Comparison of lingual tonsil size as depicted on MR imaging between children with obstructive sleep apnea despite previous tonsillectomy and adenoidectomy and normal controls

Association between tonsillectomy and risk of oropharyngeal cancer: a systematic review

Objective

Studies have demonstrated that tonsillectomy may alter the risk of oropharyngeal cancer (OPC). We systematically reviewed the evidence and pooled data to examine such an association.

Methods

PubMed, Embase, and Scopus were searched up to 25th April 2023. Studies reporting an association between tonsillectomy and oropharyngeal cancer risk at any site were included.

Results

Five studies were eligible. All examined the risk of tonsillar and base of the tongue (BOT) cancer with prior history of tonsillectomy. On meta-analysis of the data, prior history of tonsillectomy was associated with a significantly decreased risk of tonsillar cancer. The second meta-analysis showed that history of tonsillectomy did not significantly alter the risk of BOT cancer. However, after exclusion of one study, the results showed an increased risk of BOT cancer with a history of tonsillectomy.

Conclusions

The scarce data available in the literature suggests that tonsillectomy may reduce the risk of tonsillar cancer but does not alter the risk of BOT cancer. Further studies are needed to explore the association between tonsillectomy and the risk of OPC.

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Tonsillectomy & Adenoidectomy: Tongue Base and Larynx

Pediatric patients with persistent obstructive sleep apnea (OSA) after adenotonsillectomy often have additional sites of upper airway obstruction such as the tongue base or larynx. Sleep endoscopy and cross-sectional, dynamic imaging can be used to direct surgical management of persistent OSA. The tongue base is one of the most common sites of obstruction in children with persistent OSA, especially for patients with Trisomy 21. Lingual tonsillectomy, tongue suspension, and/or posterior midline glossectomy may be used to address lingual tonsil hypertrophy and tongue base obstruction. Epiglottopexy and/or supraglottoplasty may be used to address laryngomalacia and epiglottic prolapse resulting in OSA.

Sleep Endoscopy and Cine Magnetic Resonance Imaging Evaluation of Children With Persistent Obstructive Sleep Apnea

OBJECTIVE

To compare findings of same-day cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) and examine how each technique uniquely contributes to the evaluation of persistent obstructive sleep apnea following adenotonsillectomy.

STUDY DESIGN

Retrospective cohort study.

SETTING

Quaternary care center.

METHODS

Chart review was performed for consecutive patients who underwent same-day cine MRI and DISE between 2015 and 2020. Descriptive statistics are reported, and Cohen kappa coefficients were calculated to evaluate the agreement between cine MRI and DISE for obstruction at the adenoids, lingual tonsils, and tongue base.

RESULTS

There were 137 patients, the mean age was 10.4 years (95% CI, 3.2-16.7), and 62.8% were male. The most common sites of obstruction on DISE were the tongue base (86.9%), velum (78.7%), epiglottis (74.5%), inferior turbinate (68.6%), and lingual tonsil (61.3%). The most common sites of obstruction on cine MRI were the hypopharynx (56.3%), tongue base (44.8%), lingual tonsil (38.0%), and macroglossia (37.6%). There was moderate agreement for adenoid hypertrophy (κ = 0.53) and poor agreement for lingual tonsil hypertrophy (κ = 0.15) and tongue base obstruction (κ = 0.09). DISE identified more instances of multilevel obstruction when compared with cine MRI (94.9% vs 48.2%).

CONCLUSION

DISE offered a better examination of nasal and supraglottic obstruction and is sensitive to partial vs complete collapse, while cine MRI offered better soft tissue resolution for lymphoid tissue hypertrophy and provided a global view of primary and secondary airway obstruction. Cine MRI and DISE are complementary modalities in the evaluation of children with persistent obstructive sleep apnea.

Adherence to CPAP therapy in Down syndrome: the population-based DISCOVERY study

STUDY OBJECTIVES

Persons with Down syndrome (DS) have an increased risk of obstructive sleep apnea (OSA) needing continuous positive airway pressure (CPAP), but data on the therapy and outcomes in this population are scarce. We aimed to compare patient characteristics and outcomes of CPAP treatment for patients with OSA with and without DS.

METHODS

This was a population-based, longitudinal study on patients initiating CPAP therapy between July 2010 and March 2018 in Sweden and a population-based sex- and age-matched control group (control:case ratio 5:1), with linked data from the Swedish National Patient Registry and the Prescribed Drug Registry (DISCOVERY study cohort).

RESULTS

Patients with DS (n = 64) had a higher apnea-hypopnea index (51.7 ± 30.3 vs 36.8 ± 29.1 events/h, P < .001), Epworth Sleepiness Scale score (13.7 ± 5.9 vs 11.0 ± 4.9, P = .001), rate of previous surgery of tonsils and/or adenoids (21.9% vs 8.2%, P = .001), and more thyroid replacement hormone therapy (45.3% vs 7.8%, P < .001), but lower use of cardiovascular drugs (7.8% vs 22.3%, P = .003) compared with controls. At follow-up after 1.3 ± 0.9 years, there were no differences in nocturnal CPAP usage time (5.6 ± 2.4 vs 5.5 ± 2.0 hours, P = .77), CPAP adherence ≥ 4 hours/night (62% vs 65%, P = .93), or improvement in Epworth Sleepiness Scale score (-5.4 ± 6.8 vs -5.0 ± 2.0, P = .84) between DS and non-DS patients.

CONCLUSIONS

OSA severity was substantially higher in patients with DS despite an increased rate of tonsil surgery. Treatment outcomes in terms of adherence and improved daytime sleepiness were comparable between groups, underlining the importance of both OSA diagnosis and treatment in patients with DS.

