Pediatric sleep surgery

Severe Pediatric Sleep Apnea: Drug-Induced Sleep Endoscopy Based Surgery

Although adenotonsillectomy is the recommended treatment of obstructive sleep apnea (OSA) in children, some patients with preoperative severe OSA (Apnea-hypopnea index/AHI > 10) remain symptomatic after surgery and may need further workup. This study aims to: (1) analyse preoperative factors and its relation with surgical failure/persistent OSA (AHI > 5 after adenotonsillectomy) in severe pediatric OSA; (2) determine the levels of airway collapse during DISE (drug induced sleep endoscopy) in cases of surgical failure; (3) evaluate the efficacy of targeted surgery based on DISE findings. This retrospective study was conducted between August and September 2020. Across 9 years (from 2011 to 2020), all children diagnosed with severe OSA in our Hospital underwent adenotonsillectomy and repeated type 1 polysomnography (PSG) 3 months after surgery. Cases of surgical failure underwent DISE for planning eventual directed surgery. Chi-square test was used to assess the relationship between persistent OSA and preoperative patients' characteristics. 80 cases of severe pediatric OSA were diagnosed (68.8% males; mean age: 4.3 years-standard deviation: 2.49; mean AHI: 16.3-standard deviation 7.14) in the aforementioned period. We found a significant association between surgical failure (11.3% of cases; mean AHI: 6.9-SD 0.91) and obesity (p = 0.002; confidence level of 95%). Neither preoperative AHI nor other PSG parameters were associated with surgical failure. In cases of surgical failure, epiglottis collapse was present in every DISEs and adenoid tissue was present in 66% of children. All cases of surgical failure had directed surgery and surgical cure (AHI ≤ 5) was obtained in 100% of cases. This study suggests that obesity is the strongest predictor of surgical failure in children with severe OSA who undergo adenotonsillectomy. Epiglottis collapse and presence of adenoid tissue are the most common findings in postoperative DISEs of children with persistent OSA after primary surgery. DISE based surgery seems a safe and effective tool to manage persistent OSA after adenotonsillectomy.

Drug-induced sleep endoscopy effect on intraoperative decision making in pediatric sleep surgery: A 2-year follow up

Objective

To further demonstrate sleep endoscopy's utility in improving surgical outcomes for pediatric OSA.

Methods

This is a retrospective review of surgically naïve patients <18 years old with diagnosed moderate-severe OSA who underwent DISE at the time of initial sleep surgery. Patients included in final analysis had both preoperative and postoperative polysomnograms. Surgical success was defined as an oAHI decrease by at least one diagnostic category. Residual OSA was defined as any patient with postoperative oAHI >1.

Results

A total of 106 patients had preoperative and postoperative polysomnograms. Patients with comorbidities comprised 53.8% of the group. Average BMI% was 88.2, with 75.5% classified as obese. The most common area of collapse was the base of tongue, occurring in 32.1% of patients. There was a statistically significant decrease from the mean preoperative oAHI of 29.7 to the mean postoperative oAHI of 6.6 (p < 0.001). Surgical success occurred in 76.4% of patients. A postoperative oAHI of <5 was achieved in 57.7% of patients with moderate or severe OSA. The average BMI% of patients who met surgical success was 86.4, while the average BMI% of patients who did not was 90.8. A postoperative oAHI of <5 was achieved in 68.4% of patients with a BMI% < 85, compared with 55.2% of patients with a BMI% ≥ 85.

Conclusion

This study supports the utilization of DISE during initial surgery for severe sleep apnea in the pediatric population. It was found to effectively aid in significantly reducing surgically naïve patients' mean oAHI.

Level of Evidence

Level III.

Management of Pediatric Obstructive Sleep Apnea After Failed Tonsillectomy and Adenoidectomy

Pediatric obstructive sleep apnea (OSA) represents a different entity from its adult counterpart and therefore requires a different therapeutic approach. Adenotonsillectomy (AT) is the primary treatment of pediatric OSA, and evidence shows it is very effective. However, there is a growing understanding that residual OSA is common, and next steps for patients who fail primary AT are less certain. This article reviews current methods of evaluating and treating these complex patients.

Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common pediatric disorder characterized by recurrent events of partial or complete upper airway obstruction during sleep which result in abnormal ventilation and sleep pattern. OSAS in children is associated with neurobehavioral deficits and cardiovascular morbidity which highlights the need for prompt recognition, diagnosis, and treatment. The purpose of this state-of-the-art review is to provide an update on the evaluation and management of children with OSAS with emphasis on children with complex medical comorbidities and those with residual OSAS following first-line treatment. Proposed treatment strategies reflecting recommendations from a variety of professional societies are presented. All children should be screened for OSAS and those with typical symptoms (e.g., snoring, restless sleep, and daytime hyperactivity) or risk factors (e.g., neurologic, genetic, and craniofacial disorders) should undergo further evaluation including referral to a sleep specialist or pediatric otolaryngologist and overnight polysomnography, which provides a definitive diagnosis. A cardiology and/or endocrinology evaluation should be considered in high-risk children. For the majority of children, first-line treatment is tonsillectomy with or without adenoidectomy; however, some children exhibit multiple levels of airway obstruction and may require additional evaluation and management. Anti-inflammatory medications, weight loss, and oral appliances may be appropriate in select cases, particularly for mild OSAS. Following initial treatment, all children should be monitored for residual symptoms and polysomnography may be repeated to identify persistent disease, which can be managed with positive airway pressure ventilation and additional surgical approaches if required.

