Persistent Obstructive Sleep Apnea Research Articles

0782 Persistent Obstructive Sleep Apnea in Medically Complex Pediatric Patients: A Multidisciplinary Treatment Approach

0782 Persistent Obstructive Sleep Apnea in Medically Complex Pediatric Patients: A Multidisciplinary Treatment Approach

Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea in a Young Child With Down Syndrome.

Obstructive sleep apnea (OSA) is common in children with Down syndrome (DS). Adenoidectomy and/or tonsillectomy are the usual first interventions employed to treat OSA in children with DS but sometimes do not achieve adequate resolution of clinical signs. Positive airway pressure treatment is often used next, but this treatment is poorly tolerated by this population. Persistent OSA can adversely affect a child's health and cognitive development. Hypoglossal nerve stimulation (HGNS), previously shown to be safe and effective in adults with OSA, has been used in children as young as 10 years old with DS and has achieved measurable neurocognitive benefits. The US Food and Drug Administration recently lowered the age for HGNS implantation to 13 years for children with DS. However, questions remain regarding treatment of refractory OSA in younger children. Here, we report the case of a 4-year-old boy with DS and treatment-refractory OSA who underwent successful HGNS implantation. The decision to proceed with HGNS implantation in such a young child involved discussions about anatomic feasibility and potential neurocognitive benefits. The device was implanted without complication and with minimal postoperative bulk. This case suggests a possible treatment option that can be discussed in the course of shared decision-making between clinicians and families of young children with DS and treatment-refractory OSA.

Monitoring of Home Respiratory Polygraphy During Mandibular Distraction Osteogenesis Succeeded by LeFort I Osteotomy in Adult Patients With Obstructive Sleep Apnea

BackgroundBilateral Internal Ramus Distraction (BIRD) is now part of select protocols for treating obstructive sleep apnea (OSA). Introducing a home monitoring protocol offers a valuable alternative to overnight laboratory polysomnography (PSG). PurposeThe purpose of this study was to evaluate and compare OSA parameters obtained via home respiratory polygraphy (HRP) and hospital PSG in a cohort of patients undergoing mandibular distraction (MD) for OSA management. Study designHospital Universitario La Princesa (Madrid) researchers conducted a prospective cohort study with patients diagnosed with moderate (AHI=15-30) to severe (AHI>30) OSA undergoing BIRD followed by LeFort maxillary osteotomy. Exclusion criteria were: severe systemic diseases, central apneas, smoking, poor dental hygiene, or prior OSA interventions. Predictor variableThe predictor variable was PSG and HRP techniques. Main outcome variablesThe main outcome variable comprises a collection of OSA parameters, including the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and time spent below 90% oxygen saturation (T90). These data were measured both before and after distraction, as well as after 6 mm, 9 mm, and 12 mm of mandibular distraction (MD). CovariatesThe covariates were age, sex, cardiovascular risk parameters, and Epworth sleepiness scale. AnalysesPearson’s correlation analyzed AHI, ODI, and T90 values from PSG and HRP. Wilcoxon Signed Rank Sum Test compared two distraction stages, and the Friedman Test evaluated three stages (p<0.05). Multiple regression analysis assessed if covariates were independent risk factors for postoperative persistent OSA. ResultsThe study included 32 patients (25% with moderate and 75% with severe OSA). Final AHI was 10.9±8.9 (events/hour) with HRP, compared to 15.2±13.4 with PSG (r=0.7, p<0.05). ODI was 9.0±8.1 (des/h) with HRP and 8.7±9.5 with PSG (r=0.85, p<0.05). T90 was 1.6±2.2 with HRP and 1.3±3.0 with PSG (r=0.6, p<0.05). Based on HRP data, AHI improved from D1 (34.0±19.5) to D2 (20.8±14.1) and D3 (12.5±10.4) (p<0.05). ODI decreased from D1 (26.1±19.0) to D2 (16.0±12.6) and D3 (9.4±8.8) (p<0.05). T90 reduced from D1 (8.2±12.6) to D2 (4.1±5.2) and D3 (1.9±2.8) (p<0.05). Multiple regression analysis of comorbidities produced non-significant results. ConclusionTo monitor BIRD through HRP has demonstrated efficacy in yielding results that align with PSG.

