Treatment of obstructive sleep apnea in children: do we really know how?

Impact of obstructive sleep apnea on clinical outcomes of hospitalization due to influenza in children: A propensity score-matched analysis of the US Nationwide Inpatient Sample 2005-2018

BACKGROUND

Previous studies have explored the association between obstructive sleep apnea (OSA) and clinical outcomes of influenza in adults, whereas limited research examined this relationship in pediatric populations. This study aimed to evaluate the clinical impact of OSA on the outcomes of pediatric influenza hospitalizations.

METHODS

This was a population-based, retrospective study. Data of children aged 1-19 years hospitalized for influenza infection were extracted from the United States (US) Nationwide Inpatient Sample Database 2005-2018. Univariable and multivariable regression analyses determined associations between OSA, length of stay (LOS), total hospital costs, pneumonia, and life-threatening events.

RESULTS

After propensity-score matching, a total of 2100 children were analyzed. The logistic analysis revealed that children with OSA had a significantly increased LOS (β = 2.29 days; 95% confidence interval, CI: 1.01-3.57, p < .001) and total hospital costs (β = 26.06 thousand dollars; 95% CI: 6.62-45.51, p = .009), and higher odds of pneumonia (aged 6-10 years: odds ratio [OR] = 1.52; 95% CI: 1.01-2.27, p = .043; aged ≥ 11 years: OR = 1.83; 95% CI: 1.33-2.53, p < .001).

CONCLUSIONS

During influenza admissions, children with OSA had longer LOS, higher hospital costs, and an increased risk of pneumonia compared to those without OSA. These findings underscore the importance of recognizing and managing OSA in influenza-related infections among children.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The interaction between neuromuscular forces, aerodynamic forces, and anatomical motion in the upper airway predicts the severity of pediatric OSA

Upper airway neuromuscular response to air pressure during inhalation is an important factor in assessing pediatric subjects with obstructive sleep apnea (OSA). The neuromuscular response's strength, timing, and duration all contribute to the potential for airway collapses and the severity of OSA. This study quantifies these factors at the soft palate, tongue, and epiglottis to assess the relationship between neuromuscular control and OSA severity in 20 pediatric subjects with and without trisomy 21, under dexmedetomidine-induced sedation. The interaction between neuromuscular force and airflow pressure force was assessed based on power transferred between the airway wall and airflow calculated from airway wall motion (from cine magnetic resonance images) and air pressure acting on the airway wall (from computational fluid dynamics simulations). Airway wall motion could be asynchronous with pressure forces due to neuromuscular activation, or synchronous with pressure forces, indicating a passive response to airflow. The obstructive apnea-hypopnea index (oAHI) quantified OSA severity. During inhalation, the normalized work done through asynchronous dilation of the airway at the soft palate, tongue, and epiglottis correlated significantly with oAHI (Spearman's ρ = 0.54, 0.50, 0.64; P = 0.03, 0.03, 0.003). Synchronous collapse at the epiglottis correlated significantly with oAHI (ρ = 0.52; P = 0.02). Temporal order of synchronous and asynchronous epiglottis motion during inhalation predicted the severity of OSA (moderate vs. severe) with 100% sensitivity and 70% specificity. Subjects with severe OSA and/or trisomy 21 have insufficient neuromuscular activation during inhalation, leading to collapse and increased neuromuscular activation. Airflow-driven airway wall motion during late inhalation likely is the main determinant of OSA severity.NEW & NOTEWORTHY This is the first study that combines cine MRI and computational fluid dynamics with in vivo synchronous respiratory flow measurement to quantify the interaction between airway neuromuscular forces, aerodynamic forces, and airway anatomy noninvasively in pediatric patients with obstructive sleep apnea (OSA). The results indicate power transfer predicts OSA severity.

Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome: Clinical and Functional Outcomes

Adenotonsillectomy (AT) is the first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS). Relatively few studies have evaluated the clinical and functional outcomes of AT in children with OSAS, but these studies show that surgery improves behavior and quality of life (QOL). However, residual OSAS after AT is reported in severe cases. This study aimed to retrospectively evaluate the clinical and functional outcomes of AT in a cohort of children with OSAS. We consecutively enrolled children with OSAS who underwent AT and were admitted to our clinic from 1 July 2020 to 31 December 2022. For each participant, medical history and physical examinations were performed. Before and after surgery, all patients underwent a standard polygraphic evaluation, and caregivers completed the OSA-18 questionnaire. A total of 65 children with OSAS, aged 2-9 years, were included. After AT, 64 (98.4%) children showed a reduction in AHI, with median (IQR) values decreasing from 13.4/h (8.3-18.5/h) to 2.4/h (1.8-3.1/h) (p-value < 0.0001). Conversely, median (IQR) SpO2 nadir increased after surgery from 89% (84-92%) to 94% (93-95%) (p-value < 0.0001). Moreover, 27 children (18%) showed residual OSAS. The OSA-18 score decreased after AT from median (IQR) values of 84 (76-91) to values of 33 (26-44) (p-value < 0.0001). A positive significant correlation was found between OSA-18 post-operative scores and AHI post-operative scores (rho 0.31; p-value = 0.01). Our findings indicate that, in children with OSAS, AT is associated with significant improvements in behavior, QOL, and polygraphic parameters. However, long-term post-surgical follow-up to monitor for residual OSAS is highly recommended, especially in more severe cases.

Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children

STUDY OBJECTIVES

The success of surgical treatment for pediatric sleep-disordered breathing is typically assessed using the mixed and obstructive apnea-hypopnea index (MOAHI). Although an important metric, previous work has shown that snoring and stertor are also associated with sleep disruption. Our aim was to assess the efficacy of surgery using the Sonomat (Sonomedical Pty Ltd), a noncontact sleep assessment system, that accurately records complete and partial upper airway obstruction.

METHODS

Forty children (< 18 years) had a Sonomat study, in their own beds, before and after surgery. As an MOAHI ≥ 1 event/h is considered abnormal, the same threshold was applied to snore/stertor runs. Median (interquartile range) values are reported.

RESULTS

Respiratory event-induced movements decreased from 12.0 (8.7-19.0) to 0.5 (0.1-3.2) events/h (P < .01), with no significant change in spontaneous movements: 12.8 (9.8-17.9) to 16.5 (13.7-26.1) events/h (P = .07). The MOAHI decreased from 4.5 (1.9-8.6) to 0.0 (0.0-0.4) events/h (P < .01). Snoring and/or stertor runs decreased from 32.8 (23.4-44.4) to 3.0 (0.2-14.6) events/h (P < .01). Thirty-four children had an MOAHI < 1 event/h following surgery; however, 20 had snore and/or stertor runs ≥ 1 event/h and 11 had snore and/or stertor runs ≥ 5 events/h. Only 14 (35%) children had a postsurgery MOAHI < 1 event/h combined with snoring and/or stertor < 1 runs/h.