CITATION

Svensson M, Ekström M, Sundh J, Ljunggren M, Grote L, Palm A. Adherence to CPAP therapy in Down syndrome: the population-based DISCOVERY study. J Clin Sleep Med. 2023;19(3):453-458.

Dynamic sleep MRI in obstructive sleep apnea: a systematic review and meta-analysis

PURPOSE

The objective of this study is to systematically review the international literature for dynamic sleep magnetic resonance imaging (MRI) as a diagnostic tool in obstructive sleep apnea (OSA), to perform meta-analysis on the quantitative data from the review, and to discuss its implications in future research and potential clinical applications.

STUDY DESIGN

A comprehensive review of the literature was performed, followed by a detailed analysis of the relevant data that has been published on the topic.

METHODS

Clinical key, Uptodate, Ovid, Ebscohost, Pubmed/MEDLINE, Scopus, Dynamed, Web of Science and The Cochrane Library were systematically searched. Once the search was completed, dynamic sleep MRI data were analyzed.

RESULTS

Nineteen articles reported on 410 OSA patients and 79 controls that underwent dynamic sleep MRI and were included in this review. For meta-analysis of dynamic sleep MRI data, eight articles presented relevant data on 160 OSA patients. Obstruction was reported as follows: retropalatal (RP) 98%, retroglossal (RG) 41% and hypopharyngeal (HP) in 5%. Lateral pharyngeal wall (LPW) collapse was found in 35/73 (48%) patients. The combinations of RP + RG were observed in 24% and RP + RG + LPW in 16%. If sedation was used, 98% of study participants fell asleep compared to 66% of unsedated participants.

CONCLUSIONS

Dynamic sleep MRI has demonstrated that nearly all patients have retropalatal obstruction, retroglossal obstruction is common and hypopharyngeal obstruction is rare. Nearly all patients (98%) who are sedated are able to fall asleep during the MRI. There is significant heterogeneity in the literature and standardization is needed.

Size of the Tonsil on Ultrasound in Children Without Tonsil-Associated Symptoms

This study was performed to establish the reference for tonsil size in children, including neonates, without tonsil-associated symptoms, in relation to anthropometric indices (sex/age/height/weight/body mass index).We evaluated the size of both tonsils in 362 children by ultrasonography. Tonsil size was calculated as 0.523abc (a, transverse diameter on the transverse image; b, longitudinal diameter on the transverse image; c, longitudinal diameter on the longitudinal image) and compared between each age year using the Wilcoxon signed rank sum test with Bonferroni correction. We evaluated the relationships between tonsil size and anthropometric indices.Among these children, tonsil size was significantly increased by the age of 3 years (0-1 vs 1-2 [volume (right) = 210.15 ± 205.27 vs 737.83 ± 335.72 mm, P (right) < 0.0001 and volume (left) = 218.26 ± 207.23 vs 645.33 ± 240.31 mm, P (left) < 0.0001]; 1-2 vs 2-3 [volume (right) = 737.83 ± 335.72 vs 1073.86 ± 468.21 mm, P (right) = 0.004 and volume (left) = 645.33 ± 240.31 vs 1109.73 ± 563.20 mm, P (left) < 0.0001]). Although there was a tendency for the tonsil size to increase in years 3-12, there was no significant difference. Using single linear regression analysis, we found a correlation between tonsil size and age (r right/left = 0.67/0.65), height (r right/left = 0.72/0.70), and weight (r right/left = 0.66/0.64), with height having the strongest correlation.In conclusion, tonsil size significantly increased by 3 years of age. Tonsil size was correlated with anthropometric indices, with height showing the strongest correlation.

Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome

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

The spectrum of obstructive sleep apnea in infants and children with Down Syndrome

OBJECTIVE

Describe the spectrum of OSA across time in infants and children with Down syndrome.

METHODS

Retrospective records review of children who underwent formal polysomnography (PSG) in one of two Australian tertiary sleep centres over selected 3.5-year periods. 152 children were identified, then all sleep study and treatment records were retrieved for the lifetime of the child through 2018.

RESULTS

3.8 ± 3.2 studies (range 1-17) were retrieved per child and 38.2% had mild disease at worst. Children having only 1 study were more likely to have a normal or mild result than those having ≥2 (chi-square 11.25, p-value 0.0008) Studies were more often severe in children age <2 compared to those ≥2 years, (chi-square 12.87, p = 0.005). After age 2 years, OSA severity increased with age. Amongst 91 (56.4%) children with ≥2 studies, 71 (78.0%) had moderate or severe disease at some time. Studies evaluating the effects of surgery (most often adenotonsillectomy) showed resolution of disease to mild or normal in 53.3%. Where ≥2 studies were evaluated, the last study polarised towards normal or mild disease 40 (44.0%), or treatment titrations 34 (37.4%) with moderate or severe disease in 17 (18.7%).

CONCLUSIONS

In a tertiary sleep unit, a full spectrum of sleep disordered breathing in Down syndrome was seen from infancy onwards. Children having only one study were more likely to have normal results. Children with multiple studies reflected disease surveillance, including follow-up after treatment interventions.

Updates on management of pediatric obstructive sleep apnea

Obstructive sleep apnea (OSA) affects about 1%-5% of the pediatric population. The consequences of untreated OSA in children include neurocognitive deficits, behavioral problems, poor school performance as well as systemic and pulmonary hypertension. The treatment options for pediatric OSA are numerous with a variety of surgical and non-surgical interventions. As our understanding of the complexities of OSA grows, the options for management have continued to expand as well. The objectives of this review are to describe the commonly prescribed treatments for pediatric OSA including adenotonsillectomy as well as use of positive airway pressure. We also highlight other surgical and non-surgical interventions available. In addition, we provide updates on current research focusing on newer diagnostic and experimental treatment modalities.

