Surgical strategies in the treatment of complex obstructive sleep apnoea in children

Prader Willi syndrome and obstructive sleep apnea: co-occurrence in the pediatric population

BACKGROUND

A high prevalence of obstructive sleep apnea (OSA) occurs in children with Prader-Willi syndrome (PWS). Yet, due in part to the relatively small samples previously used, the prevalence of OSA has varied greatly across studies. It is also unclear if factors such as age, gender, body mass index (BMI), or type of genetic imprinting are associated with increased risk for OSA among children with PWS.

OBJECTIVES

To evaluate the (a) prevalence of OSA, as well as narcolepsy, in pediatric populations diagnosed with PWS; (b) effects of age, gender, body mass index, and genetic imprinting on OSA severity; and (c) efficacy of adenotonsillectomy (AT) for decreasing OSA severity in this population.

METHODS

All studies assessing OSA among children with PWS through August 2013 were identified using the PubMed/Medline, Psych Info, Cochrane library, and Google Scholar data bases.

RESULTS

Fourteen studies of children diagnosed with PWS and who were assessed for OSA using polysomnography (PSG) met inclusion criteria (n = 224 children). The prevalence of OSA across studies was 79.91% (n = 179/224). Among youths with OSA, 53.07% had mild OSA, 22.35% moderate OSA, and 24.58% severe OSA. Narcolepsy was found to occur in 35.71% of children with PWS. Adenotonsillectomy was associated with improvement in OSA for most children with PWS. However, residual OSA was present in the majority of cases post-surgery.

CONCLUSION

This study confirms the high prevalence of OSA and narcolepsy among children with PWS. Screening for OSA and narcolepsy among children with PWS is recommended. In addition, while adenotonsillectomy was effective in reducing OSA for some children, alternative treatments may need to be considered, given the only moderate response rate.

The role of distraction osteogenesis in the management of craniofacial syndromes

In patients with craniofacial syndromes, the skeletal discrepancy is often severe, and the ability to achieve the desired movement by immediate surgical repositioning is difficult because of restrictions of the soft-tissue envelope. The technique of distraction osteogenesis has provided an additional option for managing congenital and acquired craniofacial deformities. The use of distraction osteogenesis is, however, still within its infancy as a treatment modality. It is unlikely that the procedure will obviate the need for definitive orthognathic surgery at skeletal maturity in most patients with craniofacial anomalies. The role of distraction osteogenesis in craniofacial surgery will continue to evolve rapidly with increasing experience and technological advancement. Because distraction osteogenesis in the facial skeleton is a relatively new approach, analysis of the contemporary literature is imperative, and future long-term studies on the effects and outcome of distraction are essential.

Pediatric obstructive sleep apnea syndrome (OSAS) for the allergist: update on the assessment and management

OBJECTIVE

The purpose of this article is to provide an understanding of the epidemiology, pathophysiology, risk factors, potentially serious complications, diagnostic modalities, and treatment options available for pediatric obstructive sleep apnea syndrome (OSAS).

DATA SOURCES

The Ovid, MEDLINE, and PubMed databases from 1950 to the present were searched for relevant articles regarding pediatric OSAS.

STUDY SELECTION

Articles describing the prevalence, mechanisms, risk factors, complications, and most recent updates on assessment and management of pediatric sleep-disordered breathing (SDB) were used for this review.

RESULTS

The data suggest that SDB may be considered a disease continuum. It ranges in severity from mild obstruction of the upper airway, producing primary snoring, to increased upper airway resistance syndrome (UARS), to continuous episodes of complete upper airway obstruction or OSAS. The degree of sleep disruption, hypoxemia, hypercapnia, and upper airway airflow reduction are main factors in determining the severity of SDB. Mounting evidence implicates OSAS as a risk factor for decreased growth, impaired neurocognitive function, and cardiovascular morbidity. The first treatment of choice for OSAS in children remains tonsillectomy and adenoidectomy.

CONCLUSIONS

Sleep-disordered breathing is common in children and can cause minor as well as major disruption of sleep and health problems requiring intervention. Despite apparent symptoms and potentially severe consequences, SDB may be underdiagnosed and unrecognized. Therefore, a high index of suspicion and detailed clinical history and physical examination should be part of any clinical assessment of a child presenting with breathing difficulty during sleep.

Primary mandibular distraction for management of nocturnal desaturations secondary to temporomandibular joint (TMJ) ankylosis

OBJECTIVES

Mandibular advancement is a proven method in the management of obstructive sleep apnoea syndrome (OSAS) which may manifest as sleep disturbances with nocturnal desaturations during sleep (NDS). The purpose of this study is to evaluate the role of primary osteo-distraction prior to ankylosis release in pediatric patients, diagnosed with NDS secondary to temporomandibular joint (TMJ) ankylosis.

METHODS

Three patients in the age group of 8-12 years diagnosed with OSAS secondary to TMJ ankylosis underwent primary osteo-distraction for mandibular advancement. They were evaluated pre- and post-operatively using radiographs, over night pulse oximetry, and subjective evaluation of their sleep patterns.

RESULTS

All the three patients showed significant improvement in their saturation levels with a mean oxygen saturation of 94.66%. There was marked reduction in their snoring and sleep/awakening patterns. The mean advancement of the mandible in the three patients was 13.8mm.

CONCLUSION

Primary mandibular distraction is an effective method of correction of nocturnal desaturations during sleep in patients with TMJ ankylosis.

