Pediatric Obstructive Sleep Apnea: Many Causes, Many Treatment Options

Surgical Options

Surgery is often an option for persistent OSA, but in addition to soft tissue obstruction the bony facial skeleton must be into account, said James Sidman, MD, from the Children’s Hospital-Minneapolis. Yet, working on bone in children is fraught with difficulties, in part because children are growing.

Mandibular surgery in very young children is very effective and has few long-term complications and numerous long-term benefits. However, the effectiveness of maxillary distraction is still unknown.

Mandibular distraction is done primarily for micrognathic children, although not all micrognathic children have Pierre-Robin sequence-some may have Treacher-Collins or other syndromes.

We begin distraction after three to five days.…If it’s an older child who is already trached or has a safe airway, then we can send them home on post-op day two or three, Dr. Sidman said. Distraction is done twice a day at about three-quarters of a millimeter. The parents can do the linear distraction and the otolaryngologist does the nonlinear distraction.

External distractors leave small marks on the side of the face, but there is no significant scarring, Dr. Sidman said. The procedure can be done in children as small as 2 or 3 kg.

Midface distractions are for nasal and nasopharyngeal obstruction, but there must be adequate bone stock, and the child should be at least 4 years old.

Models help with surgical planning. The models are plastic and based on the patient’s CT scans. We use models of the facial skeleton that we operate on beforehand, and put the distractors on the models, so we have our vectors exactly planned before we operate, Dr. Sidman said.

The maxillary procedure is generally reserved for children who can’t tolerate CPAP or BiPAP, who have severe obstruction as seen through endoscopy. However, the operation is not proven long-term and there is significant relapse when there is insufficient bone stock.

Once you’ve done the distraction, consider going in and putting in either absorbable plates or long-term titanium plates to try to help hold the regenerate in position long-term, he said.

Obstruction at the Tongue Base

Obstruction at the base of the tongue is another important cause of persistent apnea. This was addressed by Sally Shott, MD, from the Cincinnati Children’s Hospital Medical Center, who described surgical interventions.

After T&A, the incidence of persistent OSA is higher in the Down syndrome population. The tongue is involved in the highest percentage-macroglossia, glossoptosis, and also enlarged lingual tonsils, she said.