Lingual Tonsil Hypertrophy Producing Obstructive Sleep Apnea

The hypertrophy of the lingual tonsil is a rare occurrence in adults. This disorder may cause obstructive sleep apnea (OSA) and also may lead to a life-threatening obstruction of the upper airway. Diagnosis of lingual tonsil hypertrophy in patients with OSA requires a careful examination by advanced technologic methods. The sleep apnea is successfully treated by lingual tonsillectomy, with or without tracheotomy. In this study the case of an adult with OSA caused by lingual tonsil hypertrophy which was treated with lingual tonsillectomy is presented, and the diagnosis and the treatment procedure of such cases are discussed.     

Diagnostic and therapeutic iter in paediatric OSAS: personal experience

Obstructive sleep apnoea syndrome in a child is characterized by prolonged episodes of obstructive hypopnoea and/or apnoea of upper airway leading to morbidity. The most common risk factor is adeno-tonsillar hypertrophy. Obstructive sleep apnoea syndrome diagnosis is based on clinical ENT evaluation and an instrumental approach, such as pulse oximetry or the gold standard overnight polysomnography. The aim is to establish, in a population of children with suspected obstructive sleep apnoea syndrome, the frequency of this disorder, the effect of adenotonsillectomy and the risk of post-operative complications. A total of 481 patients (297 male, 184 female) with suspected obstructive sleep apnoea syndrome (aged 2-14 years) were evaluated between March 2007 and April 2010 and divided into 3 morphological phenotypes: classic, adult and congenital. All patients underwent ENT assessment and a pulse oximetry with 4 channels cardiopulmonary monitoring. The examination following the Brouillette criteria was defined as negative, positive or inconclusive; when positive, adenotonsillectomy was the first therapeutic approach. At 6 months after surgery, all patients underwent check-up pulse oximetry. Of the overall sample, 96% of the patients had a classical phenotype, 3% an adult type and 1% a congenital type. The monitoring resulted pathological in 19% (17% of them were at increased post-operative risk), negative in 61% and inconclusive in 20%. All 5 patients with congenital phenotype were positive. Of the positive patients, 86% underwent adenotonsillectomy and a control pulse oximetry 6 months thereafter, 96% resulted negative. Pulse oximetry was efficient in order to avoid incorrect surgery indications, improving appropriateness and safety of adenotonsillectomy in children with obstructive sleep apnoea syndrome. Adenotonsillectomy showed a success rate of 96% and there were no episodes of post-surgery complications in particular in those patients at increased risk.     

Computer-assisted quantitative upper airway analysis following modified uvulopalatal flap and lateral pharyngoplasty for obstructive sleep apnoea: a prospective case-controlled study

Clin. Otolaryngol. 2012, 37 , 188–196 Objectives: The study aims to perform static and dynamic quantitative assessment of the anatomical changes of the upper airway before and after modified uvulopalatal flap and lateral pharyngoplasty and comparison of the improvement in airway dimensions, collapsibility and extent of normalisation to that of control patients. Design: Prospective case‐controlled study. Setting: Computer‐assisted quantitative measurement is used to compare upper airway parameters before and after modified uvulopalatal flap and lateral pharyngoplasty in patients with obstructive sleep apnoea (OSA). Participants: Patients with obstructive sleep apnoea diagnosed on sleep study and failed positive airway pressure therapy. Main outcome measures: Sleep study results, upper airway parameters and symptom score following surgery and its comparison to normal patients to assess the degree and extent of normalisation. Results: Thirty‐five study and 32 control subjects were recruited and completed the study. All the retropalatal airway dimensions like area, transverse diameter, longitudinal diameter and collapsibility showed statistically significant improvement following surgery. The success rate of this surgery is 43% (15 of 35) overall, 58% (14 of 24) for patients with isolated palatal obstruction and only 9% (1 of 11) for patients with multi‐level obstruction. Comparing obstructive sleep apnoea to the control subjects, there are obvious and logical differences in their biostatistics, sleep study parameters and airway dimensions. The postoperative obstructive sleep apnoea retropalatal longitudinal diameter has a higher tendency of normalising to be comparable to those of control patients. Conclusions: Modified uvulopalatal flap and lateral pharyngoplasty is an effective surgical technique for the treatment of obstructive sleep apnoea. The surgery increases the resting retropalatal dimensions and reduces the retropalatal collapsibility.     

