Managing obstructive sleep apnoea in children: the role of craniofacial morphology

The Relationship between Nocturnal Enuresis and Obstructive Sleep Apnea in Children

BACKGROUND

The aim of this study is to determine the prevalence of nocturnal enuresis (NE) in children with obstructive sleep apnea (OSA), the effect of adenotonsillectomy (AT) and the width of the arches, and to compare them with control children without respiratory problems.

METHODS

Children from 2 to 12 years old were divided into three groups: children with OSA and NE (n = 51), children with OSA without NE (n = 79), and the control group (n = 168). NE was defined as at least one bedwetting incident per month. Arch widths were measured at the baseline and one year after. OSA was diagnosed by means of polysomnography, and the apnea-hypopnea index (AHI) was obtained. Parents completed the Pediatric Sleep Questionnaire (PSQ) to classify their children into those with and without NE.

RESULTS

NE was present in 39.2% of children with OSA compared to 28% in the control group (p = 0.04). After AT, 49% of the children with OSA and NE significantly improved. Both OSA groups had narrower arch widths than the control group (p = 0.012), with the NE group having the narrowest widths. NE is more prevalent in children with OSA and should be considered one of the first signs of breathing disorders. Adenotonsillectomy reduces NE in about half of the affected children. Both arch widths are narrower in children with OSA, particularly in those with NE.

Effectiveness of functional orthopedic appliances as an alternative treatment among children and adolescents with obstructive sleep apnea: Systematic review and meta-analysis

INTRODUCTION

The objective here was to review the efficacy of functional jaw orthopedic appliances for treating children/adolescents with obstructive sleep apnea (OSA), through correlating the apnea/hypopnea index (AHI) and oxygen saturation (SaO₂) in polysomnography (PSG), in addition to questionnaire scores from the obstructive sleep apnea-18 (OSA-18).

METHODS

The PRISMA 2020 guidelines¹ were followed. A search was conducted in October 2021, with updating to May 2022, in the MEDLINE/PubMed, BVS (LILACS/BBO), ISI, SciELO (Web of Science), COCHRANE, EMBASE, SCOPUS and WHO databases and the gray literature. Data selection and extraction were performed by two independent reviewers, with Cohen kappa testing. All articles included in the meta-analyses showed good quality and low risk of bias. Statistical analyses were performed in the "R" software, using means with standard deviations, and differences in the means were represented graphically in forest plots. Heterogeneity was tested using I², in random-effect models.

RESULTS

From before to after treatment, treated individuals showed improved AHI, SaO₂ and OSA-18 scores². Comparing treated individuals and controls, AHI decreased in treated individuals and increased in controls. For SaO₂, the increase in treated individuals was greater than in controls. For OSA-18, daytime/nighttime symptoms decreased in treated individuals and increased in controls.

CONCLUSION

Functional jaw orthopedic appliances are appropriate and effective for children/adolescents with OSA whose etiology is deficient maxillomandibular growth and development. Functional jaw orthopedics treats the form and function of the stomatognathic system, thereby enhancing quality of life.

PROSPERO REGISTRATION PROTOCOL

CRD42021253341.

Gut microbiota dysbiosis in 4- to 6-year-old children with obstructive sleep apnea-hypopnea syndrome

OBJECTIVE

Several experiments on animals have reported the relationship between obstructive sleep apnea-hypopnea syndrome (OSAHS) and gut microbiota. We investigated the gut microbiota composition of children aged 4-6 years with OSAHS to complement the pathogenesis and clinical screening methods of OSAHS.

METHODS

We collected feces from 43 children with OSAHS and 45 controls aged 4-6 years. We extracted total bacterial DNA from feces and analyzed the composition of gut microbiota through 16S ribosomal RNA sequencing.

RESULTS

There were significant differences in bacteria producing short-chain fatty acids (SCFAs) between OSAHS children and controls, including Faecalibacterium, Roseburia, and a member of Ruminococcaceae. A gut microbiota model for pediatric OSAHS screening showed that the receiver operating characteristic-area under the curve (ROC-AUC) was 0.794 with 79.1% and 80.0% sensitivity and specificity, respectively. Functional analysis of the gut microbiota revealed several alterations in metabolism.