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond T&A – Tongue Base and Larynx

Pediatric patients with persistent obstructive sleep apnea (OSA) after adenotonsillectomy often have additional sites of upper airway obstruction such as the tongue base or larynx. Sleep endoscopy and cross-sectional, dynamic imaging can be used to direct the surgical management of persistent OSA. The tongue base is one of the most common sites of obstruction in children with persistent OSA, especially for patients with Trisomy 21. Lingual tonsillectomy, tongue suspension, and/or posterior midline glossectomy may be used to address lingual tonsil hypertrophy and tongue base obstruction. Epiglottopexy and/or supraglottoplasty may be used to address laryngomalacia and epiglottic prolapse resulting in OSA. Evidence shows that surgery can lead to significant improvement in postoperative polysomnographic outcomes. Important considerations following surgery of the tongue base and larynx include bleeding, edema, oropharyngeal stenosis, and dysphagia.

Association of allergic rhinitis with persistent obstructive sleep apnea: A secondary analysis of the childhood adenotonsillectomy trial

Study objectivesAllergic rhinitis (AR) is frequently reported in children suffering from obstructive sleep apnea (OSA). This study aimed to assess whether children with AR are more likely to experience persistent OSA after AT. MethodsThis study is a secondary analysis of a multi-center randomized clinical trial, the Childhood Adenotonsillectomy Trial. Children were categorized into the AR group or Non-AR group according to AR response. A subgroup analysis was conducted using a logistic regression model. ResultsA total of 372 children (177 boys [47.6%]; median [IQR] age, 6.0 [5.0–8.0] years) were analyzed. Approximately 25% (93/372) of children presented with AR. Baseline data indicated higher PSQ scores and OSA-18 scores in the AR group. Children with AR demonstrated lower OSA resolution rates after AT (aOR, 0.43; 95% CI, 0.19 to 0.96). However, there was no significant difference in OSA resolution between the AR and Non-AR groups who underwent watchful waiting (aOR, 0.98; 95% CI, 0.50 to 1.93). Also, the AR group was more likely to maintain a PSQ score greater than 0.33 after AT (OR, 2.16; 95% CI, 1.01 to 4.61). There was no significant association between AR and higher follow-up OSA-18 scores after AT and watchful waiting. ConclusionsIn this secondary analysis, children with AR were more likely to experience persistent OSA, highlighting the importance of effective AR management even post-adenotonsillectomy. A purposefully designed, prospective randomized trial is needed to verify the association between AR and persistent OSA. Trial registrationClinicalTrials.gov Identifier: NCT00560859.

Factors Associated with Persistent Obstructive Sleep Apnea After Bariatric Surgery: A Narrative Review.

The prevalence of obstructive sleep apnea (OSA) among the bariatric surgery population is estimated to be 45-70%. However, weight loss obtained by bariatric surgery is not always associated with full remission of OSA, suggesting that other confounding factors are present. This article aims to review the current literature, focusing on factors that could predict the persistence of OSA after bariatric surgery. For this purpose, relevant studies of more than 50 patients that assessed pre- and post-operative presence and severity of OSA detected by poly(somno)graphy (PG/PSG) in bariatric populations were collected. Six retrospective and prospective studies were evaluated that included 1302 OSA patients, with a BMI range of 42.6 to 56 kg/m2, age range of 44.8 to 50.7 years, and percentage of women ranging from 45% to 91%. The studies were very heterogeneous regarding type of bariatric surgery, diagnostic criteria for OSA and OSA remission, and delay of OSA reassessment. OSA remission was observed in 26% to 76% of patients at 11-12 months post-surgery. Loss to follow-up was high in all studies, leading to a potential underestimation of OSA remission. Based on this limited sample of bariatric patients, age, pre-operative OSA severity, proportion of weight loss, and type 2 diabetes (T2D) were identified as factors associated with OSA persistence but the results were inconsistent between studies regarding the impact of age and the magnitude of weight loss. Several other factors may potentially lead to OSA persistence in the bariatric surgery population, such as fat distribution, ethnicity, anatomical predisposition, pathophysiological traits, supine position, and REM-predominant hypopnea and apnea. Further well-conducted multicentric prospective studies are needed to document the importance of these factors to achieve a better understanding of OSA persistence after bariatric surgery in obese patients.