Pilot study of the potential of 3D ultrasound to measure tonsillar volume and hypertrophy

OBJECTIVE

Obstructive sleep apnea (OSA), results in approximately 4-5 million outpatient visits per year in the United States. In pediatric patients, OSA is primarily caused by adenotonsillar hypertrophy, and therefore, adenotonsillectomy remains an effective surgical treatment. We investigate whether 3D ultrasound (3DUS) imaging can accurately and objectively assess tonsillar hypertrophy for the potential identification and stratification of candidates for adenotonsillectomy.

METHODS

A prospective study was performed evaluating pediatric patients (N = 17) between the ages of 4-14 years who were undergoing adenotonsillectomy for OSA symptoms. On the day of surgery, tonsillar ultrasound was performed by a single attending radiologist. Tonsillectomy was performed and each tonsils' principal axes and physical volume by water submergence were measured. The findings were compared using paired T-test, Pearson correlation coefficient and Bland-Altman analysis.

RESULTS

The average tonsillar physical measurements of length, width and height were 1.54 ± 0.28, 2.0 ± 0.31 cm and 2.72 ± 0.41 cm, and 1.73 ± 0.17, 1.61 ± 0.21 mm and 2.98 ± 0.28 mm from physical and 3DUS estimations, respectively (P < 0.001 for all measurements). The average tonsillar volume was 3.84 ± 1.23 ml and 4.30 ± 1.15 ml from physical and 3DUS measurements, respectively (p = 0.04). The Bland-Altman mean difference ± 95% limit of agreement between length, width, height, and volume results from the two measurements were -0.186 ± 2.01 cm, -0.393 ± 6.33 cm, 0.25 ± 7.71 cm, and 0.45 ± 2.32 ml, respectively.

CONCLUSION

While 3DUS is feasible, it may not be an accurate estimate of tonsillar volume for assessing hypertrophy. A larger study will be required to establish the accuracy of 3DUS measurements of tonsillar volume.

Outcomes in children with down syndrome and mild obstructive sleep apnea treated non-surgically

OBJECTIVES

Nasal steroids, oral anti-leukotrienes and supplemental oxygen are effective in the treatment of mild obstructive sleep apnea (OSA) in otherwise healthy children. However, their efficacy is unknown in children with Down syndrome (DS). Here we examine the effect of single medication therapy versus observation versus oxygen on polysomnographic outcomes in these children.

METHODS

We reviewed children (<18 years) diagnosed with DS and mild OSA (obstructive apnea-hypopnea index [oAHI] ≥1 to <5 events/hour) treated non-surgically (with supplemental oxygen, one medication, or observation) between 2012 and 2017. Demographic data, comorbid diagnoses, and pre- and posttreatment polysomnograms were analyzed. We assessed pre- and posttreatment oAHI, oxyhemoglobin saturation nadir, percent total sleep time (%TST) in rapid eye movement (REM), and end-tidal carbon dioxide (ETCO₂ ) >50 mmHg.

RESULTS

Twenty-four children met inclusion criteria; 10 treated with medication, one with oxygen, and 13 with observation (baseline oAHI was 3.5, 3.3, and 2.9 events/hour, respectively). There was no significant change in oAHI, oxyhemoglobin saturation nadir, ETCO₂ , or percent TST in REM after treatment for any treatment group (P = .21-.94). There was no association between reported symptoms and AHI severity or change in AHI. OSA resolved in one patient treated with observation and two treated with medication, but worsened in two each in the medication and observation groups. Resolution of OSA occurred in 20% treated with medication, 7.7% with observation, and 0% with oxygen (P = .82).

CONCLUSION

In our cohort, resolution of mild OSA was low. This suggests that consideration should be given to multimodality treatments in children with DS and mild OSA. Prospective studies will help establish effectiveness in this cohort.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1828-1835, 2020.

Managing the Child with Persistent Sleep Apnea

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

Outcomes of Tongue Base Reduction and Lingual Tonsillectomy for Residual Pediatric Obstructive Sleep Apnea after Adenotonsillectomy

Introduction  Upper airway obstruction at multiple sites, including the velum, the oropharynx, the tongue base, the lingual tonsils, or the supraglottis, has been resulting in residual obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy (TA). The role of combined lingual tonsillectomy and tongue base volume reduction for treatment of OSA has not been studied in nonsyndromic children with residual OSA after TA. Objective  To evaluate the outcomes of tongue base volume reduction and lingual tonsillectomy in children with residual OSA after TA. Methods  A retrospective chart review was conducted to obtain information on history and physical examination, past medical history, findings of drug-induced sleep endoscopy (DISE), of polysomnography (PSG), and surgical management. Pre- and postoperative PSGs were evaluated to assess the resolution of OSA and to determine the improvement in the obstructive apnea-hypopnea index (oAHI) before and after the surgery. Results  A total of 10 children (5 male, 5 female, age range: 10-17 years old, mean age: 14.5 ± 2.6 years old) underwent tongue base reduction and lingual tonsillectomy. Drug-induced sleep endoscopy (DISE) revealed airway obstruction due to posterior displacement of the tongue and to the hypertrophy of the lingual tonsils. All of the patients reported subjective improvement in the OSA symptoms. All of the patients had improvement in the oAHI. The postoperative oAHI was lower than the preoperative oAHI ( p  < 0.002). The postoperative apnea-hypopnea index during rapid eye movement sleep (REM-AHI) was lower than the preoperative REM-AHI ( p  = 0.004). Obstructive sleep apnea was resolved in children with normal weight. Overweight and obese children had residual OSA. Nonsyndromic children had resolution of OSA or mild OSA after the surgery. Conclusions  Tongue base reduction and lingual tonsillectomy resulted in subjective and objective improvement of OSA in children with airway obstruction due to posterior displacement of the tongue and to hypertrophy of the lingual tonsils.

