P < 0.01). Neither type nor number of surgical interventions was associated with improved outcomes (P = 0.51, P = 0.89 respectively).

CONCLUSIONS

Treatment of OSA in children with achondroplasia remains challenging. Although reduction of OAHI is possible, caregivers should be counseled about the likelihood of persistent OSA and the potential for multilevel airway surgery.

Prevalence of obstructive sleep apnea in children with laryngomalacia and value of polysomnography in treatment decisions

OBJECTIVES

Children with laryngomalacia may present with obstructive sleep apnea (OSA). The role of polysomnography (PSG) in treatment decision making for laryngomalacia is not well defined. We aimed to investigate the prevalence of OSA in children with laryngomalacia and the role of PSG in treatment decision.

METHODS

Retrospective medical record review of children with laryngomalacia, confirmed by direct laryngoscopy, during a period of 3 years. Demographic data, presenting symptoms, severity classification, comorbidities and pre- and postoperative PSG data were retrieved and analyzed. Data are expressed as a median (25th - 75th percentile).

RESULTS

Forty-six patients were with diagnosed laryngomalacia between March 2016 and April 2019. A complete data set was available for 44 patients, 24 males and 20 females. The median age at the time of PSG was 12 weeks (6.3-29.8). Thirty-four children (77.4%) were diagnosed with concomitant OSA. A diagnosis of OSA changed the severity classification and treatment decision in 24 cases (54.5%). Twenty-three patients underwent supraglottoplasty, five patients were treated with continuous positive airway pressure (CPAP) and nine patients had both treatments. Seven patients received conservative treatment. The obstructive apnea/hypopnea index decreased from 8.9 events/hour (4.4-12.1) to 2.4 events/hour (1.5-4.4) after supraglottoplasty (p = 0.009).

CONCLUSIONS

A diagnosis of OSA was established in 77.4% of patients with larygomalacia The presence of OSA may increase the severity of symptoms in laryngomalacia, leading to a transition from watchful-waiting to active intervention with CPAP therapy or supraglottoplasty. Supraglottoplasty is a safe and effective surgical procedure for laryngomalacia. When performed in the setting of laryngomalacia with concomitant OSA, it also significantly improves OSA symptomatology.

Evaluation of Upper Airway in Children with Obstructive Sleep Apnea Using Cone-Beam Computed Tomography

OBJECTIVE

Cone-beam computed tomography (CBCT) offers three-dimensional structures in assessing upper airway of patients. This study aims to compare the cone-beam computerized tomography scan measurements between children with obstructive sleep apnea (OSA) and primary snoring.

STUDY DESIGN

Case-control study.

METHODS

This prospective study was conducted in a tertiary referral center. Thirty-six children with moderate-to-severe OSA (with apnea-hypopnea index [AHI] > 5 events/hour) and 36 age-, gender-, and obesity-matched children with primary snoring (AHI <1) were enrolled. The measurements in CBCT parameters were compared between children with moderate-to-severe OSA and primary snorers by conditional logistic regression model.

RESULTS

A total of 72 children (mean age, 7.9 ± 2.8 years; 64% male) were included. Children with moderate-to-severe OSA had a significantly smaller nasopharyngeal (2900 ± 1400 vs. 3800 ± 1800 mm³ , P = .017) and oropharyngeal airway volume (5600 ± 2700 vs. 7400 ± 4000 mm³ , P = .026) than those with primary snoring. Children with moderate-to-severe OSA, as compared to primary snorers, also had a significantly smaller minimal airway area in nasopharynx (77.4 ± 37.7 vs. 107.7 ± 52.0 mm² , P = .006) and oropharynx (66.6 ± 61.9 vs. 101.6 ± 65.8 mm² , P = .023). Moreover, the airway length was not significantly different between children with moderate-to-severe OSA and primary snoring.

CONCLUSIONS

The three-dimensional CBCT airway analysis could be used as a useful tool to evaluate upper airway in children with OSA.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:680-685, 2021.