Socioeconomic status is associated with pediatric adenotonsillectomy outcomes: A single institution study

ObjectiveOur institution serves a diverse patient population across a large metropolitan city. Literature has shown pediatric otolaryngology patients with lower socioeconomic status (SES) have higher rates of sleep-disordered breathing, delays in treatment time, and greater risks of complications post-tonsillectomy. This study aims to examine the effects of SES on adenotonsillectomy outcomes performed at our institution. Study designA retrospective chart review including 1560 pediatric patients (ages 0–18) who underwent adenotonsillectomy between January 2015 and December 2020. SettingLarge metropolitan hospital, level 1 trauma center. MethodsOutcome variables included postoperative hospital admission, phone calls, 30-day follow-up, and persistent obstructive sleep apnea (OSA). Descriptive statistics using Wilcoxon Signed Rank Tests and univariate and multivariate logistic regression modeling were used to determine statistically significant covariates at α = 0.05. ResultsThe cohort included Non-Hispanic White (n = 488, 31 %), Non-Hispanic Black (n = 801, 51 %), Hispanic (n = 210, 13 %), and other (n = 61, 4 %) groups. Using multivariate regression, privately insured patients were less likely to have moderate-to-severe OSA before surgery (0.65 95 % CI 0.45, 0.93 p = 0.017) and be admitted postoperatively (0.73, 0.55–0.96, p < 0.01), while more likely to have postoperative follow-up phone calls (1.57, 1.19–2.09, p < 0.01) and visits (1.53, 1.22–1.92, p < 0.01). Increased income was associated with decreased rehospitalizations within three months of surgery (0.98, 0.97–1.00, p < 0.01). ConclusionThis study suggests SES significantly affects adenotonsillectomy outcomes. Further studies are warranted to provide better care for all pediatric patients.

An approach to the upper airway evaluation in pediatric persistent obstructive sleep apnea.

In pediatrics, obstructive sleep apnea syndrome (OSAS) is a disorder associated with multiple consequences at the cognitive and behavioral level. The main associated risk factor is the presence of tonsillar hypertrophy and adenoids. An adenotonsillectomy is the first-line treatment. The incidence of persistent OSAS varies from 15% to 75%, depending on comorbidities. This is a challenge in terms of management; it requires a comprehensive approach for an adequate diagnosis and treatment. The objective of this bibliographic review is to propose a diagnostic and therapeutic approach for persistent OSAS.

Does REM AHI Predict Persistent OSA After Pediatric Adenotonsillectomy?

The utility of REM AHI in managing pediatric obstructive sleep apnea (OSA) is not fully understood. This study aimed to evaluate the relationship of preoperative REM AHI to postoperative persistence of OSA in children who underwent adenotonsillectomy. This retrospective chart review identified children under the age of 18 years that received an adenotonsillectomy for OSA and a preoperative and postoperative polysomnogram. Children with craniofacial or neuromuscular disorders or a tracheostomy were excluded. The primary outcome was the postoperative persistence of OSA, defined as a postoperative obstructive apnea-hypopnea index (oAHI) ≥ 1.5 events/hour. REM-predominant OSA was defined as a ratio of REM/NREM AHI ≥ 2. REM AHI minus NREM AHI and REM AHI minus oAHI helped to identify patients with a larger distribution of REM AHI. A total of 353 patients were included. Postoperative persistent OSA was seen in 232 (65.7%) children. The preoperative REM AHI, REM AHI minus NREM AHI, and REM AHI minus oAHI of children with persistent OSA did not differ significantly from children with resolution of OSA. Rates of persistence were not different between those with REM-predominant OSA and REM-independent OSA (63.8% vs 70.7%, P = .218). This study suggests that preoperative REM AHI may be a poor predictor of OSA persistence after adenotonsillectomy. Further study is needed to help characterize how pre-operative REM AHI should impact clinicians' decision making, family counseling and recommendations.