CONCLUSIONS

Although surgery is effective in improving breathing, success rates are overestimated using the MOAHI. Our results indicate that snoring and/or stertor are still present at levels that may disrupt sleep despite a normalization of the MOAHI and that when obstructed breathing was objectively measured, there was a large variation in its response to surgery.

CITATION

Norman MB, Harrison HC, Sullivan CE, Milross MA. Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children. J Clin Sleep Med. 2022;18(6):1649-1656.

Prevalence of malocclusions and oral dysfunctions in children with persistent sleep-disordered breathing after adenotonsillectomy in the long term

STUDY OBJECTIVES

To evaluate the prevalence of craniofacial/orthodontic abnormalities and oral dysfunctions in a population of children with persistent sleep-disordered breathing despite adenotonsillectomy.

METHODS

Medical charts of 4,000 children with sleep-disordered breathing operated on in a tertiary hospital were retrospectively reviewed. Patients reporting persistent sleep-disordered breathing symptoms were invited to an orthodontic/myofunctional evaluation following the Sleep Clinical Score), followed by a 1-night ambulatory type III sleep study.

RESULTS

One hundred nonsyndromic symptomatic patients were examined (mean age 8.8 ± 3.5 years), from 1 to 12 years after surgery (mean 4.6 ± 3.1 years); 24% were overweight/obese; 69 had a sleep study. Although prevalent, oronasal abnormalities and malocclusions were not specifically associated with pathological sleep parameters (cartilage hypotonia 18%, septal deviation 5%, short lingual frenulum 40%). Malocclusions were associated with a higher respiratory event index in children under 8 years only, whereas an impaired nasal dilator reflex and tongue immaturity were associated with an increased obstructive respiratory event index in all patients (1.72 ± 2.29 vs 0.72 ± 1.22 events/h, P = .011) and Respiratory Event Index, respectively (3.63 ± 3.63 vs 1.19 ± 1.19 events/h). Male sex, phenotype, nasal obstruction, oral breathing, and young age at surgery (< 3 years) were significantly related to higher respiratory event index. Using the Sleep Clinical Score > 6.5 cut-off, patients with persistent sleep apnea were significantly distinct from chronic snoring (2.72 ± 2.67 vs 0.58 ± 0.55, P < .01).

CONCLUSIONS

Oronasal anatomical and functional abnormalities were quite prevalent and various in persistent sleep-disordered breathing after adenotonsillectomy. Nasal disuse and tongue motor immaturity were associated with a higher obstructive respiratory event index in the long term, whereas craniofacial risk factors might have a more pronounced impact at younger age.

Evaluation of neurocognitive abilities in children affected by obstructive sleep apnea syndrome before and after adenotonsillectomy

Obstructive sleep apnoea syndrome (OSAS) is the most severe form of sleep-related disordered breathing (SRDB) and is characterised by snoring, apnoeas, and/or hypopnoeas associated to hypoxia, hypercarbia, or repeated arousals from sleep. OSAS has three major categories of morbidities: neurobehavioural, cardiovascular and somatic growth failure. The gold standard for objective diagnosis of obstructive-SRDB severity is polysomnography (PSG). The indication for surgical treatment in children is moderate-severe OSAS (AHI, apnoea hypopnoea index > 5/h) and in mild OSAS (AHI 2-5/h) with complications or morbidity. The entire spectrum of PSG-defined SRDB (ranging from Primary Snoring to severe OSAS) may correlate with behavioural, attentional and executive function deficits relating to hypoxia and sleep disruption: in some cases, these alterations may mimic attention deficit hyperactivity disorder (ADHD). The aim of this research was to evaluate visuoperceptual and constructional abilities, paediatric sleep questionnaire and polysomnographic scores before and 6 months after adenotonsillectomy with objective and subjective information. We included 59 children who underwent neuropsychiatric and otolaryngologist clinical evaluation and the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI); children parents were asked to fill in the Paediatric Sleep Questionnaire (PSQ); each child underwent PSG. At 6 months after adenotonsillectomy, all patients were evaluated again. There is a significant difference in PSQ parameters, VMI standard, visual tests scores and PSG parameters before and after adenotonsillectomy in children affected by OSAS. These results showed the achievement of therapeutic benefits with improvement of the quality of life for both children and their parents.

Predictive equation for optimal continuous positive airway pressure in children with obstructive sleep apnoea

Aim

A subgroup of children with obstructive sleep apnoea (OSA) requires treatment with continuous positive airway pressure (CPAP). This study's aims were: 1) to determine if the optimal CPAP for the treatment of OSA in children correlates with body mass index (BMI); 2) to determine the correlation between polysomnographic variables and optimal CPAP in children with OSA; and 3) to develop a CPAP predictive equation for children with OSA.

Methods

This was a retrospective study of children with OSA who underwent CPAP titration studies. Patients with craniofacial abnormalities (except Down syndrome) and neuromuscular diseases were excluded. Polysomnograms were done using Sandman Elite. Correlations between optimal CPAP, clinical and polysomnographic variables were analysed. A multivariable linear regression model for optimal CPAP was developed.

Results

198 children (mean±sd age 13.1±3.6 years) were studied. Optimal CPAP had a significant positive correlation with age (rho=0.216, p=0.002), obstructive apnoea-hypopnoea index (rho=0.421, p<0.001), 3% oxygen desaturation index (rho=0.417, p<0.001), rapid eye movement respiratory disturbance index (rho=0.378, p<0.001) and BMI z-score (rho=0.160, p=0.024); and a significant negative correlation with arterial oxygen saturation measured by pulse oximetry nadir (rho= −0.333, p<0.001). The predictive equation derived was:

Optimal CPAP (cmH₂O)=6.486+0.273·age (years)−0.664·adenotonsillectomy

(no=1, yes=0)+2.120·Down syndrome (yes=1, no=0)+0.280·BMI z-score.

Conclusion

The equation developed may help to predict optimal CPAP in children with OSA. Further studies are required to validate this equation and to determine its applicability in different populations.

A predictive equation may help derive the optimal CPAP for the treatment of obstructive sleep apnoea in childrenhttp://bit.ly/2wTf6Bw

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.