Alternative Approaches to Adenotonsillectomy and Continuous Positive Airway Pressure (CPAP) for the Management of Pediatric Obstructive Sleep Apnea (OSA): A Review

Continuous positive airway pressure (CPAP) is considered first-line treatment in the management of pediatric patients without a surgically correctible cause of obstruction who have confirmed moderate-to-severe obstructive sleep apnea (OSA). The evidence supports its reduction on patient morbidity and positive influence on neurobehavioral outcome. Unfortunately, in clinical practice, many patients either refuse CPAP or cannot tolerate it. An update on alternative approaches to CPAP for the management of OSA is discussed in this review, supported by the findings of systematic reviews and recent clinical studies. Alternative approaches to CPAP and adenotonsillectomy for the management of OSA include weight management, positional therapy, pharmacotherapy, high-flow nasal cannula, and the use of orthodontic procedures, such as rapid maxillary expansion and mandibular advancement devices. Surgical procedures for the management of OSA include tongue-base reduction surgery, uvulopalatopharyngoplasty, lingual tonsillectomy, supraglottoplasty, tracheostomy, and hypoglossal nerve stimulation. It is expected that this review will provide an update on the evidence available regarding alternative treatment approaches to CPAP for clinicians who manage patients with pediatric OSA in daily clinical practice.

Epiglottopexy with or without aryepiglottic fold division: Comparing outcomes in the treatment of pediatric obstructive sleep apnea

OBJECTIVE

To determine the success of epiglottopexy with or without aryepiglottic fold division for treatment of patients with obstructive sleep apnea (OSA) with epiglottic obstruction.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care academic hospital.

METHODS

Children with sleep study proven OSA who underwent epiglottopexy with or without aryepiglottic fold division from January 2013 to June 2017 were included. The epiglottis contributed to airway obstruction in all patients. Pre- and post-operative apnea-hypopnea index (AHI) were compared. Age, sex, body mass index (BMI) z-score and post-operative complications were also evaluated. Success was defined by post-operative AHI < 5.0 with resolution of OSA symptoms or AHI ≤ 1.0 events per hour.

RESULTS

Twenty-eight children (age 2-17 years) underwent either epiglottopexy with division of aryepiglottic folds (N = 18) or epiglottopexy alone (N = 10). There was no difference in preoperative age, AHI, or BMI between the groups. Post-operative AHI was lower in the group undergoing epiglottopexy alone (AHI 1.50) versus with aryepiglottic fold division (AHI 3.17) (P < 0.05). No difference was found in mean AHI improvement between the two groups. For the entire cohort, success criteria were met by 53.6% of patients for AHI < 5.0 without symptoms and 25.0% of patients for AHI ≤ 1.0, with no difference in surgical success between procedures (P > 0.05).

CONCLUSIONS

Children undergoing epiglottopexy with division of aryepiglottic folds for laryngeal collapse were as likely to have improved OSA symptoms as children undergoing epiglottopexy alone.

Adenotonsillectomy for the Treatment of Obstructive Sleep Apnea in Children with Prader-Willi Syndrome: A Meta-analysis

Objective

Adenotonsillectomy outcomes in obstructive sleep apnea (OSA) treatment among children with Prader-Willi syndrome (PWS) remain unclear. This study aimed to elucidate the effectiveness of adenotonsillectomy in OSA treatment among children with PWS.

Data Source

PubMed, MEDLINE, Embase, and Cochrane Review up to February 2019.

Review Methods

The registry number of the protocol published on PROSPERO was CRD42015027053. Two authors independently searched the relevant database. Polysomnography outcomes in these children were examined, including net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum and mean oxygen saturation, the overall success rate for a postoperative AHI <1, and the overall success rate for a postoperative AHI <5.

Results

Six studies with 41 patients were analyzed (mean age, 5.0 years; 55% boys; mean sample size, 6.8 patients). All children had PWS and received adenotonsillectomy for the treatment of OSA. The AHI was 13.1 events per hour (95% CI, 11.0-15.1) before surgery and 4.6 events per hour (95% CI, 4.1-5.1) after surgery. The mean change in the AHI was a significant reduction of 8.0 events per hour (95% CI, −10.8 to −5.1). The overall success rate was 21% (95% CI, 11%-38%) for a postoperative AHI <1 and 71% (95% CI, 54%-83%) for a postoperative AHI <5. Some patients developed velopharyngeal insufficiency postoperatively.