Clinical Application of Pediatric Sleep Endoscopy: An International Survey.

To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE. A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations. A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral. Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

Challenges and adverse events in pediatric hypoglossal nerve stimulation

IntroductionHypoglossal nerve stimulation was recently FDA approved for use in children with Down Syndrome and persistent obstructive sleep apnea. Although there is a robust experience in hypoglossal nerve stimulation in adults, we observed several challenges that are unique to providing this therapy to a complex pediatric population with a high rate of sensory processing disorders. We sought to review the adverse events and challenges to inform clinicians as hypoglossal nerve stimulation becomes a more accessible option for this complex population. MethodsRetrospective case series of children with Down Syndrome and persistent OSA who underwent hypoglossal nerve stimulation. Inclusion and exclusion criteria included Down Syndrome, age 10–22 years, persistent severe OSA after adenotonsillectomy (AHI>10 with <25 % central or mixed events), inability to tolerate positive airway pressure, and absence of concentric palatal collapse on sleep endoscopy. Patients were identified and their charts were reviewed. Adverse events and their subsequent management were recorded. The major outcome variable was the total number of adverse events. ResultsA total of 53 patients underwent implantation of a hypoglossal nerve stimulator; 35 (66 %) patients were male and the average age at implantation was 15.1 years (standard deviation 3.0y). A total of 30 adverse events were noted, including 17 nonserious and 13 serious. The most common nonserious complications included temporary tongue discomfort, rash at the surgical site, and cellulitis. Serious complications included readmission (for cellulitis, pain, and device extrusion), reoperation (most commonly for battery depletion) and pressure ulcer formation. ConclusionHypoglossal nerve stimulation provides a much-needed therapy for children with DS and persistent OSA after adenotonsillectomy. Although there is a robust experience in providing this treatment to adults, many considerations must be made when adapting this technology to a pediatric population with a high rate of sensory processing disorders.

Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate

The purpose of this study was to evaluate long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea (OSA). Retrospective matched-cohort study SETTING: Two craniofacial centers in Los Angeles, CA PATIENTS: Patients (n=166) with cleft lip and palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty from 1992 to 2022 were identified. An age- and diagnosis-matched control group of 67 patients with CLP/iCP without velopharyngeal insufficiency (VPI) was also identified. The pharyngoplasty group underwent sphincter pharyngoplasty, whereas the non-VPI group had no history of VPI surgery or sphincter pharyngoplasty. Postoperative speech outcomes, revision surgeries, and incidence of OSA were evaluated. Multivariable regression was used to evaluate independent predictors of OSA. Among the patients in the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of the patients who underwent pharyngoplasty required a revision surgery, with a median time to primary revision of 3.9 years (IQR, 1.9-7.0 years). OSA rates increased significantly among the pharyngoplasty cohort, from 3% before surgery to 14.5% after surgery (p<0.001). The average time from sphincter pharyngoplasty to OSA diagnosis was 4.4±2.4 years. Multivariable analysis results indicated that sphincter pharyngoplasty surgery was independently associated with a fourfold increase in OSA (p=0.03). Although sphincter pharyngoplasty remains successful in improving long-term speech outcomes, persistent OSA is a sequela that should be monitored beyond the immediate postoperative period.

Persistent sleep-disordered breathing independently contributes to metabolic syndrome in prepubertal children.

