- Email: [email protected]
Utility of concurrent direct laryngoscopy and bronchoscopy with drug induced sleep endoscopy in pediatric patients with obstructive sleep apnea
Accepted Manuscript Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea Morgan Bliss, Swati Yanamadala, Peter Koltai PII:
S0165-5876(18)30174-5
DOI:
10.1016/j.ijporl.2018.04.009
Reference:
PEDOT 8966
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 2 October 2017 Revised Date:
8 April 2018
Accepted Date: 10 April 2018
Please cite this article as: M. Bliss, S. Yanamadala, P. Koltai, Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea, International Journal of Pediatric Otorhinolaryngology (2018), doi: 10.1016/j.ijporl.2018.04.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea Morgan Bliss, MD1
RI PT
Swati Yanamadala, MD2 Peter Koltai, MD3
1
SC
Department of Otolaryngology-Head and Neck Surgery, Rady Children's Hospital San Diego, University of California-San Diego. 3020 Children’s Way, San Diego, CA 92126. [email protected] 2
3
M AN U
Department of Medicine, Stanford University. 300 Pasteur Drive, Stanford, CA 94305. [email protected]
Department of Otolaryngology-Head and Neck Surgery, Stanford University. 801 Welch Rd, Stanford, CA 94305. [email protected] Potential conflicts of interest: None
Corresponding author:
TE D
Financial disclosures: None
AC C
EP
Morgan Bliss Rady Children's Hospital San Diego/UCSD 3020 Children’s Way, MC 5024 San Diego, CA 92126. Office: 858-309-7701 Email: [email protected]
Key Words: sleep apnea, obstructive; bronchoscopy; child; trachea Accepted for poster presentation at the ASPO 2016 Annual Meeting, May20-22, Chicago, IL.
ACCEPTED MANUSCRIPT
Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea
Abstract
RI PT
Objectives: The goal of this report was to find the frequency of synchronous airway lesions (SAL) identified during microdirect laryngoscopy and bronchoscopy (MDLB) that influenced treatment decisions beyond the information provided by drug induced sleep endoscopy (DISE)
SC
alone in children with obstructive sleep apnea (OSA) at a tertiary care pediatric hospital.
Methods: This was a retrospective chart review of all pediatric patients who underwent drug
M AN U
induced sleep endoscopy in conjunction with direct laryngoscopy and bronchoscopy as part of a comprehensive airway evaluation for obstructive sleep apnea at a tertiary care pediatric hospital. Results: Three hundred thirty-five patients with obstructive sleep apnea were evaluated with both sleep endoscopy and direct laryngoscopy with bronchoscopy. Five percent of patients had
TE D
SAL identified on MDLB contributing to airway obstruction. Three patients (0.9%) who underwent MDLB for OSA required surgical correction of SAL that was identified. Conclusion: In a limited subset of patients, direct laryngoscopy with bronchoscopy provides
AC C
1. Introduction
EP
additional positive findings to aid with treatment planning for obstructive sleep apnea.
Obstructive sleep apnea (OSA) is a common condition in childhood, generally caused by
enlarged tonsils and adenoids. However, in children with OSA who have small tonsils and adenoids or who have had adenotonsillectomy, drug induced sleep endoscopy (DISE) has been shown to be an effective technique in identifying sites of obstruction and directing treatment [1]. DISE is often performed concurrently with direct laryngoscopy and bronchoscopy (MDLB),
ACCEPTED MANUSCRIPT
however, the incremental value of MDLB over DISE alone for these children remains unclear. The goal of this report was to find the frequency of synchronous airway lesions identified during
children with OSA at a tertiary care pediatric hospital.
2. Methods
After institutional review board (IRB) approval, a retrospective cohort study identified
SC
2.1
RI PT
MDLB that influenced treatment decisions beyond the information provided by DISE alone in
patients who underwent direct laryngoscopy and bronchoscopy at Lucile Packard Children’s
M AN U
Hospital from 2006 through 2014. Operative reports, clinic notes, and sleep studies were reviewed. Both children with refractory OSA after adenotonsillectomy and those with small tonsils and adenoids and no prior surgery were included. Children from 2 months to 18 years of age with obstructive sleep apnea were included in the study. Patients were excluded from the
2.2
TE D
study if direct laryngoscopy and bronchoscopy was not performed at the time of surgery.
