Evaluation & Management of

1

Evaluation & Management of

Pediatric Obstructive Sleep Apnea

Stacey Ishman, MD, MPH, FAAP Surgical Director, Upper Airway Center

Director, Otolaryngology Outcomes Research

Divisions Otolaryngology & Pulmonary Medicine

Acknowledge: Scott Brietzke, MD, MPH

None

Objective

1. To compare guidelines from the AASM, AAO-HNS and AAP for diagnosis/management of OSA

2. To formulate a plan for evaluation and management of children with persistent obstructive sleep apnea (OSA) following adenotonsillectomy (T&A)

3. To understand the options and evidence for sleep surgical procedures currently utilized for treatment of OSA after T&A

Pediatric OSA

• 2 to 4% of pediatric population

• Two patterns seen in children

• Complete obstructive apneas

• Partial upper airway obstruction with

hypoventilation

Pediatric OSA

• Higher prevalance in pts with

• Craniofacial anomalies

• Pierre-Robin sequence, Apert syndrome…

• Neuromuscular diseases

• Cerebral palsy

• Muscular dystrophy

• Obesity

• Achondroplasia

• Mucopolysaccharidoses (Hurlers>Hunters)

#1 Cause of OSA in Children

Pediatric Sleep Disordered Breathing

Clinical Practice Guidelines

“Oto” 2011 “Sleep”2011 “Peds” 2012

Committee Composition

Oto Peds Sleep Otolaryngologist – 5

Sleep Medicine – 3

Peds Pulm – 1

Anesthesia – 1

Research - 1

Peds Pulm - 6

Pediatrician – 3

Otolaryngologist – 1

Neonatologist – 1

Neuropsychologist -1

Sleep Med - 11

Target Audience

Oto Peds Sleep Otolaryngologist in any

practice setting where a

child would be

evaluated

uncomplicated

childhood OSAS in an

otherwise healthy child

...who is being evaluated

in the primary care

setting

pediatric physicians

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Purpose

Oto Peds Sleep to define actions that

could be taken by

otolaryngologists to

deliver quality care

1) increase recognition

of OSAS by primary care

clinicians to minimize

delay in diagnosis 2)

evaluate diagnostic

techniques 3) describe

treatment options

4) provide guidelines for

follow-up 5) discuss

areas requiring further

research

to evaluate the

validity and reliability of

PSG and to determine

its clinical utility for

assessment and

management of various

respiratory disorders

howtoblogabook.com

Methodology “OTO”

• Strong Recommendation

– Benefits> Harm – strong evidence

• Recommendation

– Benefits>Harm – evidence not as strong

• Option

– Quality of evidence suspect OR little advantage

• No Recommendation

blog.plista.com

PSG: “Obvious” High Risk Cases

Oto Peds Sleep Obesity

Down Syndrome

Craniofacial abnormalities

Neuromuscular disorders

Sickle cell disease

Mucopolysaccharidoses

RECOMMENDATION,

GRADE C

Not within the

scope

Obesity

Down Syndrome

Craniofacial abnormalities

Neuromuscular disorders

Prader-Willi

Chiari malformations

Pierre Robin Sequence

ALTE

STANDARD

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PSG: Oto - High Risk Cases PSG: “Healthy” Child

Oto Peds Sleep advocate for PSG prior

to tonsillectomy for SDB

in children…for whom

the need for surgery is

uncertain or when there

is discordance between

tonsillar size on physical

exam and the reported

severity of SDB

RECOMMENDATION,

GRADE C

If a child snores on a

regular basis and has

complaints shown in

Table 2 clinicians should

either 1) obtain PSG or

2) refer to a sleep

specialist or

otolaryngologist

RECOMMENDATION,

GRADE B

PSG is indicated when

the clinical assessment

suggests the diagnosis

of OSAS in children

STANDARD

PSG: “Healthy” Child

Oto Peds Sleep advocate for PSG prior

to tonsillectomy for SDB

in children…for whom

the need for surgery is

uncertain or when there

is discordance between

tonsillar size on physical

exam and the reported

severity of SDB

RECOMMENDATION,

GRADE C

If a child snores on a

regular basis and has

complaints shown in

Table 2 clinicians should

either 1) obtain PSG or

2) refer to a sleep

specialist or

otolaryngologist

RECOMMENDATION,

GRADE B

PSG is indicated when

the clinical assessment

suggests the diagnosis

of OSAS in children

STANDARD

History

• 12 article identified

• 11/12 concluded clinical evaluation is

inaccurate in diagnosing OSA

• Level of evidence was B/B+

Brietzke et al. Otolaryngol Head Neck Surg 2004;131:827-32.