Obstructive sleep apnea (OSA) is a risk factor for metabolic syndrome (MetS) in adults, but its association in prepubertal children is still questionable due to the relatively limited cardiometabolic data available and the phenotypic heterogeneity. To identify the role of OSA as a potential mediator of MetS in prepubertal children. A total of 255 prepubertal children from the Childhood Adenotonsillectomy Trial were included, with standardized measurements taken before OSA treatment and 7 months later. MetS was defined if three or more of the following criteria were present: adiposity, high blood pressure, elevated glycemia, and dyslipidemia. A causal mediation analysis was conducted to assess the effect of OSA treatment on MetS. OSA treatment significantly impacted MetS, with the apnea-hypopnea index emerging as mediator (p = .02). This mediation role was not detected for any of the individual risk factors that define MetS. We further found that the relationship between MetS and OSA is ascribable to respiratory disturbance caused by the apnea episodes, while systemic inflammation as measured by C-reactive protein, is mediated by desaturation events and fragmented sleep. In terms of evolution, patients with MetS were significantly more likely to recover after OSA treatment (odds ratio = 2.56, 95% confidence interval [CI] 1.20-5.46; risk ratio = 2.06, 95%CI 1.19-3.54) than the opposite, patients without MetS to develop it. The findings point to a causal role of OSA in the development of metabolic dysfunction, suggesting that persistent OSA may increase the risk of MetS in prepubertal children. This mediation role implies a need for developing screening for MetS in children presenting OSA symptoms.

Accuracy of parental perception of nighttime breathing in children with Down syndrome after adenotonsillectomy.

Clinical practice guidelines recommend screening all children with Down syndrome for obstructive sleep apnea with polysomnography by age 4 years. Because persistent obstructive sleep apnea (obstructive apnea-hypopnea index > 1 event/h) following adenotonsillectomy (T&A) is common in children with Down syndrome, it is important to know whether clinicians can rely on parental assessment postoperatively. The primary objective is to identify accuracy of parental perception of nighttime breathing following T&A compared with preoperative assessment. Patients with Down syndrome who underwent T&A along with polysomnography prior to and after the surgical procedure were included. Parents completed a 3-question pre- and postsurgery survey regarding nighttime symptoms. The responses were categorized into 3 groups: infrequent (< 3 nights/wk), sometimes (> 3 nights/wk but < 6 nights/wk), or frequent (≥ 6 nights/wk) on at least 1 question. The primary end point was identifying the accuracy of parental perception of nighttime breathing in children with Down syndrome following T&A. A total of 256 children met inclusion criteria, of which 117 (46%) were included. A total of 71 (68%) children had an obstructive apnea-hypopnea index > 5 events/h preoperatively compared with 55 (47%) postoperatively. There was no association between parents' perception of symptoms and obstructive sleep apnea categorization postoperatively (P > .05) or of parents' perception of symptoms improving and obstructive sleep apnea categorization improving postoperatively (P > .05). Despite previous experience, parents are unable to predict nighttime breathing patterns following a T&A. We recommend obtaining a polysomnogram rather than relying on parental assessment to determine whether a T&A has been successful. Chabuz CA, Lackey TG, Pickett KL, Friedman NR. Accuracy of parental perception of nighttime breathing in children with Down syndrome after adenotonsillectomy. J Clin Sleep Med. 2024;20(2):237-243.

Medical Treatment of Obstructive Sleep Apnea in Children.

Obstructive sleep apnea (OSA) is characterized by recurrent complete or partial obstruction of the upper airway. The prevalence is 1-4% in children aged between 2 and 8 years and rising due to the increase in obesity rates in children. Although persistent OSA following adenotonsillectomy is usually associated with obesity and underlying complex disorders, it can also affect otherwise healthy children. Medical treatment strategies are frequently required when adenotonsillectomy is not indicated in children with OSA or if OSA is persistent following adenotonsillectomy. Positive airway pressure treatment is a very effective modality for persistent OSA in childhood; however, adherence rates are low. The aim of this review article is to summarize medical treatment options for OSA in children.

