A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA

Objective

A pilot study to identify risk factors predicting post-operative complications in children with severe OSA undergoing adenotonsillectomy.

Methods

Retrospective review in a tertiary care academic institution. Two-stage least squares regression analysis and instrumental variable analysis to allow for modeling of pre- and peri-operative risk factors as having significance in predicting post-operative morbidity.

Results

Eighty-three children (mean age 4.88 ± 3.09 years) with apnea-hypopnea index (AHI) ≥10 who were observed overnight following adenotonsillectomy were evaluated for rates of major (increased level of care, CPAP/BiPAP use, pulmonary edema and reintubation) and minor (oxygen saturation <90%) airway complications as well as total observation costs. Major and minor complications occurred in 4.8% and 19.3% of children, respectively. Age <2 years (p < 0.01), AHI >24 (p < 0.05), intra-operative laryngospasm requiring treatment (p < 0.05), oxygen saturations <90% on room air in PACU (p < 0.05) and PACU stay >100 min (p < 0.01) independently predicted post-operative complications. Children with any one of these factors experienced a 38% complication rate versus 4% in all others.

Conclusions

This pilot study identified pre- and peri-operative risk factors that collectively can be investigated as predictors of post-operative airway complications in a prospective study. By identifying preliminary results comparing the complication rates between those children with and without these risk factors, we will be able to calculate the sample size for a future prospective validation study. Such a study is necessary to understand the safety and potential significant cost savings of observing children without risk factors on the pediatric floor and not in an ICU setting. A best practice algorithm can be created for children with severe OSA only after completing this prospective study.     

Gastroesophageal reflux as a predictor of complications after adenotonsillectomy in young children

Objective

To examine characteristics of young children with gastroesophageal reflux (GER) who experienced complications within the first 24 h after adenotonsillectomy.

Study design

Subset analysis of a larger retrospective cohort.

Methods

A retrospective chart review was performed at a tertiary care children's hospital. Consecutive records of children 3 years old and younger undergoing adenotonsillectomy (AT) over a 5-year period were reviewed. Children with a clinical history of GER were selected for the study.

Results

993 children were included in the initial analysis, and GER was found to be a significant independent variable predictive of early complications. 81 children with a history of GER were included in this study and 8 (9.9%) were found to have experienced complications within the first 24 h. Six of the complications were airway-related; two required re-intubation within the first 24 h. All 8 children with complications had symptoms of sleep-disordered breathing and two had documented severe obstructive sleep apnea (AHI 18.6 and 27.2). Seven children had other risk factors for complications after AT. Eighteen (22%) children had a prolonged length of stay (range 2–7 days); additional risk factors were present in these patients as well.

Conclusions

Knowledge of risk factors for complications following adenotonsillectomy is critical for identifying at-risk patients that may warrant closer post-operative observation. GER has been previously identified as a risk factor for complications in young children. Upon closer analysis, young children with GER who have other known risk factors may be at a further increased risk for airway complications and prolonged hospitalization. Parents of these children can be counseled on the post-operative risks and the possibility of a longer hospitalization.     

Do synchronous airway lesions predict treatment failure after adenotonsillectomy in children less than 3 years of age with obstructive sleep apnea?

Objectives

Determine the efficacy of adenotonsillectomy and the role of synchronous airway lesions in treatment failure in children younger than 3 years of age with obstructive sleep apnea.

Methods

A retrospective chart review was conducted for children younger than 3 years of age with obstructive sleep apnea who were evaluated and treated at a tertiary care hospital between 2005 and 2011. All participants underwent adenotonsillectomy or powered-intracapsular tonsillectomy with adenoidectomy and had both pre- and post-operative polysomnograms. Children eligible for airway evaluation underwent flexible laryngoscopy, direct laryngoscopy or bronchoscopy. For analysis, participants were categorized as cured or not-cured with an obstructive apnea–hypopnea index (OAHI) threshold of ≥1.4 indicating residual obstructive sleep apnea.