CONCLUSION

The composition of gut microbiota in OSAHS children is partially changed. The altered intestinal flora may provide a new screening method for the diagnosis of children with OSAHS. The prediction of gut microbiota function suggests that intestinal metabolic function may be altered in OSAHS children.

The Ogival Palate: A New Risk Marker of Sudden Unexpected Death in Infancy?

OBJECTIVE

Ogival palate (i.e., a narrow and high-arched palate) is usually described in obstructive breath disorder but has been found in infants unexpectedly deceased. We studied the association between ogival palate and sudden unexpected death in infancy (SUDI) on the basis of a computed tomography (CT) evaluation.

METHODS

We conducted a monocentric case-control study of children under 2 years of age who died of SUDI, for which a head CT scan and an autopsy were performed between 2011 and 2018. Each case was matched by sex and age (± 30 days) to two controls selected among living children in the same center who benefited from a cranio-encephalic CT scan. Four parameters of the hard palate were measured by CT: height, width, length, and sagittal angle; the height/width ratio was calculated. The presence of an ogival palate was also subjectively evaluated by the radiologists, independently from the measurements. Standardized odds ratios (OR) were calculated using conditional logistic regression models, all expressed for +1 standard deviation (SD).

RESULTS

Thirty-two deceased children were matched to 64 living control children. Mean ages were 5.0 and 5.3 months, respectively. Twenty-eight cases were considered to have died as a result of SIDS. The mean heights of the hard palate were significantly higher in the deceased children [4.1 (± 0.7) millimeters (mm)] than in the living children [3.2 (± 0.6) mm], with OR (+1SD) = 4.30 (95% confidence interval [CI], 2.04-9.06, P = 0.0001). The mean widths of the hard palate were 21.0 (± 1.9) mm and 23.2 (± 2.1) mm, respectively, with OR = 0.15 (95% CI, 0.06-0.40, P = 0.0001). The mean sagittal angles were significantly more acute in deceased children [134.5° (± 9.3)] than in living children [142.9° (± 8.1)], with OR = 0.28 (95% CI, 0.14-0.56, P = 0.0003). The mean height/width ratios were 19.8 (± 3.7) and 14.1 (± 3.3), respectively, with OR = 6.10 (95% CI, 2.50-14.9, P = 0.0001). The hard palate was subjectively considered as ogival in 59.4% (19/32) of the cases versus 12.5% (8/64) of the controls.

CONCLUSION

Radiological features of the ogival palate were strongly associated with SUDI. This observation still needs to be confirmed and the corresponding clinical features must be identified.

Alloplastic Temporomandibular Joint Reconstruction in Congenital Craniofacial Deformities

ABSTRACT

Temporomandibular joint (TMJ) reconstruction with alloplastic prosthesis is a commonly performed procedure, which can be used as a treatment for improving pathologic conditions affecting the TMJ. Depending of the severity of the condition, the patient's ability to eat can be impaired, which in turn can affect their quality of life. Several syndromes can affect the patient's facial features, and some of those also affect TMJ's. Use of alloplastic prosthesis in TMJ's affecting syndromes, by means of correcting TMJ conditions and mandibular deformities, is still rather uncommon. Purpose of our study is to review the use TMJ total prosthesis as a treatment modality for correcting TMJ conditions and the reconstruction of mandibular deformities in congenital syndromes affecting the facial features. This study consists of a retrospective cohort of patients treated with TMJ reconstruction with alloplastic prosthesis at the Helsinki University Hospital during the past decade. All subjects with congenital syndrome who underwent TMJ reconstruction were included the study. The cohort consisted of seven patients and ten joints treated. Temporomandibular joints affecting syndromes were Goldenhar syndrome, hemifacial macrosomia, Nager syndrome, and Treacher-Collins syndrome. The majority of the patients have had several previous operative treatments on the facial skeleton during their childhood, which in turn probably affected and compromised the TMJ surgery outcome. Mouth opening was sufficiently achieved as average maximal opening was 34 mm (range 24-42 mm) postoperatively. Temporomandibular joint reconstruction with alloplastic prosthesis can offer new tools and approaches for treatment of facial deformities in syndromes with craniofacial abnormalities. Impaired jaw functions and asymmetry can be addressed with the use of alloplastic prostheses, achieving sufficient mouth opening and restoring the symmetry of the lower facial skeleton.

