Intranasal corticosteroids for mild childhood obstructive sleep apnea--a randomized, placebo-controlled study

Advances in Sleep-Disordered Breathing in Children

Pediatric sleep-disordered breathing disorders are a group of common conditions, from habitual snoring to obstructive sleep apnea (OSA) syndrome, affecting a significant proportion of children. The present article summarizes the current knowledge on diagnosis and treatment of pediatric OSA focusing on therapeutic and surgical advancements in the field in recent years. Advancements in OSA such as biomarkers, improving continuous pressure therapy adherence, novel pharmacotherapies, and advanced surgeries are discussed.

The impact of adenotonsillectomy on healthcare utilization in children with obstructive sleep apnea: Experience of an integrated medical model

BACKGROUND AND OBJECTIVES

Studies suggest that children with obstructive sleep apnea (OSA) have increased healthcare utilization patterns in comparison to matched controls. However, the effect of adenotonsillectomy (AT) on utilization patterns in these children is poorly understood. Additionally, no previous studies have compared the effect of AT on healthcare utilization patterns across different OSA severity groups. The aim of this retrospective cohort study is to assess the effects of surgical treatment on the level of healthcare utilization among children with OSA at a large integrated multicenter healthcare system.

METHODS

Retrospective analysis was performed of children aged 3-12 diagnosed with OSA via an attended polysomnogram (PSG) between December 2016 and February 2019. Demographic variables including age (at time of PSG), body mass index (BMI), race, and ethnicity were obtained. Variables for healthcare utilization were assessed for 12 months prior to PSG, and for 12 months after PSG (or after AT, delayed for the first 30 days after surgery to account for surgery-related visits). Healthcare utilization variables assessed included the total number of outpatient visits, inpatient, and emergency department (ED) visits, visits involving diagnostic codes associated with upper respiratory infection (URI), otitis media (OM), and allergic rhinitis (AR), prescription data involving intranasal steroids or leukotriene receptor antagonists (LTRA), and communication data such as secure message load and specialty referrals. Repeated measure linear difference-in-difference (D-I-D) models were used to assess the causal impact of AT on healthcare utilization outcomes. Sensitivity analyses were performed using modeling with a Poisson distribution and as an unadjusted model, with statistical significance set to p < 0.05.

RESULTS

Analysis elicited 577 children identified with OSA. Of these, 336 (58.2 %) underwent observation while 241 (41.8 %) underwent AT. The mean age was 6.4 years, with a slight male predominance (60.5 %). Analysis of baseline healthcare utilization patterns revealed that the treatment group had a significantly higher number of baseline inpatient/ED visits and OM visits in comparison to the observation group, but no differences in regards to baseline outpatient visits, or in visits involving URI or AR. Analysis of the entire OSA cohort via D-I-D modelling showed a significantly larger reduction in outpatient visits, secure messages, specialty referrals, and the use of intranasal steroid and LTRA in the treatment group compared to the observation group. Stratification of children based on OSA severity showed that the significant differences in healthcare utilization attributed to surgical treatment were primarily driven by the severe OSA group. Children with severe OSA who underwent AT showed significant reductions in most variables including outpatient visits, inpatient/ED visits, and OM visits. Alternatively, the only significant reductions in healthcare utilization among children with mild OSA treated with AT were in AR visits, intranasal steroid use, and LTRA use. Pattern changes among children with moderate OSA compared similarly to those with mild OSA.

CONCLUSION

To the authors' knowledge this study represents the largest available study assessing the impact of AT on healthcare utilization in children with OSA that also considers the effect of OSA severity on utilization patterns. AT appears to decrease healthcare utilization patterns, particularly in children with severe OSA. Alternatively, children with mild or moderate OSA treated with AT had only modest reductions in healthcare utilization patterns.

Treatment of the Nose for Patients with Sleep Apnea

Nasal obstruction is common in patients with obstructive sleep apnea (OSA) and may variably impact symptoms and severity of OSA. It is associated with decreased continuous positive airway pressure (CPAP) compliance, and both medical and surgical management of nasal obstruction have resulted in increased CPAP adherence. Treatment of OSA with comorbid rhinitis via topical nasal steroids demonstrates a beneficial impact on daytime sleepiness. Isolated nasal surgery has been shown to result in decreased daytime sleepiness and snoring, with minimal effect on OSA severity.

Pharmacological interventions for pediatric obstructive sleep apnea (OSA): Network meta-analysis

IMPORTANCE

Pediatric obstructive sleep apnea (OSA) is a common disease that can have significant negative impacts on a child's health and development. A comprehensive evaluation of different pharmacologic interventions for the treatment of OSA in children is still lacking.

OBJECTIVE

This study aims to conduct a comprehensive systematic review and network meta-analysis of pharmacological interventions for the management of obstructive sleep apnea in pediatric population.

DATA SOURCES

PubMed, Web of Science, Embase, The Cochrane Library, and CNKI were searched from 1950 to November 2022 for pediatric OSA.

STUDY SELECTION

Multiple reviewers included Randomized controlled trials (RCTs) concerning drugs on OSA in children.

DATA EXTRACTION AND SYNTHESIS

Multiple observers followed the guidance of the PRISMA NMA statement for data extraction and evaluation. Bayesian network meta-analyses(fixed-effect model) were performed to compare the weighted mean difference (WMD), logarithmic odds ratios (log OR), and the surface under the cumulative ranking curves (SUCRA) of the included pharmacological interventions. Our protocol was registered in PROSPERO website (CRD42022377839).

MAIN OUTCOME(S) AND MEASURE(S)

The primary outcomes were improvements in the apnea/hypopnea index (AHI), while secondary outcomes included adverse events and the lowest arterial oxygen saturation (SaO2).

RESULTS

17 RCTs with a total of 1367 children with OSA aged 2-14 years that met the inclusion criteria were eventually included in our systematic review and network meta-analysis. Ten drugs were finally included in the study. The results revealed that Mometasone + Montelukast (WMD-4.74[95%CrIs -7.50 to -2.11], Budesonide (-3.45[-6.86 to -0.15], and Montelukast(-3.41[-5.45 to -1.39] exhibited significantly superior therapeutic effects compared to the placebo concerning apnea hypopnea index (AHI) value with 95%CrIs excluding no effect. Moreover, Mometasone + Montelukast achieved exceptionally high SUCRA values for both AHI (85.0 %) and SaO2 (91.0 %).

CONCLUSIONS AND RELEVANCE

The combination of mometasone furoate nasal spray and oral montelukast sodium exhibits the highest probability of being the most effective intervention. Further research is needed to investigate the long-term efficacy and safety profiles of these interventions in pediatric patients with OSA.

The impact of intranasal corticosteroids in a prospective cohort of children with sleep disordered breathing

INTRODUCTION

Sleep disordered breathing (SDB) is common in children and the most common reason for adenotonsillectomy. This large observational cohort study from a specialist outpatient clinic describes the impact of intranasal steroids (INS) on symptom improvement and the need for surgery.

METHOD

Observational cohort study of 568 children assessing the impact of INS using the OSA-5 questionnaire with clinical and surgical outcome measures.

