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Surgical management of sleep-disordered breathing in children
Operative Techniques in Otolaryngology (2015) 26, 100–104
Surgical management of sleep-disordered breathing in children Hannah Qualls, MD, Frank Rimell, MD From the Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota KEYWORDS Sleep-disordered breathing; Sleep apnea; Obstructive sleep apnea; Pediatric; Adenotonsillectomy; Lingual tonsillectomy; Midline glossectomy; Supraglottoplasty; Turbinoplasty; Tracheostomy; Drug-induced sleep endoscopy; DISE; Distraction osteogenesis
Pediatric obstructive sleep apnea is a multifactorial condition, with anatomical and neuromuscular components, significantly affecting the child's quality of life and long-term health outcomes. Workup may include polysomnography, endoscopy, and imaging to identify primary sites of obstruction. Adenotonsillectomy remains one of the first-line surgical options, with multiple modalities described. Palate and pharyngeal surgeries include lateral pharyngoplasty, modified expansion pharyngoplasty, and uvulopalatopharyngoplasty. Lingual tonsillectomy, midline posterior glossectomy, and tongue base suspension have been used to relieve the tongue base component of obstructive sleep apnea. Laryngomalacia, whether congenital or occult in the older pediatric patient, may cause obstruction and necessitate supraglottoplasty with or without epiglottopexy. Patients with syndromes, those with craniofacial abnormalities, and those with concomitant neurologic conditions often require multiple and more complex surgical interventions. Tracheostomy definitively relieves upper airway obstruction. r 2015 Elsevier Inc. All rights reserved.
Introduction Sleep-disordered breathing affects children from birth to adulthood and is associated with asthma, obesity, and multiple congenital conditions. Etiologies include anatomical abnormalities, body habitus, metabolic disorders, and neurologic disorders. Sequelae range from neurocognitive effects, such as hyperactivity and poor school performance, to cardiovascular and pulmonary effects, to alterations in growth and development. Pediatric obstructive sleep apnea may lead to permanent sequelae on the individual's health as an adult.1,2 Address reprint requests and correspondence: Frank Rimell, MD, Department of Otolaryngology, University of Minnesota, Minneapolis, MN. E-mail address: [email protected] http://dx.doi.org/10.1016/j.otot.2015.03.010 1043-1810/r 2015 Elsevier Inc. All rights reserved.
Approximately 1%-6% of children are affected internationally, based on studies using polysomnography (PSG) to evaluate school-age children with and without symptoms.3,4 In children with obesity, the prevalence of obstructive sleep apnea ranges from 13%-59%.5,6 The economic burden across the generalized population is substantial. Adult motor vehicle accidents related to obstructive sleep apnea are estimated to cost 15.9 billion US dollars annually.7,8 In the setting of pediatric sleep apnea, health care use increases by more than 215%-236% compared with the baseline population, owing to hospitalizations, multiple clinic visits, and treatment for upper respiratory infections.9,10 As with other pediatric illnesses, this leads to associated costs when a child must be absent from daycare or school, causing her primary caregiver to miss work or provide childcare. Pediatric sleep-disordered breathing has been characterized as having 4 phenotypes: lymphoid hypertrophy, obesity,
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craniofacial, and neuromuscular.2 The severity of obstructive sleep apnea has been demonstrated to correlate with upper respiratory tract lymphoid tissue bulk, rather than with body mass index.6 The age of onset and the ability to surgically treat sleep-disordered breathing depends on the phenotype of a given pediatric patient. Sleep-disordered breathing in the neonate and infant derive from congenital craniofacial anomalies, neurologic abnormalities, neuromuscular immaturity, and poor sensorimotor integration.11 Although genetic, neurologic, and craniofacial anomalies continue to play a role, lymphoid hypertrophy becomes the primary etiology in children between 2 and 8 years of age. From 8 years to adulthood, obesity plays a more significant role.
Patient selection and evaluation The gold standard for diagnosis and characterization of pediatric sleep-disordered breathing remains formal PSG. Although underutilized, these studies are costly, time intensive, and not readily accessible to every patient.12 A systematic review by Brietzke et al13 evaluated 12 studies comparing history and physical examination with PSG, concluding that history and physical alone are not reliable for diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. Standardized questionnaires are often sensitive, but not generally specific. Home nocturnal pulse oximetry requires PSG corroboration if result is negative, but in a patient with suspected obstructive sleep apnea (OSA) and a positive pulse oximetry test result, it has a positive predictive value of 97%. There is consistency between oximetry tests on different nights.14,15 AAOHNS 2011 clinical practice guidelines recommend formal PSG before tonsillectomy in pediatric patients ages 2-18 years with sleep-disordered breathing and obesity, trisomy 21, craniofacial abnormalities, neuromuscular disorders, mucopolysaccharidoses, sickle cell disease, or in the setting of poor correlation between symptom severity and physical examination without other comorbidities. The guidelines also recommend overnight observation of pediatric patients after tonsillectomy for severe OSA with apneahypopnea index (AHI) Z10 or SpO2 nadir o80% or both, or age less than 3 years.16 Other guidelines state that all children with trisomy 21 should undergo PSG before the age of 4 years and children with Prader-Willi syndrome should undergo PSG before treatment with recombinant growth hormone.17,18 A more recent development in the evaluation of pediatric sleep-disordered breathing is drug-induced sleep endoscopy. Performance of sedated endoscopy allows assessment of the site(s) most involved in a patient's obstructive sleep apnea and allows for directed surgical intervention.19-21 Compared with awake endoscopy, it better demonstrates collapse of the tongue base and pharyngeal wall.22
Adenotonsillectomy Waldeyer ring, comprising the adenoids, palatine tonsils, and lingual tonsil, is a collection of lymphoid tissues surrounding
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the entrance to the aerodigestive tract. Hypertrophy may lead to nasal obstruction, snoring, obstructive sleep apnea, choking, and dysphagia. Adenotonsillectomy remains the mainstay of pediatric obstructive sleep apnea treatment, with 250,000 procedures performed annually. In children with OSA without comorbid conditions, high preoperative AHI has been shown to correlate with large tonsil size, but not correlate with symptoms, age, sex, and ethnicity. PSG parameters and quality of life improve with adenotonsillectomy, but there is poor correlation between objective and subjective measurements. The literature indicates normalization of postoperative parameters in children with mild OSA, and improvement without normalization of AHI in children with moderate to severe OSA.23,24 Recent meta-analyses show that treatment success occurs in 59.8% (defined by AHI o 1) to 82.9% (AHI o 5) of patients following adenotonsillectomy.25,26 Before adenotonsillectomy, the palate and uvula must be inspected to ensure the absence of a submucous cleft, indicated by bifid uvula, groove in the midline of the palate, and a notch in the posterior hard palate. Failure to recognize submucous clefting risks velopharyngeal insufficiency following adenoidectomy. Modalities for reducing hypertrophic adenoid tissue include cold steel curettage, electrothermal reduction with cautery, radiofrequency ablation, or excision with an adenoid microdebrider. Hemostasis is achieved initially by placing tonsil sponges in the nasopharynx during tonsillectomy, and then cauterizing residual bleeding foci. Hypertrophic palatine tonsils have been addressed in a variety of ways, from tonsillectomy to tonsillotomy to submucosal volume reduction. In tonsillectomy, the tonsil is dissected free of the adjacent muscle, with