History

• None had an adequate balance sensitivity & specificity

• High sensitivity (positive = actually positive)

• Low specificity (negative = actually negative)


History

Positive predictive value below 1 èè Overdiagnosis of OSA

when compared to PSG


History

• A “positive” history is very reliable

– BUT cannot tell you the severity

• A negative history is NOT very reliable

– Poor quality – How much are the parents

observing?

– If the risk/consequences are high – will need

to use objective testing

– This includes post-operative patients

Limitations of the History

Oto Peds Sleep Caregiver reports of

snoring, witnessed

apnea or other nocturnal

symptoms may be

unreliable if the

caregiver does not

directly observe the

child while sleeping or

only observes the child

early in the evening

the sensitivity and

specificity of the history

and physical exam are

poor

Snoring and other

nocturnal

symptoms…showed

inconsistent

correlations with

respiratory parameters

of PSG

marquelrussell.com

Does it Matter?

Does it Matter?

Limitations of the Physical Exam

Oto Peds Sleep “tonsil size does not

predict the severity of

OSAS”

“the size of the tonsils

cannot be used to

predict the presence of

OSAS in an individual

child”

“The task force found

that clinical evaluation

alone does not have

sufficient sensitivity or

specificity to establish a

diagnosis of OSAS”

• Association between subjective pediatric

tonsil size (0 to 4+) and PSG OSA Severity

– Weak at best

• Conclude subjective tonsil size has

limitations for clinical decision making

01

02

03

04

0

1 2 3 4Tonsil_Size

Spearman's rho = 0.0282

Test of Ho: preop_rdi and

tonsil are Independent

Prob > |t| = 0.8847

28

• Based on physical examination

• Preliminary Data

Tonsillar Staging

Tonsil

Grade

Description

Grade 0 No Tonsils

Grade I 0-24% Filling oropharynx

Grade II 25-49%

Grade III 50-74%

Grade IV 75-100%

29

Modified Mallampati Staging

30

31

Results- Pre and Post Surgical RDI

32

0

5

10

15

20

25

30

1 2 3 4

Avera

ge R

DI

Friedman Staging System

Post-Surgical Improvement in RDI

Pre-Op RDI

Post-Op RDI

Percent Surgical Success

33

0

20

40

60

80

100

1 2 3 4

Perc

en

t S

uccess

Friedman Staging System

Percent Surgical Success

Alternatives to PSG

Oto Peds Sleep “Laboratory-based PSG

remains the gold

standard for the

diagnosis of OSA in

children….the panel

recommends against the

routine use of PM over

in laboratory PSG”

RECOMMENDATION

“If PSG is not available,

then clinicians may order

alternative diagnostic

test such as nocturnal

video recording,

nocturnal oximetry,

daytime nap PSG, or

ambulatory PSG ”

OPTION, GRADE C

“Nap (abbreviated) PSG

is not recommended

for the evaluation of

OSAS”

OPTION

*Separate statement

paper on portable

monitors recommends

against use in children

glimpseofpeace.blogspot.com

Adenotonsillectomy

Oto Peds Sleep “Clinicians should

counsel caregivers about

tonsillectomy as a means

to improve health in

children with abnormal

PSG who also have tonsil

hypertrophy and sleep

disordered breathing”

RECOMMENDATION,

GRADE C

“If a child has a clinical

examination consistent

with adenotonsilar

hypertrophy, and does

not have a

contraindication to

surgery, the clinician

should recommend AT as

the first line of

treatment”

RECOMMENDATION,

GRADE B

“Adenotonsillectomy

(AT) is commonly

performed as a first-

line treatment of OSAS

in children”

Adenotonsillectomy – healthy kids

Postoperative Followup

Oto Peds Sleep “Clinicians should

counsel caregivers and

explain that SDB may

persist or recur after

tonsillectomy and may

require further

management”

RECOMMENDATION,

GRADE C

“Clinicians should

clinically reassess all

patients with OSAS for

persisting signs and

symptoms after therapy

to determine whether

further treatment is

required.”