RESULTS

The mean OSA-5 score at first visit was 7.78. Symptoms were persistent for a median 9 months (range 2-72). 51% underwent a trial of INS with 56% reporting symptomatic improvement. The mean score decreased from 8.2 to 5.5 (p < 0.0001) in those prescribed INS. They had a significantly higher symptom load (p < 0.01), turbinate size (p < 0.005) and history of atopy (p < 0.01) than the non-trial group. The rate of surgery in the non-trial group was 56% compared with 38% in those who had INS (p < 0.001). With increasing symptom burden, the reported improvement with INS and comparative reduction in surgery increased. Baseline OSA-5 scores were predictive of rates of surgery. Atopic status or age did not influence response to INS.

CONCLUSION

The mean score at first visit and the median duration of symptoms indicated significant persistent symptoms in this cohort. The use of INS improved symptoms of SDB in 56%. The need for surgery in the group that received INS was 38% compared with 56% in those not trialling INS, despite the non-trial group having significantly less symptoms and signs. Symptomatic improvement was not influenced by age or atopic status.

The First-Line Approach in Children with Obstructive Sleep Apnea Syndrome (OSA)

Obstructive sleep apnea syndrome (OSA) is the main manifestation of sleep-disordered breathing in children. Untreated OSA can lead to a variety of complications and adverse consequences mainly due to intermittent hypoxemia. The pathogenesis of OSA is multifactorial. In children aged 2 years or older, adenoid and/or tonsil hypertrophy are the most common causes of upper airway lumen reduction; obesity becomes a major risk factor in older children and adolescents since the presence of fat in the pharyngeal soft tissue reduces the caliber of the lumen. Treatment includes surgical and non-surgical options. This narrative review summarizes the evidence available on the first-line approach in children with OSA, including clinical indications for medical therapy, its effectiveness, and possible adverse effects. Literature analysis showed that AT is the first-line treatment in most patients with adenotonsillar hypertrophy associated with OSA but medical therapy in children over 2 years old with mild OSA is a valid option. In mild OSA, a 1- to 6-month trial with intranasal steroids (INS) alone or in combination with montelukast with an appropriate follow-up can be considered. Further studies are needed to develop an algorithm that permits the selection of children with OSA who would benefit from alternatives to surgery, to define the optimal bridge therapy before surgery, to evaluate the long-term effects of INS +/- montelukast, and to compare the impact of standardized approaches for weight loss.

Effectiveness of Intranasal Mometasone Furoate vs Saline for Sleep-Disordered Breathing in Children: A Randomized Clinical Trial

Importance

Obstructive sleep-disordered breathing (SDB) in children is characterized by snoring and difficulty breathing during sleep. SDB affects at least 12% of otherwise healthy children and is associated with significant morbidity. Evidence from small clinical trials suggests that intranasal corticosteroids improve SDB as measured by polysomnography; however, the effect on symptoms and quality of life is unclear.

Objective

To determine whether intranasal mometasone furoate is more effective than intranasal saline for improving symptoms and quality of life in children with SDB.

Design, Setting, and Participants

The MIST trial was a multicenter, randomized, double-blind, placebo-controlled trial, recruiting participants from June 8, 2018, to February 13, 2020. Children aged 3 to 12 years who were referred to a specialist for significant SDB symptoms were included; exclusions were previous adenotonsillectomy, body mass index greater than the 97th percentile, and severe SDB. Randomization was stratified by site, and data were analyzed on an intention-to-treat basis from October 28, 2020, to September 25, 2022.

Interventions

Participants were randomly assigned to receive mometasone furoate, 50 μg, or sodium chloride (saline), 0.9%, 1 spray per nostril daily, dispensed in identical bottles.

Main Outcomes and Measures

The primary outcome was resolution of significant SDB symptoms (ie, reduction to a level no longer requiring referral to a specialist as per the American Academy of Pediatrics guidelines) at 6 weeks, measured by parental report of symptoms using the SDB Score.

Results

A total of 276 participants (mean [SD] age, 6.1 [2.3] years; 146 male individuals [53%]) were recruited, 138 in each treatment arm. Resolution of significant SDB symptoms occurred in 56 of 127 participants (44%) in the mometasone group and 50 of 123 participants (41%) in the saline group (risk difference, 4%; 95% CI, -8% to 16%; P = .51) with 26 participants lost to follow-up and missing values managed by multiple imputation. The main adverse effects were epistaxis, affecting 12 of 124 participants (9.7%) in the mometasone group and 18 of 120 participants (15%) in the saline group, and nasal itch/irritation, affecting 12 of 124 participants (9.7%) in the mometasone group and 22 of 120 participants (18%) in the saline group.

Conclusions and Relevance

Results of this randomized clinical trial suggest that there was no difference in treatment effect between intranasal mometasone and saline for the management of SDB symptoms. The results suggest that almost one-half of children with SDB could be initially managed in the primary care setting and may not require referral to specialist services, as is currently recommended.

Trial Registration

Australian New Zealand Clinical Trials Registry: ANZCTRN12618000448246.

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.

Sleep-Related Drug Therapy in Special Conditions: Children

Pharmacologic treatment of the most common pediatric sleep disorders lacks evidence, and alternative methods, which have been proved to alleviate the symptoms, are preferred in most cases. The implementation of specific guidelines is of great importance because sleep disorders in children are not rare and they can negatively affect children's development and their cognitive and social skills. This article summarizes the current therapeutic management of sleep disorders in children, bearing in mind the absence of evidence-based guidelines on this topic.

Outcomes of Intranasal Corticosteroid Treatment and Associated Factors in Children With Clinically Diagnosed Obstructive Sleep Apnea

Background and Objective Many studies have supported the potential effect of anti-inflammatory medications treatment for childhood obstructive sleep apnea (OSA). This study aimed to evaluate the outcomes of intranasal corticosteroid treatment in children with OSA symptoms and adenoid hypertrophy (AH), and to identify factors associated with the treatment outcome.Methods This retrospective study included children aged 1–15 years who snored, had sleeprelated symptoms, and received intranasal corticosteroid treatment for 4–16 weeks. Treatment outcome was considered a success if all symptoms were completely resolved or if the child still snored without sleep-related symptoms; treatment was considered a failure if the child still snored and had concomitant sleep-related symptoms.Results Among the 328 eligible children, 109 (33.2%) experienced treatment failure. The age of the children was significantly higher in the failure group than in the success group (median [interquartile range], 5.5 [3.4, 8.4] vs. 4.2 [3.2, 6.3]; p = 0.004). The percentage of children with allergic rhinitis (AR) symptoms at follow-up visit was also significantly higher in the failure group than in the success group (44% vs. 27.9% with mild AR and 9.2% vs. 4.1% with moderateto-severe AR, p < 0.001). Multiple logistic regression revealed a significant association between treatment failure and older age (odds ratio [95% confidence interval], 1.13 [1.04–1.23]) and presence of mild AR (2.29 [1.39–3.77]) and moderate-to-severe AR (3.17 [1.20–8.39]).Conclusions Among children with OSA and AH, one-third experienced treatment failure, and the associated factors were older age and presence of AR symptoms.