Paediatric traffic accident and obstructive sleep apnoea by antrochoanal polyps: case report and literature review

Antrochoanal polyps are hyperplasias of the nasal mucosa, which have their origin in the maxillary sinus and extend through the nasal cavity and the choanae into the naso- and oropharynx. In children antrochoanal polyps represent one of the more frequent manifestations of paediatric nasal polyposis. Most studies on antrochoanal polyps in children report only on nasal obstruction, hyponasal speech and snoring, which are also encountered in the most common cause of obstructive sleep apnoea syndrome; i.e. adenoid or tonsillar hyperplasia. Only very few studies report on additional health hazards by antrochoanal polyps ranging from obstructive sleep apnoea syndrome to swallowing disorders and cachexia.We present the case of an 8 year old girl with a bicycle accident caused by excessive daytime sleepiness and obstructive sleep apnoea syndrome due to an extensive antrochoanal polyp. After a transnasal polypectomy and meatotomy type II the obstructive sleep apnoea and day time sleepiness resolved completely.Awareness of this additional health hazard is important and correct evaluation and timely diagnosis of a potential antrochoanal polyp is mandatory because minimally invasive rhinosurgery is highly curative in preventing further impending problems.     

Down's syndrome with lingual tonsil hypertrophy producing sleep apnoea

A 12-year-old girl is presented with Down's syndrome and lingual tonsillitis causing sleep apnoea. In order to overcome her sleep apnoea she adopted a functional sleeping posture. The sleep apnoea was successfully treated by a single staged lingual tonsillectomy without preliminary tracheostomy. A return to a normal sleeping posture occurred spontaneously in the early post-operative period.     

Myotonometry demonstrates changes of lingual musculature in obstructive sleep apnoea

Upper airway dilator muscles are important in the pathogenesis of obstructive sleep apnoea (OSA). Previously, soft palate and tongue muscles of patients with OSA have been studied from a histological point of view. Electromyographic studies revealed increased activity of upper airway dilator muscles. We used computerized endopharyngeal myotonometry (CEM) to measure the biomechanical properties of lingual musculature, mainly the genioglossal muscle, to characterize changes of tongue muscles in patients with OSAS. The method records and analyzes the response of the tongue sublingually after a brief mechanical impact. It enabled us to evaluate the most important parameters of tissue tone – stiffness, which is expressed as a frequency, and elasticity, as a logarithmic decrement of the damped oscillation. The results of CEM indicated that patients with OSAS show an increased stiffness (14.1 ± 0.7 Hz) of the tongue in comparison with non-snoring subjects (11.5 ± 0.2 Hz). The elasticity of the tongue is decreased, which is numerically expressed as an increased decrement (4.0 ± 0.2) in patients with OSA in comparison with non-snorers (2.2 ± 0.2). Changes in the biomechanical characteristics of lingual musculature during wakefulness could result from pathophysiological processes caused by obstructive sleep apnoea. Received: 14 December 2000 / Accepted: 28 June 2001     

甲状腺功能低下并发阻塞性睡眠呼吸暂停综合征3例报告

目的：探讨甲状腺功能低下与阻塞性睡眠呼吸暂停综合征(OSAS)之间的关系以及诊断和治疗。方法：报告3例甲状腺功能低下并发OSAS患者的临床资料并复习相关文献。其中1例辅以持续正压通气(CPAP)治疗．1例行悬雍垂腭咽成形术(UPPP)，1例单纯用甲状腺素替代治疗。结果：采用甲状腺素替代治疗后，可缓解症状和改善夜间睡眠呼吸暂停。结论：甲状腺功能低下常并发OSAS，采用甲状腺素替代治疗可取得一定的效果，但常需配合CPAP或手术治疗。     