scalpel or snare, or with monopolar or bipolar electrocautery, radiofrequency coblation, or harmonic scalpel. Electrocautery uses thermal energy to divide tissue and achieve hemostasis, which causes increased pain compared with sharp dissection techniques. Radiofrequency dissection creates a plasma layer that melts through tissue and seals blood vessels and may cause less pain than electrocautery techniques.27 The harmonic scalpel uses ultrasonic vibration to divide tissue and coagulate blood vessels.28 Intracapsular tonsillectomy or tonsillotomy may be performed with microdebrider or radiofrequency; in these procedures, hypertrophic tonsil tissue is removed while preserving the tonsillar capsule and protecting the pharyngeal muscles, potentially reducing pain and recovery time.29,30-33 Interstitial radiofrequency bipolar thermal volume reduction also preserves parapharyngeal muscles and reduces the tonsil volume by 40% on average.34,35 Risks and complications of adenotonsillectomy include postoperative hemorrhage; dehydration; temporary or permanent lingual or hypoglossal nerve injury with tongue numbness, weakness, or altered taste and sensation; injury to the carotid artery; glossopharyngeal nerve injury; regrowth of the lymphoid tissue, necessitating revision surgery; velopharyngeal insufficiency; injury to the torus tubarius, resulting in Eustachian tube dysfunction; and nasopharyngeal stenosis.36-38
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Pharyngeal and palate surgery Pharyngeal wall collapse has been demonstrated to contribute to both adult and pediatric OSA. Several variations on pharyngoplasty stent the pharynx to address obstruction at this site. Lateral pharyngoplasty involves suturing the anterior and posterior tonsillar pillars together to close the tonsillar fossa after tonsillectomy, leading to statistically significant AHI reduction, although not resolution of OSA.39,40 In expansion pharyngoplasty, the palatopharyngeus muscle is anteriorly rotated and suspended on the soft palate after tonsillectomy, leading to statistically significant reduction of AHI in adults.41 Modified expansion pharyngoplasty, involving tonsillectomy followed by dividing the superficial fibers of the palatopharyngeus and tunneling them upward into the palate, shows a greater cure rate for OSA than adenotonsillectomy alone.42 Uvulopalatopharyngoplasty has been studied as an alternative to tracheostomy for the complex pediatric patient with OSA with neurologic comorbidities, but, with the exception of 1 case report, is not used in otherwise healthy children.43-46
Tongue base surgery Lingual tonsil hypertrophy has been associated with persistent OSA after adenotonsillectomy and is more common in children with obesity or trisomy 21.47-49 Lingual tonsillectomy has been performed in adults with electrocautery, laser, and radiofrequency ablation, and in children, with laser or radiofrequency ablation. Lingual tonsillectomy is performed by retracting the tongue with a clamp or silk stitch, exposing the tongue base with a conventional laryngoscope or GlideScope, marking the site of the lingual arteries and hypoglossal nerves, then ablating the hypertrophic lingual tonsil tissue.48,49 One approach involves a small anterior tongue incision, tunneling posteriorly, and submucosally ablating the hypertrophic tissue.50 Midline posterior glossectomy has been used in drug-induced sleep endoscopy-directed treatment of pediatric OSA.51 Tongue base suspension has been used in children with complex OSA and cerebral palsy. The technique is similar to that described in adults: the genial tubercle is exposed and a selftapping screw is placed, a suture is secured to the screw, passed through the tongue base, and tightened until the tongue base advances a few millimeters, and then secured.46
Nasal surgery Inferior turbinate reduction is performed for primary nasal obstruction in most cases; sleep apnea is the indication in 16% of cases. A survey of pediatric otolaryngologists revealed that 80% of turbinoplasties are performed in conjunction with other procedures. Primary modalities in current use are coblator and microdebrider.52 The coblator is inserted into the soft tissue of the medial aspect of the inferior turbinate and used to perform cold ablation according to the device manufacturer's instructions, with
care taken to protect the nasal ala and septum when removing the device. The microdebrider is used to remove submucous soft tissue while leaving the mucosa and turbinate bone intact. The inferior turbinate may be outfractured in an older teenage patient whose nasal development would be expected to be complete, based on age and sex. Most complications are minor; most commonly noted are epistaxis, nasal crusting, and failure of the procedure to produce the desired outcome.
Surgery for laryngomalacia In neonates, particularly premature infants and those with comorbid neurologic conditions, the immature cartilages and sensorimotor coordination of the airway can combine to cause laryngomalacia, which may contribute to OSA.11,53 Occult laryngomalacia may also be present in older children as a component of OSA.54,55 Following preliminary examination with flexible laryngoscopy, the airway should be surgically examined to confirm the diagnosis and treat the condition. Direct laryngoscopy is performed in the anesthetized patient with an appropriately sized laryngoscope. If the aryepiglottic folds are foreshortened, causing the epiglottis to prolapse, they may be divided with cold steel or CO2 laser; redundant arytenoid mucosa may be sharply excised or removed with a microdebrider.56-58 Epiglottopexy may also be performed with CO2 laser: after direct laryngoscopy and suspension, laser is applied to the lingual surface of the epiglottis in a linear fashion, with or without laser ablation of the tongue base mucosa and suturing to promote adherence between the epiglottis and tongue base.59,60
Special considerations Children with syndromes have a high rate of obstructive sleep apnea, related to craniofacial abnormalities, macroglossia, and hypotonia, and often require multiple or more complex procedures.61 Anatomical abnormalities include micrognathia, which may be isolated versus secondary to Pierre Robin sequence or other syndromes, and midface hypoplasia.62,63 Both may both be treated with distraction osteogenesis.64,65 In cleft palate repair (Pierre Robin sequence, 22q11.2 deletion, and isolated), correction of velopharyngeal insufficiency can lead to obstructive sleep apnea.66 Patients with 22q11.2 deletion syndromes and other syndromes are at risk for medialized internal carotid arteries, which increase the risk of pharyngeal surgeries.67 Pyriform aperture stenosis and choanal atresia both cause nasal obstruction, which may require anatomic correction. Hypotonia secondary to trisomy 21, cerebral palsy, mucopolysaccharidoses, and other neurologic conditions may necessitate additional procedures beyond adenotonsillectomy. Trisomy 21, Beckwith-Wiedemann, Prader-Willi, and mucopolysaccharidoses are also accompanied by macroglossia. Lymphatic and vascular malformations of the oral cavity, tongue, pharynx, and airway may be other
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causes of obstruction.48,61 Additionally, there are cases of laryngeal lesions causing obstructive sleep apnea in neurofibromatosis.68 Tracheostomy is employed if other surgical interventions are inadequate, severe neurologic comorbidities are present, or the airway is obstructed when the patient is awake. This bypasses the entire upper airway, definitively correcting obstructive sleep apnea.
Conclusions Pediatric obstructive sleep apnea is a multifactorial condition, with anatomical and neuromuscular components, significantly affecting the child's quality of life and longterm health outcomes. Therapies may be better directed using endoscopy and imaging to identify primary sites of obstruction. Adenotonsillectomy remains one of the firstline surgical options. Other procedures on the palate, pharynx, tongue base, larynx, craniofacial structures have also been described. Tracheostomy definitively relieves upper airway obstruction. Patients with syndromes, those with craniofacial abnormalities, and those with concomitant neurologic conditions often require multiple and more complex surgical interventions.