After performing DISE [2], airway evaluation with MDLB was done. The vocal cords are
EP
topically anesthetized and a suspended Lindholm laryngoscope is used expose the larynx. A 0-
AC C
degree telescope is then used to inspect the airway while the patient is breathing spontaneously.
3. Results 3.1
Three hundred thirty-five children with obstructive sleep apnea who underwent (MDLB)
concurrently with DISE were identified. Average age at the time of surgery was 7 years. One hundred sixty-two children (48%) had a history of intubation prior to MDLB. This includes one hundred forty-one children who had been intubated only during prior adenotonsillectomy and
ACCEPTED MANUSCRIPT
twenty-one children who were intubated for other reasons. Fifty-one children evaluated had an underlying genetic disorder (15%). This includes eighteen children with trisomy 21. Forty-six children were obese (13%), as defined by a body mass index at or above the 95th percentile for
defined by birth prior to 37 weeks gestation.
We included children with other major medical co-morbidities because they are more
SC
3.2
RI PT
children of the same age. Nineteen were identified as having a history of prematurity (5%), as
likely to have refractory OSA after adenotonsillectomy, and because results of prior studies
or craniofacial problems [3].
3.3
M AN U
suggest that there may be a larger proportion of SALs in children with neuromuscular disorders
Since our goal was to characterize the incremental value of MDLB over DISE alone in
TE D
identifying SALs, lesions such as laryngomalacia, vocal fold paralysis or paresis, vocal nodules, or enlarged lingual tonsils which were apparent on the DISE were not considered in the results of
3.4
EP
this study.
Synchronous airway lesions (SAL) were identified in 17 patients (5%) during MDLB.
AC C
The most common were subglottic stenosis, subglottic cysts and vascular compression. One of these patients had two lesions identified. Three of the 17 children (18%) had surgical correction of the SAL. Surgical intervention consisted of incision of subglottic cyst with balloon dilation in two patients with subglottic cysts, and balloon dilation in one patient with grade two subglottic stenosis. These results are summarized in Table 1. There were no complications associated with MDLB.
ACCEPTED MANUSCRIPT
3.5
Thirty-three percent of patients who were intubated for any reason other than
adenotonsillectomy had a SAL identified on MDLB. Only three percent of patients who were
RI PT
not intubated or were intubated only during adenotonsillectomy had a SAL identified. Using Fisher’s exact test, history of intubation for any reason other than adenotonsillectomy is
associated with SAL (P < 0.0001). All children with clinically significant and surgically
SC
correctable lesions did have a history of prior intubation. No patients with SAL identified on
M AN U
MDLB had a documented history of stridor on physical exam prior to MDLB.
No children with SAL identified on MDLB were obese. When analyzed individually, neither genetic disorder nor history of prematurity was a predictor for SAL. However, when comparing the rate of SAL in all children with history of prematurity or with genetic, neurologic,
TE D
or craniofacial co-morbidities (19%) to the rate of SAL in otherwise healthy children who were full term (0.4%), there is a significant association between co-morbidity and SAL (P < 0.0001). The average patient age when a SAL was identified on MDLB was 5 years. The average patient
The apnea hypopnea index(AHI) was available for two hundred twenty-five children.
AC C
3.6
EP
age when no synchronous airway lesion was found on MDLB was 7 years.
The overall average AHI was 13. The AHI was available for fifteen of the seventeen patients with synchronous airway lesions. The average AHI in this group was 15. The difference in AHI between groups was not statistically significant.
ACCEPTED MANUSCRIPT
4. Discussion 4.1
This report highlights a low 5% rate of SALs identified on MDLB, with less than 1% rate
of SALs which require additional surgical correction. Based on these findings, we conclude that
RI PT
MDLB in most cases is unnecessary. Our results suggest that concurrent MDLB with DISE may have utility in a limited subset of pediatric patients with OSA who have a history of intubation
genetic, neurologic or craniofacial co-morbidity.
With the increasing use of distal chip fiberoptic scopes for flexible laryngoscopy and
M AN U
4.2
SC
for any reason other than adenotonsillectomy, or have a history of prematurity, or history of
DISE, it has become easier to visualize lesions of the subglottis during flexible laryngoscopy. This technology may also help surgeons to select patients with OSA who may benefit from further evaluation with MDLB after a potentially concerning lesion is identified on distal chip
4.3
TE D
laryngoscopy or DISE.