RECOMMENDATION,

GRADE B

“Children with mild

obstructive sleep apnea

syndrome pre-

operatively should have

clinical evaluation

following adeno-

tonsillectomy to assess

for residual symptoms.

If there are residual

symptoms of OSAS, PSG

should be performed. ”

STANDARD

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Persistent OSA after T&A

Oto Peds Sleep

No comments

“Clinicians should refer patients for CPAP

management if symptoms/signs (Table 2)

or objective evidence of OSAS persists

after adenotonsillectomy” RECOMMENDATION, GRADE C

“Clinicians may prescribe topical

intranasal corticosteroids for children

with mild OSAS in whom T&A is

contraindicated or for children with mild

postoperative OSAS”

OPTION, GRADE B

“PSG is

indicated for

positive airway

pressure (PAP)

titration in

children with

obstructive

sleep apnea

syndrome ”

STANDARD

Postoperative Monitoring

Oto Peds Sleep “Clinicians should admit

children with OSA

documented in results of

PSG for inpatient,

overnight monitoring

after tonsillectomy, if

they are under age 3

years or have severe

oxygen saturation nadir

less than 80%, or both”

RECOMMENDATION,

GRADE C

“Clinicians should

monitor high-risk

patients (Table 5)

undergoing

adenotonsillectomy as

inpatients post-

operatively”

RECOMMENDATION,

GRADE B

“PSG is indicated for

positive airway

pressure (PAP) titration

in children with

obstructive sleep apnea

syndrome ”

STANDARD

Should They Stay or Should They Go?

Obvious cases

• 3 or under, prematurity

• Obese

• Craniofacial Syndromes

• “Severe” disease

• Failure to thrive

www.rorycoplin.com

Oto Recommendations

• PSG for SDB in children in whom the need

for surgery is uncertain or discordance

between tonsillar size and severity of SDB

• Communicate PSG results to anesthesia

Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J. 2011 May; 37(5):1000-1028.

Oto Recommendations

• Admit children with OSA if:

– < 3 years

– AHI>10 events/hour

– Oxygen saturation nadir <80%

Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J. 2011 May; 37(5):1000-1028.

AAP Recommendations

• Admit children with OSA if:

– < 3 years

– AHI≥24 events/hour

– Oxygen saturation nadir <80%

– Peak end tidal CO2 >60mmHg

Marcus C et al. Pediatrics. 2012; 130:576.

Putting the Puzzle Together….

• Clinical Evaluation

– Verify the quality of the history

– Remember that the specificity is low

– Get a 3D impression of the tonsils (gag)

allthingsd.com


• Use of PSG

– Diagnostic uncertainty

– Higher operative risk

• Bleeding dyscrasia

• Malignant hyperthermia

allthingsd.com


• Pros of PSG

– Recognize nonobstructive disease to avoid surgery

– Negative study allow high risk children to defer or

delay surgery

– Baseline to compare with future results

– Assist with perioperative planning – admission,

cardiac evaluation, preoperative CPAP, opioids

procondebaters.wordpress.com

Putting the Puzzle Together…. Cons of PSG

• High cost

• Limited availability

• Delay in treatment

• Does not change admission for high-risk children

copyfight.corante.com

• Post-op Monitoring

– Outpatient with observation period

• 2 vs 4 hours as a minimum

– Inpatient

• 3 or under (10 kg), history of prematurity

• Obese, craniofacial syndrome, neuromuscular


allthingsd.com

• Post-op PSG

– When there is any doubt

• Persistent symptoms of SDB/OSA

– High risk for persistent OSA

• Obesity

• Down’s Syndrome …


dchawks.com 50

Management of

Persistent Pediatric OSA

Options

• Non-surgical treatment

– Weight loss/Sleep Hygiene

– Pharmacotherapy

– Palate expansion/Dental appliances

– CPAP

• Surgical treatments

– Adenoidectomy

– Tonsillectomy vs. tonsillotomy

– Nasal treatments

– Tongue/tongue base procedures

Non-surgical modalities

– Weight loss

– Sleep hygiene

– Pharmacotherapy

– Oral appliances/Rapid Maxillary Expansion

– Nasal continuous positive airway pressure

Medical Weight Loss

• 10yr Counseled behavior & dietary approach • 34% had 20% weight loss • 30% were no longer obese

