Adult and Pediatric Adult and Pediatric Obstructive Sleep ApneaObstructive Sleep Apnea

Prof. Dr. Jehad Al-BabaProf. Dr. Jehad Al-Baba

Chief of E.N.T DepartmentChief of E.N.T Department

Everyone has brief pause in his or her breathing Everyone has brief pause in his or her breathing pattern called Apnea , the word comes from pattern called Apnea , the word comes from the Greek word meaning “Without the Greek word meaning “Without Breathing” Breathing”

{Respiratory pause that exceeds 3 standard {Respiratory pause that exceeds 3 standard deviation of the mean breath time for an deviation of the mean breath time for an infant or a child at any particular age}infant or a child at any particular age}

There are three types of Apnea:There are three types of Apnea: - Obstructive,- Obstructive, - Central,- Central, - Mixed.- Mixed.

Cont. ApneaCont. Apnea

Obstructive apnea – cessation of airflow for Obstructive apnea – cessation of airflow for at least 10 seconds with respiratory effortat least 10 seconds with respiratory effort

Central apnea – cessation of airflow for at Central apnea – cessation of airflow for at least 10 seconds without respiratory effortleast 10 seconds without respiratory effort

Mixed apnea – characteristics of both for at Mixed apnea – characteristics of both for at least 10 secondsleast 10 seconds

Hypopnea – hypoventilation secondary to Hypopnea – hypoventilation secondary to partial obstructionpartial obstruction

Disorder Of breathing during sleep Disorder Of breathing during sleep characterized by prolonged partial upper characterized by prolonged partial upper airway obstruction and /or intermittent airway obstruction and /or intermittent complete obstruction (obstructive apnea) complete obstruction (obstructive apnea) that disrupts normal ventilation during that disrupts normal ventilation during sleep and normal sleep patterns.sleep and normal sleep patterns.

Obstructive Sleep ApneaObstructive Sleep Apnea

85% of adult patients are male.85% of adult patients are male. Men 4%, Female 2%.Men 4%, Female 2%. 2/32/3rdrd obese. obese. Contributes to HTN and cardiovascular Contributes to HTN and cardiovascular

disease.disease. Increased motor vehicle accidents.Increased motor vehicle accidents.

PathophysiologyPathophysiology

Pharyngeal collapsePharyngeal collapse Decreased airway patencyDecreased airway patency Increase in negative pressureIncrease in negative pressure Becomes a vicious cycle.Becomes a vicious cycle.

SymptomsSymptoms Snoring*Snoring* Excessive daytime sleepiness*Excessive daytime sleepiness* Restless sleepRestless sleep Personality changesPersonality changes HeadachesHeadaches Sexual dysfunctionSexual dysfunction Job performance Job performance Sleep hygieneSleep hygiene Bed partner’s input *Bed partner’s input *

Physical ExamPhysical Exam

Vital signsVital signs Head & Neck examHead & Neck exam Flexible endoscopyFlexible endoscopy

Vital signsVital signs

HeightHeight WeightWeight Collar sizeCollar size Blood pressureBlood pressure Calculate BMICalculate BMI

Wt (kg) / Ht (meters) squaredWt (kg) / Ht (meters) squared Men >27.8, Women >27.3Men >27.8, Women >27.3

ExaminationExamination

TongueTongue Palate Palate UvulaUvula Tonsils Tonsils Nasal cavityNasal cavity HyoidHyoid MandibleMandible MaxillaMaxilla

CephalometricsCephalometrics

Standardized lateral radiographs Standardized lateral radiographs Examines bony and soft-tissue structureExamines bony and soft-tissue structure Two-dimensional evaluationTwo-dimensional evaluation Lack of volumetric dataLack of volumetric data Maxillomandibular surgery, oral appliancesMaxillomandibular surgery, oral appliances

PolysomnogramPolysomnogram

EEGEEG EKGEKG Submental EMGSubmental EMG Anterior tibialis Anterior tibialis

EMGEMG EOGEOG

Nasal/oral airflowNasal/oral airflow Pulse oximetryPulse oximetry Respiratory Respiratory

movementmovement Sleeping positionSleeping position Esophageal Esophageal

manometrymanometry

TreatmentTreatment

Nonsurgical modalitiesNonsurgical modalities Surgical modalitiesSurgical modalities