References 1. Alexander NS, Schroeder JW: Pediatric obstructive sleep apnea syndrome. Pediatr Clin North Am 60(4):827-840, http://dx.doi.org/ 10.1016/j.pcl.2013.04.009. [review], 2013 2. Schwengel DA, Dalesio NM, Stierer TL: Pediatric obstructive sleep apnea. Anesthesiol Clin 32(1):237-261, http://dx.doi.org/10.1016/ j.anclin.2013.10.012, 2014 3. Bixler EO, Vgontzas AN, Lin HM, et al: Sleep disordered breathing in children in a general population sample: Prevalence and risk factors. Sleep 32(6):731-736, 2009 4. Li AM, So HK, Au CT, et al: Epidemiology of obstructive sleep apnoea syndrome in Chinese children: A two-phase community study. Thorax 65(11):991-997, http://dx.doi.org/10.1136/thx.2010.134858, 2010 5. Verhulst SL, Van Gaal L, De Backer W, et al: The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev 12(5):339-346, http://dx.doi.org/10.1016/ j.smrv.2007.11.002. [Epub 2008 Apr 11], 2008 6. Arens R, Sin S, Nandalike K, et al: Upper airway structure and body fat composition in obese children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 183(6):782-787, http://dx.doi.org/10.1164/rccm. 201008-1249OC. [Epub 2010 Oct 8], 2011 7. Leger D, Bayon V, Laaban JP, et al: Impact of sleep apnea on economics. Sleep Med Rev 16(5):455-462, http://dx.doi.org/10.1016/ j.smrv.2011.10.001. [Epub 2012 Jan 12], 2012 8. Sassani A, Findley LJ, Kryger M, et al: Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep 27(3):453-458, 2004 9. Reuveni H, Simon T, Tal A, et al: Health care services utilization in children with obstructive sleep apnea syndrome. Pediatrics 110(1 Pt 1): 68-72, 2002 10. Tarasiuk A, Greenberg-Dotan S, Simon-Tuval T, et al: Elevated morbidity and health care use in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 175(1):55-61. [Epub 2006 Oct 12], 2007 11. Thompson DM: Abnormal sensorimotor integrative function of the larynx in congenital laryngomalacia: A new theory of etiology. Laryngoscope 117:1-33, http://dx.doi.org/10.1097/MLG.0b013e31804 a5750, 2007
103
12. Friedman NR: Pediatric sleep studies: When and how often are they necessary? Curr Opin Otolaryngol Head Neck Surg 21(6):557-566, http://dx.doi.org/10.1097/MOO.0b013e328365ba8d, 2013 13. Brietzke SE, Katz ES, Roberson DW: Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/ hypopnea syndrome? A systematic review of the literature Otolaryngol Head Neck Surg 131:827-832, 2004 14. Brouillette RT, Morielli A, Leimanis A, et al: Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics 105:405-412, 2000 15. Pavone M, Cutrera R, Verrillo E, et al: Night-to-night consistency of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatr Pulmonol 48(8):754-760, http://dx.doi.org/10.1002/ ppul.22685. [Epub 2013 Mar 26], 2013 16. Roland PS, Rosenfeld RM, Brooks LJ, et al: Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 145:S1-S15, 2011 17. Bull MJ: Clinical report: Health supervision for children with Down syndrome. Pediatrics 128:393-406, 2011 18. Deal CL, Tony M, Höybye C, et al: 2011 Growth Hormone in PraderWilli Syndrome Clinical Care Guidelines Workshop Participants Growth Hormone Research Society workshop summary: Consensus guidelines for recombinant human growth hormone therapy in PraderWilli syndrome. J Clin Endocrinol Metab 98:E1072-E1087, 2013 19. Durr ML, Meyer AK, Kezirian EJ, et al: Drug-induced sleep endoscopy in persistent pediatric sleep-disordered breathing after adenotonsillectomy. Arch Otolaryngol Head Neck Surg 138(7):638-643, http://dx.doi.org/10.1001/archoto.2012.1067, 2012 20. Ulualp SO, Szmuk P: Drug-induced sleep endoscopy for upper airway evaluation in children with obstructive sleep apnea. Laryngoscope 3(1):292-297, http://dx.doi.org/10.1002/lary.23832. [Epub 2012 Nov 20], 2013 21. Boudewyns A, Verhulst S, Maris M, et al: Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome. Sleep Med pii: S1389-9457(14):00330-X, http://dx.doi.org/10.1016/j.sleep.2014. 06.016. [Epub ahead of print], 2014 22. Fishman G1, Zemel M, DeRowe A, et al: Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: Inter-observer correlation and comparison with awake endoscopy. Int J Pediatr Otorhinolaryngol 77(5):752-755, http://dx.doi.org/10.1016/j.ijporl. 2013.02.002. [Epub 2013 Feb 22], 2013 23. Mitchell RB: Adenotonsillectomy for obstructive sleep apnea in children: Outcome evaluated by pre- and postoperative polysomnography. Laryngoscope 117(10):1844-1854, 2007 24. Kang KT, Weng WC, Lee CH, et al: Discrepancy between objective and subjective outcomes after adenotonsillectomy in children with obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 151(1): 150-158. [Epub ahead of print], 2014 25. Brietzke SE, Gallagher D: The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/ hypopnea syndrome: A meta-analysis. Otolaryngol Head Neck Surg 134(6):979-984, 2006 26. Friedman M, Wilson M, Lin HC, et al: Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140(6): 800-808, http://dx.doi.org/10.1016/j.otohns.2009.01.043, 2009 27. Temple RH, Timms MS: Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 61(3):195-198, 2001 28. Wiatrak BJ, Willging JP: Harmonic scalpel for tonsillectomy. Laryngoscope 112(8 Pt 2 (suppl 100)):14-16, 2002 29. Koltai PJ, Solares CA, Mascha EJ, et al: Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope 112 (8 Pt 2 (suppl 100)):17-19, 2002 30. Leinbach RF, Markwell SJ, Colliver JA, et al: Hot versus cold tonsillectomy: A systematic review of the literature. Otolaryngol Head Neck Surg 129(4):360-364, 2003 31. Shah UK, Theroux Z, Shah GB, et al: Resource analysis of tonsillectomy in children. Laryngoscope 124(5):1223-1228, http://dx. doi.org/10.1002/lary.24388. [Epub 2013 Oct 7], 2014
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32. Friedman M, Wilson MN, Friedman J, et al: Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140(3):358-362, http://dx.doi.org/10.1016/j.otohns.2008.11.031, 2009 33. Wilson YL, Merer DM, Moscatello AL: Comparison of three common tonsillectomy techniques: A prospective randomized, double-blinded clinical study. Laryngoscope 119(1):162-170, http://dx.doi.org/ 10.1002/lary.20024, 2009 34. Pfaar O, Spielhaupter M, Schirkowski A, et al: Treatment of hypertrophic palatine tonsils using bipolar radiofrequency-induced thermotherapy (RFITT). Acta Otolaryngol 127(11):1176-1181, 2007 35. Pizak J, Macokova P, Zabrodsky M, et al: Influence of radiofrequency surgery on architecture of the palatine tonsils. Biomed Res Int 2014:598257, http://dx.doi.org/10.1155/2014/598257. [Epub 2014 Mar 26], 2014 36. Johnson LB, Elluru RG, Myer CM: Complications of adenotonsillectomy. Laryngoscope 112(8 Pt 2 (suppl 100)):35-36, 2002 37. Tomita H, Ohtuka K: Taste disturbance after tonsillectomy. Acta Otolaryngol Suppl 546:164-172, 2002 38. Sulman CG: Pediatric sleep surgery. Front Pediatr 2:51, http://dx.doi. org/10.3389/fped.2014.00051. [eCollection 2014], 2014 39. Chiu PH, Ramar K, Chen KC, et al: Can pillar suturing promote efficacy of adenotonsillectomy for pediatric OSAS? A prospective randomized controlled trial Laryngoscope 123(10):2573-2577, http://dx. doi.org/10.1002/lary.24011. [Epub 2013 Aug 5], 2013 40. Guilleminault C, Li K, Quo S, et al: A prospective study on the surgical outcomes of children with sleep-disordered breathing. Sleep 27 (1):95-100, 2004 41. Pang KP, Woodson BT: Expansion sphincter pharyngoplasty: A new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 137(1):110-114, 2007 42. Ulualp SO: Modified expansion sphincter pharyngoplasty for treatment of children with obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg 140(9):817-822, http://dx.doi.org/10.1001/jamaoto.2014.1329, 2014 43. Abdu MH, Feghali JG: Uvulopalatopharyngoplasty in a child with obstructive sleep apnea. A case report. J Laryngol Otol 102 (6):546-548, 1988 44. Seid AB, Martin PJ, Pransky SM, et al: Surgical therapy of obstructive sleep apnea in children with severe mental insufficiency. Laryngoscope 100(5):507-510, 1990 45. Kerschner JE, Lynch JB, Kleiner H, et al: Uvulopalatopharyngoplasty with tonsillectomy and adenoidectomy as a treatment for obstructive sleep apnea in neurologically impaired children. Int J Pediatr Otorhinolaryngol 62(3):229-235, 2002 46. Hartzell LD, Guillory RM, Munson PD, et al: Tongue base suspension in children with cerebral palsy and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 77(4):534-537, http://dx.doi.org/10.1016/j.ijporl.2013. 