Neural crest-specific deletion of Bmp7 leads to midfacial hypoplasia, nasal airway obstruction, and disordered breathing modelling Obstructive Sleep Apnea

Pediatric obstructive sleep apnea (OSA), a relatively common sleep-related breathing disorder (SRBD) affecting approximately 1-5% of children, is often caused by anatomical obstruction and/or collapse of the nasal and/or pharyngeal airways. The resulting sleep disruption and intermittent hypoxia lead to various systemic morbidities. Predicting the development of OSA from craniofacial features alone is currently not possible and a controversy remains if upper airway obstruction facilitates reduced midfacial growth or vice-versa. Currently, there is no rodent model that recapitulates both the development of craniofacial abnormalities and upper airway obstruction to address these questions. Here, we describe that mice with a neural crest-specific deletion of Bmp7 (Bmp7ncko) present with shorter, more acute angled cranial base, midfacial hypoplasia, nasal septum deviation, turbinate swelling and branching defects, and nasal airway obstruction. Interestingly, several of these craniofacial features develop after birth during periods of rapid midfacial growth and precede the development of an upper airway obstruction. We identified that in this rodent model, no single feature appeared to predict upper airway obstruction, but the sum of those features resulted in a reduced breathing frequency, apneas and overall reduced oxygen consumption. Metabolomics analysis of serum from peripheral blood identified increased levels of hydroxyproline, a metabolite upregulated under hypoxic conditions. As this model recapitulates many features observed in OSA, it offers unique opportunities for studying how upper airway obstruction affects breathing physiology and leads to systemic morbidities.

Screening of obstructive sleep apnea (OSA) risk in adolescent population and study of association with craniofacial and upper airway morphology

Background

Obstructive sleep apnea (OSA) is a common form of sleep-disordered breathing with high prevalence and associated co-morbidities. It still goes largely under-reported due to events occurring in sleep and difficulty in identifying predisposing factors.

Aims

To perform questionnaire-based screening of OSA-risk in adolescents and study association of OSA-risk with craniofacial and upper airway morphology.

Material and methods

Modified STOP-BANG questionnaire was used for screening OSA-risk in adolescent orthodontic patients (10-19 years) in a government dental hospital in India. Patients were categorised into two groups: OSA-risk and non-risk, based on the questionnaire scores, and were subsequently evaluated for craniofacial and upper airway morphology, both on examination and on lateral cephalometric radiographs.

Results

Documented a high prevalence of 14% for OSA-risk in adolescent orthodontic patients. The extra-oral and intra-oral parameters found significantly associated with OSA-risk were convex profile [Odd's ratio (OR) - 3.824], steep mandibular plane angle [MPA] (OR- 79.75), Type 3/4 faucial pillars (OR- 11.227), Class II molar relationship (OR - 4.518), ovoid upper arch form (OR - 13.750). In addition, the cephalometric parameters: ANB (p- 0.025), SN-MP (p- 0.007), BA-SN (p- 0.020), PNS-AD1 (p < 0.001), PNS-AD2 (p - 0.001) also showed highly significant association to OSA-risk. The ROC curves demonstrated high sensitivity and specificity for PNS-AD1 (60%,83.3%), PNS-AD2 (73.3%, 70%) and SN-MP (60%,70%), respectively for OSA-risk.