Continuous positive airway pressure for children: A discussion on how to maximize compliance

As pediatric sleep facilities and resources expand, increasing numbers of children with sleep-disordered breathing requiring continuous positive airway pressure (CPAP) treatment are being identified. Despite extensive expertise in treating adults with CPAP, many centres have little experience using CPAP in the pediatric population. The successful initiation and continued effective treatment with CPAP requires a unique and specialized approach to the pediatric patient and their family. Nearly, half of children needing CPAP will be uncooperative upon initial exposure to this unusual treatment. This review aims to outline an approach to the successful initiation of CPAP treatment in children including some trouble-shooting strategies to maximize initial and ongoing compliance with prescribed therapy.

Awake upper airway obstruction in children with spastic quadriplegic cerebral palsy

OBJECTIVE

Some children with severe cerebral palsy develop symptoms of upper airway obstruction (UAO) while awake. The aetiology, natural history and treatment of this complication have not previously been systematically described. This study documents a case series of children with severe cerebral palsy admitted to hospital because of severe awake UAO and reviews the relevant literature.

METHODS

The case records of children admitted to hospital with UAO while awake over an 8-month period were reviewed. Details of antecedent illness, comorbidities, acute management and follow up were collated. One case is presented in detail.

RESULTS

Eight children were admitted with UAO. Seven children required intensive care admission. One child died, and two underwent tracheostomy. Nasendoscopy showed pharyngeal collapse without anatomical obstruction in the majority. One child was discovered to have a brainstem malignancy.

CONCLUSIONS

Upper airway obstruction is a potentially severe and life-threatening complication of cerebral palsy. In this series, a majority of children had obstruction related to pharyngeal hypotonia and collapse. This can lead to prolonged hospitalization and intensive care admission. It may raise difficult management issues.

Obstructive sleep apnea in children

Despite increasing recognition of childhood obstructive sleep apnea syndrome (OSAS) as a significant public health problem, treatment of the condition remains inconsistent. Some children are screened using polysomnography and treated only when objective respiratory disturbances are identified. Many others receive adenotonsillectomy based only on signs and symptoms of upper airway obstruction without ever having a formal sleep study. Outcome-based data regarding the effectiveness of adenotonsillectomy, continuous positive airway pressure, and other treatments for childhood OSAS remain extremely limited. In this article, the major therapeutic options for treatment of childhood OSAS are reviewed. Adenotonsillectomy remains the most frequently used treatment for uncomplicated OSAS in children, but residual airway obstruction persists in a notable minority of patients. Nasal continuous positive airway pressure is used for children who are not good surgical candidates or who have failed previous surgical treatment, but is sometimes not tolerated by young children or their parents. Various alternative treatments are used on an individualized basis for children who cannot use the two first-line therapies for sleep apnea.

Obstructive sleep apnea syndrome in children: controversies in diagnosis and treatment

Obstructive sleep apnea syndrome (OSAS) is a common, under-recognized condition in childhood with significant morbidities if undiagnosed and untreated. The American Academy of Pediatrics recently issued a clinical practice guideline for the diagnosis and management of childhood OSAS. It was accompanied by a comprehensive evidence-based technical report that summarized the available literature supporting the guideline. The current review highlights areas of controversy and uncertainty that limit the development of more definitive standards of practice, updates the reader to several newer publications relevant to diagnosis and treatment of childhood OSAS, and identifies future directions for clinical research.

OSAS in children

BACKGROUND

Major risk factors for obstructive sleep apnea syndrome (OSAS) in children include adenotonsillar hypertrophy, neuromuscular disease and syndromes such as Down's or Pierre-Robin's syndrome; there is currently no consensus concerning diagnosis and therapy.

METHODS

The study analyses 40 children, aged 2 through 14 years, with macroscopic tonsillar hypertrophy (without recurrent tonsillitis but with OSAS) underwent adenotonsillectomy. Parents were invited to indicate the intensity of their children's symptomatology using a subjective evaluation scale, each patient underwent cephalometric analysis and polysomnography (PSG) before and after surgery.

RESULTS

The subjective scale of symptoms passed from 3.01 before treatment to 0.42 after treatment, rhinomanometry, passed from 3.456 to 0.896 p after 1 month the surgical operation (P<0.05). The polysomnography showed a resolution of the number of obstructive events in 37 patients and a reduction in 3 patients and RDI index fell from a mean of 26.9-2.6 after therapy. The average of oxygen saturation changed from 79% before treatment to 95% after therapy.

CONCLUSIONS

Adenotonsillectomy plays a major role in the treatment of OSAS.

Obstructive sleep-disordered breathing in children: new controversies, new directions

Although it may seem that confusion and uncertainty reign in the field of pediatric sleep medicine, the recent realizations that the scope of childhood SDB is wider, the symptomatology is broader, and the prevalence is higher than previously believed are major advances. Likewise, recent acknowledgment of the lack of true "gold standards" for diagnosing UARS and OSAS in children is also a major advancement in this field. Critical assessment of the current "state of the art" by the 2002 AAP Technical Report on the Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome [37] is another major advance that sets the stage for the next steps. The field needs an evidence-based definitions conference, standardization of definitions across all research studies, and much more research on clinical features, pathophysiology, diagnosis, and treatment of the "new" obstructive SDB, including the full range of morbidity caused by increased upper airway resistance. This should include further inquiry into the origins of adult morbidity that resulted from childhood SDB and how it can be prevented.