01.001. [Epub 2013 Jan 26], 2013 47. Fricke BL, Donnelly LF, Shott SR, et al: Comparison of lingual tonsil size as depicted on MR imaging between children with obstructive sleep apnea despite previous tonsillectomy and adenoidectomy and normal controls. Pediatr Radiol 36(6):518-523. [Epub 2006 Apr 5], 2006 48. Abdel-Aziz M, Ibrahim N, Ahmed A, et al: Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: Operative problems and management. Int J Pediatr Otorhinolaryngol 75(9):1127-1131, http://dx.doi.org/10.1016/j.ijporl.2011. 06.003. [Epub 2011 Jul 7], 2011 49. Guimaraes CV, Kalra M, Donnelly LF, et al: The frequency of lingual tonsil enlargement in obese children. AJR Am J Roentgenol 190 (4):973-975, http://dx.doi.org/10.2214/AJR.07.3020, 2008 50. Maturo SC, Mair EA: Submucosal minimally invasive lingual excision: An effective, novel surgery for pediatric tongue base reduction. Ann Otol Rhinol Laryngol 115(8):624-630, 2006
51. Wootten CT, Chinnadurai S, Goudy SL: Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 78(7):1158-1162, http://dx. doi.org/10.1016/j.ijporl.2014.04.041. [Epub 2014 May 2], 2014 52. Jiang ZY, Pereira KD, Friedman NR, et al: Inferior turbinate surgery in children: A survey of practice patterns. Laryngoscope 122(7):1620-1623, http://dx.doi.org/10.1002/lary.23292. [Epub 2012 Apr 26], 2012 53. Zafereo ME, Taylor RJ, Pereira KD: Supraglottoplasty for laryngomalacia with obstructive sleep apnea. Laryngoscope 118(10):1873-1877, http://dx. doi.org/10.1097/MLG.0b013e31817e7441, 2008 54. Chan DK, Truong MT, Koltai PJ: Supraglottoplasty for occult laryngomalacia to improve obstructive sleep apnea syndrome. Arch Otolaryngol Head Neck Surg 138(1):50-54, http://dx.doi.org/10.1001/ archoto.2011.233, 2012 55. Thevasagayam M, Rodger K, Cave D, et al: Prevalence of laryngomalacia in children presenting with sleep-disordered breathing. Laryngoscope 120 (8):1662-1666, http://dx.doi.org/10.1002/lary.21025, 2010 56. Erickson B, Cooper T, El-Hakim H: Factors associated with the morphological type of laryngomalacia and prognostic value for surgical outcomes. JAMA Otolaryngol Head Neck Surg 140(10):927-933, http://dx. doi.org/10.1001/jamaoto.2014.1843, 2014 57. Soong WJ, Shiao AS, Jeng MJ, et al: Comparison between rigid and flexible laser supraglottoplasty in the treatment of severe laryngomalacia in infants. Int J Pediatr Otorhinolaryngol 75(6):824-829, http://dx.doi.org/ 10.1016/j.ijporl.2011.03.016. [Epub 2011 Apr 21], 2011 58. Zalzal GH, Collins WO: Microdebrider-assisted supraglottoplasty. Int J Pediatr Otorhinolaryngol 69(3):305-309. [Epub 2004 Dec 8], 2005 59. Whymark AD, Clement WA, Kubba H, et al: Laser epiglottopexy for laryngomalacia: 10 years' experience in the west of Scotland. Arch Otolaryngol Head Neck Surg 132(9):978-982, 2006 60. Werner JA, Lippert BM, Dünne AA, et al: Epiglottopexy for the treatment of severe laryngomalacia. Eur Arch Otorhinolaryngol 259 (9):459-464. [Epub 2002 Jun 13], 2002 61. Sudarsan SS, Paramasivan VK, Arumugam SV, et al: Comparison of treatment modalities in syndromic children with obstructive sleep apnea—A randomized cohort study. Int J Pediatr Otorhinolaryngol 78 (9):1526-1533, http://dx.doi.org/10.1016/j.ijporl.2014.06.027. [Epub 2014 Jul 7], 2014 62. Maeda K, Tsuiki S, Nakata S, et al: Craniofacial contribution to residual obstructive sleep apnea after adenotonsillectomy in children: A preliminary study. J Clin Sleep Med 10(9):973-977, http://dx.doi. org/10.5664/jcsm.4028, 2014 63. Lam DJ, Jensen CC, Mueller BA, et al: Pediatric sleep apnea and craniofacial anomalies: A population-based case-control study. Laryngoscope 120(10):2098-2105, http://dx.doi.org/10.1002/lary.21093, 2010 64. Taylor BA, Brace M, Hong P: Upper airway outcomes following midface distraction osteogenesis: A systematic review. J Plast Reconstr Aesthet Surg. 67(7):891-899, http://dx.doi.org/10.1016/j.bjps.2014. 02.013. [Epub 2014 Feb 22], 2014 65. Tahiri Y, Viezel-Mathieu A, Aldekhayel S, et al: The effectiveness of mandibular distraction in improving airway obstruction in the pediatric population. Plast Reconstr Surg 133(3):352e-359e, http://dx.doi.org/ 10.1097/01.prs.0000438049.29258.a8, 2014 66. Crockett DJ, Goudy SL, Chinnadurai S, et al: Obstructive sleep apnea syndrome in children with 22q11.2 deletion syndrome after operative intervention for velopharyngeal insufficiency. Front Pediatr 2(84), http://dx. doi.org/10.3389/fped.2014.00084. [eCollection 2014], 2014 67. Raol N, Caruso P, Hartnick CJ: Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency. Ann Otol Rhinol Laryngol 124(4):261-265, 2015 68. Setabutr D, Perez MR, Truong MT, et al: Neurofibromatosis of the larynx causing stridor and sleep apnea. Am J Otolaryngol 35 (5):631-635, http://dx.doi.org/10.1016/j.amjoto.2014.04.009. [Epub 2014 May 4], 2014
Surgical management of sleep-disordered breathing in children Hannah Qualls, MD, Frank Rimell, MD From the Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota KEYWORDS Sleep-disordered breathing; Sleep apnea; Obstructive sleep apnea; Pediatric; Adenotonsillectomy; Lingual tonsillectomy; Midline glossectomy; Supraglottoplasty; Turbinoplasty; Tracheostomy; Drug-induced sleep endoscopy; DISE; Distraction osteogenesis
Pediatric obstructive sleep apnea is a multifactorial condition, with anatomical and neuromuscular components, significantly affecting the child's quality of life and long-term health outcomes. Workup may include polysomnography, endoscopy, and imaging to identify primary sites of obstruction. Adenotonsillectomy remains one of the first-line surgical options, with multiple modalities described. Palate and pharyngeal surgeries include lateral pharyngoplasty, modified expansion pharyngoplasty, and uvulopalatopharyngoplasty. Lingual tonsillectomy, midline posterior glossectomy, and tongue base suspension have been used to relieve the tongue base component of obstructive sleep apnea. Laryngomalacia, whether congenital or occult in the older pediatric patient, may cause obstruction and necessitate supraglottoplasty with or without epiglottopexy. Patients with syndromes, those with craniofacial abnormalities, and those with concomitant neurologic conditions often require multiple and more complex surgical interventions. Tracheostomy definitively relieves upper airway obstruction. r 2015 Elsevier Inc. All rights reserved.