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.

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.

Efficacy of a mandibular advancement intraoral appliance (MOA) for the treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients: A pilot-study

BACKGROUND

To evaluate the treatment efficacy of a mandibular advancement intraoral appliance (MOA) for treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients.

MATERIAL AND METHODS

Eighteen patients (mean=8.39 years old, women=44.4%) were selected. Sleep disorders, sleep bruxism, and temporomandibular disorders were assessed by the Sleep Disturbance Scale for Children (SDSC), the BiteStrip® (portable SB device), and the Research Diagnostic Criteria for Temporomandibular Disorders, respectively. The clinical diagnosis of OSAS was confirmed with a type 3 portable monitor device (ApneaLinkTM Plus). A silicon-based material MOA was used by patients for 60 days, and the results were compared to baseline.

RESULTS

The median RDI was significantly reduced from 10 to 4.5 events/hour. Nadir SpO2 significantly increased from 82.6% to 88.9%. Total snoring events/hour have also significantly decreased from 205.5 to 91.5. Signs and symptoms of TMD remained unaltered. There was also a reduction from moderate to absence of SB in 12 patients. Similarly, all variables measured by the SDSC have had very significant reductions: disorders of initiating and maintaining sleep, sleep disordered breathing, disorders of arousal, nightmares, sleep wake transition disorders, disorders of excessive somnolence, and sleep hyperhidrosis.

CONCLUSIONS

In selected cases, OA maybe considered as an alternative for the OSAS treatment.

Trends in management of obstructive sleep apnea in pediatric patients with Down syndrome

INTRODUCTION

Residual obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) is a common problem in children with Down Syndrome (DS). Our objective was to describe trends in surgical and medical management of OSA in pediatric patients with DS, and to present an algorithmic approach to managing these children.

METHODS

Retrospective case series of children with DS seen at a tertiary care medical center between 1/2008-6/2016 who underwent polysomnography (PSG) after having a T&A performed for sleep disordered breathing (SDB).

RESULTS

Sixty-five patients met inclusion criteria. The mean age at T&A was 4.8 years and 52.0% were male. The mean apnea-hypopnea index (AHI) was 23.2 events/hour for patients who had pre-T&A PSGs. The mean AHI was 10.7 events/hour after T&A. Twenty-three patients (35.4%) underwent at least one additional surgical procedure after T&A; 5 (7.7%) patients had ≥ two additional procedures. The most common additional surgical procedures were revision adenoidectomies (n = 8) and lingual tonsillectomies (n = 13). Fifteen (23.1%) patients underwent at least one drug-induced sleep endoscopy (DISE) to help direct selection of surgical site/s.

CONCLUSIONS

Residual OSA is common after T&A in children with Down syndrome and can be managed by additional surgical interventions in many instances with successful reduction of the AHI. DISE has become part of a standard algorithm for managing persistent OSA in children with Down syndrome after T&A.

Correlation between gonial angle and dynamic tongue collapse in children with snoring/sleep disordered breathing - an exploratory pilot study

BACKGROUND

Drug induced sleep endoscopy (DISE) is hoped to identify reasons of failure of adenotonsillectomy (AT) in treating pediatric sleep disordered breathing (SDB). Maxillomandibular disproportion has been studied as another association which may explain alternative pathogenesis of SDB. We aimed to explore the relation between the size of the gonial angle and inclination of the epiglottis measured from cone beam CT (CBCT) and tongue base collapse based on DISE in children with SDB.

METHOD

A retrospective chart review was conducted at a tertiary pediatric center. Children (6-17 years old) assessed at a multi-disciplinary Upper Airway Clinic, diagnosed with SDB and maxillo-mandibular disproportion (MMD), and who underwent DISE were eligible. Variables obtained from the electronic medical records of the clinic and prospective database included demographics, comorbidities, surgeries performed, investigations, DISE findings and CBCT findings. The gonial angle of subjects with and without tongue base collapse (TBC) on SNP were compared.

RESULTS

In total 29 patients (13 male, 8 female) age 6-17 (median= 9) were eligible for the study from January 2009 - July 2016. We included 11 subjects, and 10 comparators. The mean gonial angle of the TBC group was 139.3°± 7.6°, while that of the comparison group was 129.4°±3.5 (mean difference -9.937, 95% CI of -15.454 to - 4.421, P = 0.001, power of test 0.95). Additionally, the mean inclination of the epiglottis had a mild positive correlation (r=0.32, p<0.05) with the gonial angle, in the whole cohort.

CONCLUSIONS

This pilot study suggests that TBC may be mediated by a wider gonial angle in children with SDB patients. The posterior tilt of the epiglottis on CBCT may be a surrogate sign of TBC.

Pulmonary edema post-adenotonsillectomy in children

Post-adenotonsillectomy pulmonary edema (pATPE) is a life-threatening condition that necessitates immediate clinical intervention. The early diagnosis and detection of the signs of this condition is vital to its treatment and patient outcome. The purpose of this review article is to present epidemiological data on the prevalence of pATPE, and address the mechanisms of development, types, etiology, pathophysiology, and management of pATPE. In order to minimize postoperative intensive care unit admission rates of pATPE, utilization of preoperative clinical assessment, operative/postoperative monitoring tools, and procedural precautions are discussed.

Pediatric Obstructive Sleep Apnea: Consensus, Controversy, and Craniofacial Considerations

Pediatric obstructive sleep apnea, characterized by partial or complete obstruction of the upper airway during sleep, is associated with multiple adverse neurodevelopmental and cardiometabolic consequences. It is common in healthy children and occurs with a higher incidence among infants and children with craniofacial anomalies. Although soft-tissue hypertrophy is the most common cause, interplay between soft tissue and bone structure in children with craniofacial differences may also contribute to upper airway obstruction. Snoring and work of breathing are poor predictors of obstructive sleep apnea, and the gold standard for diagnosis is overnight polysomnography. Most healthy children respond favorably to adenotonsillectomy as first-line treatment, but 20 percent of children have obstructive sleep apnea refractory to adenotonsillectomy and may benefit from positive airway pressure, medical therapy, orthodontics, craniofacial surgery, or combined interventions. For children with impairment of facial skeletal growth or craniofacial anomalies, rapid maxillary expansion, midface distraction, and mandibular distraction have all been demonstrated to have therapeutic value and may significantly improve a child's respiratory status. This Special Topic article reviews current theories regarding the underlying pathophysiology of pediatric sleep apnea, summarizes standards for diagnosis and management, and discusses treatments in need of further investigation, including orthodontic and craniofacial interventions. To provide an overview of the spectrum of disease and treatment options available, a deliberately broad approach is taken that incorporates data for both healthy children and children with craniofacial anomalies.

