Managing the Child with Persistent Sleep Apnea

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Key points

  • Pediatric obstructive sleep apnea may persist after adenotonsillectomy and can be challenging to manage.

  • Evaluation of persistent disease should focus on identifying the causes of upper airway obstruction––this is often accomplished with drug-induced sleep endoscopy and/or cine MRI.

  • Surgical interventions targeted to the site of obstruction may improve polysomnographic parameters.

  • Further research is needed to identify which management protocols lead to the best outcomes for children with

Assessment of persistent obstructive sleep apnea

According to the American Academy of Otolaryngology-Head and Neck Surgery Tonsillectomy in Children guidelines, caregivers of patients undergoing adenotonsillectomy should be counseled about the risk of persistent disease and instructed to present for evaluation if obstructive symptoms return following surgery.12 In patients returning for evaluation of persistent obstruction following adenotonsillectomy a detailed history and physical examination should be performed. The provider should inquire

Treatment of persistent obstructive sleep apnea

There are numerous treatment options for children with persistent OSA following adenotonsillectomy. Because data comparing different interventions for persistent disease in children are limited, it can be difficult for providers and caregivers to determine the best option for any given child. Because of this, shared decision-making tools may be useful when discussing management options, as it is essential to obtain input from caregivers (and patients when appropriate).24 Other factors to

Summary

Persistent OSA in children following adenotonsillectomy can be challenging for providers to manage. Evaluation of persistent disease should focus on identifying the causes of upper airway obstruction using physical examination, DISE, and/or cine MRI. Interventions should be tailored to address the patient’s symptoms, sites of obstruction, and preference for surgical versus medical management. Surgical interventions targeted to the site of obstruction may improve PSG and QOL outcomes. Further

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References (66)

  • K.P. Pang et al.

    Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea

    Otolaryngol Head Neck Surg

    (2007)
  • S.A. Mickelson

    Nasal surgery for obstructive sleep apnea syndrome

    Otolaryngol Clin North Am

    (2016)
  • C. Guilleminault et al.

    Critical role of myofascial reeducation in pediatric sleep-disordered breathing

    Sleep Med

    (2013)
  • J.C. Lumeng et al.

    Epidemiology of pediatric obstructive sleep apnea

    Proc Am Thorac Soc

    (2008)
  • A.M. Li et al.

    Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study

    Thorax

    (2008)
  • O.S. Capdevila et al.

    Pediatric obstructive sleep apnea: complications, management, and long-term outcomes

    Proc Am Thorac Soc

    (2008)
  • H.L. Tan et al.

    Obstructive sleep apnea in children: a critical update

    Nat Sci Sleep

    (2013)
  • C.M. Baldassari et al.

    Pediatric obstructive sleep apnea and quality of life: a meta-analysis

    Otolaryngol Head Neck Surg

    (2008)
  • R. Bhattacharjee et al.

    Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study

    Am J Respir Crit Care Med

    (2010)
  • C.L. Marcus et al.

    A randomized trial of adenotonsillectomy for childhood sleep apnea

    N Engl J Med

    (2013)
  • R.F. Baugh et al.

    Clinical practice guideline: tonsillectomy in children

    Otolaryngol Head Neck Surg

    (2011)
  • S.L. Ishman et al.

    Techniques for evaluation and management of tongue-base obstruction in pediatric obstructive sleep apnea

    Curr Opin Otolaryngol Head Neck Surg

    (2018)
  • C.B. Croft et al.

    Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea

    Clin Otolaryngol Allied Sci

    (1991)
  • P.V. Manickam et al.

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

    Laryngoscope

    (2016)
  • M.J. Gazzaz et al.

    Does drug-induced sleep endoscopy change the surgical decision in surgically naïve non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study

    J Otolaryngol Head Neck Surg

    (2017)
  • J. Hybášková et al.

    Drug-induced sleep endoscopy changes the treatment concept in patients with obstructive sleep apnoea

    Biomed Res Int

    (2016)
  • E.J. Kezirian et al.

    Drug-induced sleep endoscopy: the VOTE classification

    Eur Arch Otorhinolaryngol

    (2011)
  • D.J. Lam et al.

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

    Laryngoscope

    (2016)
  • S.R. Shott et al.

    Cine magnetic resonance imaging: evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with Down syndrome

    Laryngoscope

    (2004)
  • M. Bergeron et al.

    Clinical outcomes after shared decision-making tools with families of children with obstructive sleep apnea without tonsillar hypertrophy

    Laryngoscope

    (2019)
  • L. Kheirandish et al.

    Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children

    Pediatrics

    (2006)
  • B. Wang et al.

    The effect of montelukast on mild persistent OSA after adenotonsillectomy in children: a preliminary study

    Otolaryngol Head Neck Surg

    (2017)
  • E.C. Uong et al.

    Adherence to nasal positive airway pressure therapy among school-aged children and adolescents with obstructive sleep apnea syndrome

    Pediatrics

    (2007)
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      Childhood obstructive sleep apnea (OSA) occurs in 6%–12% of children and may have significant physical, behavioral, and neurocognitive sequelae [1]. The most common treatment for pediatric OSA is adenotonsillectomy surgery [2]. Regardless of the high morbidity of OSA, it has been reported that up to 90% of these patients did not receive a prior diagnosis [3].

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    Disclosure Statement: The authors have no relevant disclosures.

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