Conclusion

Adenotonsillectomy was associated with OSA improvement among children with PWS. However, residual OSA was frequently observed postoperatively in these patients.

Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of the Art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management.

Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis

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.

Common Pediatric Airway Disorders

Pediatric airway disorders may be congenital (anatomical) or acquired (infectious) and may involve the upper, lower, or entire airway, with obstruction being a common feature. The pathophysiology of upper airway obstruction in infants, children, and adolescents is distinctly different due to the anatomic differences that evolve with growth. Accordingly, clinical presentation and consequences of airway obstruction vary by age. This article reviews the common upper airway disorders by age with a review of classic presentation, recommended diagnostic steps, and management considerations for the general pediatrician. [Pediatr Ann. 2019;48(4):e162-e168.].

Effect of Adenotonsillectomy on Ambulatory Blood Pressure in Pediatric Obstructive Sleep Apnea: 6-Month Follow-up Study

Objective

To investigate 24-hour ambulatory blood pressure changes 6 months after surgery among children with obstructive sleep apnea.

Study Design

Prospective interventional study.

Setting

Tertiary medical hospital.

Subjects and Methods

Children aged 4 to 16 years with symptoms of obstructive sleep apnea (apnea-hypopnea index >1) were recruited. All children underwent adenotonsillectomy and postoperative polysomnography overnight. The 24-hour ambulatory blood pressure was measured before and 6 months after surgery.

Results

The study cohort enrolled 124 children: mean (SD) age, 7.3 (3.1) years; 73% boys. After surgery, the apnea-hypopnea index significantly decreased from 13.3 (18.1) to 3.3 (7.2) events per hour ( P < .001). Overall systolic blood pressure and diastolic blood pressure were not significantly different following surgery, while daytime systolic blood pressure was slightly increased (114.3 to 117.3 mm Hg, P < .01) postoperatively. The hypertensive group (n = 43) exhibited significantly decreased levels of overall diastolic, nighttime systolic, and nighttime diastolic blood pressure ( P < .05), and 54% of hypertensive children became nonhypertensive after surgery. The nonhypertensive group (n = 81) showed slightly increased levels of nocturnal overall systolic, daytime systolic, and nighttime systolic blood pressure. A generalized linear mixed model revealed that children with hypertension had a greater decrease in systolic and diastolic ambulatory blood pressure during the daytime and nighttime (all P < .05) than those without hypertension.

Conclusions

Ambulatory blood pressure changes after adenotonsillectomy among children with obstructive sleep apnea are minimal. The decrease in ambulatory blood pressure after surgery is more prominent for hypertensive children than nonhypertensive children.

Shar Pei Larynx: Supraglottic and Postcricoid Mucosal Redundancy and Its Association With Medical Comorbidities

Objectives:

The aim of this study is to describe a clinical entity the authors term “Shar Pei larynx,” characterized by redundant supraglottic and postcricoid mucosa that the authors hypothesize coexists in patients with obstructive sleep apnea, laryngopharyngeal reflux, and obesity. By exploring this hypothesis, the authors hope to set the foundation for future research with the goal of identifying whether Shar Pei larynx is a marker for untreated sleep apnea or other diseases.

Study Design:

Retrospective chart review.

Setting:

Two tertiary care academic institutions.

Methods:

Data were collected from a 5-year period by querying for patients described to have “Shar Pei larynx” or “posterior supraglottic and/or postcricoid mucosal redundancy” on laryngoscopic findings. Relevant demographic and clinical characteristics were analyzed, with a focus on associations with obesity, sleep apnea, and laryngopharyngeal reflux.