Efficacy of orthodontic treatment versus adenotonsillectomy in children with moderate obstructive sleep apnoea and mandibular retrognathia: study design and protocol for a non-inferiority randomised controlled trial

INTRODUCTION

Orthodontic treatment and adenotonsillectomy (AT) are both conventional treatments for paediatric obstructive sleep apnoea (OSA). Each approach has distinct treatment advantages; however, there is currently a lack of solid evidence to support their efficacy comparison. We hypothesise that the objective effect of orthodontic treatment is not inferior to AT in children with moderate OSA and mandibular retrognathia, but orthodontic treatment has the advantage of promoting dentofacial growth.

METHODS AND ANALYSIS

This is a randomised, open-label, parallel-group, active controlled trial that will study the efficacy of orthodontic treatment versus AT in children with moderate OSA accompanied by tonsillar adenoid hypertrophy and mandibular retrognathia. A total of 98 patients will be enrolled and randomised in a 2:1 ratio to either orthodontic treatment or AT group. Participants will be recruited at Shanghai Stomatological Hospital, Shanghai Children's Hospital of Shanghai Jiaotong University and Children's Hospital of Fudan University, which are all located in Shanghai, China. The primary endpoint is the per cent change in the obstructive apnoea-hypopnoea index from baseline (month 0) to the primary endpoint (month 7), and the mean reduction in A point, nasion and B point angle on cephalometric measurements by lateral X-ray films. Important secondary efficacy endpoints include sleep duration with oxygen saturation below 90% according to polysomnography and subjective symptoms (assessed by the OSA-20 questionnaire), etc. Safety endpoints will also be evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of Shanghai Stomatological Hospital (approval no. (2021)002), Shanghai Children's Hospital of Shanghai Jiaotong University (approval no. 2021R046-F01) and Children's Hospital of Fudan University (approval no. (2021)136). Before enrolment, a qualified clinical research assistant will obtain written informed consent from both the participants and their guardians after full explanation of this study. The results will be presented at national or international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000037288.

Sleep Complaints Among School Children

Sleep complaints are common among children. These include both night-time and daytime symptoms, such as trouble falling asleep, problems in maintaining sleep, snoring, and unusual events during sleep and daytime functioning impairment. However, sleep complaints in children are often overlooked and undertreated in clinical practice. Untreated sleep problems may further impact on children's development and will persist into adulthood in some cases. This review summarizes the common sleep complaints and disorders in school children, and provides an overview of the epidemiology, clinical features, consequences, and treatment of the sleep problems.

Management of obstructive sleep apnea in children: a Canada-wide survey

BACKGROUND

Obstructive sleep apnea frequently persists in children following adenotonsillectomy, which is the first-line treatment recommended for obstructive sleep apnea with adenotonsillar hypertrophy. Drug-induced sleep endoscopy (DISE) is a diagnostic tool increasingly used to assess pediatric obstructive sleep apnea, but its use has not been standardized. The overarching goal of this study was to document the current practice of Canadian otolaryngologists managing this population.

METHODS

A nation-wide online cross-sectional survey of Canadian otolaryngologist members of the Canadian Society of Otolaryngology - Head and Neck Surgery and the Association d'otorhinolaryngologie et chirurgie cervico-faciale du Québec. The 58-question electronic survey was developed based on a validated survey redaction guide with the aim to assess management and treatment of pediatric obstructive sleep apnea, as well as indications and performance of DISE. Consensus on practice items was defined by a minimum of 75% similar answers.

RESULTS

One hundred and nine Canadian otolaryngologists completed the survey on management of pediatric obstructive sleep apnea, among which 12 of them completed the questions on DISE. Overall, there was a poor rate of agreement of 55% among the respondents for the 58 questions altogether. There was a consensus to assess pediatric obstructive sleep apnea clinically ± with videos (82.6%), to assess adenotonsillar hypertrophy clinically (93.6%) and with flexible scope in the office (80.7%), as well as for the airway sites examined endoscopically during DISE. However, there was no consensus regarding anesthetic protocol and scoring system. DISE was mostly performed in cases of persistent obstructive sleep apnea after adenotonsillectomy rather than before performing any surgical procedure. There was no difference in the management of obstructive sleep apnea between otolaryngologists who perform DISE and those who do not. The only difference between otolaryngologists who practice in community centers versus in tertiary care centers was the more frequently use of the Brodsky tonsil scale by the latter ones.

CONCLUSION

This Canadian-wide survey highlighted a lack of consensus in the management of pediatric obstructive sleep apnea and DISE. Certain aspects regarding DISE remain unclear, including establishment of its ideal timing in order to eventually avoid unnecessary tonsillectomies.

Systemic corticosteroids could be used as bridge treatment in children with obstructive sleep apnea syndrome waiting for surgery

PURPOSE

Local and systemic inflammatory markers and pro-inflammatory cytokines are increased in children with obstructive sleep apnea syndrome (OSAS). Therefore, systemic or topical anti-inflammatory agents are used to treat this syndrome. We evaluated the treatment with systemic corticosteroids in children with severe OSAS and adenotonsillar hypertrophy before surgery.

METHODS

This was an unblinded open label study. Children with severe OSAS (diagnosed through polysomnography, obstructive apnea-hypopnea index [AHI] > 10 eV/h) were recruited. Exclusion criteria included age < 3 years, history of acute or chronic cardiorespiratory or neuromuscular or metabolic disease; major craniofacial abnormalities; and chromosomal syndromes and epilepsy. Computer-generated random numbers were used for simple randomization of subjects. All children were treated with intranasal beclomethasone spray, and 15 children additionally received oral betamethasone and 0.1 mg/kg per day for 7 days. Sleep clinical record (SCR) and pulsoximetry were performed before and after 7 days in all children.

RESULTS

Among 28 children with severe OSAS mean age was 4.5 ± 1.8 years, AHI 20.4 ± 1.8 eV/h). In children treated with intranasal and oral corticosteroids, mean (95.3 ± 1.1 vs 97.0 ± 0.8%, p = 0.0001) and minimum oxygen saturation (78.8 ± 6.3 vs 89.2 ± 4.2, p = 0.001) improved, and the SCR score (12.6 ± 1.2 vs 8.3 ± 1.1, p = 0.0001) was reduced. Children treated only with intranasal beclomethasone spray showed no differences in outcome measures before and after treatments. When we considered the oximetry measures, after corticosteroid treatment, we obtained statistical differences between the 2 groups (p < 0.01).

CONCLUSIONS

These results seem to suggest that a short course of oral betamethasone could be useful to treat children with severe OSAS and adenotonsillar hypertrophy waiting for surgery.

Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases

BACKGROUND

In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine.

METHODS

Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published.

RESULTS

The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm.

CONCLUSIONS

We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.

Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

Paediatrics: how to manage obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is defined as the intermittent reduction or cessation of airflow due to partial or complete obstruction of the upper airway during sleep. Paediatric OSAS has specific contributing factors, presenting symptoms and management strategies in various age groups. Untreated OSAS can lead to detrimental effects on neurocognitive development and cardiovascular and metabolic functions of a growing child. In the past decade, practice guidelines have been developed to guide the evaluation and management of OSAS. This article provides a narrative review on the current diagnostic and treatment options for paediatric OSAS. Alternative diagnostic tools other than the standard polysomnography are discussed. Adenotonsillectomy is considered the first-line therapy yet it is not suitable for treatment of all OSAS cases. Nocturnal non-invasive positive airway pressure ventilation is effective and could be the priority treatment for patients with complex comorbidities, residual OSAS post-adenotonsillectomy or obesity. However, intolerance and non-adherence are major challenges of positive airway pressure therapy especially in young children. There is increasing evidence for watchful waiting and other gentler alternative treatment options in mild OSAS. The role of anti-inflammatory drugs as the primary or adjunctive treatment is discussed. Other treatment options, including weight reduction, orthodontic procedures and myofunctional therapy, are indicated for selected patients. Nevertheless, the successful management of paediatric OSAS often requires a multidisciplinary team approach.

[Drugs affecting obstructive sleep apnea syndrome]

Sleep-disordered breathing is one of the most common sleep-associated disorders. At the same time, their prevalence tends to increase with age. One of the most common forms of respiratory failure during sleep is obstructive sleep apnea syndrome (OSA), which is characterized by repeated episodes of cessation of breathing or a significant decrease in respiratory flow while maintaining respiratory effort as a result of obstruction of the upper respiratory tract. Drugs have different effects on OSA. There are drugs that worsen OSA, drugs that do not affect OSA, and drugs that improve OSA. Benzodiazepines, opioids, muscle relaxants, and male hormones adversely affect OSA. Also of clinical interest are drugs that do not affect OSA and can even potentially improve respiratory function during sleep. These include anti-inflammatory drugs, diuretics, bronchodilators, acetylcholinesterase inhibitors, antiparkinsonian, decongestant drugs, drugs for intranasal use, topical soft tissue lubricant, female sex hormones. Finally, the effect of a number of drugs on OSA is not definitively established and requires further study (benzodiazepine receptor agonist hypnotics, angiotensin-converting enzyme inhibitors, opiate receptor antagonists, antidepressants, proton-pump inhibitors, TNF-α antagonists, glutamate receptor antagonists, drugs for the treatment of acromegaly, drugs for the treatment of narcolepsy). Raising awareness of doctors of different specialties about the impact of various drugs on OSA can not only prevent the deterioration of respiratory distress during sleep, but also, with a rational individual approach, makes it possible to even improve the quality of sleep and blood saturation, thereby contributing to a more favorable course of OSA and the underlying disease.

Efficacy of Adenoidectomy for the Treatment of Mild Sleep Apnea in Children

OBJECTIVES

(1) To assess outcomes in children undergoing adenoidectomy for the treatment of mild obstructive sleep apnea (OSA). (2) To identify clinical factors that predict which children will have persistent obstruction following adenoidectomy.

STUDY DESIGN

Case series with chart review over a 10-year period.

SETTING

Tertiary children's hospital.

SUBJECTS AND METHODS

Children between 2 and 17 years old undergoing adenoidectomy for treatment of mild OSA (obstructive apnea-hypopnea index [AHI] between 1 and 5 on polysomnogram) were included. The need for additional medical or surgical intervention following adenoidectomy was recorded. When available, postoperative polysomnogram data were reviewed.

RESULTS

In total, 134 children with a mean age of 5.4 years were included. Fifty-three percent (n = 71) were female and 57% (n = 76) were black. The mean (SD) baseline AHI was 2.2 (1.09). Caregivers reported a moderate impact of sleep disturbance on quality of life with a mean (SD) preoperative total OSA-18 score of 64.1 (19.28). Postadenoidectomy outcomes were reported for 105 patients (78%) with a mean follow-up time of 6 months. Sixty-nine percent (n = 72) of children had resolution of obstructive symptoms. While 31% (n = 33) of children required additional intervention following adenoidectomy, only 6.8% (n = 9) underwent a subsequent tonsillectomy. Demographic factors such as age and baseline AHI did not predict which children required additional treatment following adenoidectomy.

CONCLUSION

Adenoidectomy may be an effective treatment for mild OSA. A randomized trial comparing outcomes for adenoidectomy and adenotonsillectomy is needed to determine the ideal surgical treatment for nonsevere OSA in children.

Sleep-Wake Disorders in Childhood

PURPOSE OF REVIEW

The presentation of sleep issues in childhood differs from the presentation in adulthood and may be more subtle. Sleep issues may affect children differently than adults, and distinct treatment approaches are often used in children.

RECENT FINDINGS

Sodium oxybate was approved by the US Food and Drug Administration (FDA) in October 2018 for an expanded indication of treatment of sleepiness or cataplexy in patients with narcolepsy type 1 or narcolepsy type 2 aged 7 years or older, with side effect and safety profiles similar to those seen in adults. Restless sleep disorder is a recently proposed entity in which restless sleep, daytime sleepiness, and often iron deficiency are observed, but children do not meet the criteria for restless legs syndrome or periodic limb movement disorder.

SUMMARY

Children's sleep is discussed in this article, including normal sleep patterns and effects of insufficient sleep. Sleep disorders of childhood are reviewed, including insomnia, obstructive sleep apnea, restless legs syndrome, parasomnias, narcolepsy, and Kleine-Levin syndrome. Children with neurologic issues or neurodevelopmental disorders frequently have sleep disorders arising from an interaction of heterogeneous factors. Further attention to sleep may often be warranted through a polysomnogram or referral to a pediatric sleep specialist. Sleep disorders may cause indelible effects on children's cognitive functioning, general health, and well-being, and awareness of sleep disorders is imperative for neurologists who treat children.

The efficacy of different treatment approaches for pediatric OSAHS patients with mandibular retrognathia: study protocol for a multicenter randomized controlled trial

Background

Pediatric obstructive sleep apnea/hypopnea syndrome (OSAHS) is a multifactorial syndrome caused by many risk factors, such as craniofacial anomalies, adenotonsillar hypertrophy, obesity, and airway inflammation. Although new treatment patterns have recently been proposed, treatment methods for children remain particularly challenging and controversial. This randomized controlled trial was designed to investigate the efficacy of adenotonsillectomy and/or orthodontic treatment for children who have mild OSAHS with mandibular retrognathia.

Methods

A sample of 352 children with mild OSAHS and mandibular retrognathia, who are aged between 7 and 10 years, will be enrolled in the study. They will be randomized into four groups: the drug treatment group, the surgical treatment group, the orthodontic treatment group, or the surgery and postoperative orthodontic group. After randomization the children will receive treatments within 4 weeks. Outcome assessment will take place at the following points: (1) baseline, (2) 7 months after the treatment starting point, (3) 12 months after the treatment starting point, and (4) 24 months after the treatment starting point. The primary endpoint of the trial is the mean change in obstructive apnea/hypopnea index. Other endpoints will consist of the lowest oxygen saturation, apnea index, and hypopnea index assessed by polysomnography, subjective symptoms (assessed by the OSA-20 questionnaire), cephalometric measurements, and morphologic analysis of the upper airway.