• Meta-analysis: 342 adults after surgery • BMI decreased 57.6 to 37.7 kg/m2

• AHI decreased 54.7 to 15.8 events/hour • Many still with moderate to severe OSA

• 34 adolescents • Mean weight loss 58kg • OSA in 19/34

– 10 underwent repeat PSG (9.1 to 0.7/hr) – resolved

Karla M et al. Obes Res 2005;13(7):1175-9.

Weight Loss

• Medical Weight loss (10-18yo; N=132) – 49 with SDB, 42 with RDI>2/hour (14>5/hr) – Overall Mean preop RDI=1.9 events/hr – 71% resolved with weight loss – 32% decrease in BMI

Hoorenbeeck K,et al. Obesity 2012;20(1):172.

Pretreatment SDB

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Weight Loss

• 5 Guidelines/Recommendations – 2007 Health Care organization 4 stage model

• Convened by AMA and CDC

– 2007 Canadian clinical practice guidelines

– 2008 Endocrine Society recommendations

– 2009 Obesity Management 7 step model

– 2010 U.S. Preventive Task Force recs

Kirschenbaum DS et al. J Consult Clin Psychol 2013, 81(2):347-60

Bariatric Surgery

• ASMBS best practice guidelines

– “mounting body of evidence supports the use of

modern surgical weight loss procedures for carefully

selected, extremely obese adolescents”

• BMI of 40 kg/m2 with other co-morbidities

– HTN, INS resistance, glucose intolerance, OSA with

AHI≥5, dyslipidemia, substantially impaired QOL/ADL

• BMI > 35 kg/m2 with major co-morbidities

– Type 2 DM, mod-svr OSA (AHI≥15),pseudotumor

cerebri, or severe NASH

Michalsky M, et al. Surgery for Obesity & Related Diseases 2012;8(1):1-7.

Bariatric Surgery

• Prospective trial (N=50)

– 14-18yo, BMI >35

– Medically supervised lifestyle vs gastric banding

– 2 years postoperatively

lifestyle surgery

Mean %EWL 13% 79%

Metabolic synd (B) 40% 36%

Metabolic syndr(2yr) 44% 0%

– Surgery group: 33% reop rate in 2 years

• Band slippage, pouch dilation, injury to port side tubing

Ibele AR, Mattar SG. Surgery Clin NA, (2011) 91(6) 1339.

Bariatric Surgery

• Prospective cohort study (N=226)

– 5-21 yo, BMI >35 kg/m

– Pre and post gastric sleeve

baseline 3yr

BMI (mean) 48 30

OSA present 43% 7% (15/16 improved)

Alqahtani AR. Surgery Obesity Related Dz. 2014;10:842.

Pharmacotherapy

• Steroids

–Oral Steroids – 5D trial (1mg/kg) – no reduction

–Nasal Steroids – 6 wk course in 25 pts – decreased RDI from 11 to 6/hr

Al-Ghamdi AS et al. Laryngoscope (1997) 107:1382-7.

Brouillette RT et al. J Pediatr (2001) 138:838-44.

Pharmacotherapy

• Leukotriene Modifiers

– Increased # leukotriene receptors in tonsils of

sleep apnea patient

– Demonstrated a specific topographic pattern of

expression

Goldbart AD et al. Chest (2004) 126:13-18.

Goldbart AD et al. AM J Resp Crit Care Med (2005) 172:364-70.

Leukotriene Modifiers

Montelukast daily use x 16 wks in 24 mild osa pts

• Improvement in hypercarbia and AHI

• Decrease in adenoid size

Goldbart AD. Pediatrics. 2012 Sep;130(3):e575-80.