The use of diagnostic sleep nasendoscopy in the management of children with complex upper airway obstruction

In this paper we present a prospective study of the role of diagnostic sleep nasendoscopy in the investigation and treatment of 20 children referred to a tertiary children's hospital with obstructive awake apnoea or severe obstructive sleep apnoea (apnoea/hypopnoea index greater than 30/h). We describe the technique of diagnostic sleep nasendoscopy and provide a classification system for documenting the findings. We demonstrate sleep nasendoscopy is an invaluable tool in the management of children who continue to have upper airway obstruction despite previous adenotonsillectomy and in children with airway obstruction due to cerebral palsy, syndromes and craniofacial malformations. With the use of pre- and post-intervention sleep studies we have shown that sleep nasendoscopy is accurate in deciding the most appropriate mode of intervention in the individual child with obstructive breathing, from (continuous positive airway pressure) CPAP to site-specific surgery. We conclude that sleep nasendoscopy combined with rigid laryngo-bronchoscopy should be standard practice in the evaluation of children with complex upper airway obstruction.     

Endoscopic evaluation and treatment of sleep-associated upper airway obstruction in infants and young children

A method is described for observing the pharyngeal airway in children with proven sleep apnoea using a flexible nasendoscope during light anaesthesia. Fifteen children were referred for endoscopic evaluation and treatment. All had documented obstructive sleep apnoea. Flexible endoscopic assessment of the airway revealed the site of obstruction in all cases and allowed a rational and successful management plan. The mechanism of obstructive sleep apnoea in infants and young children is discussed and the findings at endoscopy and results of treatment are reported.     

The seroprevalence of Helicobacter pylori infection in patients with obstructive sleep apnoea: a preliminary study

We investigated the seroprevalence of Helicobacter pylori in patients with obstructive sleep apnoea. A prospective clinical study consisting of 19 patients, aged 23-72 years with confirmed obstructive sleep apnoea by overnight polysomnography, and 36 control subjects, aged 25-61 years with no history of obstructive sleep apnoea and gastroesophageal reflux complaints, was conducted. Titres of serum H. pylori IgG antibody were assayed by a serum enzyme-linked immunoabsorbant assay. The difference between the study and control groups was analysed by chi-squared test. Seventeen of the 19 patients (89.5%) were found to be H. pylori positive. However, 21 of the 36 control subjects (58.3%) were H. pylori positive. The seropositivity of H. pylori in obstructive sleep apnoea patients was found to be significantly higher than the control group (P = 0.017). The result of our study shows that there is a high association between H. pylori infection and obstructive sleep apnoea. This data may be important for future treatment strategies of the disease.     

Parapharyngeal mass presenting with sleep apnoea

A 60-year-old man presented with a history of progressive sleep disturbance due to an intraoral parapharyngeal salivary gland tumour. The sleep study performed post-operatively showed rapid resolution of nocturnal hypoxic episodes. This appears to be the first recorded case of a parapharyngeal mass causing sleep apnoea and we review the current literature on obstructive sleep apnoea.     

Sleep apnoea of unusual origin

A 72-year-old man presented with a history of progressive sleep apnoea. The cause was a large superior laryngeal nerve schwannoma arising in the left parapharyngeal space. This had a ball-valve effect on the laryngeal inlet. Superior laryngeal nerve schwannomas are very rare. No documented case has presented with obstructive sleep apnoea before.     

Síndrome de apnea obstructiva en niños

Obstructive sleep apnoea syndrome is a well-known clinical entity in adults but until now it has been less well studied in children. In recent years there has been a dramatic increase in the recognition of sleep disorders in children. Our goal is to analyze scientific data published in the last few years. We reviewed published articles regarding paediatric obstructive sleep apnoea syndrome and extracted the clinical symptoms, diagnosis and treatment options. In conclusion, the natural course and long-term prognosis of childhood obstructive sleep apnoea syndrome are not well-known and further studies are needed in this area.     