Discussion

The results of this study will provide valuable evidence for the merits and long-term efficacy of different treatment approaches and contribute to facilitating the multidisciplinary treatment of pediatric OSAHS.

Trial registration

ClinicalTrials.gov: NCT03451318. Registered on 2 March 2018 (last update posted 19 April 2018).

Children with Down syndrome and mild OSA: treatment with medication versus observation

STUDY OBJECTIVES

Children with Down syndrome (DS) have a high prevalence of obstructive sleep apnea (OSA). Anti-inflammatory medications have been shown to be an effective treatment for mild OSA in otherwise healthy children. However, the efficacy in children with DS and mild OSA has not been investigated. Our aim was to examine the polysomnographic changes of children with DS and mild OSA treated with medication.

METHODS

A retrospective chart review was performed in children with DS (< 18 years) and mild OSA (obstructive apnea-hypopnea index ≤ 5 events/h) diagnosed by polysomnography (PSG) between 2006 and 2018. Patients were included if they were treated with medications (intranasal corticosteroids and/or montelukast) or by observation with a duration of at least 3 months and had baseline and follow-up PSGs. Demographic data, comorbid diagnoses, and PSG data were collected and analyzed.

RESULTS

Forty-five children met inclusion criteria. In the medication group, 29 children were identified. The median age was 7.4 years (interquartile range [IQR] 4.9-9.3). In the observation group, 16 children were identified. The median age was 4.0 years (IQR 3.2-5.3). The median time from baseline to follow-up PSG was 14.0 months (IQR 10.0-22.9) for the medication group and 10.5 months (IQR 6.5-33.5) for the observation group. There were no significant changes in the median obstructive apnea-hypopnea index from the baseline to follow-up PSG in either the medication group (2.8 [IQR 2.2-3.6) versus 3.5 [IQR 1.4-4.8) events/h; P = .25) or the observation group (2.3 [IQR 1.3-3.1] versus 2.9 [IQR 1.9-6.8] events/h; P = .12). Similarly, there were no significant differences in apnea-hypopnea index, oxygen nadir or end-tidal carbon dioxide between the groups (P = .07-1).

CONCLUSIONS

In our cohort, medication therapy did not significantly improve polysomnographic measures in children with DS and mild OSA. Several factors such as hypotonia and relative macroglossia may explain the ineffectiveness of medical therapy for OSA in this population. Further prospective studies are necessary to confirm these results and to evaluate if a subgroup of DS children may benefit from medical therapy.

Extranasal Manifestations of Allergy in the Head and Neck

PURPOSE OF REVIEW

Allergic rhinitis and allergic asthma are well-described disease entities with broad exposure in clinical and research allergy forums. Associations between allergic inflammation and upper airway diseases of chronic laryngitis, otitis media, obstructive sleep apnea, and oral allergy syndrome are less well understood and described in the literature.

RECENT FINDINGS

This review discusses the relationship between atopy and diseases of the upper airway, oral cavity, larynx, and ear. The similar respiratory mucosal lining the upper aerodigestive tract, with sensitized mast cells and inflammatory mediators in the submucosa, results in a variety of extranasal manifestations of allergic diseases in the head and neck which are less well characterized. Associations between allergic inflammation and upper airway diseases of chronic laryngitis, otitis media, obstructive sleep apnea, and oral allergy syndrome are less well understood and described in the literature. This review will summarize the relevant pathophysiology and symptomology, association with allergic sensitization, and clinical considerations of these disorders.

Environmental Factors as Modulators of the Relationship between Obstructive Sleep Apnea and Lesions in the Circulatory System

Obstructive sleep apnea (OSA) is a growing social problem, particularly in well-developed countries. It has been demonstrated that obstructive sleep apnea is a significant risk factor for cardiovascular diseases, including arterial hypertension, ischemic heart disease, heart failure, rhythm/conduction disturbances, as well as cerebral stroke. The pathophysiology of these diseases is complex and multifactorial. We present the current state of research on behavioral and environmental factors that influence the relationship between OSA and cardiovascular changes. We discuss the relationship between obesity, alcohol, sedatives, environmental tobacco smoke, allergic diseases and environmental pollution on the one hand and OSA on the other. In this context, the environment should be considered as an important modulator of the relationship between OSA and cardiovascular diseases.

Management of paediatric obstructive sleep apnoea: A systematic review and network meta-analysis

BACKGROUND

Obstructive sleep apnoea (OSA) affects many children, and adenotonsillar hypertrophy is the most common cause of paediatric OSA.

AIM

Despite the growing treatment options, there is no comprehensive comparison of all interventions. We aimed to compare and rank the effectiveness of various treatments in a network meta-analysis.

DESIGN

Literature was searched from inception to 13 May 2018 for paediatric OSA with adenotonsillar hypertrophy. The outcomes were the changes in apnoea-hypopnea index (AHI), oxyhaemoglobin desaturation index (ODI), and lowest arterial oxygen saturation (SaO₂ ). Frequentist approach to network meta-analysis was used. Treatment hierarchy was summarized according to the surfaces under the cumulative ranking curves.

RESULTS

Fourteen trials comprising 1064 paediatric OSA participants evaluating ten interventions (adenotonsillectomy, adenotonsillectomy + pharyngoplasty, adenotonsillotomy, antimicrobial therapy, steroids, leukotriene receptor antagonists [LTRAs], steroids + LTRAs, rapid maxillary expansion [RME], placebo, and no treatment) were identified for network meta-analysis. In terms of effectiveness in AHI reduction, surgical approach was still the most effective intervention than no treatment. RME was one of the most effective interventions to improve lowest SaO₂ . No comparisons showed statistical significance in reducing ODI.

CONCLUSIONS

Irrespective of the intervention used, complete resolution of OSA was not achieved in most trials.

Anti-inflammatory medications for obstructive sleep apnoea in children

BACKGROUND

Obstructive sleep apnoea (OSA) is characterised by partial or complete upper airway obstruction during sleep. Approximately 1% to 4% of children are affected by OSA, with adenotonsillar hypertrophy being the most common underlying risk factor. Surgical removal of enlarged adenoids or tonsils is the currently recommended first-line treatment for OSA due to adenotonsillar hypertrophy. Given the perioperative risk and an estimated recurrence rate of up to 20% following surgery, there has recently been an increased interest in less invasive alternatives to adenotonsillectomy. As the enlarged adenoids and tonsils consist of hypertrophied lymphoid tissue, anti-inflammatory drugs have been proposed as a potential non-surgical treatment option in children with OSA.

OBJECTIVES

To assess the efficacy and safety of anti-inflammatory drugs for the treatment of OSA in children.

SEARCH METHODS

We identified trials from searches of the Cochrane Airways Group Specialised Register, CENTRAL and MEDLINE (1950 to 2019). For identification of ongoing clinical trials, we searched ClinicalTrials.gov and the World Health Organization (WHO) trials portal.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing anti-inflammatory drugs against placebo in children between one and 16 years with objectively diagnosed OSA (apnoea/hypopnoea index (AHI) ≥ 1 per hour).