Results:

Thirty-two patients were identified with physical findings consistent with Shar Pei larynx. Twenty-six patients (81.3%) were obese; 16 (50%) were morbidly obese. Twenty-two patients (68.8%) either had an existing diagnosis of obstructive sleep apnea or were diagnosed on polysomnography performed after initial evaluation. Sixteen patients (50%) had type 2 diabetes mellitus, and 87.5% of these patients were obese. Twenty-eight patients (87.5%) noted histories of reflux, with a median reflux symptom index of 27 of 45. Five patients underwent procedures to reduce mucosal redundancy related to Shar Pei larynx.

Conclusions:

This pilot study confirms that the majority of patients diagnosed with Shar Pei larynx also had diagnoses of obesity, obstructive sleep apnea, and reflux disease. The demonstrated association is strong enough to warrant further study.

24-Hour Ambulatory Blood Pressure after Adenotonsillectomy in Childhood Sleep Apnea

OBJECTIVE

To assess the effects of adenotonsillectomy (T&A) on ambulatory blood pressure (ABP) in childhood obstructive sleep apnea (OSA).

STUDY DESIGN

From 2012 to 2017, children aged 4-16 years with symptoms and polysomnography-diagnosed OSA (apnea-hypopnea index [AHI] >1) underwent T&A. PSG studies and 24-hour ABP monitoring were performed before and at 3 months after surgery.

RESULTS

In total, 159 children were enrolled (mean age, 7.8 ± 3.3 years; 72% male). T&A significantly reduced the AHI from 12.4 ± 15.9 events/hour to 2.7 ± 5.7 events/hour (P < .001). A decrease was observed in the children's overall diastolic blood pressure (65.1 ± 6.1 mm Hg to 63.8 ± 7.4 mm Hg, P = .04) after surgery. In subgroup analysis, 100 (63%) patients were classified as nonhypertensive, and 59 (37%) were classified as hypertensive. Linear mixed model analysis revealed that compared with the children without hypertension, those with hypertension had superior improvement in systolic and diastolic blood pressure during daytime and nighttime (all P values < .01). The ABP changes after surgery were not correlated with the AHI changes. Finally, preoperative hypertension was an independent risk factor of postoperative hypertension among these children (OR 3.66; 95% CI 1.70-7.86).

CONCLUSIONS

Overall, in children with OSA, the 24-hour ABP change after T&A is small. However, among children with preoperative hypertension, there is significant BP improvement after T&A surgery.

Laryngomalacia: is there an evidence base for management?

Background:

The advent of supraglottoplasty clearly has transformed the surgical management of severe laryngomalacia. The condition, however, generally runs a milder course, with spontaneous resolution the norm.

Objectives:

To identify gaps in the knowledge and identify topics for future study.

Method:

Systematic review of the literature.

Results:

The literature suggests that there is a range of abnormalities leading to the typical collapsing upper airway, and that neurological disease, other airway abnormalities, syndromes and gastroesophageal reflux all contribute to disease severity and influence outcomes. The procedures involved in supraglottoplasty are rarely specified, the indications for surgery are vaguely defined and the role of medical therapy is unclear.

Conclusion:

Every review article or survey of opinion suggests that there is still a marked variation in individual practice and a lack of consensus.

Lingual Tonsillectomy for Pediatric Persistent Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

Objective

To determine the role of lingual tonsillectomy (LT) in pediatric patients with persistent obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy (T&A).

Data Sources

PubMed, OVID-MEDLINE, and Cochrane Central from 2006 to 2017.

Review Methods

Inclusion criteria included English-language studies containing original data on LT in pediatric patients with persistent OSA. Exclusion criteria included case reports and studies without outcome measures. Two investigators independently reviewed all manuscripts and performed quality assessment using validated tools. Meta-analysis was performed.