Nonsurgical TreatmentNonsurgical Treatment

Weight lossWeight loss Sleep hygieneSleep hygiene PharmacotherapyPharmacotherapy Nasal continuous positive airway pressureNasal continuous positive airway pressure Oral appliancesOral appliances

Nonsurgical TreatmentNonsurgical Treatment

Weight lossWeight loss Get below “trigger weight”Get below “trigger weight” Diet, exercise, bariatric surgery, medicationsDiet, exercise, bariatric surgery, medications

Sleep hygieneSleep hygiene Avoidance of sedativesAvoidance of sedatives Positional changesPositional changes

PharmacotherapyPharmacotherapy

Protriptyline – decreases REM sleepProtriptyline – decreases REM sleep Xanthine based drugsXanthine based drugs SteroidsSteroids AntibioticsAntibiotics Nasal medicationsNasal medications

CPAPCPAP

Titrated to limit all respiratory eventsTitrated to limit all respiratory events 50-90% acceptance – better if daytime 50-90% acceptance – better if daytime

symptoms improvedsymptoms improved Side effects in 40-50%Side effects in 40-50%

Oral appliancesOral appliances

Advances the mandibleAdvances the mandible Retains the tongue anteriorlyRetains the tongue anteriorly

UPPPUPPP Fujita (1981) Fujita (1981) Most common procedureMost common procedure 1st line tx for retropalatal collapse1st line tx for retropalatal collapse 10-50% success.10-50% success.

Mandibular Osteotomy with Mandibular Osteotomy with Genioglossus AdvancementGenioglossus Advancement

Enlarges the retrolingual airway without Enlarges the retrolingual airway without disturbing dentitiondisturbing dentition

Prevents retrolingual collapsePrevents retrolingual collapse

Tongue reductionTongue reduction

Lingual tonsillectomyLingual tonsillectomy Laser midline glossectomyLaser midline glossectomy LingualplastyLingualplasty Radiofrequency volumetric tissue reductionRadiofrequency volumetric tissue reduction

Nasal surgeryNasal surgery

Improved symptoms and CPAPImproved symptoms and CPAP SeptoplastySeptoplasty Turbinate reductionTurbinate reduction Functional nasal reconstructionFunctional nasal reconstruction

TracheostomyTracheostomy Bypasses all areas of obstructionBypasses all areas of obstruction Virtually 100% effectiveVirtually 100% effective Two indicationsTwo indications

Temporary procedure during airway Temporary procedure during airway reconstructionreconstruction

Severe OSA when CPAP refused, Severe OSA when CPAP refused, ineffective, or not tolerated or if other ineffective, or not tolerated or if other conditions exacerbated by the apneasconditions exacerbated by the apneas

Line the tract with skin flapsLine the tract with skin flaps Lack of social acceptance Lack of social acceptance

Apnea in ChildhoodApnea in Childhood

OSA result from:OSA result from:

Adenotonsillar hypertrophy.Adenotonsillar hypertrophy.

Neuromuscular diseases.Neuromuscular diseases.

Craniofacial abnormalitiesCraniofacial abnormalities . .

True OSA result in:True OSA result in:

Neurocognitive impairment.Neurocognitive impairment.

Behavioral problems.Behavioral problems.

Failure to thrive.Failure to thrive.

Cor pulmonal , particularly Cor pulmonal , particularly

in sever cases.in sever cases.

Enuresis.Enuresis.

Habitual (nightly) snoring.Habitual (nightly) snoring. Disturbed sleep .Disturbed sleep . Daytime neurobehavioral problems.Daytime neurobehavioral problems. Daytime sleepness may occur but is Daytime sleepness may occur but is

uncommon in young children.uncommon in young children.