Results

Thirty-nine children met inclusion criteria and 41% had a post-operative OAHI ≤ 1.4 by polysomnogram. Children failing adenotonsillectomy, (OAHI ≥ 1.4) had a significantly higher pre-operative OAHI (p < 0.001) and lower nadir SpO₂ (p < 0.03) than those considered cured. Thirty-eight percent of the total population underwent airway evaluation, and synchronous airway lesions were identified in 60% of that cohort. None of the children required surgery for their synchronous airway lesions and there was no significant difference between outcome groups in number of patients who underwent airway evaluation or had synchronous airway lesions (p = 1 and p = 0.14, respectively).

Conclusions

Adenotonsillectomy is effective for obstructive sleep apnea in children younger than 3 years of age and the presence of a synchronous airway lesion does not necessarily predict treatment failure.     

Is day stay adenotonsillectomy safe in children with mild to moderate obstructive sleep apnoea? A retrospective review of 100 patients

Objective

This study explored the perioperative course of 100 children with polysomnogram (PSG) proven mild to moderate OSA to evaluate if day stay adenotonsillectomy is safe.

Methods

A retrospective chart review of patients who had undergone tonsillectomy with or without adenoidectomy following an overnight PSG at The Children's Hospital at Westmead Sleep Laboratory. 263 records were reviewed. Patients with apnoea hypopnea index (AHI) ≥1 and <15/h and/or a final sleep study report of mild to moderate OSA were included. Exclusion criteria were age <3 years, weight <10 kg, or any significant co-morbidities or other surgery that would preclude day stay surgery. Demographic, PSG and post-operative data was analyzed.

Results

No major respiratory complications occurred. No patient required an unplanned medical review for respiratory concerns, or admission to a high care facility. Eleven children left recovery with oxygen prescribed. One child had a desaturation to 88% in recovery, and one child had laryngospasm. The nine other children required oxygen to maintain saturation >90%.Supplemental oxygen was prescribed to 7 patients on the ward. Of these, three patients received supplemental oxygen beyond 6 h. The other 97 patients had an uncomplicated post-operative course and would have been suitable for day-stay surgery. Increasing severity of OSA grade on pre-operative PSG was significantly associated with post-operative supplemental oxygen use (p = 0.003; Cochrane-Armitage test for trend).

Conclusions

Children who are otherwise well with mild to moderate OSA have a sufficiently low risk of respiratory complications following adenotonsillectomy to permit day-stay surgery in the setting of appropriate facilities with careful post-operative monitoring for the first 6 h to identify a small sub-group who require overnight observations.     

Validation of a pediatric obstructive sleep apnea screening tool

Objective

Pediatric obstructive sleep apnea (OSA) is a prevalent but under-diagnosed disease. The importance of screening for OSA in every child has been recently re-emphasized by the American Academy of Pediatrics Guidelines. Although several screening questionnaires are available for pediatric OSA, they are either complicated to use or not sensitive enough, and therefore OSA is seldom screened in primary care settings. Here, we validated a previously developed short (6-item) hierarchically-based screening questionnaire tool for pediatric OSA.

Methods

Parents of 85 children referred for a sleep study at a pediatric community-based sleep clinic completed the questionnaire and their children underwent an overnight PSG. Receiver operator curve analyses and other predictive scales were assessed.

Results

The 6-item questionnaire exhibited favorable sensitivity and fair specificity for diagnosis of OSA, which varied depending on the apnea–hypopnea index used for OSA definition.

Conclusions

A 6-item questionnaire is a sensitive and easy-to-use screening tool for pediatric OSA in a pediatric sleep clinic setting.     

Clinical indicators that predict the presence of moderate to severe obstructive sleep apnea after adenotonsillectomy in children

Objective

To determine if clinical indicators can predict the presence of moderate to severe Obstructive Sleep Apnea (OSA) after Adenotonsillectomy (T&A) in children.

Study Design

Retrospective study.

Setting

Urban Tertiary Care Pediatric Hospital.

Methods

Parents of children (< 18 yrs.) with OSA completed a 55-item questionnaire based on their child’s symptoms at the time of preoperative polysomnography and then again at the follow up polysomnography completed 3 to 6 months after T&A.

Main outcome measures

55 item questionnaire, polysomnography variables.

