Oral and Maxillofacial Surgery Clinics of North America
Pediatric Airway Abnormalities: Evaluation and Management
Introduction
The anatomy of the upper airway bears important influence on airflow and breathing cycles. The structures may limit the movement of air and also influence the dynamics of the regulation of airway reflexes and muscular tone. Many of these issues change with state. The state of sleep, in particular, is a time period in which airflow may be more disrupted, suggesting airway dysfunction. Sleep-disordered breathing (SDB) syndromes are typically divided into those related to hypoventilation and those changing the respiratory pattern, such as apnea. Apneas are typically classified as obstructive, central, and mixed. These pauses or interruptions of breathing are commonly recognized in children with cleft lip and cleft palate (CP) and other craniofacial syndromes, with an increased incidence noted in the literature. Observed cessation of airflow at the level of the nose or mouth, whether there is partial or complete obstruction, makes continued respiratory effort against a collapsed upper airway futile. Therefore, apneas are frequently associated with poor and fragmented sleep as well as arousals. The associated hypoxia, hypercapnia, and bradycardia can all lead to possible adverse effects on the child's daytime behavior, cardiovascular system, neurocognitive function, and growth.1 With the possible detrimental effects of obstructive events on children, early recognition and detection lead to more effective treatment and are considered integral in any craniofacial practice.
Section snippets
Anatomic and physiologic considerations
The airway can be divided into levels, beginning at the superiorly positioned area of the nose and nasopharynx, which communicate inferiorly with the oropharynx and descending into the laryngopharynx. At the level of the nose, the external and internal nasal valves are the main areas thought to provide resistance to flow. The nasal turbinates then direct flow, whether laminar or turbulent, with hypertrophy of the turbinates leading to obstruction. The upper airway is capable of collapse, and
Clinical presentation and diagnosis
Nocturnal signs and symptoms of OSAS usually include heavy snoring, restlessness, increased respiratory effort, posturing or positioning, and intermittent apneas or pauses. Daytime signs and symptoms include nasal obstruction, hyponasal speech, mouth breathing, hyperactivity, and impaired memory and cognitive function. The symptoms of social withdrawal, hypersomnolence, and poor academic performance have also been reported.14, 15 Other clinical signs and symptoms include intracranial
Risks of SDB secondary to corrective surgical procedures
Airway obstruction in individuals with CL/P has long been recognized as a complication of the primary and secondary reconstructive surgical procedures performed to improve speech and feeding. Primary cheilorhinoplasty is rarely associated with airway compromise with only case reports alluding to increased nasal obstruction resulting in exacerbation of the underlying OSA. Increased risk of OSA has been observed after palatoplasty. Differences in techniques, age at the time of surgery, and the
Treatment of SDB
Treatment of SDB in children with craniofacial conditions depends on the severity of the disease, cause, age of the patient, and family/social circumstances influencing the ability to comply with treatment.1 Treatment with early airway intervention has been shown to improve feeding, growth, breathing, and sleep. MacLean and colleagues5 reviewed many treatment options considered for infants and children with isolated CL/P, including tonsillectomy with or without adenoidectomy, CPAP, or bilevel
Summary
The airway complaints of patients with craniofacial disorders should be assessed in wake and sleep as part of the initial clinical evaluation to avoid the significant morbidity and mortality associated with airway obstruction. When airway obstruction is recognized, the appropriate intervention should be implemented and outcomes should be closely monitored to ensure effective management.
Regardless of the cause or severity of the airway obstruction, the treatment of children with craniofacial
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The authors have nothing to disclose.