There are a few limitations to this study. Due to the retrospective nature of the study, it is
EP
difficult to know for sure whether any of the subglottic lesions identified on MDLB may have also been at least partially visible on DISE. As such, the incremental benefit of concurrent
AC C
MDLB with DISE may be even lower than the findings of this study demonstrate. An additional limitation of this study is that post-operative polysomnograms were not available for some of the children who were found to have SAL on MDLB. Future investigations could compare long term outcomes of children with OSA and SAL who were treated with surgery versus observation alone.
ACCEPTED MANUSCRIPT
4.4
This is the first study analyzing the marginal benefit of performing MDLB in addition to
DISE specifically in patients with OSA. Previous studies have shown that sleep endoscopy is effective at identifying SAL and plays a significant role in determining the final treatment plan
RI PT
[2-7]. In contrast, the current retrospective cohort study shows that less than 1% of patients with difficult to treat OSA had a change in treatment plan due to findings from the MDLB. The
SC
outcome of this review has changed how we practice.
5. Conclusion
M AN U
We conclude that in most cases MDLB concurrently with DISE is unnecessary, except in the subset of patients with history of intubation for reason other than adenotonsillectomy, history
AC C
EP
TE D
of prematurity, or history of genetic, neurologic or craniofacial co-morbidity.
ACCEPTED MANUSCRIPT
Table 1. Synchronous Airway Lesions Identified During MDLB
6 3 3 2 2 1 1
16% 66% 0% 0% 0% 0% 0%
1.7 3 9.6 1 11.5 12 2
18*
18%
5
Subglottic stenosis Subglottic cyst Vascular compression Tracheobronchomalacia Laryngeal cleft Tracheal stenosis Hypopharyngeal hemangioma
Goldenhar
M AN U
All SAL identified on MDLB
Comorbidity (number of patients with comorbidity) Prematurity (1), ** Prematurity(2), hydrocephalus, BW Developmental delay DiGeorge Chromosomal translocation
RI PT
Required Surgical Intervention
SC
Frequency
Average Age at Diagnosis (years)
AC C
EP
TE D
*One patient in the study had two separate synchronous airway lesions identified on MDLB **BW: Beckwith- Wiedemann
ACCEPTED MANUSCRIPT
References [1] Lin AC, Koltai PJ. 2012. International journal of pediatrics 2012; 2012: 576719.
RI PT
[2] Truong MT, Woo VG, Koltai PJ. 2012. International journal of pediatric otorhinolaryngology 2012; 76: 722-727.
Pediatric pulmonology 2005; 40: 205-210.
SC
[3] Goldberg S, Shatz A, Picard E, Wexler I, Schwartz S, Swed E, Zilber L, Kerem E. 2005.
[4] Michelson A, Hawley K, Anne S. Do synchronous airway lesions predict treatment failure
Ped Otolaryngol. 2014; 78: 1439-1443.
M AN U
after adenotonsillectomy in children less than 3 years of age with obstructive sleep apnea? Int J
[5] Rastatter J, Schroeder J, French A, Holinger L. Synchronous airway lesions in children younger than age 3 years undergoing adenotonsillectomy. Otolaryngol Head Neck. 2011; 145:
TE D
309-313.
[6] Mandell D, Yellon R. Synchronous airway lesions and esophagitis in children undergoing adenoidectomy. Arch Otolaryngol Head and Neck Surg. 2007; 133:375-380.
EP
[7]Jaroslava Hybášková, Ondřej Jor, Vilém Novák, Karol Zeleník, PetrMatoušek, and Pavel Ko mínek. Drug-Induced Sleep Endoscopy Changes the Treatment Concept in Patients with
AC C
Obstructive Sleep Apnoea. Bio med Res Int. 2016;2016:6583216.