DATA COLLECTION AND ANALYSIS

Two authors independently performed screening, data extraction, and quality assessment. We separately pooled results for the comparisons 'intranasal steroids' and 'montelukast' against placebo using random-effects models. The primary outcomes for this review were AHI and serious adverse events. Secondary outcomes included the respiratory disturbance index, desaturation index, respiratory arousal index, nadir arterial oxygen saturation, mean arterial oxygen saturation, avoidance of surgical treatment for OSA, clinical symptom score, tonsillar size, and adverse events.

MAIN RESULTS

We included five trials with a total of 240 children aged one to 18 years with mild to moderate OSA (AHI 1 to 30 per hour). All trials were performed in specialised sleep medicine clinics at tertiary care centres. Follow-up time ranged from six weeks to four months. Three RCTs (n = 137) compared intranasal steroids against placebo; two RCTs compared oral montelukast against placebo (n = 103). We excluded one trial from the meta-analysis since the patients were not analysed as randomised. We also had concerns about selective reporting in another trial. We are uncertain about the difference in AHI (MD -3.18, 95% CI -8.70 to 2.35) between children receiving intranasal corticosteroids compared to placebo (2 studies, 75 participants; low-certainty evidence). In contrast, children receiving oral montelukast had a lower AHI (MD -3.41, 95% CI -5.36 to -1.45) compared to those in the placebo group (2 studies, 103 participants; moderate-certainty evidence). We are uncertain whether the secondary outcomes are different between children receiving intranasal corticosteroids compared to placebo: desaturation index (MD -2.12, 95% CI -4.27 to 0.04; 2 studies, 75 participants; moderate-certainty evidence), respiratory arousal index (MD -0.71, 95% CI -6.25 to 4.83; 2 studies, 75 participants; low-certainty evidence), and nadir oxygen saturation (MD 0.59%, 95% CI -1.09 to 2.27; 2 studies, 75 participants; moderate-certainty evidence). Children receiving oral montelukast had a lower respiratory arousal index (MD -2.89, 95% CI -4.68 to -1.10; 2 studies, 103 participants; moderate-certainty evidence) and nadir of oxygen saturation (MD 4.07, 95% CI 2.27 to 5.88; 2 studies, 103 participants; high-certainty evidence) compared to those in the placebo group. We are uncertain, however, about the difference in desaturation index (MD -2.50, 95% CI -5.53 to 0.54; 2 studies, 103 participants; low-certainty evidence) between the montelukast and placebo group. Adverse events were assessed and reported in all trials and were rare, of minor nature (e.g. nasal bleeding), and evenly distributed between study groups. No study examined the avoidance of surgical treatment for OSA as an outcome.

AUTHORS' CONCLUSIONS

There is insufficient evidence for the efficacy of intranasal corticosteroids for the treatment of OSA in children; they may have short-term beneficial effects on the desaturation index and oxygen saturation in children with mild to moderate OSA but the certainty of the benefit on the primary outcome AHI, as well as the respiratory arousal index, was low due to imprecision of the estimates and heterogeneity between studies. Montelukast has short-term beneficial treatment effects for OSA in otherwise healthy, non-obese, surgically untreated children (moderate certainty for primary outcome and moderate and high certainty, respectively, for two secondary outcomes) by significantly reducing the number of apnoeas, hypopnoeas, and respiratory arousals during sleep. In addition, montelukast was well tolerated in the children studied. The clinical relevance of the observed treatment effects remains unclear, however, because minimal clinically important differences are not yet established for polysomnography-based outcomes in children. Long-term efficacy and safety data on the use of anti-inflammatory medications for the treatment of OSA in childhood are still not available. In addition, patient-centred outcomes like concentration ability, vigilance, or school performance have not been investigated yet. There are currently no RCTs on the use of other kinds of anti-inflammatory medications for the treatment of OSA in children. Future RCTs should investigate sustainability of treatment effects, avoidance of surgical treatment for OSA, and long-term safety of anti-inflammatory medications for the treatment of OSA in children and include patient-centred outcomes.

[Medical treatment of obstructive sleep-disordered breathing in children and adolescents]

Obstructive sleep disordered breathing (OSDB), in children and adolescents, need to be treated quite soon to avoid complications. A paediatrician, a sleep specialist, an orthodontist, an ENT and a myofunctional therapist will examine together the children with OSDB and determine the best personalised surgical and medical treatments for each of them. Only medical treatments are reviewed in this article. An international consensus recommended adenotonsillectomy as the first line therapy in young with OSDB. Usually adenotonsillectomy is combined with several important adjunctive medical treatments. Overweight and obesity frequent in adolescents, worsen OSDB and increase persistent OSDB after adenotonsillectomy. Weight loss is obtained by dietary restriction, physical activity, psychological support and sleep hygiene rules. Anti-inflammatory drugs (corticosteroids and leukotriene receptor antagonists) have shown their efficacy in children with moderate OSDB. Orthodontic treatments, rapid maxillary expansion or oral appliance, are used in selected patients according to their maxillo-facial disturbances in adjunction to adenotonsillectomy. Nasal CPAP is rarely useful except in severe OSDB specially in persistent OSDB after adenotonsillectomy. Finally, active or passive, myofunctional therapy is, according to some authors, an indispensable adjunct treatment to avoid persistent OSDB after adenotonsillectomy. These personalized medical treatments of OSDB are either administered jointly with adenotonsillectomy or in a hierarchal order.

Impact of montelukast and fluticasone on quality of life in mild pediatric sleep apnea

OBJECTIVES

Research has shown improvement in apnea-hypopnea index in children with mild obstructive sleep apnea treated with anti-inflammatory medications. Data on quality of life outcomes in children receiving these medications is lacking. We aim to assess quality of life in children with mild obstructive sleep apnea treated with montelukast and fluticasone.

METHODS

Children between 3 and 16 years old with mild sleep apnea (apnea-hypopnea index > 1 and ≤ 5) presenting to a pediatric otolaryngology clinic were recruited prospectively and treated with 4 months of montelukast and fluticasone. Subjects' caregivers completed the OSA-18, a validated quality of life survey, at baseline and 4 months. Children with ongoing obstruction at follow-up underwent adenotonsillectomy.

RESULTS

Thirty-one patients were included. Mean (SD) age was 6.8 (3.9) years. Most subjects (54.8%) were black and 48% were obese. Mean (SD) apnea-hypopnea index of the subjects was 2.8 (1.0). The mean (SD) baseline OSA-18 score was 60.2 (18.5), indicating a moderate impact of sleep disturbance on quality of life. Following treatment, there was significant improvement (p < 0.005) in mean OSA-18 score. Four children discontinued montelukast due to behavioral side effects. Seven children (22%) underwent adenotonsillectomy after failing medical therapy. Demographic factors such as obesity [OR 0.63 (0.11, 3.49)] and apnea hypopnea index [OR 1.38 (0.59, 3.66)] failed to predict which children would respond to anti-inflammatory medications.

CONCLUSIONS

Children with mild obstructive sleep apnea treated with montelukast and fluticasone experience significant improvements in quality of life. Further research is needed to determine optimal duration of therapy.