Combo Montelukast/Nasal Steroid

Montelukast daily use x 12 wks in 752 mild osa pts

• Normalization PSG in 62%

• Less likely to work in children > 7 years or obesity

Kheirandish-Gozal L. Chest. 2014;146(1):88-95.

0

1

2

3

4

5

pretreatment

posttreatment

Oral Appliances

• Most effective in nonobese patients with retro or micrognathia

• Better for mild to moderate cases

• 20 healthy kids versus 20 with mild to moderate OSA – Reduced mandibular length – Overbite – Superior hyoid bone position – Smaller dental arch

Cozza et al. Eur J Orthod (2004) 26:523-30.

Evaluation for Surgery

• Physical examination • Cine MRI • Sleep endoscopy

Villa MP et al. Sleep Med. 2007;8(2):128.

Villa MP et al. Sleep Breath. 2011;15:179.

Cine MRI

• 2003 – 32 children with and without OSA

– Airway measurement/collapsibility differ

• 2004 – 15 children with Down Synd

– Relative macroglossia 74%

– Glossoptosis 63%

– Recurrent/enlarged adenoids 63%

– Enlarged lingual tonsils 30%

– Hypopharyngeal collapse 22%

• 2008/2010 – reproduced results

Lane F et al. Radiology. 2003;227:239.

Shott S et al. Laryngoscope. 2004;114(10):1724.

Guimaraes C et al. Ped Radiology. 2008;38:1062.

Schaaf WE et al. Am J on Roentgenology. 2010;194(5):120.

Cine MRI - Axial

Hypopharyngeal

collapse

Glossoptosis

Cine MRI

Indications for DISE

• Indications currently under debate

• Original papers focused on syndromic children

• Evolution to:

– Persistent pediatric OSA

– Children without obvious area of obstruction

– Children with significant comorbidities

– State-dependent laryngomalacia

• Anesthesia to approximate natural sleep

• Look at the dynamic movement of the

airway

• Use flexible laryngoscopy or bronchoscopy

Drug induced sleep endoscopy

• 1986 - Sher - syndromic children with PRS

– Reported Glossoptosis & pharyngeal collapse

• 1991 - Sleep endoscopy was described by Croft

and Pringle

Croft CB. Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea. Clin

Otolaryngol Allied Sci. 1991;16(5):504.

Sher A et al. IJPO. 1986;11(2):135.



• Then mentioned recently in pediatric

literature as a valuable tool in management

of persistent pediatric OSA by identifying

site of obstruction

Lin AC, Koltai PJ. Sleep Endoscopy in the Evaluation of Pediatric OSA. IJPO 2012; 2012:576719

DISE

• 2000 -2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

tongue base

supraglottic collapse

*

* *

*

* = persistent

OSA

Occult Laryngomalacia Severe OSA

Surgical Treatment Beyond T&A

– Adenoidectomy – revision

– Completion Tonsillectomy

– Palatal surgery (UPPP)

– Nasal surgery

– Maxillary expansion

– Tongue/tongue base procedures

– Supraglottoplasty

Adenoidectomy

– Long-term follow-up (3-5 years)

• Snoring 88%, Obstructed breathing 44%

– 32 no improvement /worsening • Adenoid hypertrophy seen in 50% (16/32)

– 174 with improved symptoms • 11% (20/174)

Joshua B. Otolaryngology–Head and Neck Surgery (2006) 135, 576.

Adenoidectomy

• Retrospective (n=48 sdb, 52 no sdb)

– Likelihood of future tonsillectomy or revision

adenoidectomy

– 38% with sdb underwent subsequent surgery versus

19% of those with nonobstructive

Brietzke S. Otolaryngology–Head and Neck Surgery (2006) 134, 979.

Tonsillotomy • Retrospective study

– 1,731 partial tonsillectomy group vs

– 1,212 patients traditional tonsillectomy

– Tonsillotomy

• Decreased posttonsillectomy hemorrhage (1.1% vs. 3.4%, p

< 0.001)

• Decreased severe pain or dehydration requiring medical

attention (3.0% vs. 5.4%, p = 0.002)

• 0.64% required revision completion tonsillectomy for

tonsillar hypertrophy

Schmidt R. Arch OtoHNS. 2007;133(9):925

Tonsillotomy

• Risk of tonsillar regrowth (0.5-17%):

– 17% (7/42) – Krespi – 1-10 year results (laser)

– 2-4% cited for symptomatic evaluation only

– Most studies with low numbers are 1 year follow-up

or less

– Risk factors for tonsil tissue recurrence ?