Demographic factors associated with postoperative polysomnography for pediatric patients with persistent obstructive sleep apnea

Demographic factors associated with postoperative polysomnography for pediatric patients with persistent obstructive sleep apnea

Medical and Surgical Approaches to Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder characterized by recurrent upper airway obstructions during sleep, leading to disrupted sleep patterns and potential health risks. This comprehensive review explores various medical and surgical modalities for the treatment of OSA. Continuous Positive Airway Pressure therapy is the standard treatment for moderate to severe cases, but long-term compliance remains a challenge. Oral appliances and novel technologies, such as Oral Pressure Therapy and Upper Airway Stimulation offer non-invasive alternatives. Surgical interventions, like Maxillomandibular Advancement, Uvulopalatopharyngoplasty, Laser-Assisted Uvulopalatoplasty, Radiofrequency Ablation, Genioglossus Muscle Advancement and Tracheostomy, provide tailored solutions for persistent OSA. Maxillomandibular Advancement in particular, has shown significant efficacy in reducing the Apnea-Hypopnea Index. Uvulopalatopharyngoplasty, while widely used, has variable success rates, often necessitating additional therapies. Laser-Assisted Uvulopalatoplasty and Radiofrequency Ablation are minimally invasive options but require careful patient selection. This review highlights the importance of individualized treatment plans, considering OSA severity, patient compliance, and comorbidities. Advances in non-invasive and minimally invasive treatments have expanded options, enhanced patient quality of life and reducing health risks. Tracheostomy, though less common today, remains valuable in specific cases. A multidimensional approach to OSA management is crucial, tailoring treatments to individual patient needs and optimizing overall well-being. Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder characterized by recurrent upper airway obstructions during sleep, leading to disrupted sleep patterns and potential health risks. This comprehensive review explores various medical and surgical modalities for the treatment of OSA. Continuous Positive Airway Pressure therapy is the standard treatment for moderate to severe cases, but long-term compliance remains a challenge. Oral appliances and novel technologies, such as Oral Pressure Therapy and Upper Airway Stimulation offer non-invasive alternatives. Surgical interventions, like Maxillomandibular Advancement, Uvulopalatopharyngoplasty, Laser-Assisted Uvulopalatoplasty, Radiofrequency Ablation, Genioglossus Muscle Advancement and Tracheostomy, provide tailored solutions for persistent OSA. Maxillomandibular Advancement in particular, has shown significant efficacy in reducing the Apnea-Hypopnea Index. Uvulopalatopharyngoplasty, while widely used, has variable success rates, often necessitating additional therapies. Laser-Assisted Uvulopalatoplasty and Radiofrequency Ablation are minimally invasive options but require careful patient selection. This review highlights the importance of individualized treatment plans, considering OSA severity, patient compliance, and comorbidities. Advances in non-invasive and minimally invasive treatments have expanded options, enhanced patient quality of life and reducing health risks. Tracheostomy, though less common today, remains valuable in specific cases. A multidimensional approach to OSA management is crucial, tailoring treatments to individual patient needs and optimizing overall well-being.

Persistent pediatric obstructive sleep apnea treated with skeletally anchored transpalatal distraction

The aim of this study was to evaluate the impact of nasomaxillary expansion using skeletally anchored transpalatal distraction (TPD) in children without transverse maxillary deficiency that were previously treated by rapid palatal expansion (RPE). Twenty-nine consecutive children were treated by TPD. Twenty-five children, aged 10-16 years completed pre- and post-operative clinical evaluations, questionnaires (OSA-18), cone beam computed tomography (CBCT), and polysomnography (PSG). The pre- and post-operative CBCT data were used to reconstruct the 3-dimensional shape of the upper airway. Two measures of airflow function (pressure and velocity) were simulated by using computational fluid dynamics (CFD) at four different airway segments (nasal, nasopharyngeal, oropharyngeal and hypopharyngeal). Twenty-three patients (92%) experienced improvement based on PSG. The apnea hypopnea index (AHI) improved from 6.72±4.34 to 3.59±5.11 (p<0.001) events per hour. Clinical symptoms based on OSA-18 scores were improved in all patients. Twenty-five patients (100%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal sidewall widening was 2.59±1.54 mm at canine, 2.91±1.23 mm at first molar and 2.30±1.29 mm at PNS. The ratio of dental expansion to nasal expansion was 1.12:1 (2.90 mm:2.59 mm) at canine and 1.37:1 (3.98 mm:2.91 mm) at first molar. The nasal airflow pressure reduced by 76% (-275.73 to -67.28 Pa) and the nasal airflow velocity reduced by over 50% (18.60 to 8.56 m/s). Nasomaxillary expansion by skeletally anchored TPD improves OSA in children without transverse maxillary deficiency that were previously treated by RPE. A nearly parallel anterior-posterior opening of the mid-palatal suture achieves enlargement of the entire nasal passage with improvement of the airflow characteristics in the nasal and pharyngeal airway. The improved airflow characteristic is significantly correlated with the improved polysomnographic findings, thus demonstrating that nasomaxillary expansion in previously expanded patients is a viable treatment option.