ACCEPTED MANUSCRIPT Table 1. Synchronous Airway Lesions Identified During MDLB
RI PT
SC
Subglottic stenosis Subglottic cyst Vascular compression Tracheobronchomalacia Laryngeal cleft Tracheal stenosis Hypopharyngeal hemangioma All SAL identified on MDLB
Average Required Age at Surgical Diagnosis Comorbidity (number of patients with Frequency Intervention (years) comorbidity) Prematurity (1), 6 16% 1.7 ** 3 66% 3 Prematurity(2), hydrocephalus, BW 3 0% 9.6 Developmental delay 2 0% 1 DiGeorge 2 0% 11.5 Chromosomal translocation 1 0% 12 1 0% 2 Goldenhar 18* 18% 5
*One patient in the study had two separate synchronous airway lesions identified on MDLB
AC C
EP
TE D
M AN U
**BW: Beckwith- Wiedemann
S0165-5876(18)30174-5
DOI:
10.1016/j.ijporl.2018.04.009
Reference:
PEDOT 8966
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 2 October 2017 Revised Date:
8 April 2018
Accepted Date: 10 April 2018
Please cite this article as: M. Bliss, S. Yanamadala, P. Koltai, Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea, International Journal of Pediatric Otorhinolaryngology (2018), doi: 10.1016/j.ijporl.2018.04.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea Morgan Bliss, MD1
RI PT
Swati Yanamadala, MD2 Peter Koltai, MD3
1
SC
Department of Otolaryngology-Head and Neck Surgery, Rady Children's Hospital San Diego, University of California-San Diego. 3020 Children’s Way, San Diego, CA 92126. [email protected] 2
3
M AN U
Department of Medicine, Stanford University. 300 Pasteur Drive, Stanford, CA 94305. [email protected]
Department of Otolaryngology-Head and Neck Surgery, Stanford University. 801 Welch Rd, Stanford, CA 94305. [email protected] Potential conflicts of interest: None
Corresponding author:
TE D
Financial disclosures: None
AC C
EP
Morgan Bliss Rady Children's Hospital San Diego/UCSD 3020 Children’s Way, MC 5024 San Diego, CA 92126. Office: 858-309-7701 Email: [email protected]
Key Words: sleep apnea, obstructive; bronchoscopy; child; trachea Accepted for poster presentation at the ASPO 2016 Annual Meeting, May20-22, Chicago, IL.
ACCEPTED MANUSCRIPT
Utility of Concurrent Direct Laryngoscopy and Bronchoscopy with Drug Induced Sleep Endoscopy in Pediatric Patients with Obstructive Sleep Apnea
Abstract
RI PT
Objectives: The goal of this report was to find the frequency of synchronous airway lesions (SAL) identified during microdirect laryngoscopy and bronchoscopy (MDLB) that influenced treatment decisions beyond the information provided by drug induced sleep endoscopy (DISE)
SC
alone in children with obstructive sleep apnea (OSA) at a tertiary care pediatric hospital.
Methods: This was a retrospective chart review of all pediatric patients who underwent drug
M AN U
induced sleep endoscopy in conjunction with direct laryngoscopy and bronchoscopy as part of a comprehensive airway evaluation for obstructive sleep apnea at a tertiary care pediatric hospital. Results: Three hundred thirty-five patients with obstructive sleep apnea were evaluated with both sleep endoscopy and direct laryngoscopy with bronchoscopy. Five percent of patients had
TE D
SAL identified on MDLB contributing to airway obstruction. Three patients (0.9%) who underwent MDLB for OSA required surgical correction of SAL that was identified. Conclusion: In a limited subset of patients, direct laryngoscopy with bronchoscopy provides
AC C
1. Introduction
EP
additional positive findings to aid with treatment planning for obstructive sleep apnea.
Obstructive sleep apnea (OSA) is a common condition in childhood, generally caused by
enlarged tonsils and adenoids. However, in children with OSA who have small tonsils and adenoids or who have had adenotonsillectomy, drug induced sleep endoscopy (DISE) has been shown to be an effective technique in identifying sites of obstruction and directing treatment [1]. DISE is often performed concurrently with direct laryngoscopy and bronchoscopy (MDLB),
ACCEPTED MANUSCRIPT
however, the incremental value of MDLB over DISE alone for these children remains unclear. The goal of this report was to find the frequency of synchronous airway lesions identified during
children with OSA at a tertiary care pediatric hospital.
2. Methods
After institutional review board (IRB) approval, a retrospective cohort study identified
SC
2.1
RI PT
MDLB that influenced treatment decisions beyond the information provided by DISE alone in
patients who underwent direct laryngoscopy and bronchoscopy at Lucile Packard Children’s
M AN U
Hospital from 2006 through 2014. Operative reports, clinic notes, and sleep studies were reviewed. Both children with refractory OSA after adenotonsillectomy and those with small tonsils and adenoids and no prior surgery were included. Children from 2 months to 18 years of age with obstructive sleep apnea were included in the study. Patients were excluded from the
2.2
TE D
study if direct laryngoscopy and bronchoscopy was not performed at the time of surgery.
After performing DISE [2], airway evaluation with MDLB was done. The vocal cords are
EP
topically anesthetized and a suspended Lindholm laryngoscope is used expose the larynx. A 0-
AC C
degree telescope is then used to inspect the airway while the patient is breathing spontaneously.