Results

97 children were included (59 Male and 38 Female). The mean preoperative apnea hypopnea index (AHI) was 30.5 ± 31.6/h and the mean postoperative AHI was 4.4 ± 6.0/h. After T&A, all 97 children had reduction in AHI, and 35 (36.1%) no longer had OSA (AHI < 1/h). The total symptom scores decreased from 15.8 ± 9.4 to 11.3 ± 8.7 after T&A (p < .0001). Fourteen symptoms highly predictive of moderate to severe OSA were identified in the univariate analysis (p < 0.1). Using a cut-point of 4, this 14-item subscale illustrated an overall predictability of 72.2% (73.7% sensitivity and 70.0% specificity) for identifying children with moderate to severe OSA.

Conclusion

A cluster of 14 clinical sleep symptoms are highly predictive of moderate to severe OSA and can serve as clinical predictor for the presence of moderate to severe OSA after T&A.     

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management

Objective

Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management.

Methods

Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year.

Results

Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Down's syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms.

Conclusions

Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.     

Velopharyngeal dysfunction in children with Prader-Willi syndrome after adenotonsillectomy

Introduction

Prader-Willi syndrome (PWS) is a rare genetic disorder with an incidence rate of 1 in 10,000–30,000. Patients with PWS typically have symptoms related to hypotonia, obesity, and hypothalamic dysfunction. A high rate of obstructive sleep apnea (OSA) is found among this population of patients. Adenotonsillectomy has been advocated as a first line approach for treatment of OSA in patients with PWS. Velopharyngeal dysfunction (VPD) is a known complication of adenotonsillectomy. VPD can also be present in patients with global hypotonia, such as those with PWS. The objective of this study is to review the occurrence of VPD in patients with PWS after adenotonsillectomy for OSA.

Methods

A retrospective review was performed of all patients with PWS and OSA from a tertiary pediatric hospital between the years of 2002 and 2012. Pre- and post-operative sleep studies and sleep disordered breathing symptoms, post-operative VPD assessment by the speech-language pathologist (SLP), and VPD treatments were evaluated.

Results

Eleven patients (five males and six females), fitting the inclusion criteria, were identified. The age of the patient at the initial otolaryngologic evaluation ranged from 2 to 9 years. All patients underwent adenotonsillectomy for sleep disordered breathing. Four patients were diagnosed with post-operative hypernasality after assessment by a speech-language pathologist. The hypernasality ranged from mild to moderately severe. Of the four patients with hypernasality, two were found to have structural issues requiring surgery (pharyngeal flap). Both of the surgical patients experienced significant improvement in their VPD after surgery. The remaining two patients were found to have articulation error patterns that were considered more developmental in nature and both responded to speech therapy. All patients, except one, had improvement in their polysomnogram or sleep symptoms after adenotonsillectomy. However, three patients continue to require continuous positive airway pressure at night.

Conclusion

Velopharyngeal dysfunction may occur after adenotonsillectomy in patients with Prader-Willi Syndrome. Families should be counseled of this risk and the potential need for operative intervention to correct it.     

Metabolic alterations in children with obstructive sleep apnea

Importance

The incidence of obesity is rising in the United States and has been linked to Obstructive Sleep Apnea (OSA) even in young children. Understanding the role that obesity and OSA play in alterations in metabolic variables that can lead to serious health issues is essential to the care and counseling of affected children.

Objectives

To evaluate the association of alterations in metabolic variables, including insulin resistance, to OSA in young, obese children.

Design

Retrospective, case-control series.

Setting

Tertiary care children's hospital.

Participants

Obese children aged 2-12 years who had undergone overnight polysomography and routine laboratory testing for lipid levels, fasting glucose, and insulin from January 1, 2006 to December 31, 2012 were identified from a TransMed Bio-Integration Suite and Epic's clarity database search.

Results

A total of 76 patients were included for analysis. Forty-three (56.6%) were male, and the mean age was 8.3 ± 2.5 years (range, 2.4–11.9 years). The mean body mass index (BMI) z score was 2.8 ± 0.75 (range, 1.7–6.3), and all patients were obese (BMI z score > 95th percentile). Twenty two patients (28.9%) had an apnea–hypopnea index (AHI) <1/h (no OSA), 27 (35.5%) an AHI≥1 < 5/h, 12 (15.8%) had an AHI ≥5 < 9.99/h, and 15 (19.7%) had an AHI≥10/h. There was no significant difference in total cholesterol, triglycerides, high and low density lipoprotein levels, systolic and diastolic blood pressure in those patients with or without OSA. Fasting insulin, blood glucose, and homeostasis model assessment (HOMA) were significantly higher in patients with OSA compared to those with no OSA (p < 0.01). AHI correlated to alterations in insulin as well as glucose homeostasis on multivariate analysis. Results from logistic regression analysis showed that fasting insulin (p < 0.01), and HOMA (p < 0.01) predicted severe OSA independent of age, gender, and BMI z score in these patients.