The Effect of Montelukast on Mild Persistent OSA after Adenotonsillectomy in Children: A Preliminary Study

This study sought to evaluate the treatment effect of montelukast in children with obstructive sleep apnea (OSA) after tonsillectomy and/or adenoidectomy (T&A). Fifty-eight children with persistent OSA after T&A were included and randomly divided into 2 groups: one group was administered montelukast for 12 weeks, and the other received no treatment. Clinical information, such as the apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (nadir SpO₂), was recorded. Symptoms of OSA were evaluated using the validated Pediatric Sleep Questionnaire (PSQ). After surgery, there was no difference in terms of AHI, nadir SpO₂, and PSQ scores between 2 groups. After the 12-week course of montelukast administration, the treatment group had significant improvement in the AHI, nadir SpO₂, and PSQ scores ( P < .001), while the no-treatment group had no change over time ( P > .05). In summary, montelukast as a complementary therapy can improve sleep disturbances in children with OSA after T&A.

Risk of failure of adenotonsillectomy for obstructive sleep apnea in obese pediatric patients

INTRODUCTION

Pediatric obesity is a leading risk factor for obstructive sleep apnea (OSA), a condition commonly treated with adenotonsillectomy (T&A). It has been hypothesized that obesity increases a child's risk of failing T&A for OSA, however this relationship has not yet been quantified. The primary objective of this study was to investigate the relationship between obesity as measured by perioperative Body Mass Index (BMI) and persistent OSA following T&A as measured by polysomnography (PSG).

STUDY DESIGN

Retrospective chart review.

METHODS

Pediatric patients who underwent T&A between Jan. 2004 and Jan. 2016 were included. We recruited both obese and non-obese patients to compare caregiver/self reported improvement. Obese patients were recruited from a weight management clinic and included if they had a BMI z-score >1.65 and had pre- and post-operative polysomnograms (PSGs). Control patients included those undergoing T&A for OSA at our institution with BMI <1.65. These patients were age matched to the obese patient population. Age, gender, perioperative BMI z-score, caregiver/self reported improvement, total Apnea-Hypopnea Index (AHI), and O₂ saturation nadir were collected where available. Univariate linear regressions were calculated between perioperative BMI z-score and PSG data.

RESULTS

26 obese study and 47 control subjects were identified for analysis. T&A resulted in statistically significant improvements in total AHI (p = 0.030) and nadir O₂ saturation (p = 0.013) in obese subjects. There was no significant difference between the rate of caregiver/self reported improvement in the two groups. There was a statistically significant correlation between perioperative BMI z-score and the change in total AHI (p = 0.049). Within our population, for every increase by 0.1 in perioperative BMI z-score, the improvement in total AHI post-operatively decreased by 1.63 events/hr. Further, patients with BMI more than 3 standard deviations away from the age-derived normative mean received essentially no benefit from T&A alone.

CONCLUSIONS

Our study established an inverse linear relationship between perioperative BMI z-score and improvement in total AHI with essentially no improvement in patients with BMI z-scores >3. Further studies are required to further elucidate this relationship and investigate the role of additional procedures in the initial management of OSA in obese children.

Obstructive Sleep Apnoea: Children are not little Adults

During a child's development, several important developmental physiological sleep processes occur, and, occasionally, pathological disorders occur, which results in differences between obstructive sleep apnoea (OSA) in adults and children. There are major differences in sleep and respiratory physiology as well as OSA symptoms and treatment options between children and adults. Many practitioners do not realize these differences, which results in delays in the diagnosis and treatment of OSA in children. The treatment options for OSA in children are markedly different compared with adults, effective in most children. The use of positive airway pressure (PAP) therapy delivered through continuous or bi-level positive airway pressure modes is successful in children and even in infants; however, there are several challenges facing parents and practitioners to achieve good compliance. The early recognition and treatment of paediatric OSA are essential to prevent deleterious consequences. This article discusses the major differences between paediatric and adult OSA and demonstrates why children are not little adults.

Tonsillectomy as prevention and treatment of sleep-disordered breathing: a report of 23 cases

BACKGROUND

The paradigm of tonsillectomy has shifted from a treatment of recurrent throat infection to one of multi-discipline management modalities of sleep-disordered breathing (SDB). While tonsillectomy as a treatment for throat problems has been performed almost exclusively by otorhinolaryngologists, tonsillectomy as a part of the armamentarium for the multifactorial, multidisciplinary therapy of sleep-disordered breathing needs a new introduction to those involved in treating SDB patients. This study has its purpose in sharing a series of tonsillectomies performed at the Seoul National University Dental Hospital for the treatment and prevention of SDB in adult patients.

METHODS

Total of 78 patients underwent tonsillectomy at the Seoul National University Dental Hospital from 1996 to 2015, and 23 of them who were operated by a single surgeon (Prof. Jin-Young Choi) were included in the study. Through retrospective chart review, the purpose of tonsillectomy, concomitant procedures, grade of tonsillar hypertrophy, surgical outcome, and complications were evaluated.

RESULTS

Twenty-one patients diagnosed with SDB received multiple surgical procedures (uvulopalatal flap, uvulopalatopharyngoplasty, genioglossus advancement genioplasty, tongue base reduction, etc.) along with tonsillectomy. Two patients received mandibular setback orthognathic surgery with concomitant tonsillectomy in anticipation of postoperative airway compromise. All patients showed improvement in symptoms such as snoring and apneic events during sleep.

CONCLUSIONS

When only throat infections were considered, tonsillectomy was a procedure rather unfamiliar to oral and maxillofacial surgeons. With a shift of primary indication from recurrent throat infections to SDB and emerging technological and procedural breakthroughs, simpler and safer tonsillectomy has become a major tool in the multidisciplinary treatment modality for SDB.