Introduction Sleep-disordered breathing affects children from birth to adulthood and is associated with asthma, obesity, and multiple congenital conditions. Etiologies include anatomical abnormalities, body habitus, metabolic disorders, and neurologic disorders. Sequelae range from neurocognitive effects, such as hyperactivity and poor school performance, to cardiovascular and pulmonary effects, to alterations in growth and development. Pediatric obstructive sleep apnea may lead to permanent sequelae on the individual's health as an adult.1,2 Address reprint requests and correspondence: Frank Rimell, MD, Department of Otolaryngology, University of Minnesota, Minneapolis, MN. E-mail address: [email protected] http://dx.doi.org/10.1016/j.otot.2015.03.010 1043-1810/r 2015 Elsevier Inc. All rights reserved.
Approximately 1%-6% of children are affected internationally, based on studies using polysomnography (PSG) to evaluate school-age children with and without symptoms.3,4 In children with obesity, the prevalence of obstructive sleep apnea ranges from 13%-59%.5,6 The economic burden across the generalized population is substantial. Adult motor vehicle accidents related to obstructive sleep apnea are estimated to cost 15.9 billion US dollars annually.7,8 In the setting of pediatric sleep apnea, health care use increases by more than 215%-236% compared with the baseline population, owing to hospitalizations, multiple clinic visits, and treatment for upper respiratory infections.9,10 As with other pediatric illnesses, this leads to associated costs when a child must be absent from daycare or school, causing her primary caregiver to miss work or provide childcare. Pediatric sleep-disordered breathing has been characterized as having 4 phenotypes: lymphoid hypertrophy, obesity,
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craniofacial, and neuromuscular.2 The severity of obstructive sleep apnea has been demonstrated to correlate with upper respiratory tract lymphoid tissue bulk, rather than with body mass index.6 The age of onset and the ability to surgically treat sleep-disordered breathing depends on the phenotype of a given pediatric patient. Sleep-disordered breathing in the neonate and infant derive from congenital craniofacial anomalies, neurologic abnormalities, neuromuscular immaturity, and poor sensorimotor integration.11 Although genetic, neurologic, and craniofacial anomalies continue to play a role, lymphoid hypertrophy becomes the primary etiology in children between 2 and 8 years of age. From 8 years to adulthood, obesity plays a more significant role.
Patient selection and evaluation The gold standard for diagnosis and characterization of pediatric sleep-disordered breathing remains formal PSG. Although underutilized, these studies are costly, time intensive, and not readily accessible to every patient.12 A systematic review by Brietzke et al13 evaluated 12 studies comparing history and physical examination with PSG, concluding that history and physical alone are not reliable for diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. Standardized questionnaires are often sensitive, but not generally specific. Home nocturnal pulse oximetry requires PSG corroboration if result is negative, but in a patient with suspected obstructive sleep apnea (OSA) and a positive pulse oximetry test result, it has a positive predictive value of 97%. There is consistency between oximetry tests on different nights.14,15 AAOHNS 2011 clinical practice guidelines recommend formal PSG before tonsillectomy in pediatric patients ages 2-18 years with sleep-disordered breathing and obesity, trisomy 21, craniofacial abnormalities, neuromuscular disorders, mucopolysaccharidoses, sickle cell disease, or in the setting of poor correlation between symptom severity and physical examination without other comorbidities. The guidelines also recommend overnight observation of pediatric patients after tonsillectomy for severe OSA with apneahypopnea index (AHI) Z10 or SpO2 nadir o80% or both, or age less than 3 years.16 Other guidelines state that all children with trisomy 21 should undergo PSG before the age of 4 years and children with Prader-Willi syndrome should undergo PSG before treatment with recombinant growth hormone.17,18 A more recent development in the evaluation of pediatric sleep-disordered breathing is drug-induced sleep endoscopy. Performance of sedated endoscopy allows assessment of the site(s) most involved in a patient's obstructive sleep apnea and allows for directed surgical intervention.19-21 Compared with awake endoscopy, it better demonstrates collapse of the tongue base and pharyngeal wall.22
Adenotonsillectomy Waldeyer ring, comprising the adenoids, palatine tonsils, and lingual tonsil, is a collection of lymphoid tissues surrounding
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the entrance to the aerodigestive tract. Hypertrophy may lead to nasal obstruction, snoring, obstructive sleep apnea, choking, and dysphagia. Adenotonsillectomy remains the mainstay of pediatric obstructive sleep apnea treatment, with 250,000 procedures performed annually. In children with OSA without comorbid conditions, high preoperative AHI has been shown to correlate with large tonsil size, but not correlate with symptoms, age, sex, and ethnicity. PSG parameters and quality of life improve with adenotonsillectomy, but there is poor correlation between objective and subjective measurements. The literature indicates normalization of postoperative parameters in children with mild OSA, and improvement without normalization of AHI in children with moderate to severe OSA.23,24 Recent meta-analyses show that treatment success occurs in 59.8% (defined by AHI o 1) to 82.9% (AHI o 5) of patients following adenotonsillectomy.25,26 Before adenotonsillectomy, the palate and uvula must be inspected to ensure the absence of a submucous cleft, indicated by bifid uvula, groove in the midline of the palate, and a notch in the posterior hard palate. Failure to recognize submucous clefting risks velopharyngeal insufficiency following adenoidectomy. Modalities for reducing hypertrophic adenoid tissue include cold steel curettage, electrothermal reduction with cautery, radiofrequency ablation, or excision with an adenoid microdebrider. Hemostasis is achieved initially by placing tonsil sponges in the nasopharynx during tonsillectomy, and then cauterizing residual bleeding foci. Hypertrophic palatine tonsils have been addressed in a variety of ways, from tonsillectomy to tonsillotomy to submucosal volume reduction. In tonsillectomy, the tonsil is dissected free of the adjacent muscle, with scalpel or snare, or with monopolar or bipolar electrocautery, radiofrequency coblation, or harmonic scalpel. Electrocautery uses thermal energy to divide tissue and achieve hemostasis, which causes increased pain compared with sharp dissection techniques. Radiofrequency dissection creates a plasma layer that melts through tissue and seals blood vessels and may cause less pain than electrocautery techniques.27 The harmonic scalpel uses ultrasonic vibration to divide tissue and coagulate blood vessels.28 Intracapsular tonsillectomy or tonsillotomy may be performed with microdebrider or radiofrequency; in these procedures, hypertrophic tonsil tissue is removed while preserving the tonsillar capsule and protecting the pharyngeal muscles, potentially reducing pain and recovery time.29,30-33 Interstitial radiofrequency bipolar thermal volume reduction also preserves parapharyngeal muscles and reduces the tonsil volume by 40% on average.34,35 Risks and complications of adenotonsillectomy include postoperative hemorrhage; dehydration; temporary or permanent lingual or hypoglossal nerve injury with tongue numbness, weakness, or altered taste and sensation; injury to the carotid artery; glossopharyngeal nerve injury; regrowth of the lymphoid tissue, necessitating revision surgery; velopharyngeal insufficiency; injury to the torus tubarius, resulting in Eustachian tube dysfunction; and nasopharyngeal stenosis.36-38