Conclusion

Metabolic alterations in glucose and insulin levels, known to be associated with obesity and increased risk for cardiovascular disease, appear to relate to the severity of OSA in young children.     

Management of complex glottic stenosis in children with recurrent respiratory papillomatosis

Objectives

To describe our management of complex glottic stenosis in tracheotomy dependent children with severe recurrent respiratory papillomatosis.

Methods

Retrospective chart review at a tertiary care children's hospital.

Results

Three children with complex glottic stenosis secondary to severe recurrent respiratory papillomatosis were treated at our institution since 2011. Two patients had complete stenosis, and the third had near-complete stenosis. Two patients were managed using balloon dilation alone, and the third also underwent laryngotracheal reconstruction with posterior costal cartilage grafting. Two patients have been successfully decannulated and the third has been tolerating continuous tracheotomy capping for greater than twelve months. All three patients underwent aggressive debridement of papillomatosis and balloon dilation every 4–6 weeks until their burden of disease was controlled. In two patients, the glottic airway was patent, and the third continued to have complete restenosis between procedures and required laryngotracheoplasty with multiple post-operative dilation procedures to establish an adequate glottic airway.

Conclusions

Severe laryngeal stenosis is a well-described complication of recurrent respiratory papillomatosis, but its management is not well-defined. Aggressive management of papillomatosis with frequent debridement is critical in successfully managing laryngeal stenosis. Balloon dilation alone may be surprisingly effective in these patients, and laryngotracheoplasty can be used as an adjunct procedure in those patients who fail balloon dilation. Given the quality of life issues and concerns regarding distal spread of disease with tracheotomies in these patients, we feel that aggressive management and early decannulation is in the patient's best interest.     

A systematic review and meta-analysis of cohort studies of echocardiographic findings in OSA children after adenotonsilectomy

Context

There is evidence that OSA in children can be associated with acute and chronic effects on the cardiovascular system due to repetitive episodes of apnea and hypoxemia.

Objective

To assess whether there is an association between OSA and echocardiographic findings in children and whether that association persists after adenotonsillectomy.

Data sources

A literature search was conducted based on PUBMED, EMBASE and LILACS.

Study selection

Children with OSA and children who did not have OSA, who were aged ≤12 years.

Data extraction

Two reviewers extracted data independently; the risk of bias was assessed by examining the selected sample, the recruitment method, completeness of follow up, and blinding.

Results

Seven studies met all the inclusion criteria and methodological requirements. There was a significant difference with elevated mean pulmonary arterial pressure levels in OSA participants compared to those without OSA at preoperative assessment [mean difference (MD) 8.67; confidential interval (CI) 95% 6.09, 11.25]. OSA participants showed a statistically significant increased interventricular septum (IVS) thickness (mm) [MD 0.60; CI 95% 0.09, 1.11]; and right ventricular (RV) dimension (cm/m) [MD 0.19; CI 95% 0.10, 0.28]. There was also a significant increase in right ventricular (RV) dimension (cm/m) [MD 0.10; CI 95% 0.05, 0.14] in OSA children.

Conclusion

There is moderate quality evidence regarding possible association between OSA and right heart repercussions. More prognosis studies are needed, to allow the combination of results in a meta-analysis.     

National UK survey on the assessment and surgical management of suspected paediatric obstructive sleep apnoea syndrome

Background

Controversy exists amongst ENT surgeons as to the best way to manage a non-syndromal and otherwise healthy child with suspected OSAS. In 2002, The American Association of Paediatricians stated that the gold standard is a full polysomnography (PSG) for all children with suspected OSA and the revised version in 2012 repeated that requirement but recognized that facilities are not always available. In 2009 a UK Multidisciplinary Consensus Statement disagreed and reserved a full PSG for younger and syndromal or complicated children.We undertook a survey of UK ENT surgeons before and after the UK Consensus Statement to identify common practice with regards to diagnosis and management of suspected paediatric obstructive sleep apnoea syndrome in the UK.