Indications for tonsillectomy stratified by the level of evidence

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Application of desaturation index in post-surgery follow-up in children with obstructive sleep apnea syndrome

Adenotonsillectomy is recommended for children who need surgery for obstructive sleep apnea syndrome (OSAS). Overnight, polysomnography (PSG) is suggested for post-surgery follow-up, but this diagnostic technique is time consuming and inconvenient. Desaturation index (DI) has been reported as a good tool for predicting both the presence and severity of OSAS in children. The purpose of this study was to determine the usefulness of the DI for post-surgery follow-up of children with OSAS. This retrospective study enrolled 42 children, aged 3-12 years, who were snorers diagnosed with OSAS by overnight PSG and who underwent an adenotonsillectomy. Pre- and postoperative PSG parameters, nocturnal pulse oximetry data, and modified Epworth sleepiness scale scores were assessed. Previously determined cut-off DI values (2.05, 3.50, and 4.15 for mild, moderate, and severe OSAS, respectively) were used to predict residual OSAS. Of the 42 children, obvious improvements were observed in apnea-hypopnea index (AHI, decreased 45.5 %), arousal index (decreased 30.5 %), DI (decreased 40.4 %), and snore index (decreased 100.3 %) compared with the preoperative measurements. Among these objective PSG measures, DI had the strongest correlation with AHI both pre- and post-surgeries (r = 0.947 and r = 0.954, respectively; p all <0.001). The DI change, before and after surgery, also had the strongest positive correlation to the AHI change (r = 0.482 and p = 0.001). Using the previously determined DI cut-off values to predict postoperative residual OSAS, there was a good positive predictive value (92.6 %) for mild residual OSAS and a good negative predictive value for moderate and severe residual OSAS (85.2 and 89.7 %, respectively). These findings suggest that DI, as determined using a nocturnal pulse oximeter, may be an alternative tool for postoperative evaluation and follow-up of children with OSAS.

Obstructive Sleep Apnea Resolution in Hypopnea- versus Apnea-Predominant Children after Adenotonsillectomy

OBJECTIVE

Given that 30% to 40% of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether children with hypopnea-predominant OSA were more likely to have complete disease resolution after adenotonsillectomy than those with apnea-predominant disease. We also identified risk factors that might modify the relationship between disease resolution and polysomnographic event type (ie, hypopnea vs apnea).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary pediatric hospital.

SUBJECTS/METHODS

Consecutive 1- to 18-year-old typically developing children diagnosed with OSA from March 2011 to December 2012 underwent adenotonsillectomy and completed pre- and postoperative polysomnography within 1 year of surgery.

RESULTS

Fifty-eight children were included (27 female; mean ± SD: age, 5.6 ± 3.1 years; body mass index z score, 1.1 ± 1.7). Overall, adenotonsillectomy resulted in significant improvement in obstructive apnea-hypopnea index (oAHI) from 23.3 ± 40.0 to 4.3 ± 8.2 events per hour (P < .001), obstructive apnea index (5.1 ± 7.4 to 0.4 ± 0.8, P < .001), and obstructive hypopnea index (oHI; 18.1 ± 37.5 to 3.7 ± 8.1, P < .001). There was complete response (oAHI <1.0 event/h) in 24 of 58 patients (41%) but no difference by event type (P = .11). On univariate analysis, only race, sex, oxygen saturation nadir, and oHI were predictive of response to adenotonsillectomy, while multivariate analysis found that prematurity, age, oxygen saturation nadir, oHI, obstructive apnea index, and oAHI were predictive. Event type was not significant, even in a model controlling for age, race, sex, prematurity, asthma, body mass index, and baseline polysomnographic variables.

CONCLUSION

This small study demonstrated no difference in disease resolution between children with hypopnea- and apnea-predominant OSA who underwent adenotonsillectomy. Additionally, adenotonsillectomy significantly improved OSA in most children, and high preoperative oAHI was associated with persistent postoperative OSA.

Obstructive sleep apnea in children: update on the recognition, treatment and management of persistent disease

Adenotonsillectomy (AT) is the recommended first-line treatment for pediatric obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy. It is now clearly established that AT results in improvement in the severity of OSA in most children. However, a significant number of OSA children undergoing AT exhibit residual persistent OSA post-surgery. Patients at increased risk of persistent OSA include those with severe disease at initial review, older or obese patients, children with underlying asthma or allergic rhinitis, and those who have concurrent underlying medical conditions, such as Trisomy 21, craniofacial syndromes or cerebral palsy. Here, we aim to highlight recent research findings into those who have persistent OSA disease, and suggest a practical approach to the management of these children.

Clinical manifestations of pediatric obstructive sleep apnea syndrome: Clinical utility of the Chinese-version Obstructive Sleep Apnea Questionaire-18

AIMS

Childhood obstructive sleep apnea syndrome (OSA) affects not only the children's physical health, but also their mental development, behavioral problems and learning difficulties. Therefore, an early diagnosis is important. However, the assessment tools of polysomnography are demanding. The Obstructive Sleep Apnea Questionnaire-18 (OSA-18) is designed to screen OSA and has good reliability and validity. The goal of this study was to validate the Chinese version of the OSA-18, to analyze the frequency of symptoms and find the most common symptoms of OSA in Taiwanese children.

METHODS

We validated the OSA-18 in an ethnic Chinese group and compared the treatment outcomes to show the sensitivity of the questionnaire. The caregivers completed the questionnaire twice at an interval of 4 weeks to test reliability. In the validation study, we included 88 OSA children. The OSA-18 and follow-up polysomnography were performed before and 6 months after adenotonsillectomy.

RESULTS

Results showed the excellent test-retest reliability (r = 0.84**) of the OSA-18. There was a statistically significant correlation between the OSA-18 and, respectively, the Apnea-Hypopnea Index (r = 0.29*), and the Hypopnea Index (r = 0.29*). Quality of life showed a significant correlation with the Apnea Index (r = 0.43**), central apnea count (r = 0.50***), and mixed apnea count (r = 0.36*). The cut-off point of the OSA-18 total scores for detecting pediatric OSA in children aged 6-12 years was 66. The common symptoms of pediatric OSA were poor attention span, loud snoring, caregiver worried about child's health, difficulty awakening, and mouth breathing.

CONCLUSIONS

Our results show that the Chinese version of the OSA-18 is a reliable and valid instrument. The questionnaire also showed improvement in the quality of life of OSA children post-adenotonsillectomy.

A Pediatric Grading Scale for Lingual Tonsil Hypertrophy

Lingual tonsil hypertrophy (LTH) is a common finding for children with residual obstructive sleep apnea (OSA) following an adenotonsillectomy. Secondary to the significant morbidity associated with OSA, identification and treatment of residual OSA are paramount. A dedicated LTH grading scale for children does not exist. The current adult LTH scale is impractical for children. Imaging is not routine for children, since it frequently requires sedation. We present a pediatric LTH grading scale with substantial interrater reliability to facilitate standardization of endoscopy findings and promote outcomes-based research for OSA surgery in children.