Persistent sleep disordered breathing after adenoidectomy and/or tonsillectomy: a long-term survey in a tertiary pediatric hospital

PURPOSE

To determine the long-term prevalence of persistent sleep disordered breathing (SDB) in children, after adenoidectomy, tonsillectomy or adenotonsillectomy, and to assess the relationship between baseline characteristics and persistent nocturnal symptoms.

METHODS

The clinical charts of children operated for adenoidectomy and/or tonsillectomy in a tertiary hospital, between January 2000 and March 2016, were retrospectively reviewed. All patients who had signs of SDB prior to surgery received a six-question validated pediatric questionnaire, the Hierarchic Severity Clinical Scale (HSCS).

RESULTS

A total of 4000 children showing SDB prior to surgery were selected out of 5809 (68.9%); 1176 parents returned the questionnaire (29.4%), with a mean age at surgery of 4.3 ± 2.2 and age at survey of 9.6 ± 3.6. Complete resolution of SDB was subjectively reported in 798 patients (67.9%), and mild SDB was suspected in 301 children (25.6%, HSCS > 0 with chronic snoring), while 77 (6.5%) had a HSCS > 2.72, suggesting persistent obstructive sleep apnea. In non-syndromic children, male sex, history of sole adenoidectomy, or sole tonsillectomy, and early age of surgery (< 2 years-old) were associated with higher HSCS scores (p < 0.05). Moreover, symptoms had a tendency to decrease from 1 to 6 years, re-occur at age 7-8, and also after 13, with boys reporting more severe symptoms, at a younger age.

CONCLUSIONS

Surgical excision of lymphoid tissue to treat SDB in childhood seems to be effective in the long term in two-thirds of subjects, while partial surgeries, specific age groups and early surgery are more likely to have persistent or recurrent symptoms.

Magnetic resonance imaging of obstructive sleep apnea in children

Sleep-disordered breathing has a spectrum of severity that spans from snoring and partial airway collapse with increased upper airway resistance, to complete upper airway obstruction with obstructive sleep apnea during sleeping. While snoring occurs in up to 20% of children, obstructive sleep apnea affects approximately 1-5% of children. The obstruction that occurs in obstructive sleep apnea is the result of the airway collapsing during sleep, which causes arousal and impairs restful sleep. Adenotonsillectomy is the first-line treatment of obstructive sleep apnea and is usually effective in otherwise healthy nonsyndromic children. However, there are subgroups in which this surgery is less effective. These subgroups include children with obesity, severe obstructive sleep apnea preoperatively, Down syndrome, craniofacial anomalies and polycystic ovarian disease. Continuous positive airway pressure (CPAP) is the first-line therapy for persistent obstructive sleep apnea despite previous adenotonsillectomy, but it is often poorly tolerated by children. When CPAP is not tolerated or preferred by the family, surgical options beyond adenotonsillectomy are discussed with the parent and child. Dynamic MRI of the airway provides a means to identify and localize the site or sites of obstruction for these children. In this review the authors address clinical indications for imaging, ideal team members to involve in an effective multidisciplinary program, basic anesthesia requirements, MRI protocol techniques and interpretation of the findings on MRI that help guide surgery.

The Role of Functional Respiratory Imaging in Treatment Selection of Children With Obstructive Sleep Apnea and Down Syndrome

STUDY OBJECTIVES

The complexity of the pathogenesis of obstructive sleep apnea (OSA) in children with Down syndrome (DS) is illustrated by a prevalence of residual OSA after adenotonsillectomy. The aim of this study was to investigate whether upper airway imaging combined with computation fluid dynamics could characterize treatment outcome after adenotonsillectomy in these children.

METHODS

Children with DS and OSA were prospectively included. All children underwent an evaluation of the upper airway and an ultra-low dose computed tomography scan of the upper airway before adenotonsillectomy. The upper airway tract was extracted from the scan and combined with computational fluid dynamics. Results were evaluated using control polysomnography after adenotonsillectomy.

RESULTS

Thirty-three children were included: 18 boys, age 4.3 ± 2.3 years, median body mass index z-score 0.6 (-2.9 to 3.0), and median obstructive apnea-hypopnea index was 15.7 (3-70) events/h. The minimal upper airway cross-sectional area was significantly smaller in children with more severe OSA (P = .03). Nineteen children underwent a second polysomnography after adenotonsillectomy. Seventy-nine percent had persistent OSA (obstructive apneahypopnea index > 2 events/h). A greater than 50% decrease in obstructive apnea-hypopnea index was observed in 79% and these children had a significantly higher volume of the regions below the tonsils.

CONCLUSIONS

This is the first study to characterize treatment outcome in children with DS and OSA using computed tomography upper airway imaging. At baseline, children with more severe OSA had a smaller upper airway. Children with a less favorable response to adenotonsillectomy had a smaller volume of regions below the tonsils, which could be due to enlargement of the lingual tonsils, glossoptosis, or macroglossia.

COMMENTARY

A commentary on this article appears in this issue on page 501.

An updated review of pediatric drug-induced sleep endoscopy

Objectives

Drug-induced sleep endoscopy (DISE) involves assessment of the upper airway using a flexible endoscope while patients are in a pharmacologically-induced sleep-like state. The aim of this article is to review the current literature regarding the role of DISE in children with obstructive sleep apnea (OSA). The indications, typical anesthetic protocol, comparison to other diagnostic modalities, scoring systems, and outcomes are discussed.

Methods

A comprehensive review of literature regarding pediatric DISE up through May 2017 was performed.