Mometasone furoate intranasal spray is effective in reducing symptoms and adenoid size in children and adolescents with adenoid hypertrophy

INTRODUCTION

The use of mometasone furoate (MF) intranasal spray in treating adenoid hypertrophy (AH) has a variable outcome due the different methods of adenoid size evaluation. The aim of our study was to evaluate the effect of MF intranasal spray in children and adolescents with AH using a reliable and consistent endoscopic evaluation.

MATERIAL AND METHOD

A prospective interventional study was conducted. Evaluation took place during the first visit (week 0) and second visit (week 12). Symptoms of nasal obstruction, rhinorrhoea, cough and snoring were assessed, and an overall total symptoms score was obtained. A rigid nasoendoscopic examination using a four-grading system of adenoid size from 1 to 4 was performed. Patients were treated with MF intranasal spray for 12 weeks. Patients' aged 7-11-years old used 1 spray in each nostril once daily, while patients aged 12-17 used two sprays in each nostril once daily. Reassessment was carried out during the second visit (week 12).

RESULTS

A total of 74 patients was recruited. There were significant improvements from week 0 to week 12 in the symptoms' score for nose obstruction, rhinorrhoea, cough, snoring including the total nasal symptoms' score (p<0.001). AH significantly reduced in size from week 0 (2.89±.87) to week 12 (1.88±.83) (p<0.001).

CONCLUSION

MF intranasal spray is effective in improving the symptoms attributed to AH as well as reducing the adenoid size. MF intranasal spray is advocated as a treatment option before adenoidectomy is considered.

[Adolescent obstructive sleep apnoea syndrome: Characteristics and treatment]

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.

Effect of topical mometasone furoate on adenoidal lymphoid tissue: a light microscopic study

Background

Adenoid hypertrophy is a common cause of upper airway obstruction, and adenoidectomy is one of the most frequently performed operations in children. Topical nasal steroids can act directly on nasopharyngeal lymphoid tissue to decrease its reactive inflammatory changes and potentially reduce its size.

Objective

To study the light microscopic changes in adenoidal lymphoid tissue after one month of topical steroid use.

Methods

Twenty-six children with adenoid hypertrophy grade 3 scheduled for adenoidectomy were randomly divided into two equal groups: one group received mometasone furoate aqueous nasal spray (Nasonex) 100 mcg/day for four weeks, and a control group received nasal normal saline 0.9 per cent for four weeks. The removed adenoids were examined histopathologically.

Results

Adenoidal tissue from the mometasone group had less reactive germinal centres and less spongiosis compared to the control group. The latter showed proliferating, reactive, variable sized and shaped lymphoid follicles, with congested blood vessels in the interfollicular areas.

Conclusion

The use of intranasal mometasone furoate aqueous nasal spray (Nasonex) for one month reduced adenoidal tissue reactive cellular changes and its vascularity. This is, however, a pilot study; a longer treatment period is needed to assess the effect of treatment on adenoidal size.

Association of allergic rhinitis with obstructive sleep apnea: A meta-analysis

BACKGROUND

The co-existence of allergic rhinitis (AR) and obstructive sleep apnea (OSA) is a common phenomenon in clinical practice. AR has long been considered a risk factor for OSA. However, the relationship is not completely clear. Therefore, we conducted a meta-analysis to evaluate the prevalence of AR in sleep-disordered breathing (SDB) /OSA and their relationship.

METHODS

A comprehensive literature search was performed in PubMed/Medline, Google Scholar, Wiley Online Library, EMBASE, and Web of Science. Data were analyzed and pooled to estimate effect size (ES) /odds ratio (OR) with 95% confidence intervals (95%CI). Heterogeneity was quantified and evaluated by chi-squared-based Q-test and I2 test, with P < .05 and I > 50% indicating evidence of heterogeneity.

RESULTS

44 studies contained 6086 participants were included in this meta-analysis. For adults, the prevalence of AR was 22.8 (95% CI, 15.0-30.6) % in SDB and 35.2 (95% CI, 25.6-44.7) % in OSA. In children with SDB and OSA, the prevalence of AR was 40.8 (95% CI, 24.3-57.2) %, and 45.2 (95% CI, 25.4-65.0) % respectively. The odds ratios of prevalence of the SDB pediatric patients with AR was 2.12 (95%CI, 1.75, 2.57; P < .0001) times higher than that of non-SDB pediatric patients. There were no significant differences between OSA adults with or without AR in BMI (Body Mass Index), neck circumference, apnea hypopnea index (AHI) and epworth sleep scale score (ESS).

CONCLUSION

The prevalence of AR in OSA/SDB is considerably high and children with SDB suffering from a higher incidence of AR than non-SDB. OSA adults accompanied with AR do not have any influences on sleep parameters.

French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) guidelines concerning the role of otorhinolaryngologists in the management of paediatric obstructive sleep apnoea syndrome: Follow-up protocol for treated children

OBJECTIVES

The authors present the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) clinical practice guidelines concerning the role of otorhinolaryngologists in the management of paediatric obstructive sleep apnoea syndrome (OSAS). This chapter is devoted to the follow-up protocol for children treated for OSAS.

METHODS

A multidisciplinary task force was commissioned to carry out a review of the scientific literature on this topic. On the basis of the articles selected and the personal experience of each member of the task force, guidelines were drafted and graded as A, B or C or expert opinion according to a decreasing level of scientific evidence, and were then reviewed by a reading committee, independently of the task force. The final guidelines were established at a consensus meeting.

RESULTS

Short-term, medium-term and long-term clinical follow-up and complementary investigations are necessary in view of the risk of residual OSAS, and the risk of recurrence of OSAS related to adenoid and tonsillar regrowth following adenotonsillectomy, the treatment most commonly performed. The modalities of follow-up after surgery, continuous positive airway pressure (CPAP) ventilation, orthodontic treatment, myofascial rehabilitation, and drug therapy are described. The indications for nasal endoscopy and sleep studies as part of follow-up are specified.

Sleep-Related Drug Therapy in Special Conditions: Children

Sleep disorders in children may lead to neurodevelopmental and neurocognitive deficits; it is important to diagnose and treat them properly. Apart from the existing challenges in diagnosis, another drawback is that few therapies are currently approved. In this article, a comprehensive summary of the most common pediatric sleep disorders, along with the various pharmacologic and nonpharmacologic approaches for their management, is presented. Special attention has been paid to the currently available treatment options for pediatric insomnia, obstructive sleep apnea, parasomnias, narcolepsy, and restless legs syndrome, and comparisons are made with the corresponding treatment options for sleep disorders in adults.

Comparison of the Efficacy, Side Effects, and Cost of Modafinil and Intranasal Mometasone Furoate in Obstructive Sleep Apnea-Hypopnea Syndrome: A Preliminary Clinical Study

Background

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by repeated episodes of reduction in airflow due to the collapse of the upper airway during sleep. The aim of this study was to compare clinical outcome, side effects, and cost of treatment between modafinil and intranasal mometasone furoate in patients with OSAHS.