Outcome of adenotonsillectomy for children with sleep apnea

BACKGROUND AND OBJECTIVES

The prevalence of obstructive sleep apnea syndrome is about 1%-4.9% in children aged 2-18 years. This is a prospective study carried out to evaluate the role of adenotonsillectomy (AT) in pediatric sleep apnea.

METHODS

Fifty children aged less than 15 years presenting with the chief complaints of snoring, mouth breathing, recurrent upper respiratory infections, and adenotonsillar hypertrophy were included in the study. Physical examination included body mass index (BMI) z-score, orodental and nasal examination, modified Mallampati scoring; whole-night level I polysomnography was conducted and repeated after three to six months of AT.

RESULTS

The mean preoperative BMI z-score was -0.76, which improved significantly to -0.15 (p < 0.001) after AT. A negative correlation was seen between respiratory distress index (RDI) and pre surgery BMI z-score. As per pre-operative RDI, OSA was classified mild in 6.7% children (31.1% as per apnea-hypopnea index [AHI]), moderate in 35.6% (31.1% as per AHI), and severe in 57.8% (37.8% as per AHI). The average RDI value reduced significantly from 16.2 ± 10.7 to 6.46 ± 4.8 (p < 0.001) and AHI from 8.5 (SD ± 5.7) to 1.3 (SD ± 1) post-operatively. Only 6.7% children could be cured with surgery, of whom none belonged to moderate or severe category. Multivariate analysis shows that initial severity of disease, modified Mallampati scores III and IV, high-arched palate, and age above eight years were associated with significant residual disease after AT.

CONCLUSION

AT was associated with a statistically significant change in RDI and AHI. However, complete resolution of OSA could be seen in a small percentage of patients with a mild degree of disease.

Treatment outcomes of obstructive sleep apnoea in obese community-dwelling children: the NANOS study

The first line of treatment of obstructive sleep apnoea syndrome (OSAS) in children consists of adenotonsillectomy (T&A). The aim of the present study was to evaluate treatment outcomes of OSAS among obese children recruited from the community.A cross-sectional, prospective, multicentre study of Spanish obese children aged 3-14 years, with four groups available for follow-up: group 1: non-OSAS with no treatment; group 2: dietary treatment; group 3: surgical treatment; and group 4: continuous positive airway pressure treatment.117 obese children (60 boys, 57 girls) with a mean age of 11.3±2.9 years completed the initial (T0) and follow-up (T1) assessments. Their mean body mass index (BMI) at T1 was 27.6±4.7 kg·m(-2), corresponding to a BMI Z-score of 1.34±0.59. Mean respiratory disturbance index (RDI) at follow-up was 3.3±3.9 events·h(-1). Among group 1 children, 21.2% had an RDI ≥3 events·h(-1) at T1, the latter being present in 50% of group 2, and 43.5% in group 3. In the binary logistic regression model, age emerged as a significant risk factor for residual OSAS (odds ratio 1.49, 95% confidence interval 1.01-2.23; p<0.05) in obese children surgically treated, and RDI at T0 as well as an increase in BMI emerged as significant risk factors for persistent OSAS in obese children with dietary treatment (OR 1.82, 95% CI 1.09-3.02 (p<0.03) and OR 8.71, 95% CI 1.24-61.17 (p=0.03)).Age, RDI at diagnosis and obesity are risk factors for relatively unfavourable OSAS treatment outcomes at follow-up.

Tailoring therapy to improve the treatment of children with obstructive sleep apnea according to grade of adenotonsillar hypertrophy

BACKGROUND

Obstructive sleep apnea (OSA) is a common disease in children with the major causes of hypertrophy of adenoid or tonsil and nasal diseases. The treatment methods for this disease include the resection of adenoid or tonsil, and drug therapy as well. However, no agreement on the selection of treatment method is available to date.

OBJECTIVE

To investigate the individualized treatment methods for children with OSA with different sizes of adenoids and tonsils.

METHODS

Children with OSA (diagnosed by polysomnography) were included into groups A (adenoid/tonsil grade ≤III) and B (adenoid/tonsil grade=IV), and further subdivided into subgroups A1 (3-month medication), A2 (3-month medication and negative-pressure sputum aspiration [NPSA]), B1 (3-month medication plus NPSA), B2 (coblation adenotonsillectomy with preoperative/postoperative medication for 3 days/2 weeks) and B3 (coblation adenotonsillectomy with preoperative/postoperative medication for 2 weeks/3 months). Six-month outcomes included quality of life for children with obstructive sleep apnea-18 item (OSA-18), obstructive apnea index (OAI), apnea hypopnea index (AHI) and lowest oxygen saturation (LSaO2).

RESULTS

Three hundred and eighty six patients (310 male; 6.70±2.44 years-old) were included. Preoperative OSA-18, OAI, AHI and LSaO2 were not significantly different. At all postoperative time points, subgroup A2 had significantly lower OSA-18 than subgroup A1; postoperative improvements in OAI, AHI and LSaO2 were also superior in subgroup A2 (P<0.05). The initial decrease in OSA-18 was not maintained in subgroups B1 and B2, whereas subgroup B3 showed a sustained reduction at 6 months. OAI and AHI were more improved in subgroup B3 (P<0.05). Surgical/anesthetic complications in subgroups B2 and B3 were 5.5% and 0%.

CONCLUSION

Conservative therapy could achieve satisfactory outcomes in children with grade III hypertrophy, while surgery and drugs could achieve good outcomes in grade IV.

Intraoperative long range optical coherence tomography as a novel method of imaging the pediatric upper airway before and after adenotonsillectomy

BACKGROUND/OBJECTIVES

While upper airway obstruction is a common problem in the pediatric population, the first-line treatment, adenotonsillectomy, fails in up to 20% of patients. The decision to proceed to surgery is often made without quantitative anatomic guidance. We evaluated the use of a novel technique, long-range optical coherence tomography (LR-OCT), to image the upper airway of children under general anesthesia immediately before and after tonsillectomy and/or adenoidectomy. We investigated the feasibility of LR-OCT to identify both normal anatomy and sites of airway narrowing and to quantitatively compare airway lumen size in the oropharyngeal and nasopharyngeal regions pre- and post-operatively.

METHODS

46 children were imaged intraoperatively with a custom-designed LR-OCT system, both before and after adenotonsillectomy. These axial LR-OCT images were both rendered into 3D airway models for qualitative analysis and manually segmented for quantitative comparison of cross-sectional area.