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Pharyngeal and palate surgery Pharyngeal wall collapse has been demonstrated to contribute to both adult and pediatric OSA. Several variations on pharyngoplasty stent the pharynx to address obstruction at this site. Lateral pharyngoplasty involves suturing the anterior and posterior tonsillar pillars together to close the tonsillar fossa after tonsillectomy, leading to statistically significant AHI reduction, although not resolution of OSA.39,40 In expansion pharyngoplasty, the palatopharyngeus muscle is anteriorly rotated and suspended on the soft palate after tonsillectomy, leading to statistically significant reduction of AHI in adults.41 Modified expansion pharyngoplasty, involving tonsillectomy followed by dividing the superficial fibers of the palatopharyngeus and tunneling them upward into the palate, shows a greater cure rate for OSA than adenotonsillectomy alone.42 Uvulopalatopharyngoplasty has been studied as an alternative to tracheostomy for the complex pediatric patient with OSA with neurologic comorbidities, but, with the exception of 1 case report, is not used in otherwise healthy children.43-46
Tongue base surgery Lingual tonsil hypertrophy has been associated with persistent OSA after adenotonsillectomy and is more common in children with obesity or trisomy 21.47-49 Lingual tonsillectomy has been performed in adults with electrocautery, laser, and radiofrequency ablation, and in children, with laser or radiofrequency ablation. Lingual tonsillectomy is performed by retracting the tongue with a clamp or silk stitch, exposing the tongue base with a conventional laryngoscope or GlideScope, marking the site of the lingual arteries and hypoglossal nerves, then ablating the hypertrophic lingual tonsil tissue.48,49 One approach involves a small anterior tongue incision, tunneling posteriorly, and submucosally ablating the hypertrophic tissue.50 Midline posterior glossectomy has been used in drug-induced sleep endoscopy-directed treatment of pediatric OSA.51 Tongue base suspension has been used in children with complex OSA and cerebral palsy. The technique is similar to that described in adults: the genial tubercle is exposed and a selftapping screw is placed, a suture is secured to the screw, passed through the tongue base, and tightened until the tongue base advances a few millimeters, and then secured.46
Nasal surgery Inferior turbinate reduction is performed for primary nasal obstruction in most cases; sleep apnea is the indication in 16% of cases. A survey of pediatric otolaryngologists revealed that 80% of turbinoplasties are performed in conjunction with other procedures. Primary modalities in current use are coblator and microdebrider.52 The coblator is inserted into the soft tissue of the medial aspect of the inferior turbinate and used to perform cold ablation according to the device manufacturer's instructions, with
care taken to protect the nasal ala and septum when removing the device. The microdebrider is used to remove submucous soft tissue while leaving the mucosa and turbinate bone intact. The inferior turbinate may be outfractured in an older teenage patient whose nasal development would be expected to be complete, based on age and sex. Most complications are minor; most commonly noted are epistaxis, nasal crusting, and failure of the procedure to produce the desired outcome.
Surgery for laryngomalacia In neonates, particularly premature infants and those with comorbid neurologic conditions, the immature cartilages and sensorimotor coordination of the airway can combine to cause laryngomalacia, which may contribute to OSA.11,53 Occult laryngomalacia may also be present in older children as a component of OSA.54,55 Following preliminary examination with flexible laryngoscopy, the airway should be surgically examined to confirm the diagnosis and treat the condition. Direct laryngoscopy is performed in the anesthetized patient with an appropriately sized laryngoscope. If the aryepiglottic folds are foreshortened, causing the epiglottis to prolapse, they may be divided with cold steel or CO2 laser; redundant arytenoid mucosa may be sharply excised or removed with a microdebrider.56-58 Epiglottopexy may also be performed with CO2 laser: after direct laryngoscopy and suspension, laser is applied to the lingual surface of the epiglottis in a linear fashion, with or without laser ablation of the tongue base mucosa and suturing to promote adherence between the epiglottis and tongue base.59,60
Special considerations Children with syndromes have a high rate of obstructive sleep apnea, related to craniofacial abnormalities, macroglossia, and hypotonia, and often require multiple or more complex procedures.61 Anatomical abnormalities include micrognathia, which may be isolated versus secondary to Pierre Robin sequence or other syndromes, and midface hypoplasia.62,63 Both may both be treated with distraction osteogenesis.64,65 In cleft palate repair (Pierre Robin sequence, 22q11.2 deletion, and isolated), correction of velopharyngeal insufficiency can lead to obstructive sleep apnea.66 Patients with 22q11.2 deletion syndromes and other syndromes are at risk for medialized internal carotid arteries, which increase the risk of pharyngeal surgeries.67 Pyriform aperture stenosis and choanal atresia both cause nasal obstruction, which may require anatomic correction. Hypotonia secondary to trisomy 21, cerebral palsy, mucopolysaccharidoses, and other neurologic conditions may necessitate additional procedures beyond adenotonsillectomy. Trisomy 21, Beckwith-Wiedemann, Prader-Willi, and mucopolysaccharidoses are also accompanied by macroglossia. Lymphatic and vascular malformations of the oral cavity, tongue, pharynx, and airway may be other
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causes of obstruction.48,61 Additionally, there are cases of laryngeal lesions causing obstructive sleep apnea in neurofibromatosis.68 Tracheostomy is employed if other surgical interventions are inadequate, severe neurologic comorbidities are present, or the airway is obstructed when the patient is awake. This bypasses the entire upper airway, definitively correcting obstructive sleep apnea.
Conclusions Pediatric obstructive sleep apnea is a multifactorial condition, with anatomical and neuromuscular components, significantly affecting the child's quality of life and longterm health outcomes. Therapies may be better directed using endoscopy and imaging to identify primary sites of obstruction. Adenotonsillectomy remains one of the firstline surgical options. Other procedures on the palate, pharynx, tongue base, larynx, craniofacial structures have also been described. Tracheostomy definitively relieves upper airway obstruction. Patients with syndromes, those with craniofacial abnormalities, and those with concomitant neurologic conditions often require multiple and more complex surgical interventions.