Material/Methods

Patients with OSAHS (N=250) were divided into two groups: the modafinil group (MG) (N=125) were treated with 100 mg modafinil twice a day; the intranasal mometasone furoate group (IMFG) (N=125) were treated with 100 μg of intranasal mometasone furoate in the evening. Quality of life, grading of OSAHS, plain-film radiography, the adenoidal-nasopharyngeal ratio (AN ratio), side effects, cost of treatment, and beneficial effects after discontinuation of treatment were evaluated for all patients.

Results

Duration of sleep apnea was significantly reduced in the IMFG compared with the MG (p=0.0145, q=9.262). Modafinil and intranasal mometasone furoate both had moderate effects on improvement of the OSAHS score. The IMFG showed a significantly greater beneficial effect on the AN ratio when compared with the MG (p=0.0001, q=6.584). No adverse events of treatment with modafinil and intranasal mometasone furoate were reported. Cost of treatment and beneficial effect after discontinuation were both significantly greater for the IMFG compared with the MG.

Conclusions

The findings of this preliminary clinical study were that for patients diagnosed with OSAHS, night-time treatment with intranasal mometasone furoate was more effective than modafinil.

Paediatric obstructive sleep apnoea: can our identification of surgical candidates be evidence-based?

BACKGROUND

Paediatric obstructive sleep apnoea is a common clinical condition managed by most ENT clinicians. However, despite the plethora of publications on the subject, there is wide variability, in the literature and in practice, on key aspects such as diagnostic criteria, the impact of co-morbidities and the indications for surgical correction.

METHODS

A systematic review is presented, addressing four key questions from the available literature: (1) what is the evidence base for any definition of paediatric obstructive sleep apnoea?; (2) does it cause serious systemic illness?; (3) what co-morbidities influence the severity of paediatric obstructive sleep apnoea?; and (4) is there a medical answer?

RESULTS AND CONCLUSION

There is a considerable lack of evidence regarding most of these fundamental questions. Notably, screening measures show low specificity and can be insensitive to mild obstructive sleep apnoea. There is a surprising lack of clarity in the definition (let alone estimate of severity) of sleep-disordered breathing, relying on what may be arbitrary test thresholds. Areas of potential research might include investigation of the mechanisms through which obstructive sleep apnoea causes co-morbidities, whether neurocognitive, behavioural, metabolic or cardiovascular, and the role of non-surgical management.

Therapeutic effects of different drugs on obstructive sleep apnea/hypopnea syndrome in children

BACKGROUND

This study aimed to compare the therapeutic effects of different drugs on obstructive sleep apnea/hypopnea syndrome (OSAHS) in children by using a network meta-analysis approach.

METHODS

PubMed, Embase and Cochrane Library were searched from the inception of each database to November 2015. Randomized controlled trials (RCTs) concerning the comparisons in the therapeutic effects of eight placebo-controlled drugs on OSAHS in children were included in this study. Network meta-analysis combined direct evidence and indirect evidence to evaluate the weighted mean difference (WMD) and surface under the cumulative ranking curves (SUCRA) of therapeutic effects of eight drugs on OSAHS in children.

RESULTS

A total of seven RCTs were finally incorporated into our network meta-analysis. Pairwise meta-analysis results revealed that therapeutic effect of placebo was significantly poorer than that of intranasal mometasone furoate, montelukast, budesonide and fluticasone concerning apnea hypopnea index (AHI) value [WMD=1.40, 95% confidence interval (CI)=1.17-1.63; WMD=2.80, 95% CI=1.01-4.59; WMD=3.50, 95% CI=3.34-3.66; WMD=7.20, 95% CI=5.26-9.14, respectively], and fluticasone is better than placebo concerning sleep efficiency (WMD=3.50, 95% CI=2.42-4.58); regarding visual analogue scale, the therapeutic effect of placebo was poorer compared with sucralfate and clindamycin (WMD=1.94, 95% CI=1.13-2.75; WMD=1.06, 95% CI=0.22-1.90), and sucralfate is better than clindamycin (WMD=-0.88, 95% CI=-1.65 to -0.11). However, network meta-analysis results showed no obvious difference in the therapeutic effects of different drugs on OSAHS regarding AHI and sleep efficiency. Furthermore, the best SUCRA value was very high for fluticasone concerning AHI (86.6%) and budesonide concerning sleep efficiency (94.0%) for OSAHS treatment.

CONCLUSIONS

Fluticasone and budesonide have relatively good effects in the treatment of OSAHS in children, thus providing an important guiding significance for the treatment of OSAHS in children.

Non-surgical treatment of obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS), a pervasive disease, is closely associated with complications such as cardiovascular diseases, neurocognitive diseases, and metabolic syndromes. Continuous positive airway pressure (CPAP) is the standard treatment for OSAS, with low compliance due to multifarious factors. The two other modes of ventilation, bi-level positive airway pressure (BPAP) and autotitrating positive airway pressure (APAP), which were developed from CPAP, are slightly different from CPAP in specific groups, as well as the corresponding treatment effect and compliance. The compliance of traditional positional therapy is not high, but with the emergence of the neck-based position treatment device, its compliance and indications have changed. Although CPAP is superior to mandibular advancement device (MAD) in improving AHI, MAD seems to be comparable to CPAP in improving other indicators. Corticosteroids and leukotriene receptor antagonists are effective treatments for mild OSAS children. Whether corticosteroids can be used in other OSAS groups and their adjunctive functions to CPAP remains unclear. The combination of these two kinds of drugs appears to be more effective than single drug. Researches on transcutaneous electrical stimulation are still not enough. Its effectiveness and stimulation settings still need further study. This review summarized the various OSAS non-surgical treatments from indications, treatment outcomes, compliance, adverse reactions, and recent progress.

Intranasal Budesonide and Quality of Life in Pediatric Sleep-Disordered Breathing: A Randomized Controlled Trial

Objective

To study the efficacy of budesonide nasal spray on the health-related quality of life and symptoms among children with sleep-disordered breathing.

Study Design

Randomized, parallel, double-blind, placebo-controlled trial.

Setting

Tertiary referral center.

Subjects and Methods

Sixty children (ages, 4-10 years) who were referred because of snoring and/or apneas for >3 months were included between January 2015 and June 2016 and randomized in a double-blind design to treatment with 64 μg/mL of budesonide nasal spray (n = 30) or placebo nasal spray (n = 30) twice daily for 6 weeks. The primary outcome measurement was the change in the mean OSA-18 total score from baseline. Other variables examined were individual OSA-18 domains, a visual analog scale for quality of life, symptoms (snoring, apneas, and nasal obstruction), and adenoid and tonsil size. The trial was investigator initiated and not sponsored by the pharmaceutical industry.

Results

Fifty-five children completed the trial. An intention-to-treat analysis revealed a significantly greater improvement in the mean OSA-18 total score after treatment with budesonide than placebo (19.5 vs 7.5, P = .0014). Intranasal budesonide also improved 2 OSA-18 domains (sleep disturbance, caregivers’ concerns), the visual analog scale score for quality of life, as well as snoring, apneas, and nasal obstruction. No serious adverse events were reported that could be linked to the treatment.

Conclusion

Among children with sleep-disordered breathing, 6 weeks’ treatment with intranasal budesonide significantly improved quality of life and symptoms as compared with placebo nasal spray.