• Young age at the time of surgery

• Acute tonsillitis during the recovery period

Krespi YP. J Otolaryngol1994;23:325.

Celenk F. Int J Pediatr Otorhinolaryngol. 2008 Jan;72(1):19

UPPP

• UPPP proposed in neurologically impaired, obese

and Downs kids – All retrospective studies

– Nasopharyngeal stenosis at increased risk when

performed along with adenoidectomy

Kerschner JE. IJPO. 2002;62(3):229.

Kostko J. IJPO. 1995;32:241.

Nasal / Nasopharyngeal

• Nasal/Nasopharyngeal

– Adenoidectomy

– Nasal turbinate reduction

– Septoplasty – concern about nasal growth

Nasal Surgery

• Nasal obstruction = potential OSA contributor

• Several studies have shown that

– Nasal obstruction alone may cause or exacerbate

apnea in some children

– Children with turbinate hypertrophy are more likely

to have persistent OSA after T&A

• No data on treatment of nasal obstruction alone

for treatment of SDB in children

Morita T et al. Am J Otolaryngol. 2004;25(5):334-338.

Sullivan S, et al. Ann Acad Med Singapore. 2008;37:645-648.

Nasal Surgery

• Meta-analysis: Effect of nasal surgery on OSA

– Reduction 11 events/hour

Ishii L, et al. OtoHNS. 2015; Epub ahead of print.

Nasal Surgery

• Randomized, controlled trial on effect of RF turbinate

ablation on NAO in adults

– Improves NAO and nasal CPAP compliance

• ? Consider nasal turbinate reduction routinely in

children with inferior turbinate hypertrophy

• ? Wait as turbinate hypertrophy noted to be commonly

improved after adenoidectomy & suggests that many

will benefit from adenoidectomy alone

Powell NB, et al. Laryngoscope. 2001;111(10):1783-1790.

Nasal Turbinate Reduction

• Nasal turbinate reduction

– Retrospective case review

– 28 T&A, 23 with T&A/Turb

With Turbinate Reduction Without Turbinate Reduction

Preop Postop Preop Postop p

AHI 15.6 (5.2-28) 0.8 (0.2-1.6) 15.0 (5.4-26) 3.5 (0.5-4.6) <0.01

Min Sat 84 (76-94) 94 (92-97) 83 (75-92) 93 (91-96) <0.05

Min xsec area 0.16 (0.08-0.24) 0.31 (0.25-0.37) 0.15 (0.05-0.26) 0.16 (0.07-0.27) <0.01

Cheng PW. Laryngoscope. 2012 Oct 15

Rapid Maxillary Expansion

• Device fitted to the molars with expansion of the maxilla

• Carried out over 12 months or less

http://www.orthopraxis.gr/?p=29&lang=en


• 2006 – Study of 14 children – Snoring & AHI reduced ( 5.8 to 1.5 events/hr) – Daytime symptoms (sleepiness, tiredness, and oral

breathing) significantly improved – Mean expansion

• 3.7 0.7 mm for the intercanine • 5.0 2.2 mm for the inter pre-molar

• 2011 – Follow-up of 10/14 – Repeat PSG in 12 and 24 months – 24 months later, improvement in AHI and clinical

symptoms persisted

Villa MP et al. Sleep Med. 2007;8(2):128.

Villa MP et al. Sleep Breath. 2011;15:179.


• 2004 –31 children (4 month followup ) – 10-20 day expansion; 6-12 months of consolidation – AHI reduced ( 12.2 to <1 events/hr) – Mean expansion

• 3.9 0.3 mm for the intermolar • 3.0 0.2 mm for the interincisive

Pirelli P et al. Sleep. 2004;27(4):761.

Procedures

• Tongue/Tongue Base

– Macroglossia

– Lingual tonsillectomy

– Glossoptosis, tongue base obstruction treatment

including surgery

• Tongue suspension suture

• Radiofrequency ablation

• Hyoid suspension

• Partial Midline Glossectomy

• Genioglossal advancement

Lingual Tonsillectomy

Fricke. Pediatr Radiol. 2006;36:518.