Results

DISE provides a thorough evaluation of sites of obstruction during sedation. It is typically indicated for children with persistent OSA after tonsillectomy, those with OSA without tonsillar hypertrophy, children with risk factors predisposing then to multiple sites of obstruction, or when sleep-state dependent laryngomalacia is suspected. The dexmedotomidine and ketamine protocol, which replicates non-REM sleep, appears to be safe and is often used for pediatric DISE, although propofol is the most commonly employed agent for DISE in adults. Six different scoring systems (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) have been used to report pediatric DISE findings, but none is universally accepted.

Conclusions

DISE is a safe and useful technique to assess levels of obstruction in children. There is currently no universally-accepted anesthetic protocol or scoring system for pediatric DISE, but both will be necessary in order to provide a consistent method to report findings, enhance communication among providers and optimize surgical outcomes.

Level of Evidence

N/A.

Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea: A Meta-analysis

Importance

Evidence indicates correlations between lingual tonsil hypertrophy and pediatric obstructive sleep apnea (OSA). However, to our knowledge, a meta-analysis of surgical outcomes for lingual tonsillectomy in children with OSA has not been conducted.

Objective

To evaluate the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric OSA.

Data Sources

The study protocol was registered on PROSPERO (CRD42015027053). PubMed, MEDLINE, EMBASE, and the Cochrane Reviews databases were searched independently by 2 authors for relevant articles published by September 2016.

Study Selection

The literature search identified English-language studies that used polysomnography to evaluate children with lingual tonsil hypertrophy and OSA after lingual tonsillectomy alone. The search keywords were lingual tonsil, lingual tonsillectomy, sleep endoscopy, sleep apnea, and child.

Data Extraction and Synthesis

Polysomnographic data from each study were extracted. A random-effects model pooled postoperative sleep variable changes and success rates for lingual tonsillectomy in treating pediatric OSA.

Main Outcomes and Measures

Four outcomes for lingual tonsillectomy were analyzed. These included net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum oxygen saturation, the overall success rate for a postoperative AHI less than 1, and the overall success rate for a postoperative AHI less than 5.

Results

This meta-analysis consisted of 4 studies (mean sample size, 18.25 patients), with a total of 73 unique patients (mean [SD] age, 8.3 [1.1] years). Fifty-nine percent (27 of 46) of the patients were male, and 1 of the 4 studies did not specify number of males. Lingual tonsillectomy was indicated for persistent OSA after adenotonsillectomy in all cases. Lingual tonsil hypertrophy was evaluated using computed tomography or magnetic resonance imaging in 1 study, sleep endoscopy in 2 studies, and cine magnetic resonance imaging in 1 study. The mean change in the AHI after lingual tonsillectomy was a reduction of 8.9 (95% CI, -12.6 to -5.2) events per hour. The mean change in the minimum oxygen saturation after lingual tonsillectomy was an increase of 6.0% (95% CI, 2.7%-9.2%). The overall success rate was 17% (95% CI, 7%-35%) for a postoperative AHI less than 1 and 51% (95% CI, 25%-76%) for a postoperative AHI less than 5. Postoperative complications that developed included airway obstruction, bleeding, and pneumonia.

Conclusions and Relevance

Lingual tonsillectomy is an effective surgical management for children with OSA caused by lingual tonsil hypertrophy, and it achieves significant improvement in the AHI and the minimum oxygen saturation. However, children frequently have residual OSA after lingual tonsillectomy, and postoperative complications must be carefully managed.

The Efficacy of Adenotonsillectomy for Obstructive Sleep Apnea in Children with Down Syndrome: A Systematic Review

Objective

Determine the efficacy of adenotonsillectomy in children with Down syndrome.

Data Sources

Databases included PubMed, EMBASE, CINAHL, and Google Scholar. The search was inclusive of all references available through January 5, 2017.

Review Methods

A systematic review of the medical literature addressing adenotonsillectomy in treating obstructive sleep apnea in children with Down syndrome was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data were pooled using a random-effects model where possible. The quality of studies was graded using the Methodological Index for Nonrandomized Studies criteria.

Results

Of the 957 articles screened, 5 met inclusion for the qualitative analysis and 3 met criteria for the quantitative analysis. The findings of the qualitative analysis were that adenotonsillectomy has a positive effect on children with Down syndrome but in many cases is noncurative, up to 75% need postoperative breathing support, there is a high rate of immediate postoperative airway needs, and there is no change in sleep efficiency or architecture. The articles consistently reported moderate success in improving polysomnographic parameters, and limited pooling of the data demonstrated a mean decrease of the apnea-hypopnea index by 51% (95% confidence interval [CI], 46%-55%).

Conclusion

A 51% reduction in the preoperative apnea-hypopnea index can be expected with the intervention of adenotonsillectomy alone in children with Down syndrome. This information is useful for counseling and managing patient and family expectations. It also serves as a reminder to clinicians to obtain a postoperative sleep study, as many of these patients will need nighttime airway support or secondary sleep surgery.

Adenotonsillectomy to treat obstructive sleep apnea: Is it enough?

Although adenotonsillectomy is the first line treatment for children with obstructive sleep apnea syndrome (0SAS),¹ improvement in objectively documented outcomes is often inadequate and a substantial number of children have residual disease. Early recognition and treatment of children with persistent OSAS is required to prevent long-term morbidity. The management of these children is frequently complex and a multidisciplinary approach is required as most of them have additional risk factors for OSAS and comorbidities. In this paper, we first provide an overview of children at risk for persistent disease following adenotonsillectomy. Thereafter, we discuss different diagnostic modalities to evaluate the sites of persistent upper airway obstruction and the currently available treatment options. Pediatr Pulmonol. 2017;52:699-709. © 2016 Wiley Periodicals, Inc.