Method

A questionnaire based on the management of a typical clinical case was sent to 542 ENT consultants in 2005 and repeated in 2011.

Results

Less than 2% used PSG in assessing the child presented in our case study in both surveys. About 70% of respondents indicated that they would proceed with management of the child with no form of sleep study at all and this clinical practice has not changed after UK Multidisciplinary Consensus Statement. The majority would treat a child with possible OSAS and no co-morbidities with adenotonsillectomy as an inpatient.

Discussion

The availability of paediatric PSG is very limited and because of a lack of normative data, uncertainty about interpretation of abnormal results, the recognition that even moderate snoring without sleep apnoea has detrimental neuro-cognitive effects and the fact that adenotonsillectomy is a very effective treatment for paediatric OSA we felt that a pragmatic and safe approach was to treat selected patients as if they had a positive PSG with appropriate anaesthetic technique and post operative care and monitoring.     

Comparison of treatment modalities in syndromic children with Obstructive Sleep Apnea—A randomized cohort study

Introduction

Obstructive Sleep Apnea (OSA) is a common medical problem in adults that is becoming increasingly recognized in children. It occurs in the pediatric age group, from newborns to teens. More recently, many specialists have estimated OSA prevalence to be between 5 and 6%. However, in syndromic children, the prevalence of OSA can be from 50 to 100%, having a significant effect on their Quality-of-Life. As they are a challenging population for management, it is essential to evaluate them thoroughly before planning appropriate intervention.

Objective

To compare the efficacy of Adenotonsillectomy (T&A) and Continuous Positive Airway Pressure (CPAP) in syndromic children [Down syndrome (DS) and Mucopolysaccharidoses (MPS)] with Obstructive Sleep Apnea (OSA).

Materials and methods

In a prospective, randomized, cohort comparative study, 124 syndromic children (DS and MPS) aged between 6 and 12 years were recruited from a private MPS support group and the Down Syndrome Society, Chennai. A standard assessment was performed on all children who entered the study including a full overnight Polysomnogram (PSG), Epworth Sleepiness Scale-Children (ESS-C) and Quality-of-Life (QOL) tool OSA-18. The children with positive PSG who consented for the study (n = 80) were randomly distributed to two groups, T&A group & CPAP group. The children were followed up with repeat PSG, clinical evaluation, ESS-C and Quality-of-Life (QOL) tool OSA-18 for a period of 1 year.

Observation and results

Follow-up was available for 73 syndromic children. Both the groups, T&A group and CPAP group, showed statistically significant (p < 0.05) improvement in Apnea-Hypoapnea Index (AHI), ESS-C, QOL from the intervention. In our study, T&A showed equal outcome compared to CPAP. The contrasting feature between the two groups was that CPAP use gave immediate sustained improvement while T&A gave gradual progressive improvement of symptoms over a period of 1 year.

Conclusion

On average, T&A gives equal outcomes as CPAP and it can be suggested as a first-line treatment in this group of syndromic children.     

Primary aerodigestive presentations of Pierre Robin sequence/complex and predictive factors of airway type and management

Objective

To document the mode and age of primary aerodigestive presentation of Pierre Robin sequence/complex (PRS/C) children to the otolaryngologist and to explore predictive factors of upper airway type and management.

Methods

This is a retrospective cohort study conducted in a tertiary pediatric referral center. A prospective surgical database was searched for children who were diagnosed with PRS/C. Demographics, presenting complaint, secondary diagnoses, type of upper airway obstruction, secondary airway lesions, presence of cleft palate, and airway interventions were collected. Multiple linear regression analysis was performed to predict upper airway obstruction type and intervention.

Results

Seventy-seven potentially eligible patients were identified. Forty-six were included (20 females). Mean age at presentation was 20.4 ± 36.9 months (range 1–191.25 months). Twenty-three primarily presented with respiratory failure, 14 with sleep disordered breathing, and nine with swallowing dysfunction. Children with presentations other than respiratory failure were older (p = 0.004). Nineteen were syndromic. Overt cleft palate was more common in those presenting with respiratory failure (p = 0.01). The type of airway obstruction encountered and use of tracheostomy were positively predicted by the primary presenting feature of respiratory failure (p < 0.05) and male gender (p < 0.05).

