What methods are optimal for identifying obstruction and treatment sites in children with persistent obstructive sleep apnea (OSA) after adenotonsillectomy?
Background: Current guidelines recommend adenotonsillectomy (T&A) as the first-line treatment for OSA. The most recent meta-analysis indicates a 34% to 40% likelihood of persistent OSA following T&A. Once the definitive diagnosis is established with polysomnography (PSG), obstruction sites are typically identified by a thorough physical examination. In addition, awake flexible laryngoscopy, lateral neck plain films, cine magnetic resonance imaging (MRI), and sleep endoscopy are also used.
Explore this issue:February 2016
Study design: Systematic review of 24 articles, with a combined population of 960 patients.
Setting: PubMed, Cochrane CENTRAL, DynaMed, UpToDate, CINAHL, and Scopus databases.
Synopsis: Three studies used cine MRI to identify the obstruction site in 33% to 93% of children. In five studies that specifically reported the percentage of patients in whom drug-induced sleep endoscopy (DISE) identified the obstruction site, DISE was successful in 100% of children. One study reported that sleep fluoroscopy identified obstruction sites not recognized on direct laryngoscopy and bronchoscopy in 27 out of 50 children. A study using plain film evaluation found that lingual tonsillar hypertrophy was more common in children with DS than in non-DS controls and could be identified on plain films. Another study of 27 children discovered through MRI use that obese children with OSA had significant residual adenoid tissue, as well as soft palate and tongue volume enlargement. Four studies reported that using supraglottoplasty to treat persistent pediatric OSA improved the mean apnea-hypopnea index (AHI) from 12.1 to 4.4 events per hour. In six studies, lingual tonsillectomy resulted in a decrease in pooled mean AHI, from 13.9 to 8.0 events per hour. A study that described the use of combined oral antileukotriene and intranasal steroid therapy for 22 children with residual OSA showed a decrease in the mean obstructive AHI from 3.9 to 0.3 events per hour. Limitations included limited available literature, including only one randomized controlled trial, and significant data heterogeneity.
Bottom line: Drug-induced sleep endoscopy and cine MRI are the most commonly reported tools to identify obstruction sites for children with persistent OSA; however, these techniques have not yet been clearly linked to outcomes.
Evidence for treatment is extremely limited and focuses primarily on lingual tonsillectomy and supraglottoplasty.
Citation: Manickam PF, Shott SR, Boss EF, Cohen AP, Meinzen-Derr JK, Amin RS, Ishman SL. Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea. Laryngoscope. 2016;126:491-500.