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

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

Young children with Down syndrome show normal development of circadian rhythms, but poor sleep efficiency: a cross-sectional study across the first 60 months of life

Objectives

To evaluate sleep consolidation and circadian activity rhythms in infants and toddlers with Down syndrome (DS) under light and socially entrained conditions within a familiar setting. Given previous human and animal data suggesting intact circadian regulation of melatonin across the day and night, it was hypothesized that behavioral indices of circadian rhythmicity would likewise be intact in the sample with DS.

Methods

A cross-sectional study of 66 infants and young children with DS, aged 5–67 months, and 43 typically developing age-matched controls. Sleep and measures of circadian robustness or timing were quantified using continuous in-home actigraphy recordings performed over seven days. Circadian robustness was quantified via time series analysis of rest-activity patterns. Phase markers of circadian timing were calculated alongside these values. Sleep efficiency was also estimated based on the actigraphy recordings.

Results

This study provided further evidence that general sleep quality is poor in infants and toddlers with DS, a population that has sleep apnea prevalence as high as 50% during the preschool years. Despite poor sleep quality, circadian rhythm and phase were preserved in children with DS and displayed similar developmental trajectories in cross-sectional comparisons with a typically developing (TD) cohort. In line with past work, lower sleep efficiency scores were quantified in the group with DS relative to TD children. Infants born with DS exhibited the worst sleep fragmentation; however, in both groups, sleep efficiency and consolidation increased across age. Three circadian phase markers showed that 35% of the recruitment sample with DS was phase-advanced to an earlier morning schedule, suggesting significant within-group variability in the timing of their daily activity rhythms.

Conclusions

Circadian rhythms of wake and sleep are robust in children born with DS. The present results suggest that sleep fragmentation and any resultant cognitive deficits are likely not confounded by corresponding deficits in circadian rhythms.

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Circadian activity rhythms are robust in young children with Down syndrome.

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Early morning activity is phase-advanced in a subgroup.

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Infants with Down syndrome show significant sleep fragmentation.

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Sleep efficiency improves with age in children with Down syndrome, but still lags the trajectory seen in typical development.

Drug-induced sedation endoscopy in surgically naive children with Down syndrome and obstructive sleep apnea

OBJECTIVE

To describe the pattern of upper airway (UA) obstruction in surgically naive children with Down syndrome and obstructive sleep apnea (OSA), and to evaluate the outcome of drug-induced sedation endoscopy (DISE)-directed treatment.

METHODS

A prospective study of DISE in surgically naive children with Down syndrome and OSA was performed. Treatment was individually tailored based on the DISE findings and was evaluated by control polysomnography (PGS). Results are presented as median (lower-upper quartile) unless otherwise stated.

RESULTS

In 41 children, aged 4.2 years (range, 2.8-6.0) with a body mass z score of 1.04 (-0.55 to 1.82) and obstructive apnea-hypopnea index (oAHI) of 10.1/h (range, 6.3-23.0), DISE was performed. Adeno-/tonsillar obstruction was found in 75.6% of the patients, and these patients subsequently underwent UA surgery. Seven patients were non-surgically treated, and three received a combined treatment. A multilevel collapse was present in 85.4%. Tongue base obstruction was present in ten patients (24.4%) and epiglottic collapse in 48.8%. Pre- and postoperative PSG data were available for 25 children (adenotonsillectomy, n = 16; tonsillectomy, n = 7; adenoidectomy, n = 2). A significant improvement in oAHI from 11.4/h (range, 7.7-27.0) to 5.5/h (range, 2.1-7.6) was found. Persistent OSA was present in 52% of the children. No significant association between different DISE findings and persistent OSA could be found.

CONCLUSION

Most patients with Down syndrome and OSA present with multilevel collapse on DISE. Adenotonsillectomy results in a significant improvement of the oAHI; however more than half of the patients had persistent OSA, probably due to multilevel collapse. Upper airway evaluation may provide more insights into the pattern of UA obstruction in patients with persistent OSA.

Multimodality assessment of upper airway obstruction in children with persistent obstructive sleep apnea after adenotonsillectomy

OBJECTIVES/HYPOTHESIS

Children with obstructive sleep apnea (OSA) may have multiple sites of upper airway obstruction (UAO). A wide variety of techniques has been used to evaluate UAO. Our aim was to compare findings of cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) in identifying UAO sites in children with persistent OSA after adenotonsillectomy (AT).

STUDY DESIGN

Retrospective chart review.

MATERIAL AND METHODS

The medical records of children who underwent DISE and cine MRI were reviewed. Data pertaining to demographics, past medical history, body mass index, polysomnography, findings of DISE, and cine MRI were obtained.

RESULTS

Fifteen children (11 boys, 4 girls; age range, 7-18 years) were identified. Comorbid conditions were Down syndrome in nine patients, cerebral palsy in one, attention deficit hyperactivity disorder in two, and asthma in three. Severity of OSA was moderate in five, and severe in 10. DISE and cine MRI showed the same UAO site in 10 patients: a single site (tongue) in nine and multiple sites (tongue and oropharynx/lateral walls) in one. DISE showed additional UAO sites undetected by cine MRI in three patients. Cine MRI showed additional UAO sites undetected by DISE in one patient. DISE and cine MRI showed different sites of obstruction in one patient.

CONCLUSIONS

Cine MRI and DISE documented single and multiple sites of UAO in children with persistent OSA after AT. Cine MRI and DISE findings were similar in the majority of the children. Assessment of the sensitivity and specificity of cine MRI and DISE in detecting sites of UAO merits further investigation.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1224-1230, 2017.