Conclusion

A substantial number of PRS/C patients present later than the neonatal period with presentations other than respiratory failure. Both male gender and presentation with respiratory failure predicted a more severe airway obstruction type and the need for trachesotomy.     

Feasibility of unattended home polysomnography in children with sleep-disordered breathing

Objective

To investigate the technical feasibility of unattended polysomnography (HPSG) for diagnosis of obstructive sleep apnea (OSA) in children.

Methods

A single-night HPSG was performed on children referred to the pediatric respiratory laboratory. Non-interpretable HPSGs were defined as: recordings with (i) loss of ≥2 of the following channels: nasal flow, or thoraco-abdominal belts, or (ii) HPSG with less than 4 h of artifact-free recording time or (iii) less than 4 h SpO2 signal.

Results

Of n = 101 included HPSGs, n = 75 were ambulatory and n = 26 in hospitalized subjects. Median (minimum–maximum) age was 2.8 (0–15.4) years. Interpretable and technically acceptable recordings were obtained in 94 subjects (93%). Only 7 recordings (4 at home versus 3 in hospitalized subjects, p-value = 0.254) were classified as non-interpretable and had to be repeated. Artifact-free recording time was 461 (23–766) min. Complete artifact-free pulse oximetry signal was obtained in 14% of the included subjects. Neither age, gender, AHI, nor place of performance was significantly associated with the interpretability of recordings.

Discussion

HPSG showed a high rate of interpretability and technical acceptance. The high technical feasibility obtained by HPSG may help to improve simple screening tests for OSA in children.     

Quality of life after adenotonsillectomy for children with sleep-disordered breathing: A linear mixed model analysis

Objective

To study changes in quality of life (QoL) after adenotonsillectomy (T&A) in children with sleep-disordered breathing (SDB), and to elucidate discrepancies in QoL improvements after T&A in children of different gender, age, adiposity status, and disease severity.

Materials and methods

Children aged 2–18 years were recruited. All children had SDB-related symptoms and underwent preoperative full-night polysomnography (PSG). Caregivers completed the first obstructive sleep apnea 18-items questionnaire (OSA-18) prior to T&A and the second OSA-18 survey within 3 months after surgery. Disease severity was defined as primary snoring (apnea/hypopnea index, AHI < 1), mild obstructive sleep apnea (OSA) (5 > AHI ≥1), and moderate-to-severe OSA (AHI ≥ 5). Discrepancies in OSA-18 score changes after T&A for different groups were assessed using the linear mixed model.

Results

In total, 144 children were enrolled (mean age, 7.0 ± 3.6 years; 76% boy). The OSA-18 total score changes after surgery were not significantly different by gender (boys vs. girls), age group (≥6 years vs. <6 years), or adiposity (obese vs. non-obese). The OSA-18 total score changes after surgery differed by disease severity (primary snoring vs. moderate-to-severe OSA, P = 0.004; mild OSA vs. moderate-to-severe OSA, P = 0.003). Children with moderate-to-severe OSA had greater improvement in OSA-18 total score after surgery than those with mild OSA or primary snoring.

Conclusions

Children with SDB had QoL improvement after T&A, as documented by OSA-18 score changes. The QoL improvement after T&A for SDB children increased as disease severity increased, and the improvement was not affected by gender, age, or adiposity.     

Obstructive sleep disorders in Prader-Willi syndrome: The role of surgery and growth hormone

Objective

To review the effectiveness and safety of surgical intervention for obstructive sleep apnea in Prader-Willi syndrome.

Background

The muscle hypotonia and obesity associated with Prader-Willi syndrome (PWS) result in a high rate of obstructive sleep apnea (OSA). The use of growth hormone therapy in these patients has been associated with sudden death, raising concerns that such treatment may exacerbate obstructive sleep apnea. As a result, it has been suggested that children with PWS be evaluated for OSA and indications for adenotonsillectomy prior to instituting growth hormone therapy. The true effectiveness of surgical intervention in these cases, however, remains in doubt.