3. Results 3.1
Three hundred thirty-five children with obstructive sleep apnea who underwent (MDLB)
concurrently with DISE were identified. Average age at the time of surgery was 7 years. One hundred sixty-two children (48%) had a history of intubation prior to MDLB. This includes one hundred forty-one children who had been intubated only during prior adenotonsillectomy and
ACCEPTED MANUSCRIPT
twenty-one children who were intubated for other reasons. Fifty-one children evaluated had an underlying genetic disorder (15%). This includes eighteen children with trisomy 21. Forty-six children were obese (13%), as defined by a body mass index at or above the 95th percentile for
defined by birth prior to 37 weeks gestation.
We included children with other major medical co-morbidities because they are more
SC
3.2
RI PT
children of the same age. Nineteen were identified as having a history of prematurity (5%), as
likely to have refractory OSA after adenotonsillectomy, and because results of prior studies
or craniofacial problems [3].
3.3
M AN U
suggest that there may be a larger proportion of SALs in children with neuromuscular disorders
Since our goal was to characterize the incremental value of MDLB over DISE alone in
TE D
identifying SALs, lesions such as laryngomalacia, vocal fold paralysis or paresis, vocal nodules, or enlarged lingual tonsils which were apparent on the DISE were not considered in the results of
3.4
EP
this study.
Synchronous airway lesions (SAL) were identified in 17 patients (5%) during MDLB.
AC C
The most common were subglottic stenosis, subglottic cysts and vascular compression. One of these patients had two lesions identified. Three of the 17 children (18%) had surgical correction of the SAL. Surgical intervention consisted of incision of subglottic cyst with balloon dilation in two patients with subglottic cysts, and balloon dilation in one patient with grade two subglottic stenosis. These results are summarized in Table 1. There were no complications associated with MDLB.
ACCEPTED MANUSCRIPT
3.5
Thirty-three percent of patients who were intubated for any reason other than
adenotonsillectomy had a SAL identified on MDLB. Only three percent of patients who were
RI PT
not intubated or were intubated only during adenotonsillectomy had a SAL identified. Using Fisher’s exact test, history of intubation for any reason other than adenotonsillectomy is
associated with SAL (P < 0.0001). All children with clinically significant and surgically
SC
correctable lesions did have a history of prior intubation. No patients with SAL identified on
M AN U
MDLB had a documented history of stridor on physical exam prior to MDLB.
No children with SAL identified on MDLB were obese. When analyzed individually, neither genetic disorder nor history of prematurity was a predictor for SAL. However, when comparing the rate of SAL in all children with history of prematurity or with genetic, neurologic,
TE D
or craniofacial co-morbidities (19%) to the rate of SAL in otherwise healthy children who were full term (0.4%), there is a significant association between co-morbidity and SAL (P < 0.0001). The average patient age when a SAL was identified on MDLB was 5 years. The average patient
The apnea hypopnea index(AHI) was available for two hundred twenty-five children.
AC C
3.6
EP
age when no synchronous airway lesion was found on MDLB was 7 years.
The overall average AHI was 13. The AHI was available for fifteen of the seventeen patients with synchronous airway lesions. The average AHI in this group was 15. The difference in AHI between groups was not statistically significant.
ACCEPTED MANUSCRIPT
4. Discussion 4.1
This report highlights a low 5% rate of SALs identified on MDLB, with less than 1% rate
of SALs which require additional surgical correction. Based on these findings, we conclude that
RI PT
MDLB in most cases is unnecessary. Our results suggest that concurrent MDLB with DISE may have utility in a limited subset of pediatric patients with OSA who have a history of intubation
genetic, neurologic or craniofacial co-morbidity.
With the increasing use of distal chip fiberoptic scopes for flexible laryngoscopy and
M AN U
4.2
SC
for any reason other than adenotonsillectomy, or have a history of prematurity, or history of
DISE, it has become easier to visualize lesions of the subglottis during flexible laryngoscopy. This technology may also help surgeons to select patients with OSA who may benefit from further evaluation with MDLB after a potentially concerning lesion is identified on distal chip
4.3
TE D
laryngoscopy or DISE.
