Pediatric Obstructive Sleep Apnea: Many Causes, Many Treatment Options

TORONTO-There is an increased awareness of sleep-disordered breathing in children, but even after tonsillectomy and adenoidectomy (T&A), between 5% and 10% of all cases have persistent obstructive sleep apnea (OSA). An expert panel at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) addressed various diagnostic, surgical, and therapeutic approaches that can be used to treat these patients.

The number of children who are being treated for sleep apnea in the country tends to be a fairly significant percentage or proportion of children, said panel moderator Peter Koltai, MD, Chair of Pediatric Otolaryngology at Stanford University.

There are many reasons for OSA treatment failure, including neuromuscular problems, craniofacial abnormalities, and problems with dental and occlusal mouth proportions, as well as special concerns such as primary macroglossia among the Down syndrome and other populations. In addition, there can be lingual tonsil hypertrophy (LTH) following T&A.

Diagnostic Evaluation

When it comes to diagnosis, its key to determine whether the child snores-though in some cases a child may have apnea yet not snore, according to Norman Friedman, MD, director of the pediatric pulmonary sleep lab at the University of Colorado. Children who don’t snore either have a neuromuscular disorder, or some palatal modification, he said.

Obesity represents the biggest predictor of persistent apnea postoperatively. Black race and family history of sleep disorder breathing are also predictors, along with presence of lingual tonsils.

To make the diagnosis, you want to be a good detective, Dr. Friedman said. Get a sleep study along with an EEG to determine whether REM sleep is achieved, and perform airflow and gas exchange studies.

Children who should get a postoperative sleep study include those with persistent symptoms, children with neuromuscular disorders, syndromic children, those who had severe OSA preoperatively, and those who underwent palatal modification. Children who are going to be treated with continuous positive airway pressure (CPAP) need a sleep study too, Dr. Friedman said.

Diagnostic tools can include flexible endoscopy, fluoroscopy, cine MRI, and lateral neck radiographs. Cephalometry reveals additional anatomy, including maxillary and mandibular deficiencies.

CPAP in Pediatric OSA Patients

On another note, CPAP is becoming more recognized as an option for treating children with persistent OSA-although it is not FDA-approved for children (its use is off-label) and many insurers won’t cover it, said John Houck, MD, from the University of Oklahoma.

We need to know, as otolaryngologists, what’s involved in CPAP, what are the problems, and what is the state of the art, he said. Most published studies in this area are case series, so the evidence is weak.