OSA Presented with the following OSA Presented with the following symptomssymptoms

Anatomic factors :Anatomic factors :

That narrow the upper airway.That narrow the upper airway. Adenotonsillar hypertrophy.Adenotonsillar hypertrophy. Trisomy 21(down syndrome) .Trisomy 21(down syndrome) . Other genetic or craniofacial syndromes. Other genetic or craniofacial syndromes.

associated withassociated with (Midface hypoplasia, Small nasopharynx, (Midface hypoplasia, Small nasopharynx,

Choanal atresia or stenosis, Macroglossia, Choanal atresia or stenosis, Macroglossia, Micrognathia or retrognathia and cleft Micrognathia or retrognathia and cleft palate).palate).

Anatomic factors :Anatomic factors :

Obesity. Obesity. Nasal obstruction.Nasal obstruction. Laryngomalacia.Laryngomalacia. Sickle cell disease.Sickle cell disease. Velopharyngeal flap repairVelopharyngeal flap repair

Neurologic factors :Neurologic factors : That decreased pharyngeal muscular dilator That decreased pharyngeal muscular dilator

activity.activity.Medications.Medications.

Sedative.Sedative. General anaesthesia.General anaesthesia.

Brain stem disorders.Brain stem disorders. Chiari-malformation.Chiari-malformation. Birth asphyxia.Birth asphyxia.

Neuromuscular diseases.Neuromuscular diseases. Muscular dystrophy.Muscular dystrophy. Cerebral palsy.Cerebral palsy.

OSA occurs in children of all ages from OSA occurs in children of all ages from neonates to adolescents.neonates to adolescents.

It is thought to be most common in preschool-It is thought to be most common in preschool-age children (which is the age when the tonsils age children (which is the age when the tonsils and adenoids are the largest in relation to the and adenoids are the largest in relation to the underlying airway size).underlying airway size).

Occurs equally among boys and girls.Occurs equally among boys and girls. The estimated prevalence of snoring in The estimated prevalence of snoring in

children is 3 to 12 %.children is 3 to 12 %. OSA affect 1 to 10 %.OSA affect 1 to 10 %.

Sleep onset

Decreased CO2Increased O2

Decreased upper airway muscle activity

Arousal from sleep

Increased upper airway muscle activity

Relief of obstructionRestoration of airflow

HypoxemiaHypercapnia

Obstructive,Hypoventilation &Apnea

Upper airway narrowing

Increased ventilatory effort

Sedation anesthesia

MuscleWeakness

Obesity

SmallAirway

Enlarged tonsil & Adenoids

Craniofacialanomalies

To identify patients who are at risk for To identify patients who are at risk for adverse outcomes.adverse outcomes.

Avoid unnecessary intervention in Avoid unnecessary intervention in patients who are not at risk for adverse patients who are not at risk for adverse outcomes.outcomes.

Evaluate which patients are at increased Evaluate which patients are at increased risk of complications resulting from risk of complications resulting from adenotonsillectomy, so that appropriate adenotonsillectomy, so that appropriate precaution can be takenprecaution can be taken..

HISTORYHISTORY In children younger than five years.In children younger than five years.

Snoring is the most common complaint.Snoring is the most common complaint. Symptoms reported by parents:Symptoms reported by parents:

Mouth breathingMouth breathing DiaphoresisDiaphoresis Paradoxicrib-cage movements Paradoxicrib-cage movements RestlessnessRestlessness Frequent awakeningsFrequent awakenings

α In children five years and older.In children five years and older.ζ EnuresisEnuresisζ Behavior problemsBehavior problemsζ Deficient attention span Deficient attention span ζ Failure to thriveFailure to thriveζ In addition to snoringIn addition to snoring

α Compared with adult. Compared with adult. α Fewer children with OSA report excessive Fewer children with OSA report excessive

daytime somnolence, with the exception of daytime somnolence, with the exception of obese children.obese children.

In extreme cases of OSA in children.In extreme cases of OSA in children. Cor pulmonal and Pulmonary Cor pulmonal and Pulmonary

hypertension may be the presenting problems.hypertension may be the presenting problems.