Combined radiofrequency surgery of the tongue base and soft palate in obstructive sleep apnoea

OBJECTIVE: To investigate the safety and efficacy of combined temperature-controlled radiofrequency volumetric tissue reduction of the tongue base and soft palate in obstructive sleep apnoea. MATERIAL AND METHODS: A total of 20 patients with obstructive sleep apnoea and combined palatal and retrolingual obstruction were included in a non-randomized clinical trial and 51 combined treatments were performed under local anaesthesia. Postoperative pain was assessed using visual analogue scales. Functional parameters, daytime sleepiness and quality of life were assessed using questionnaires (Epworth Sleepiness Scale, Short Form-36) before and 12 weeks after the last treatment session. Concurrently, polysomnography was performed on two consecutive nights. Results The mean postoperative pain score dropped from 5.6 at Day 1 to 0.6 at Day 7. Painkillers were taken for a mean of 3.3 days. There were no postoperative complications or changes in functional parameters. Daytime sleepiness improved significantly (p<0.05). The mean respiratory disturbance index was reduced from 25.3+/-11.4 to 16.7+/-15.3 (p<0.05). Six out of 18 (33%) patients were cured after a mean of 2.7 treatment sessions. CONCLUSION: Combined radiofrequency volumetric tissue reduction of the tongue base and soft palate is a safe and effective treatment for obstructive sleep apnoea.     

Schnarchen bei Kindern

Background

Snoring in children is a prevalent symptom and may be an indicator of obstructive sleep apnoea. Despite its importance, there is no national guideline on its appropriate management.

Objective

To provide recommendations for the management of snoring in children and adolescents treated in a primary care setting.

Methods

A total of 16 national paediatric sleep experts were included in a Delphi process and formulated recommendations in the form of a step-wise work-up procedure.

Results

The following 8 steps were developed: (1) Identification of true cases of habitual snoring. (2) Identification of high-risk patients who should undergo polysomnography in a sleep laboratory. (3) Identification of mild cases that may be treated with anti-inflammatory medication. (4) Identification of cases that should be referred to an otorhinolaryngologist for potential surgery. (5) Performance of polysomnography in cases that remain unclear despite steps 3 and 4 to rule out obstructive sleep apnoea. (6) Reconsideration of surgery in cases with moderate to severe obstructive sleep apnoea. (7) Identification of severe sleep apnoea cases requiring continuous positive airway pressure therapy. (8) Identification of cases suitable for orthodontic treatment, craniofacial surgery or speech therapy.

Conclusion

This guideline should help to improve the management of snoring children and adolescents in Germany.     

Assessment of predictive ability of Epworth scoring in screening of patients with sleep apnoea

METHOD: Numerous studies have considered the benefits, and the disadvantages, of the Epworth Sleepiness Scale. Following an extensive literature review, we found that the evidence was inconclusive as regards the diagnostic efficacy of Epworth scoring for obstructive sleep apnoea syndrome. We undertook a retrospective study of 343 patients who underwent a sleep assessment over a 10-year period at the Monklands Hospital. ANALYSIS AND RESULTS: A total of 238 patients did not have sleep apnoea whereas 105 patients did. The mean Epworth score in patients with obstructive sleep apnoea syndrome was 10.94 (95 per cent confidence interval 9.46-11.42), and in the non-apnoeic group it was 7.73 (95 per cent confidence interval 7.04-8.41). Logistic regression and receiver operating characteristic curves were used to assess the predictive ability of Epworth scoring. The scores only explained 7-10 per cent of the variation in the probability of occurrence of obstructive sleep apnoea syndrome. The odds ratio for Epworth scoring was 1.118, and only 69 per cent of cases were correctly classified by the Scale. CONCLUSIONS: The literature review suggested that the Epworth Sleepiness Scale is associated with a low effect size and/or low predictive value when correlated or regressed on the Apnoea-Hypopnoea Index or Respiratory Disturbance Index, thus limiting its value as a screening test. Our study concluded that the Epworth Scale is only marginally useful in predicting the occurrence of obstructive sleep apnoea syndrome. We believe that every patient with a direct or witnessed history of sleep apnoea with obstructive symptoms have some form of sleep assessment.     