Previous tonsillectomy modifies odds of tonsil and base of tongue cancer

BACKGROUND

Tonsillectomy is a commonly performed surgical procedure that involves removal of the palatine tonsils. The purpose of this study is to examine the association between previous tonsillectomy and odds of oropharyngeal squamous cell carcinoma (OPSCC) in a large population-based case-control study. We hypothesise that previous tonsillectomy is associated with a decreased odds of tonsil cancer with no impact on the odds of developing base of tongue (BOT) cancer.

METHODS

This was a population-based, frequency-matched case-control study with multinomial logistic regression, including 1378 controls, 108 BOT cancer cases, and 198 tonsil cancer cases. Demographic and risk factor data were collected using a structured questionnaire during an in-home visit conducted by trained nurse-interviewers. The human papillomavirus (HPV) tumour status was determined through Luminex-based multiplex PCR and p16 status by immunohistochemistry.

RESULTS

Previous tonsillectomy was associated with a nearly two-fold increased odds of BOT cancer (OR=1.95, 95% CI 1.25-3.06, P=0.003) and a large decrease in the odds of tonsil cancer (OR=0.22, 95% CI 0.13-0.36, P<0.001). When HPV status was considered, tonsillectomy was associated with a decreased odds of HPV-positive tonsil cancer (OR=0.17, 95% CI 0.08-0.34, P<0.001) and an increased risk of HPV-positive BOT cancer (OR=2.46, 95% CI 1.22-4.95, P=0.012). When p16 status was considered, tonsillectomy was associated with an increased odds of p16-positive BOT cancer (OR=2.24, 95% CI 1.16-4.35, P=0.017) and a decreased odds of p16-positive tonsil cancer (OR=0.14, 95% CI 0.07-0.31, P<0.001).

CONCLUSIONS

Previous tonsillectomy modifies the odds of both tonsil and BOT cancer, with decreased odds of tonsil cancer and increased odds of BOT cancer. A history of previous tonsillectomy may play a role in OPSCC risk stratification when considered along with other covariates such as sexual history, smoking status, and age.

Assessment of pediatric obstructive sleep apnea using a drug-induced sleep endoscopy rating scale

OBJECTIVES/HYPOTHESIS

Assess the reliability of a Sleep Endoscopy Rating Scale (SERS) and its relationship with pediatric obstructive sleep apnea (OSA) severity.

STUDY DESIGN

Retrospective case series of pediatric patients who underwent drug-induced sleep endoscopy (DISE) at the time of surgery for OSA from January 1, 2013 to May 1, 2014.

METHODS

Three blinded otolaryngologists scored obstruction on DISE recordings as absent (0), partial (+1), or complete (+2) at six anatomic levels: nasal airway, nasopharynx, velopharynx, oropharynx, hypopharynx, and arytenoids. Ratings were summed for a SERS total score (range, 0-12). Reliability was calculated using a κ statistic with linear weighting. SERS ratings and obstructive apnea-hypopnea index (OAHI) were compared using Spearman correlation. A receiver operating characteristic (ROC) analysis determined the ability of the SERS total score to predict severe OSA (OAHI >10).

RESULTS

Thirty-nine patients were included (mean age, 8.3 ± 5.1 years; 36% obese; mean OAHI, 19.1 ± 23.7). Intrarater and inter-rater reliability was substantial-to-excellent (κ = 0.61-0.83) and fair-to-substantial (κ = 0.33-0.76), respectively. Ratings correlated best with OAHI for the oropharynx (r = 0.54, P = .02), hypopharynx (r = 0.48, P = .04), and SERS total score (r = 0.75, P = .002). In ROC analysis, a SERS total score ≥6 demonstrated sensitivity/specificity of 81.8%/87.5%, respectively, and correctly classified 84% of patients.

CONCLUSIONS

The SERS can be applied reliably in children undergoing DISE for OSA. Ratings of the oropharynx, hypopharynx, and SERS total score demonstrated significant correlation with OSA severity. A SERS total score ≥6 was an accurate predictor of severe OSA.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1492-1498, 2016.

Upper airway morphology in Down Syndrome patients under dexmedetomidine sedation

BACKGROUND AND OBJECTIVES

Children with Down Syndrome are vulnerable to significant upper airway obstruction due to relative macroglossia and dynamic airway collapse. The objective of this study was to compare the upper airway dimensions of children with Down Syndrome and obstructive sleep apnea with normal airway under dexmedetomidine sedation.

METHODS

IRB approval was obtained. In this retrospective study, clinically indicated dynamic sagittal midline magnetic resonance images of the upper airway were obtained under low (1mcg/kg/h) and high (3mcg/kg/h) dose dexmedetomidine. Airway anteroposterior diameters and sectional areas were measured as minimum and maximum dimensions by two independent observers at soft palate (nasopharyngeal airway) and at base of the tongue (retroglossal airway).

RESULTS AND CONCLUSIONS

Minimum anteroposterior diameter and minimum sectional area at nasopharynx and retroglossal airway were significantly reduced in Down Syndrome compared to normal airway at both low and high dose dexmedetomidine. However, there were no significant differences between low and high dose dexmedetomidine in both Down Syndrome and normal airway. The mean apnea hypopnea index in Down Syndrome was 16±11. Under dexmedetomidine sedation, children with Down Syndrome and obstructive sleep apnea when compared to normal airway children show significant reductions in airway dimensions most pronounced at the narrowest points in the nasopharyngeal and retroglossal airways.

Diagnostic Role of Magnetic Resonance Imaging in Obstructive Sleep Apnea Syndrome

We aim to review the diagnostic role of magnetic resonance (MR) imaging in obstructive sleep apnea syndrome (OSAS). Basic background about sleep apnea, MR anatomy of the pharyngeal airway, and MR imaging sequences applied in obstructive sleep apnea are discussed. Static and dynamic MR imaging is used in the assessment of patients with OSAS. Magnetic resonance imaging can detect the level, degree, and cause of obstruction in the upper airway that guide the clinical diagnosis and treatment. Imaging is used for prediction of treatment outcome and monitoring and follow-up of patients with OSAS after therapy.