There are a few limitations to this study. Due to the retrospective nature of the study, it is
EP
difficult to know for sure whether any of the subglottic lesions identified on MDLB may have also been at least partially visible on DISE. As such, the incremental benefit of concurrent
AC C
MDLB with DISE may be even lower than the findings of this study demonstrate. An additional limitation of this study is that post-operative polysomnograms were not available for some of the children who were found to have SAL on MDLB. Future investigations could compare long term outcomes of children with OSA and SAL who were treated with surgery versus observation alone.
ACCEPTED MANUSCRIPT
4.4
This is the first study analyzing the marginal benefit of performing MDLB in addition to
DISE specifically in patients with OSA. Previous studies have shown that sleep endoscopy is effective at identifying SAL and plays a significant role in determining the final treatment plan
RI PT
[2-7]. In contrast, the current retrospective cohort study shows that less than 1% of patients with difficult to treat OSA had a change in treatment plan due to findings from the MDLB. The
SC
outcome of this review has changed how we practice.
5. Conclusion
M AN U
We conclude that in most cases MDLB concurrently with DISE is unnecessary, except in the subset of patients with history of intubation for reason other than adenotonsillectomy, history
AC C
EP
TE D
of prematurity, or history of genetic, neurologic or craniofacial co-morbidity.
ACCEPTED MANUSCRIPT
Table 1. Synchronous Airway Lesions Identified During MDLB
6 3 3 2 2 1 1
16% 66% 0% 0% 0% 0% 0%
1.7 3 9.6 1 11.5 12 2
18*
18%
5
Subglottic stenosis Subglottic cyst Vascular compression Tracheobronchomalacia Laryngeal cleft Tracheal stenosis Hypopharyngeal hemangioma
Goldenhar
M AN U
All SAL identified on MDLB
Comorbidity (number of patients with comorbidity) Prematurity (1), ** Prematurity(2), hydrocephalus, BW Developmental delay DiGeorge Chromosomal translocation
RI PT
Required Surgical Intervention
SC
Frequency
Average Age at Diagnosis (years)
AC C
EP
TE D
*One patient in the study had two separate synchronous airway lesions identified on MDLB **BW: Beckwith- Wiedemann
ACCEPTED MANUSCRIPT
References [1] Lin AC, Koltai PJ. 2012. International journal of pediatrics 2012; 2012: 576719.
RI PT
[2] Truong MT, Woo VG, Koltai PJ. 2012. International journal of pediatric otorhinolaryngology 2012; 76: 722-727.
Pediatric pulmonology 2005; 40: 205-210.
SC
[3] Goldberg S, Shatz A, Picard E, Wexler I, Schwartz S, Swed E, Zilber L, Kerem E. 2005.
[4] Michelson A, Hawley K, Anne S. Do synchronous airway lesions predict treatment failure
Ped Otolaryngol. 2014; 78: 1439-1443.
M AN U
after adenotonsillectomy in children less than 3 years of age with obstructive sleep apnea? Int J
[5] Rastatter J, Schroeder J, French A, Holinger L. Synchronous airway lesions in children younger than age 3 years undergoing adenotonsillectomy. Otolaryngol Head Neck. 2011; 145:
TE D
309-313.
[6] Mandell D, Yellon R. Synchronous airway lesions and esophagitis in children undergoing adenoidectomy. Arch Otolaryngol Head and Neck Surg. 2007; 133:375-380.
EP
[7]Jaroslava Hybášková, Ondřej Jor, Vilém Novák, Karol Zeleník, PetrMatoušek, and Pavel Ko mínek. Drug-Induced Sleep Endoscopy Changes the Treatment Concept in Patients with
AC C
Obstructive Sleep Apnoea. Bio med Res Int. 2016;2016:6583216.
ACCEPTED MANUSCRIPT Table 1. Synchronous Airway Lesions Identified During MDLB
RI PT
SC
Subglottic stenosis Subglottic cyst Vascular compression Tracheobronchomalacia Laryngeal cleft Tracheal stenosis Hypopharyngeal hemangioma All SAL identified on MDLB
Average Required Age at Surgical Diagnosis Comorbidity (number of patients with Frequency Intervention (years) comorbidity) Prematurity (1), 6 16% 1.7 ** 3 66% 3 Prematurity(2), hydrocephalus, BW 3 0% 9.6 Developmental delay 2 0% 1 DiGeorge 2 0% 11.5 Chromosomal translocation 1 0% 12 1 0% 2 Goldenhar 18* 18% 5
*One patient in the study had two separate synchronous airway lesions identified on MDLB
AC C
EP
TE D
M AN U
**BW: Beckwith- Wiedemann