Lingual tonsillectomy in a child with obstructive sleep apnea: a novel technique

We report on a case of lingual tonsillar hyperplasia contributing to refractory obstructive sleep apnea in a 5-year-old patient. We describe a novel technique utilizing suspension laryngoscopy and a laryngeal angled shaver to remove obstructive lingual tonsillar tissue. We review the available techniques for lingual tonsillectomy and propose theoretical advantages to the novel approach.     

Obstructive sleep apnoea in adults presenting with snoring

Snoring is a common disorder, and may be associated with obstructive sleep apnoea, although there is little published information on the incidence of apnoea in snorers. This study aimed to assess the upper airway and to relate the findings to sleep study data in a population of patients referred by their general practitioners with loud snoring. Each patient had a full history, weight and height measurements, nasal examination, rhinomanometry, peroral grading of the oropharyngeal features, and fibreoptic pharyngoscopy with a modified Muller manoeuvre, followed by a sleep study. The results in our group of 35 patients demonstrate a high incidence of obstructive sleep apnoea (46%). Factors which correlated well with apnoea were excessively loud snoring, a narrow oropharynx, and marked obesity; 94% of patients with one or more of these features had evidence of sleep apnoea.     

Health outcome measurements in children with sleep disordered breathing.

OBJECTIVE: To validate the Child Health Questionnaire, measure quality of life in children with obstructive sleep apnoea and assess the impact of surgery. METHODS: The primary carer of a consecutive series of 42 patients with sleep disordered breathing referred to a paediatric otolaryngology clinic completed the Child Health Questionnaire (version PF 28). Questionnaires were analysed for data quality and completeness, item/scale correlation, internal consistency and discriminant validity, interscale correlation and reliability. Following overnight pulse oximetry 37 children were diagnosed with obstructive sleep apnoea and underwent adenotonsillectomy. RESULTS: Child Health Questionnaire Physical Functioning 28 demonstrated excellent measuring characteristics in our population. Compared with normative data, children with obstructive sleep apnoea and their carers suffer a significant quality of life deficit, involving 10 of 13 subscales of the Child Health Questionnaire. This was most prominent in parental emotional impact, general health perception and family activities. There was no correlation between the severity of obstructive sleep apnoea and quality of life indices. Following surgery, there was a significant improvement in all Child Health Questionnaire subscales, which became equivalent to healthy children. CONCLUSION: The Child Health Questionnaire Physical Functioning 28 is an accurate and reliable way of assessing the impact of obstructive sleep apnoea on the quality of life in children in Britain. This appears to be significant in most aspects of a child's life, but is fully reversed following surgery.     

Pseudoaneurysm of the lingual artery after temperature-controlled radiofrequency tongue base reduction: a severe complication

Temperature-controlled radiofrequency reduction (TCRF) of the tongue base has been developed as an alternative option for the treatment of patients with obstructive sleep apnea syndrome. The technique is propagated as an easy and safe surgical method. The case of a 34-year-old male patient with obstructive sleep apnea syndrome who underwent TCRF is reported. Fourteen days after surgery was performed, heavy bleeding at the base of the tongue occurred. Computed tomography and digital subtraction angiography imaging revealed a pseudoaneurysm of the lingual artery, which was treated endovascularly by detachable and free platinum coils during the same session. The article reports the first case of pseudoaneurysm under TCRF of the tongue base and discusses the diagnostic and therapeutic procedure to handle and avoid life-threatening complications under this method of treatment.