A Pediatric Grading Scale for Lingual Tonsil Hypertrophy

Lingual tonsil hypertrophy (LTH) is a common finding for children with residual obstructive sleep apnea (OSA) following an adenotonsillectomy. Secondary to the significant morbidity associated with OSA, identification and treatment of residual OSA are paramount. A dedicated LTH grading scale for children does not exist. The current adult LTH scale is impractical for children. Imaging is not routine for children, since it frequently requires sedation. We present a pediatric LTH grading scale with substantial interrater reliability to facilitate standardization of endoscopy findings and promote outcomes-based research for OSA surgery in children.

Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

Although adenotonsillectomy is accepted as a first-line therapy for pediatric obstructive sleep apnea (OSA), there is currently no consensus regarding optimal methods for identifying the sites of obstruction or treatment of children with persistent disease after surgery. With this in mind, our aim was to systematically review the English-language literature pertaining to these issues.

STUDY DESIGN

Systematic review.

METHODS

We searched all indexed years of Pubmed, Cochrane CENTRAL, DynaMed, UpToDate, CINAHL, and Scopus for English-language articles containing original human data, with ≥ 7 participants, all < 18 years old. Data regarding study design, demographics, clinical characteristics/outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by two investigators.

RESULTS

Of 758 identified abstracts, 24 articles (combined population = 960) were ultimately included. Seventeen (71%) described methods to identify site(s) of obstruction: drug-induced sleep endoscopy (11/24), cine magnetic resonance imaging (MRI) (3/24), and alternative imaging (3/24). Treatment options included lingual tonsillectomy (n = 6), with success rates of 57% to 88% (Cohen's effect size d = 1.38), as well as supraglottoplasty (n = 4), with success rates of 58% to 72% (d = 0.64). Additional treatments included medications and surgery (e.g., partial midline glossectomy and tongue suspension).

CONCLUSIONS

Drug-induced sleep endoscopy and cine MRI are the most commonly reported tools to identify sites of obstruction for children with persistent OSA; however, these techniques have not yet been clearly linked to outcomes. Evidence for treatment is extremely limited and focuses primarily on lingual tonsillectomy and supraglottoplasty. Also, reports regarding appropriate patient selection and outcomes in obese or otherwise healthy children are scant.

Intraoperative long range optical coherence tomography as a novel method of imaging the pediatric upper airway before and after adenotonsillectomy

BACKGROUND/OBJECTIVES

While upper airway obstruction is a common problem in the pediatric population, the first-line treatment, adenotonsillectomy, fails in up to 20% of patients. The decision to proceed to surgery is often made without quantitative anatomic guidance. We evaluated the use of a novel technique, long-range optical coherence tomography (LR-OCT), to image the upper airway of children under general anesthesia immediately before and after tonsillectomy and/or adenoidectomy. We investigated the feasibility of LR-OCT to identify both normal anatomy and sites of airway narrowing and to quantitatively compare airway lumen size in the oropharyngeal and nasopharyngeal regions pre- and post-operatively.

METHODS

46 children were imaged intraoperatively with a custom-designed LR-OCT system, both before and after adenotonsillectomy. These axial LR-OCT images were both rendered into 3D airway models for qualitative analysis and manually segmented for quantitative comparison of cross-sectional area.

RESULTS

LR-OCT images demonstrated normal anatomic structures (base of tongue, epiglottis) as well as regions of airway narrowing. Volumetric rendering of pre- and post-operative images clearly showed regions of airway collapse and post-surgical improvement in airway patency. Quantitative analysis of cross-sectional images showed an average change of 70.52mm(2) (standard deviation 47.87mm(2)) in the oropharynx after tonsillectomy and 105.58mm(2) (standard deviation 60.62mm(2)) in the nasopharynx after adenoidectomy.

CONCLUSIONS

LR-OCT is an emerging technology that rapidly generates 3D images of the pediatric upper airway in a feasible manner. This is the first step toward development of an office-based system to image awake pediatric subjects and thus better identify loci of airway obstruction prior to surgery.

Obstructive sleep apnea in children: a critical update

Obstructive sleep apnea (OSA) in children is a highly prevalent disorder caused by a conglomeration of complex pathophysiological processes, leading to recurrent upper airway dysfunction during sleep. The clinical relevance of OSA resides in its association with significant morbidities that affect the cardiovascular, neurocognitive, and metabolic systems. The American Academy of Pediatrics recently reiterated its recommendations that children with symptoms and signs suggestive of OSA should be investigated with polysomnography (PSG), and treated accordingly. However, treatment decisions should not only be guided by PSG results, but should also integrate the magnitude of symptoms and the presence or absence of risk factors and signs of OSA morbidity. The first-line therapy in children with adenotonsillar hypertrophy is adenotonsillectomy, although there is increasing evidence that medical therapy, in the form of intranasal steroids or montelukast, may be considered in mild OSA. In this review, we delineate the major concepts regarding the pathophysiology of OSA, its morbidity, diagnosis, and treatment.

Poor Sleep as a Precursor to Cognitive Decline in Down Syndrome : A Hypothesis

We propose that sleep disruption is a lever arm that influences how cognition emerges in development and then declines in response to Alzheimer disease in people with Down syndrome. Addressing sleep disruptions might be an overlooked way to improve cognitive outcomes in this population. This article is a contribution to a Special Issue on Down Syndrome curated by the editors of the Journal of Alzheimer’s Disease & Parkinsonism.

Complicated airway due to unexpected lingual tonsil hypertrophy

We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.