Methods

Retrospective review of patients with a diagnosis of PWS who underwent adenoidectomy or adenotonsillectomy from January 2001 to July 2009 at a regional, tertiary care children's hospital. Patients underwent pre-operative and post-operative polysomnography. Differences between pre-operative and post-operative body-mass index (BMI), apnea-hypopnea index (AHI), and median oxygen saturation and oxygen saturation nadir were analyzed.

Results

Five patients were identified during the study period. Three patients underwent adenotonsillectomy, 1 patient adenoidectomy alone, and another adenotonsillectomy with uvulopalatopharyngoplasty (UPPP). While median AHI was found to have decreased from 16.4 to 4.4, no statistically significant change could be demonstrated (p = 0.274). Mean O₂ and nadir O₂ saturation also improved, but without reaching statistical significance. No intra-operative complications were noted.

Conclusions

Our series, and other small case series, have demonstrated that complete resolution of sleep apnea in PWS patients is difficult to obtain with upper airway surgery alone. It is suggested that children with PWS being considered for growth hormone therapy undergo assessment for OSA by polysomnography. Patients identified with OSA should be referred for management by tonsillectomy and/or continuous positive airway pressure (CPAP) and then reassessed for residual airway obstruction prior to instituting hormonal therapy.     

Obstructive sleep apnea in younger school children with Down syndrome

Objective

We aimed to assess the prevalence of obstructive sleep apnea (OSA) in 8 year old school children with Down syndrome (DS). While the prevalence in otherwise healthy children is below 5%, the prevalence estimates in children with DS are uncertain (30–80%). OSA directly affects cognitive development and school performance.

Study design

Population based cross sectional study in a limited geographical area.

Methods

Polysomnography (PSG) with video and audio recordings was performed in 8-year-old children with DS in a pediatric sleep unit according to the guidelines of American Academy of Sleep Medicine. Twenty-nine of all 32 children with DS within a restricted area comprising >50% of the Norwegian population and 54% of the children with DS born in Norway in 2002 were enrolled.

Results

This study reports an apnea hypopnea index AHI > 1.5 in 28 of 29 children and an obstructive apnea index (OAI) > 1 in 24 of 29 children. 19 children (66%) had an AHI > 5 and 17 children (59%) had an OAI > 5 which indicated moderate to severe OSA. No correlation was found between OSA and obesity or gender.

Conclusion

The high prevalence of disease found in these previously undiagnosed 8-year-old children underlines the importance of performing OSA diagnostics in children with DS throughout childhood. These findings suggest that the prevalence of OSA remains high up to early school years. In contrast to earlier publications, this current study has the advantage of being population based, the study is performed on children of a narrow age band to estimate prevalence of disease and the diagnostic gold standard of PSG is applied.     

Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea

Objectives

In this study we determine the subjective and objective outcomes of pediatric patients with refractory OSA undergoing drug-induced sleep endoscopy (DISE)-directed surgical treatment.

Methods

31 consecutive children with OSA following TA underwent DISE. 26 completed DISE-directed operative management of the level(s) of ongoing upper airway obstruction. Pre- and postoperative OSA were assessed through a detailed history (of nighttime symptoms (NS) and daytime symptoms (DS)), physical examination, and polysomnography.

Results

Age ranged 5–18 years (mean 9.7 ± 3.4). Fourteen of 26 had trisomy 21 (51%). Operations were performed in the following frequencies: lingual tonsillectomy (LT) (22), midline posterior glossectomy (MPG) (16), revision adenoidectomy (11), inferior turbinate submucosal resection (7), uvulopalatoplasty (2), and supraglottoplasty (2). Overall, 92% reported subjective improvement. NS improved from 5.8 ± 2.9 preoperatively to 2.1 ± 2.5 postoperatively (p < 0.05), while DS improved from 2.1 ± 1.3 preoperatively to 0.6 ± 1.1 postoperatively (p < 0.05). Seventeen patients completed preoperative polysomnography, while only 11 of them also completed postoperative polysomnography. Mean OAHI fell from 7.0 (±5.8) events/hr to 3.6 (±1.8) events/hr (t-test, p = 0.09).

Conclusions

Individualized, multilevel, DISE-directed operative therapy was associated with substantial improvement in subjective measures of sleep.