References 1. Alexander NS, Schroeder JW: Pediatric obstructive sleep apnea syndrome. Pediatr Clin North Am 60(4):827-840, http://dx.doi.org/ 10.1016/j.pcl.2013.04.009. [review], 2013 2. Schwengel DA, Dalesio NM, Stierer TL: Pediatric obstructive sleep apnea. Anesthesiol Clin 32(1):237-261, http://dx.doi.org/10.1016/ j.anclin.2013.10.012, 2014 3. Bixler EO, Vgontzas AN, Lin HM, et al: Sleep disordered breathing in children in a general population sample: Prevalence and risk factors. Sleep 32(6):731-736, 2009 4. Li AM, So HK, Au CT, et al: Epidemiology of obstructive sleep apnoea syndrome in Chinese children: A two-phase community study. Thorax 65(11):991-997, http://dx.doi.org/10.1136/thx.2010.134858, 2010 5. Verhulst SL, Van Gaal L, De Backer W, et al: The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev 12(5):339-346, http://dx.doi.org/10.1016/ j.smrv.2007.11.002. [Epub 2008 Apr 11], 2008 6. Arens R, Sin S, Nandalike K, et al: Upper airway structure and body fat composition in obese children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 183(6):782-787, http://dx.doi.org/10.1164/rccm. 201008-1249OC. [Epub 2010 Oct 8], 2011 7. Leger D, Bayon V, Laaban JP, et al: Impact of sleep apnea on economics. Sleep Med Rev 16(5):455-462, http://dx.doi.org/10.1016/ j.smrv.2011.10.001. [Epub 2012 Jan 12], 2012 8. Sassani A, Findley LJ, Kryger M, et al: Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep 27(3):453-458, 2004 9. Reuveni H, Simon T, Tal A, et al: Health care services utilization in children with obstructive sleep apnea syndrome. Pediatrics 110(1 Pt 1): 68-72, 2002 10. Tarasiuk A, Greenberg-Dotan S, Simon-Tuval T, et al: Elevated morbidity and health care use in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 175(1):55-61. [Epub 2006 Oct 12], 2007 11. Thompson DM: Abnormal sensorimotor integrative function of the larynx in congenital laryngomalacia: A new theory of etiology. Laryngoscope 117:1-33, http://dx.doi.org/10.1097/MLG.0b013e31804 a5750, 2007
103
12. Friedman NR: Pediatric sleep studies: When and how often are they necessary? Curr Opin Otolaryngol Head Neck Surg 21(6):557-566, http://dx.doi.org/10.1097/MOO.0b013e328365ba8d, 2013 13. Brietzke SE, Katz ES, Roberson DW: Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/ hypopnea syndrome? A systematic review of the literature Otolaryngol Head Neck Surg 131:827-832, 2004 14. Brouillette RT, Morielli A, Leimanis A, et al: Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics 105:405-412, 2000 15. Pavone M, Cutrera R, Verrillo E, et al: Night-to-night consistency of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatr Pulmonol 48(8):754-760, http://dx.doi.org/10.1002/ ppul.22685. [Epub 2013 Mar 26], 2013 16. Roland PS, Rosenfeld RM, Brooks LJ, et al: Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 145:S1-S15, 2011 17. Bull MJ: Clinical report: Health supervision for children with Down syndrome. Pediatrics 128:393-406, 2011 18. Deal CL, Tony M, Höybye C, et al: 2011 Growth Hormone in PraderWilli Syndrome Clinical Care Guidelines Workshop Participants Growth Hormone Research Society workshop summary: Consensus guidelines for recombinant human growth hormone therapy in PraderWilli syndrome. J Clin Endocrinol Metab 98:E1072-E1087, 2013 19. Durr ML, Meyer AK, Kezirian EJ, et al: Drug-induced sleep endoscopy in persistent pediatric sleep-disordered breathing after adenotonsillectomy. Arch Otolaryngol Head Neck Surg 138(7):638-643, http://dx.doi.org/10.1001/archoto.2012.1067, 2012 20. Ulualp SO, Szmuk P: Drug-induced sleep endoscopy for upper airway evaluation in children with obstructive sleep apnea. Laryngoscope 3(1):292-297, http://dx.doi.org/10.1002/lary.23832. [Epub 2012 Nov 20], 2013 21. Boudewyns A, Verhulst S, Maris M, et al: Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome. Sleep Med pii: S1389-9457(14):00330-X, http://dx.doi.org/10.1016/j.sleep.2014. 06.016. [Epub ahead of print], 2014 22. Fishman G1, Zemel M, DeRowe A, et al: Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: Inter-observer correlation and comparison with awake endoscopy. Int J Pediatr Otorhinolaryngol 77(5):752-755, http://dx.doi.org/10.1016/j.ijporl. 2013.02.002. [Epub 2013 Feb 22], 2013 23. Mitchell RB: Adenotonsillectomy for obstructive sleep apnea in children: Outcome evaluated by pre- and postoperative polysomnography. Laryngoscope 117(10):1844-1854, 2007 24. Kang KT, Weng WC, Lee CH, et al: Discrepancy between objective and subjective outcomes after adenotonsillectomy in children with obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 151(1): 150-158. [Epub ahead of print], 2014 25. Brietzke SE, Gallagher D: The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/ hypopnea syndrome: A meta-analysis. Otolaryngol Head Neck Surg 134(6):979-984, 2006 26. Friedman M, Wilson M, Lin HC, et al: Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140(6): 800-808, http://dx.doi.org/10.1016/j.otohns.2009.01.043, 2009 27. Temple RH, Timms MS: Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 61(3):195-198, 2001 28. Wiatrak BJ, Willging JP: Harmonic scalpel for tonsillectomy. Laryngoscope 112(8 Pt 2 (suppl 100)):14-16, 2002 29. Koltai PJ, Solares CA, Mascha EJ, et al: Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope 112 (8 Pt 2 (suppl 100)):17-19, 2002 30. Leinbach RF, Markwell SJ, Colliver JA, et al: Hot versus cold tonsillectomy: A systematic review of the literature. Otolaryngol Head Neck Surg 129(4):360-364, 2003 31. Shah UK, Theroux Z, Shah GB, et al: Resource analysis of tonsillectomy in children. Laryngoscope 124(5):1223-1228, http://dx. doi.org/10.1002/lary.24388. [Epub 2013 Oct 7], 2014
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Operative Techniques in Otolaryngology, Vol 26, No 2, June 2015