Effect of drug induced sleep endoscopy on intraoperative decision making in pediatric sleep surgery

OBJECTIVES

To demonstrate the effect of drug induced sleep endoscopy (DISE) on intra-operative decision making during pediatric sleep surgery for obstructive sleep apnea (OSA).

METHODS

A retrospective chart review was performed on pediatric (3-17 years) patients with moderate-to-severe OSA (7.2-71.8) who underwent drug induced sleep endoscopy at the time of initial sleep surgery. The characteristics evaluated included age, race, gender, site of obstruction, type of surgical intervention, pre- and post-operative apnea and hypopnea index. Of the 26 patients that were identified, 18 had both a pre- and post-operative polysomnograms result.

RESULTS

All patients underwent DISE immediately prior to surgical treatment. The mean pre-operative AHI for the 18 patients with post-operative polysomnogram results was 21.3 (7.2-71.8). The mean post-operative AHI for the 18 patients was 7.6 (0.7-25.1). There was a significant difference between pre- and post-operative AHI (p < 0.001). Of the 26 patients, the most common area of collapse was the soft palate, occurring in 17/26 (65.4%) patients. Base of tongue involvement was found to be present in 11/26 (42.3%) patients, and the epiglottis was involved in 4/26 (15.4%). Evidence of multilevel collapse was observed in 6/26 (23.1%) patients. Patients observed to have palatal collapse underwent a pharyngoplasty (20/26; 76.9%) at the time of adenotonsillectomy. Three (11.5%) patients underwent a tongue reduction.

CONCLUSION

This study provides additional evidence that DISE can affect intra-operative decision making, with the potential for improved post-operative outcomes. A randomized controlled study is needed to determine if these outcomes are better than what can be achieved without DISE.

Managing the Child with Persistent Sleep Apnea

Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA.

Refractory sleep-disordered breathing due to unilateral lingual tonsillar hypertrophy in a child with Proteus Syndrome

Proteus Syndrome (PS) is a rare congenital overgrowth disease affecting bones, skin, adipose and the central nervous system. The result is asymmetric, disfiguring hypertrophy which can manifest as craniofacial dysmorphia and aerodigestive tract abnormalities. We report the case of obstructive lingual tonsillar hypertrophy resulting in residual sleep disordered breathing after adenotonsillectomy in a child with PS, a previously unrecognized manifestation of the disease. Endoscopic treatment with coblation effectively and safely treated the obstructive symptoms.

Stakeholder-Engaged Measure Development for Pediatric Obstructive Sleep-Disordered Breathing: The Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents

Importance

Parental decision making about adenotonsillectomy (AT) for obstructive sleep-disordered breathing (oSDB) is associated with decisional conflict that may be alleviated with improved knowledge about symptoms and treatments.

Objective

To develop a measure of parental knowledge about oSDB and AT.

Design, Setting, and Participants

A sequential design was used for scale development. A prototype measure containing 9 oSDB and AT themes and 85 items was administered in survey format via an online platform. Participants included 19 clinician experts (otolaryngologists and pediatricians) and 13 laymen (parents of children who snore or do not snore, and other adults). Quantitative and qualitative responses were used to modify the measure and create the knowledge scale. Content validity of the scale was established through expert feedback and evaluation. Criterion validity was established with t test comparisons of experts with laymen. Reliability of the responses was assessed with Cronbach α testing.

Main Outcomes and Measures

An 85-item prototype measure and 39-item modified measure were evaluated for consensus/approval and psychometric integrity.

Results

Of 45 potential participants, 32 individuals (71%) responded to the prototype scale. Respondents included 19 clinician experts (59%) (otolaryngologists and pediatricians) and 13 laymen (41%) (parents of children who snore [n = 8] or do not snore [n = 2] and other adults [n = 3]); demographic data were not collected. Content analysis and qualitative feedback were largely rated positively: 27 respondents (84%) stated that the measure was a good evaluation of knowledge, 30 respondents (94%) commented that the items were clear, and 31 individuals (97%) approved of its organization, although there were several suggestions for rewording and/or addition of response options. Experts identified themes most important for assessing oSDB (symptoms) and AT (experiences: risks and benefits) knowledge. These qualitative comments were used to modify the scale, and items were eliminated if more than 2 were reported as misleading or less than 85% of clinicians provided correct responses. Five themes (oSDB symptoms, treatment options, AT risks, anesthesia, and AT benefits) and 39 items composed the final scale. Experts scored higher than laymen on the oSDB and AT Knowledge Scale for Parents overall (17 [94%] vs 12 [67%]; Cohen d = 1.96; 95% CI, 1.05-2.86) and within all themes, including experiences of children with oSDB (19 [88%] vs 13 [62%]; Cohen d = 1.53; 95% CI, 0.71-2.32), treatment options (19 [97%] vs 12 [68%]; Cohen d = 1.74; 95% CI, 0.88-2.57), AT risks (17 [97%] vs 12 [59%]; Cohen d = 1.94; 95% CI, 1.03-2.83), anesthesia (17 [97%] vs 12 [79%]; Cohen d = 1.09; 95% CI, 0.29-1.88), and AT benefits (17 [95%] vs 12 [67%]; Cohen d = 1.28; 95% CI, 0.46-2.09), demonstrating criterion validity. All responses demonstrated high reliability (Cronbach α = 0.94).

Conclusions and Relevance

The oSDB and AT Knowledge Scale for Parents is psychometrically sound for use in the assessment of parental knowledge.

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.

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE

Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index.

METHODS

We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room.

RESULTS

Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224).

CONCLUSION

Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.