Tonsillectomy in Children with 22q11.2 Deletion Syndrome

Tonsillectomy is one of the most common procedures performed in children, however there are currently no published studies evaluating tonsillectomy in children with 22q11.2 deletion syndrome (22q11DS). With this study, our goal was to investigate the indications, efficacy, and complications of tonsillectomy in a pediatric cohort of patients with 22q11DS. This is a retrospective chart review of patients in our 22q Center's repository. Inclusion criteria were a diagnosis of 22q11DS and a history of tonsillectomy or adenotonsillectomy. Data collected included: indications for tonsillectomy, preoperative and postoperative polysomnography (PSG) results, and surgical complications. In total, 33 patients were included. Most common indications for tonsillectomy were facilitation with speech surgery (n = 21) and sleep-disordered breathing (SDB)/obstructive sleep apnea (OSA) (n = 16). Average length of stay was 1.15 days. Most patients (69%) had some degree of persistent OSA on postoperative PSG. Complications occurred in 18% of patients and included respiratory distress, hemorrhage, and hypocalcemia. This study demonstrates tonsillectomy was a commonly performed procedure in this cohort of patients with 22q11DS. These data highlight the potential need for close postoperative calcium and respiratory monitoring. The data were limited with respect to PSG outcomes, and future studies are needed to better characterize OSA outcomes and complications in this patient population.

Severe Pediatric Sleep Apnea: Drug-Induced Sleep Endoscopy Based Surgery.

Although adenotonsillectomy is the recommended treatment of obstructive sleep apnea (OSA) in children, some patients with preoperative severe OSA (Apnea-hypopnea index/AHI > 10) remain symptomatic after surgery and may need further workup. This study aims to: (1) analyse preoperative factors and its relation with surgical failure/persistent OSA (AHI > 5 after adenotonsillectomy) in severe pediatric OSA; (2) determine the levels of airway collapse during DISE (drug induced sleep endoscopy) in cases of surgical failure; (3) evaluate the efficacy of targeted surgery based on DISE findings. This retrospective study was conducted between August and September 2020. Across 9years (from 2011 to 2020), all children diagnosed with severe OSA in our Hospital underwent adenotonsillectomy and repeated type 1 polysomnography (PSG) 3months after surgery. Cases of surgical failure underwent DISE for planning eventual directed surgery. Chi-square test was used to assess the relationship between persistent OSA and preoperative patients' characteristics. 80 cases of severe pediatric OSA were diagnosed (68.8% males; mean age: 4.3years-standard deviation: 2.49; mean AHI: 16.3-standard deviation 7.14) in the aforementioned period. We found a significant association between surgical failure (11.3% of cases; mean AHI: 6.9-SD 0.91) and obesity (p = 0.002; confidence level of 95%). Neither preoperative AHI nor other PSG parameters were associated with surgical failure. In cases of surgical failure, epiglottis collapse was present in every DISEs and adenoid tissue was present in 66% of children. All cases of surgical failure had directed surgery and surgical cure (AHI ≤ 5) was obtained in 100% of cases. This study suggests that obesity is the strongest predictor of surgical failure in children with severe OSA who undergo adenotonsillectomy. Epiglottis collapse and presence of adenoid tissue are the most common findings in postoperative DISEs of children with persistent OSA after primary surgery. DISE based surgery seems a safe and effective tool to manage persistent OSA after adenotonsillectomy.