Poor growth and FTT are more common in children Poor growth and FTT are more common in children with sleep-disordered breathingwith sleep-disordered breathing. . Growth velocity increases after Growth velocity increases after

adenotonsillectomyadenotonsillectomy Decreased production of growth hormone Decreased production of growth hormone

during fragmented sleep may contribute further during fragmented sleep may contribute further to poor growth.to poor growth.

Obstructive Sleep Apnea Screening Quiz

Do your children have any of the following symptoms that can Do your children have any of the following symptoms that can be associated with sleep apnea? be associated with sleep apnea? continuous loud snoringepisodes of not breathing at night (apnea) failure to thrive (weight loss or poor weight gain) mouth breathing enlarged tonsils and adenoids problems sleeping and restless sleep excessive daytime sleepiness morning headaches daytime cognitive and behavior problems, including problems paying attention, aggressive behavior and hyperactivity, which can lead to problems at school

Evaluation of the childs general apperance,with careful attention Evaluation of the childs general apperance,with careful attention to craniofacial characteristics, such as:to craniofacial characteristics, such as:

α Midface hypoplasia Midface hypoplasia

α MicrognathiaMicrognathia

Evaluation for nasal obstruction depends on the child's age.Evaluation for nasal obstruction depends on the child's age.

α Septal deviation Septal deviation

α Naso-lacrimal cysts Naso-lacrimal cysts

α Choanal atresiaChoanal atresia

α Nasal aperture stenosis Must be considered in infantsNasal aperture stenosis Must be considered in infants

fig 2

Arrows indicate Arrows indicate prominent adenoidal prominent adenoidal tissue in the posterior tissue in the posterior nasopharynx, resulting nasopharynx, resulting in upper airway in upper airway narrowingnarrowing

2-Lateral neck radiography.2-Lateral neck radiography.

WHAT WHAT ABOUT ABOUT

MANAGMENTMANAGMENT

MEDICALMEDICAL

CPAPCPAP AntibioticsAntibiotics Weight lossWeight loss Nasal steroidsNasal steroids Systemic steroidsSystemic steroids

SURGICALSURGICAL

AdenotonsillectomyAdenotonsillectomy UvulopalatopharyngoplastUvulopalatopharyngoplast

yy TracheotomyTracheotomy

OSA is more common in children with craniofacial OSA is more common in children with craniofacial syndromessyndromes..

1-Children who have syndromes with craniosynostosis:1-Children who have syndromes with craniosynostosis:

-Apert's syndrome, -Apert's syndrome,

-Crouzon's disease, -Crouzon's disease,

-Pfeiffer's syndrome,-Pfeiffer's syndrome,

-Saether-Chotzen syndrome,-Saether-Chotzen syndrome,

-abnormalities of the skull base,-abnormalities of the skull base,

-Accompanying maxillary hypoplasia,-Accompanying maxillary hypoplasia,

May have nasopharyngeal obstructionMay have nasopharyngeal obstruction

22--Children with syndromes that involve micrognathiaChildren with syndromes that involve micrognathia::- - Treacher collins syndromeTreacher collins syndrome , ,

- - Pierre Robin syndromePierre Robin syndrome , ,- - Goldenhar's syndromeGoldenhar's syndrome , ,

Become obstructed at the hypo pharyngeal levelBecome obstructed at the hypo pharyngeal level

3-Children with Trisomy 21 :3-Children with Trisomy 21 :

A narrow upper airway combined with Macroglossia A narrow upper airway combined with Macroglossia and hypotonic musculature predispose them to OSAand hypotonic musculature predispose them to OSA

The surgical management of craniofacial The surgical management of craniofacial syndromes and OSA in children frequently syndromes and OSA in children frequently requires more than standard requires more than standard adenotonsillectomy.adenotonsillectomy.

In children with midfacial hypoplasia, In children with midfacial hypoplasia, craniofacial advancement may be indicated.craniofacial advancement may be indicated.

Glossopexy, mandibular distraction or Glossopexy, mandibular distraction or advancement, or tongue suspension should advancement, or tongue suspension should be considered in patients with micrognathiabe considered in patients with micrognathia