RESULTS

LR-OCT images demonstrated normal anatomic structures (base of tongue, epiglottis) as well as regions of airway narrowing. Volumetric rendering of pre- and post-operative images clearly showed regions of airway collapse and post-surgical improvement in airway patency. Quantitative analysis of cross-sectional images showed an average change of 70.52mm(2) (standard deviation 47.87mm(2)) in the oropharynx after tonsillectomy and 105.58mm(2) (standard deviation 60.62mm(2)) in the nasopharynx after adenoidectomy.

CONCLUSIONS

LR-OCT is an emerging technology that rapidly generates 3D images of the pediatric upper airway in a feasible manner. This is the first step toward development of an office-based system to image awake pediatric subjects and thus better identify loci of airway obstruction prior to surgery.

Mandibular surgery: technologic and technical improvements

The ability of surgeons to use advanced techniques can significantly improve both surgical outcome and patient satisfaction. Surgical evolution in mandibular orthognathic surgery is no exception, because advancements have aided both surgical planning and technique. It is important for clinicians to be aware of the historical progression of improvements in this technique and appreciate the technologic advancements as they are happening. Computer-driven surgical planning is becoming increasingly popular, providing surgeons and patients with the ability to adjust to intraoperative and postoperative variations. By using these capabilities, clinicians are now able to give patients the best possible outcomes.

Canadian Association of Neuroscience Review: Respiratory Control and Behavior in Humans: Lessons from Imaging and Experiments of Nature

The purpose of this review is to demonstrate that respiration is a complex behavior comprising both brainstem autonomic control and supramedullary influences, including volition. Whereas some fundamental mechanisms had to be established using animal models, this review focuses on clinical cases and physiological studies in humans to illustrate normal and abnormal respiratory behavior. To summarize, central respiratory drive is generated in the rostroventrolateral medulla, and transmitted to both the upper airway and to the main and accessory respiratory muscles. Afferent feedback is provided from lung and muscle mechnoreceptors, peripheral carotid and aortic chemoreceptors, and multiple central chemoreceptors. Supramedullary regions, including cortex and subcortex, modulate or initiate breathing with volition, emotion and at the onset of exercise. Autonomic breathing control can be perturbed by brainstem pathology including space occupying lesions, compression, congenital central hypoventilation syndrome and sudden infant death syndrome. Sleep-wake states are important in regulating breathing. Thus, respiratory control abnormalities are most often evident during sleep, or during transition from sleep to wakefulness. Previously undiagnosed structural brainstem pathology may be revealed by abnormal breathing during sleep. Ondine's curse and 'the locked-in syndrome' serve to distinguish brainstem from supramedullary regulatory mechanisms in humans: The former comprises loss of autonomic respiratory control and requires volitional breathing for survival, and the latter entails loss of corticospinal or corticobulbar tracts required for volitional breathing, but preserves autonomic respiratory control.

Psychological screening for the children with habitual snoring

OBJECTIVES

Adenotonsillar hypertrophy is the major determinants of habitual snoring in pediatric population. Behavioral hyperactivity and schooling problems have been repeatedly reported in these children, and it may underlie more extensive behavioral disturbances, particularly for the obese children. The aim of the present study is to evaluate the incidence and characteristics of emotional and behavioral problems using outpatient-based psychological screening tools in the children with habitual snoring.

METHODS

Total 235 patients and 170 controls, who aged 4-9 years were enrolled. Body mass index (BMI) z-score was obtained for age and gender and parental sleep-related breathing disorder (SRBD) questionnaire was used to assess severity of sleep-disordered breathing (SBD). Psychological assessment was performed using standardized questionnaires including Strength and Difficulties Questionnaire (SDQ), Children's Depression Inventory (CDI) and Screen for Child Anxiety Related Emotional Disorders (SCARED).

RESULTS

Children presenting habitual snoring had significantly higher mean scores on almost all scales of SDQ, and SCARED than community controls. Around 20% of the children with habitual snoring, compared with 10-11% of controls had significant levels of distress that could adversely impact treatment outcomes. There was no interaction between obstructive sleep apnea severity and behavioral ratings. The scores for emotional distress and hyperactivity were more prominent in the obese children. Significant psychological distress or impairment in social interactions was observed in children with higher SRBD scores.

CONCLUSIONS

Our findings suggest that the presence of habitual snoring in young children is associated wide spectrum of behavioral problems and the level of psychological distress might be evaluated at the time of the diagnosis.

Pediatric sleep surgery

Adenotonsillectomy is the most common surgery performed for sleep disordered breathing with good outcomes. Children with obesity, craniofacial disorders, and neurologic impairment are at risk for persistent sleep apnea after adenotonsillectomy. Techniques exist to address obstructive lesions of the palate, tongue base, or craniofacial skeleton in children with persistent sleep apnea. Children with obstructive sleep apnea have a higher rate of peri-operative complications.

The relationship between depressive symptoms and obstructive sleep apnea in pediatric populations: a meta-analysis

BACKGROUND

A higher incidence of depressive disorders and symptoms has been suggested among children suffering from obstructive sleep apnea (OSA). Yet, the extent to which OSA is related to increased depression is unclear.

OBJECTIVES

To evaluate (a) the relationship between depressive symptoms and OSA in pediatric populations, and (b) the efficacy of adenotonsillectomy (AT) for decreasing depressive symptoms among children with OSA.

METHODS

A meta-analysis was conducted to assess the relationship between depressive symptoms and OSA, and the efficacy of AT for decreasing depressive symptoms. Studies reporting depressive symptoms of children with OSA through January 2013 were included.

RESULTS

Eleven studies assessed depressive symptoms in both children diagnosed with OSA (n = 894) and a comparison group (n = 1,096). A medium relationship was found between depressive symptoms and OSA (Hedges' g = 0.43, 95% CI: 0.22-0.64; p = 0.0005). Addressing the second question, 9 studies (n = 379 children) examined depressive symptoms pre- and post-AT. A medium improvement in depressive symptoms was found at follow-up (Hedge's g = 0.41, 95% CI: 0.20-0.62; p ≤ 0.001).

CONCLUSION

Our findings suggest that depressive symptoms are higher among children with OSA. Therefore, patients with depressive symptomatology should receive screening for sleep disordered breathing. Treatment of OSA with AT might decrease clinical symptoms of depression, reduce pharmacotherapy, improve sleep patterns, and promote better health.