Radiology studies and flexible endoscopy show hypertrophy in

Down Syndrome and Obesity

Flex scope showing hypertrophy

Lingual Tonsillectomy

Manickam et al. Laryngoscope. 2015; Epub ahead of print.

Author N Mean age Resolution O2 Sat

pre/post

AHI

pre/post

Abdul-Aziz 16 NR 68% 84/91 10.5/3.2

Chen 68 11 57% 89/91 11.8/5.7

Truong 31 7 NR NR 18.3/9.7

Lin 26 11 61% 89/90 14.7/8.1

Wootten 9 9 66% 83/84 8.5/4.1

Tongue Suspension Suture • Case reports showing variable success

• Wooten/Shott -2010 - 31 patients – with RFA BOT

•Mean age = 11 years; 9/31 Downs

•Success = 61% (66% no DS)

Radiofrequency Ablation

•Safety with tongue lymphatic malformation

•Study combined with tongue suspension

•Meta-analysis in adults •Mean treatments = 4.3 (2.4-5.5 range)

•Long-term changes

• ESS 32% reduction at 24m (OR 0.68, .43-.73)

• RDI 45% reduction at 24m (OR .55, .45-.72)

Farrar. Laryngoscope. 2008;118:1878.

Partial Midline Glossectomy

•Submucosal lingual excision (SMILE) •Pediatric cadaver studies only

•Endoscopic guidance with coblation

•Equivalent to RF BOT – 55% change in AHI (2008)

•RCT: UPPP with 1)RF vs 2)SMILE-RF vs 3)SMILE-harmonic

Babademez et al. OtoHNS. 2011;145(5):858.

Friedman M. Oto HNS. 2008;139:378.

Maturo SC. Ann Otol Rhinol Laryngol. 2006 ;115(8):624.

Partial Midline Glossectomy •PMG – Clark/Shott – 2011 ASPO

•22 Patients

•Success in 59%

•Current treatment protocol includes PMG with

tongue suspension if needed

Shott S. Curr Opin Otolaryngol Head Neck Surg. 2011 Dec;19(6):449.

Supraglottoplasty after T&A

Manickam et al. Laryngoscope. 2015; Epub ahead of print.

Author N Mean age Resolution O2 Sat

pre/post

AHI

pre/post

Chen 24 7 56% 88/89 14.9/4.9

Chen & Truong 9 NR NR NR 10.4/2.9

Truong 8 NR NR NR 9.7/5.7

Digoy 36 5 72% 83/87 13.3/4.1

Additional Procedures

•Genioglossal advancement •Pediatric case reports

•Adults - 70% reduction in RDI • With multiple adjunctive procedures

•Consider older kids with well-developed mandible

•Mandibular & craniofacial procedures •Tongue-lip adhesion

•Mandibular distraction osteogenesis

•Tracheostomy Miller FR. Oto HNS. 2004;130:73.

Procedures

••

•

Other Procedures

• Tracheostomy

– Highly effective

– Useful in kids with multiple

levels of obstruction or

neurologic impairment

– Increased risk of

perioperative complications COMPLICATIONS

Respiratory

1992 – 69 pts – 16 (23%) with complications

• Retrospective chart review

• Complications associated with:

– Younger than 3

– Severe OSA

– Weight <5%ile

– Craniofacial abnormalities

• Recommended hospitalization postop for all

McColley SA et al. Arch OtoHNS. (1992) 118(9):940.

Complications

Respiratory

1994 – 37 pts – 10 with complications

• Retrospective chart review

Rosen G et al. Pediatrics. (1994) 93(5):784.

Complications

Respiratory

1994 – Recommended selected admission after T&A

Rosen G et al. Pediatrics. (1994) 93(5):784.

Complications

Effect of Anesthesia on Sleep

1988– 8 healthy volunteers (20s)-isoflurane (3hr)

• Reduction in slow-wave sleep first night

• Sleep after surgery is low in REM and slow-wave sleep

• Poor sleep in the immediate postoperative period

– Analgesic drugs

– Pain

– Environmental noise

– Disturbance by nursing interventions

– Anxiety in unfamiliar environment

Moote CA, Knill RL. Anesthesiology. (1988) 69:327.