Results

Of the 866 abstracts identified, 5 studies met inclusion criteria. All studies were case series (level of evidence 4). Outcome measures included apnea-hypopnea index (AHI), minimum oxygen saturation (minSaO2), comorbidity status, and adverse events. Qualitatively, all studies demonstrated reduction in AHI and increase in minSaO2 after LT. Comorbidities may not affect the success of LT for lingual tonsil hypertrophy (LTH). LT had similar adverse event rates as T&A. Meta-analysis was performed on 4 studies. LT showed a mean change in reduction of AHI and increase of minSaO2 of −6.64 (95% CI, −8.63 to −4.65) and 4.17 (95% CI, 1.25-7.08), respectively. The overall success rate, defined as postoperative AHI <5, was 52%.

Conclusion

LT for LTH can be a safe and effective adjunct surgery for persistent OSA in patients after T&A. LT may reduce AHI and increase minSaO2, though complete resolution of OSA is rare. Given the limited number of patients studied, no formal recommendations can be made for the routine use of LT for LTH in persistent pediatric OSA.

Update on pathophysiology and treatment of childhood obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is common in childhood and is characterized by recurrent upper airway obstructive events during sleep that produce significant neurocognitive and cardiovascular sequelae. The pathophysiology of childhood OSAS is complex and involves mechanical airway obstruction often secondary to adenotonsillar hypertrophy. However, neuromotor abnormalities and instability of central ventilatory control are also implicated. Several surgical and non-surgical treatment options for childhood OSAS are available, and will be discussed. Some of these include adenotonsillectomy, lingual tonsillectomy, supraglottoplasty, continuous positive airway pressure (CPAP), rapid maxillary expansion, oral appliance therapy, anti-inflammatory treatments, and supplemental oxygen.

Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea: A Meta-analysis

Importance

Evidence indicates correlations between lingual tonsil hypertrophy and pediatric obstructive sleep apnea (OSA). However, to our knowledge, a meta-analysis of surgical outcomes for lingual tonsillectomy in children with OSA has not been conducted.

Objective

To evaluate the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric OSA.

Data Sources

The study protocol was registered on PROSPERO (CRD42015027053). PubMed, MEDLINE, EMBASE, and the Cochrane Reviews databases were searched independently by 2 authors for relevant articles published by September 2016.

Study Selection

The literature search identified English-language studies that used polysomnography to evaluate children with lingual tonsil hypertrophy and OSA after lingual tonsillectomy alone. The search keywords were lingual tonsil, lingual tonsillectomy, sleep endoscopy, sleep apnea, and child.

Data Extraction and Synthesis

Polysomnographic data from each study were extracted. A random-effects model pooled postoperative sleep variable changes and success rates for lingual tonsillectomy in treating pediatric OSA.

Main Outcomes and Measures

Four outcomes for lingual tonsillectomy were analyzed. These included net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum oxygen saturation, the overall success rate for a postoperative AHI less than 1, and the overall success rate for a postoperative AHI less than 5.

Results

This meta-analysis consisted of 4 studies (mean sample size, 18.25 patients), with a total of 73 unique patients (mean [SD] age, 8.3 [1.1] years). Fifty-nine percent (27 of 46) of the patients were male, and 1 of the 4 studies did not specify number of males. Lingual tonsillectomy was indicated for persistent OSA after adenotonsillectomy in all cases. Lingual tonsil hypertrophy was evaluated using computed tomography or magnetic resonance imaging in 1 study, sleep endoscopy in 2 studies, and cine magnetic resonance imaging in 1 study. The mean change in the AHI after lingual tonsillectomy was a reduction of 8.9 (95% CI, -12.6 to -5.2) events per hour. The mean change in the minimum oxygen saturation after lingual tonsillectomy was an increase of 6.0% (95% CI, 2.7%-9.2%). The overall success rate was 17% (95% CI, 7%-35%) for a postoperative AHI less than 1 and 51% (95% CI, 25%-76%) for a postoperative AHI less than 5. Postoperative complications that developed included airway obstruction, bleeding, and pneumonia.

Conclusions and Relevance

Lingual tonsillectomy is an effective surgical management for children with OSA caused by lingual tonsil hypertrophy, and it achieves significant improvement in the AHI and the minimum oxygen saturation. However, children frequently have residual OSA after lingual tonsillectomy, and postoperative complications must be carefully managed.