Distraction osteogenesis for management of obstructive sleep apnea secondary to TMJ ankylosis

Mandibular retrognathism due to temporomandibular joint (TMJ) ankylosis is one of the important contributing factors to the obstructive sleep apnea(OSA). Such patients suffer from number of apneic or hyponeic events during sleep, snoring, daytime sleepiness, fatigue, inability to concentrate, irritability. At the same time facial asymmetry due TMJ ankylosis lead to a progressive lack of confidence. Distraction osteogenesis is a less invasive surgical technique in the management of OSA, secondary to TMJ ankylosis. This modality not only treats the OSA but also corrects the facial asymmetry at the same time, and the results have been gratifying.

Comparison of oxygen desaturation patterns in children and adults with sleep-disordered breathing

PURPOSE

Although the number of apnea-hypopnea episodes per hour apnea-hypopnea index (AHI) is typically used to evaluate sleep-disordered breathing (SDB) in adults, it does not provide an accurate characterization of SDB in children. We investigated differences in SDB patterns in children and adults to evaluate SDB severity in children.

MATERIALS AND METHODS

Fifteen adults (mean age, 45.3 ± 8.4 years) and 15 children (mean age, 6.7 ± 3.9 years) with adenotonsillar hypertrophy underwent standard polysomnography. The change of oxygen saturation (ΔSpO2) was defined as the difference between baseline SpO₂ during stable nighttime breathing and the lowest SpO₂ accompanied by an apnea-hypopnea event. The number of apnea-hypopnea episodes was determined using two different criteria to define an episode (criterion 1: cessation of airflow for at least 10s; criterion 2: cessation of airflow for at least two consecutive breaths).

RESULTS

Mean ΔSpO₂ accompanied by obstructive apneas lasting ≤10 s was significantly greater in children than in adults, although there was no significant difference in the duration of apnea-hypopnea episodes. The slope of the regression line between ΔSpO₂ and apnea-hypopnea duration in children was greater than in adults (P<0.005). AHI in children was higher when calculated using criterion 2 compared to criterion 1 (10.9 ± 9.4 vs. 6.5 ± 4.9/h, P=0.003).

CONCLUSIONS

ΔSpO₂ is a good indicator of SDB severity in children, and should therefore be considered in the diagnosis and treatment of pediatric SDB along with AHI.

Pediatric sleep apnea: Five things you might not know

Obstructive sleep apnea is a frequently overlooked, treatable disorder that is common among children. This article discusses 5 important aspects of this disorder that might not be known to the general pediatric practitioner or pediatric neurologist. These aspects are important in screening, properly evaluating, and treating children with obstructive sleep apnea.

Novel pharmacological approaches for treatment of obstructive sleep apnea in children

INTRODUCTION

The lymphadenoid tissues in the upper airway are sparse and organized lympho-epithelial structures playing an important role against foreign pathogens, with the palatine tonsils being the major components of the lymphoid tissues contained in the Waldeyer's ring. Obstructive sleep apnea (OSA) has emerged as a very frequent condition in the pediatric age range that is associated with substantial neurobehavioral, cardiovascular and metabolic morbidities. Adenotonsillar hypertrophy is the major pathophysiological contributor to OSA occurrence in children.

AREAS COVERED

Here, the authors provide a systematic review and summary of some of the known histological and pathological features of human lymphadenoid tissues and their fundamental immunological functions, provide insights into the pathophysiology of pediatric OSA, particularly focusing on inflammatory pathways and the available outcomes associated with targeting such pathways with compounds such as corticosteroids and leukotriene modifiers. Furthermore, they present findings from an unbiased approach to discovery of therapeutic targets and formulate constructs toward putative future interventional approaches for this highly prevalent condition.

EXPERT OPINION

Surgical approaches for pediatric OSA may not be as effective as previously anticipated. Accordingly, expanded use of existing systemic or topical anti-inflammatory agents or development of novel compounds targeting selected immune cell populations underlying pathophysiological determinants of OSA is needed.

Improved objective outcomes and quality of life after adenotonsillectomy with inferior turbinate reduction in pediatric obstructive sleep apnea with inferior turbinate hypertrophy

OBJECTIVES/HYPOTHESIS

Whether adenotonsillectomy (AT) is sufficient for pediatric obstructive sleep apnea syndrome (OSAS) with persistent severe allergic rhinitis (PSAR) remains unclear. This study attempts to identify the role of inferior turbinate reduction in treating pediatric OSAS with PSAR.

STUDY DESIGN

Case series with planned data collection.

METHODS

Fifty-one subjects aged 3 to 12 years with OSAS and PSAR were enrolled. Among them, 23 patients underwent AT concurrent with microdebrider-assisted inferior turbinoplasty (MAIT) (group AT-MAIT) and 28 patients underwent AT alone (group AT). Before surgery and at 1 year after surgery, objective outcomes were assessed using overnight polysomnography and acoustic rhinometry. Subjective outcomes were evaluated using the Obstructive Sleep Apnea (OSA)-18 quality-of-life questionnaire (OSA-18).

RESULTS

Following surgery, the median apnea-hypopnea index, minimal oxygen saturation, and snoring index were 0.8 (/h), 94 (%), and 104 (/h) in group AT-MAIT, respectively, compared with 3.5 (/h), 93 (%), and 158 (/h) in group AT, respectively (P < .05). In group AT-MAIT, the median postoperative minimal cross-sectional area recorded by acoustic rhinometry was 0.31 cm(2) , significantly larger than 0.16 cm(2) in group AT (P < .01). Compared with postoperative scores in group AT, those in group AT-MAIT were significantly improved in domains of physical symptoms, emotional symptoms, daytime function, caregiver concerns, and overall OSA-18 scores (P < .05).

CONCLUSIONS

Analytical results suggest that AT with concurrent MAIT achieves favorable subjective and objective outcomes in pediatric OSAS with PSAR. We believe that volume reduction of the inferior turbinate plays an important role in treating pediatric OSAS with inferior turbinate hypertrophy.

Surgical therapy of obstructive sleep apnea: a review

Obstructive sleep apnea (OSA) is a disease characterized by intermittent and repetitive narrowing of the airway during sleep. Surgical therapies for the treatment of OSA aim to improve airway patency by addressing selected site(s) of obstruction. Because several areas may each be responsible for the narrowing, different surgical modalities have also been developed. In this review, we give an overview of surgery for each of potential obstruction site(s). As a consequence of the multi-factorial and heterogeneous etiology of OSA, surgical therapies need to be selected and performed specifically for each patient, as there is no perfect surgery that will fit all patients. As with any other treatment modalities for OSA, surgical therapies have variable efficacy, but are a very important tool on OSA management in selected patients and have been shown effectiveness in decreasing the morbidity and mortality associated with the disease.