Complications

Sleep after T&A

2005– PSG 1st postop night after T&A for OSA (N=10)

– 5 mild OSA (1-10 events/hr)

– 5 severe OSA (>10 events/hr)

Nixon G et al. Ped Pulm. (2005) 39:332.

Complications

All 3 to 5 years old

Sleep after T&A 2005– PSG 1st postop night after T&A for OSA (N=10)

Nixon G et al. Ped Pulm. (2005) 39:332.

Complications

preop

1st night postop

6 weeks postop

Analgesic Sensitivity in OSA

2004– Age and preoperative sat nadir correlated with total opioid dose (N=46)

Brown K et al. Anesthesiology. (2004) 100:806.

Complications

Mean age = 43±19 months

Analgesic Sensitivity in OSA

2006– Children with preoperative sat nadir <85% required ½ opioid after surgery than those ≥85% (N=22)

Concluded: Recurrent hypoxemia in OSA associated with increased opioid sensitivity


Complications

Mean age = 43±19 months

Postoperative Pain Management

2006– Children with preoperative sat nadir <85% required ½ opioid after surgery than those ≥85% (N=22)

Concluded: Recurrent hypoxemia in OSA associated with increased opioid sensitivity


Complications

Mean age = 43±19 months • Morbidly obese 13yo with sleep apnea

• T&A, UPPP and SMR turbinate resection 12/9/13

• Planned admission to the PICU

• Severe bleeding, transfusions

• Cardiac arrest & anoxic brain death

• Declared dead POD3 - eval that included 2 EEG

• Goldman et al. 2013 M&M after T&A

– AAO newsletter, 552 respondents

– 51 mortalities reported

• 4 with anoxic brain injury

Sales

Pediatric

Adult

Unknown


–Mechanism

• Medication 22%

• Pulmonary/CV factors 20%

• Hemorrhage 16%

• Perioperative events 7%

• Progression of underlying disease 5%

• Unexplained (All but 1 outside) 31%


– Preop OSA dx NOT associated with increased risk of

death or anoxic brain injury

– Timing

• 55% in the first 2 days after surgery

– Events unrelated to bleeding accounted for the

preponderance of deaths & anoxic brain injury

• Hill, Hartnick et al. 2011 Risk factors for airway

complications in T&A for severe osa

– N=83 with AHI>10 – all admitted

– Major complications – 4.8%

• Increased level of care

• CPAP/BIPAP use

• Pulmonary edema

• Reintubation

– Minor Complications – 19.3%

• Oxygen sat < 90%

Hill et al. IJPO. 2011;75(11):1385.

• Hill, Hartnick et al. 2011 Risk factors for airway

complications in T&A for severe osa

– Independent predictors of complications

• Age < 2 years

• AHI >= 24 events/hour

• Intraop laryngospasm requiring treatment

• Oxygen sats <90% on RA in PACU

• PACU stay > 100 mins

– Any of these factors – 38% complications (vs 2%)

Hill et al. IJPO. 2011;75(11):1385.

• Dalesio, Smith, Ishman et al.

– CO2 driver of complications

– Unadjusted Modeling

• Sat nadir 0.0096

• Peak CO2 < 0.001

– Adjusted model

• Age significant and correlated with sat nadir/peak CO2

• ? Confounder of the relationship between CO2 and

complications

• Dalesio, Smith, Ishman et al.

– CO2 driver of complications

– Unadjusted Modeling

• Sat nadir 0.0096

• Peak CO2 < 0.001

– Adjusted model

• Age significant and correlated with sat nadir/peak CO2

• ? Confounder of the relationship between CO2 and

complications

• Gaps:

– Who needs to be admitted?

– What level of admission is necessary?

• Floor, ICU, stepdown

– What is appropriate and safe pain control in these

children?

#8

Thank You Stacey Ishman, MD, MPH

Surgical Director, Upper Airway Center

Multidisciplinary Treatment of Children with

Persistent Sleep Apnea

[email protected]

Documents

Evaluation & Management of