32. Friedman M, Wilson MN, Friedman J, et al: Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140(3):358-362, http://dx.doi.org/10.1016/j.otohns.2008.11.031, 2009 33. Wilson YL, Merer DM, Moscatello AL: Comparison of three common tonsillectomy techniques: A prospective randomized, double-blinded clinical study. Laryngoscope 119(1):162-170, http://dx.doi.org/ 10.1002/lary.20024, 2009 34. Pfaar O, Spielhaupter M, Schirkowski A, et al: Treatment of hypertrophic palatine tonsils using bipolar radiofrequency-induced thermotherapy (RFITT). Acta Otolaryngol 127(11):1176-1181, 2007 35. Pizak J, Macokova P, Zabrodsky M, et al: Influence of radiofrequency surgery on architecture of the palatine tonsils. Biomed Res Int 2014:598257, http://dx.doi.org/10.1155/2014/598257. [Epub 2014 Mar 26], 2014 36. Johnson LB, Elluru RG, Myer CM: Complications of adenotonsillectomy. Laryngoscope 112(8 Pt 2 (suppl 100)):35-36, 2002 37. Tomita H, Ohtuka K: Taste disturbance after tonsillectomy. Acta Otolaryngol Suppl 546:164-172, 2002 38. Sulman CG: Pediatric sleep surgery. Front Pediatr 2:51, http://dx.doi. org/10.3389/fped.2014.00051. [eCollection 2014], 2014 39. Chiu PH, Ramar K, Chen KC, et al: Can pillar suturing promote efficacy of adenotonsillectomy for pediatric OSAS? A prospective randomized controlled trial Laryngoscope 123(10):2573-2577, http://dx. doi.org/10.1002/lary.24011. [Epub 2013 Aug 5], 2013 40. Guilleminault C, Li K, Quo S, et al: A prospective study on the surgical outcomes of children with sleep-disordered breathing. Sleep 27 (1):95-100, 2004 41. Pang KP, Woodson BT: Expansion sphincter pharyngoplasty: A new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 137(1):110-114, 2007 42. Ulualp SO: Modified expansion sphincter pharyngoplasty for treatment of children with obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg 140(9):817-822, http://dx.doi.org/10.1001/jamaoto.2014.1329, 2014 43. Abdu MH, Feghali JG: Uvulopalatopharyngoplasty in a child with obstructive sleep apnea. A case report. J Laryngol Otol 102 (6):546-548, 1988 44. Seid AB, Martin PJ, Pransky SM, et al: Surgical therapy of obstructive sleep apnea in children with severe mental insufficiency. Laryngoscope 100(5):507-510, 1990 45. Kerschner JE, Lynch JB, Kleiner H, et al: Uvulopalatopharyngoplasty with tonsillectomy and adenoidectomy as a treatment for obstructive sleep apnea in neurologically impaired children. Int J Pediatr Otorhinolaryngol 62(3):229-235, 2002 46. Hartzell LD, Guillory RM, Munson PD, et al: Tongue base suspension in children with cerebral palsy and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 77(4):534-537, http://dx.doi.org/10.1016/j.ijporl.2013. 01.001. [Epub 2013 Jan 26], 2013 47. Fricke BL, Donnelly LF, Shott SR, et al: Comparison of lingual tonsil size as depicted on MR imaging between children with obstructive sleep apnea despite previous tonsillectomy and adenoidectomy and normal controls. Pediatr Radiol 36(6):518-523. [Epub 2006 Apr 5], 2006 48. Abdel-Aziz M, Ibrahim N, Ahmed A, et al: Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: Operative problems and management. Int J Pediatr Otorhinolaryngol 75(9):1127-1131, http://dx.doi.org/10.1016/j.ijporl.2011. 06.003. [Epub 2011 Jul 7], 2011 49. Guimaraes CV, Kalra M, Donnelly LF, et al: The frequency of lingual tonsil enlargement in obese children. AJR Am J Roentgenol 190 (4):973-975, http://dx.doi.org/10.2214/AJR.07.3020, 2008 50. Maturo SC, Mair EA: Submucosal minimally invasive lingual excision: An effective, novel surgery for pediatric tongue base reduction. Ann Otol Rhinol Laryngol 115(8):624-630, 2006
51. Wootten CT, Chinnadurai S, Goudy SL: Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 78(7):1158-1162, http://dx. doi.org/10.1016/j.ijporl.2014.04.041. [Epub 2014 May 2], 2014 52. Jiang ZY, Pereira KD, Friedman NR, et al: Inferior turbinate surgery in children: A survey of practice patterns. Laryngoscope 122(7):1620-1623, http://dx.doi.org/10.1002/lary.23292. [Epub 2012 Apr 26], 2012 53. Zafereo ME, Taylor RJ, Pereira KD: Supraglottoplasty for laryngomalacia with obstructive sleep apnea. Laryngoscope 118(10):1873-1877, http://dx. doi.org/10.1097/MLG.0b013e31817e7441, 2008 54. Chan DK, Truong MT, Koltai PJ: Supraglottoplasty for occult laryngomalacia to improve obstructive sleep apnea syndrome. Arch Otolaryngol Head Neck Surg 138(1):50-54, http://dx.doi.org/10.1001/ archoto.2011.233, 2012 55. Thevasagayam M, Rodger K, Cave D, et al: Prevalence of laryngomalacia in children presenting with sleep-disordered breathing. Laryngoscope 120 (8):1662-1666, http://dx.doi.org/10.1002/lary.21025, 2010 56. Erickson B, Cooper T, El-Hakim H: Factors associated with the morphological type of laryngomalacia and prognostic value for surgical outcomes. JAMA Otolaryngol Head Neck Surg 140(10):927-933, http://dx. doi.org/10.1001/jamaoto.2014.1843, 2014 57. Soong WJ, Shiao AS, Jeng MJ, et al: Comparison between rigid and flexible laser supraglottoplasty in the treatment of severe laryngomalacia in infants. Int J Pediatr Otorhinolaryngol 75(6):824-829, http://dx.doi.org/ 10.1016/j.ijporl.2011.03.016. [Epub 2011 Apr 21], 2011 58. Zalzal GH, Collins WO: Microdebrider-assisted supraglottoplasty. Int J Pediatr Otorhinolaryngol 69(3):305-309. [Epub 2004 Dec 8], 2005 59. Whymark AD, Clement WA, Kubba H, et al: Laser epiglottopexy for laryngomalacia: 10 years' experience in the west of Scotland. Arch Otolaryngol Head Neck Surg 132(9):978-982, 2006 60. Werner JA, Lippert BM, Dünne AA, et al: Epiglottopexy for the treatment of severe laryngomalacia. Eur Arch Otorhinolaryngol 259 (9):459-464. [Epub 2002 Jun 13], 2002 61. Sudarsan SS, Paramasivan VK, Arumugam SV, et al: Comparison of treatment modalities in syndromic children with obstructive sleep apnea—A randomized cohort study. Int J Pediatr Otorhinolaryngol 78 (9):1526-1533, http://dx.doi.org/10.1016/j.ijporl.2014.06.027. [Epub 2014 Jul 7], 2014 62. Maeda K, Tsuiki S, Nakata S, et al: Craniofacial contribution to residual obstructive sleep apnea after adenotonsillectomy in children: A preliminary study. J Clin Sleep Med 10(9):973-977, http://dx.doi. org/10.5664/jcsm.4028, 2014 63. Lam DJ, Jensen CC, Mueller BA, et al: Pediatric sleep apnea and craniofacial anomalies: A population-based case-control study. Laryngoscope 120(10):2098-2105, http://dx.doi.org/10.1002/lary.21093, 2010 64. Taylor BA, Brace M, Hong P: Upper airway outcomes following midface distraction osteogenesis: A systematic review. J Plast Reconstr Aesthet Surg. 67(7):891-899, http://dx.doi.org/10.1016/j.bjps.2014. 02.013. [Epub 2014 Feb 22], 2014 65. Tahiri Y, Viezel-Mathieu A, Aldekhayel S, et al: The effectiveness of mandibular distraction in improving airway obstruction in the pediatric population. Plast Reconstr Surg 133(3):352e-359e, http://dx.doi.org/ 10.1097/01.prs.0000438049.29258.a8, 2014 66. Crockett DJ, Goudy SL, Chinnadurai S, et al: Obstructive sleep apnea syndrome in children with 22q11.2 deletion syndrome after operative intervention for velopharyngeal insufficiency. Front Pediatr 2(84), http://dx. doi.org/10.3389/fped.2014.00084. [eCollection 2014], 2014 67. Raol N, Caruso P, Hartnick CJ: Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency. Ann Otol Rhinol Laryngol 124(4):261-265, 2015 68. Setabutr D, Perez MR, Truong MT, et al: Neurofibromatosis of the larynx causing stridor and sleep apnea. Am J Otolaryngol 35 (5):631-635, http://dx.doi.org/10.1016/j.amjoto.2014.04.009. [Epub 2014 May 4], 2014