Conclusions

The study supported applicability of modified STOP-BANG questionnaire for OSA-risk in Indian adolescents. The parameters [extra-oral, intra-oral, cephalometric and upper airway (PNS-AD1, PNS-AD2, SN-MP)] significantly associated with OSA-risk, were identified.

Comparison of screening methods for obstructive sleep apnea in the context of dental clinics: A systematic review

OBJECTIVE

To review the available bibliographic data to identify the best screening methods to detect potential obstructive sleep apnea (OSA) patients during dental clinical practice.

METHODS

Relevant studies published up to April 2020 were sourced from PubMed, Embase, MEDLINE, Cochrane, and LILACS databases.

RESULTS

Thirty studies were selected. For adults, the screening methods available to the dentist included questionnaires, scales, indexes, pulse oximetry, and anatomical factors. A combination of questionnaires is potentially the most reliable method to detect OSA risk. For children, only information on questionnaires and anatomical factors was found; two questionnaires accurately identified potential OSA risk cases. Anatomical factors also displayed a significant relation with OSA for both populations.

CONCLUSION

Dentists have a fundamental role in early detection of potential OSA cases since they can use the methods identified in this review to perform an initial screening of the population.

ABBREVIATIONS

OSA: Obstructive sleep apnea; PSG: Polysomnography; HST: Home sleep study; BMI: Body mass index; PPV: Positive predictive value; NPV: Negative predictive value; AHI: Apnea hypopnea index; RDI: Respiratory disturbance index; ODI: Oxygen desaturation index; PSQ: Pediatric Sleep Questionnaire; SRBD: Sleep-related breathing disorder; CSHQ: Children's Sleep Habits Questionnaire; ESS: Epworth Sleepiness Scale; PSQI: Pittsburgh Sleep Quality Index.

Development, validation and application of a 3D printed model depicting adenoid hypertrophy in comparison to a Nasoendoscopy

Background

The exploration of tridimensional (3D) technology of computational tomography and the development of valid 3D printed models may improve the assessment of adenoid obstruction. The identification of an enlarged adenoid in childhood would streamline the referral of appropriately selected cases to an otolaryngologist, leading to early treatment of affected children when indicated. The objective of this study is to validate the use of a 3D printed model depicting adenoid hypertrophy based on the pediatric otolaryngologist, head and neck surgeon (OHNS) participants assessment.

Methods

A cross-sectional study was performed to develop and validate 3D depictions, including print-outs, of the nasopharynx including different degrees of Adenoidal Hypertrophy (AH). The print-outs were obtained from 14 Cone-beam computed tomography (CBCT) scans of 14 children (12 boys, 2 girls; mean age of 10.61 years) representing grades 1, 2, 3, and 4 nasopharyngeal adenoidal obstructions, according to a previously Nasoendoscopy-graded (NE) classification by a licensed OHNS. The prevalence of AH in this study was 36%. Two OHNS were recruited to assess the print-outs representing two different representations of the nasopharyngeal airway, the lumen (LU) and adenoid mass (AD). LU and AD were visualized in 2D - pictures- and in 3D – printed prototypes. Intraclass correlation was used to assess intra- and inter-reliability. The validity of our depictions was analyzed through comparison (accuracy and correlation) to the reference standard (NE). The data were clustered to calculate the sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). Cross-tab and Pearson’s T-test were performed.

Results

Overall, the 3D depiction tools showed different diagnostic capabilities. AD representations showed strong (AD 2D, 75%) to almost perfect (AD 3D, 88%) accuracy compared to NE. Excellent sensitivity and specificity were observed for the AD 3D (100, 70%), as well as adequate PPV and NPV (66 and 97% respectively), with only 5% of false-negative cases.

Conclusion

The use of Dolphin software for the acquisition of a 3D printed prototype of the nasopharyngeal adenoidal region seems promising. These prototypes may be a practical and readily available alternative for the assessment of the nasopharyngeal obstructed area. CBCT in children must be taken under strong solid indications. Early referral to an OHNS for a full assessment remains the main objective in children with unclear symptoms.