Evaluation and Management of Persistent Pediatric Obstructive Sleep Apnea

1 Introduction

According to a 2009 meta-analysis, 35% to 40% of children who undergo adenotonsillectomy (T&A) for obstructive sleep apnea (OSA) have persistent disease after surgery. Our discussion will briefly outline techniques currently used to identify sites of obstruction in these patients and will subsequently describe current medical and surgical management options for persistent OSA.

2 Identification of Sites of Obstruction

For children with persistent OSA, a thorough physical examination should be conducted. This should be aimed at identifying potential sites of obstruction ( Table 69.1 ) and additional factors that may be pertinent to the management of OSA. Body mass index (BMI) should be documented, as should syndromic features, neurologic status, and the presence of hypotonia. The modified Mallampati score should also be obtained.

Table 69.1

Comparison of DISE, Cine MRI, and Physical Examination in the Evaluation of Children With Persistent OSA

	DISE	Cine MRI	Transnasal Flexible Laryngoscopy
Requires sedation	X	X
Allows identification of sleep-dependent conditions	X	X
Assesses multiple upper airway sites simultaneously		X
Allows for easy visualization of laryngeal obstruction	X		X
Allows for treatment at the time of evaluation	X		X (if done in the perioperative setting)
Easy implementation	X		X

DISE, Drug-induced sleep endoscopy; MRI, magnetic resonance imaging; OSA , obstructive sleep apnea.

Lateral cervical x-rays and flexible fiber-optic laryngoscopy can be used to assess possible regrowth of adenoidal tissue and to identify lingual tonsillar hypertrophy. In children with craniofacial disorders or retrognathia, skull x-rays or high-resolution computed tomography can be used to define the anatomy, thereby identifying specific areas of obstruction.

In light of the fact that airway reflexes and tone differ in the awake and asleep states, drug-induced sleep endoscopy (DISE) and cine magnetic resonance imaging (MRI) are increasingly being used in the overall assessment. These studies, as well as studies pertaining to additional methods of identifying sites of obstruction, are summarized in a 2016 systematic review by Manickam et al.

2.1 DISE

DISE is performed with the administration of an anesthetic that mimics natural sleep. A flexible endoscope is passed transnasally into the pharynx and larynx to evaluate possible sites of obstruction; this can be done immediately before sleep surgery. Although DISE and cine MRI effectively identify sites of obstruction in the oral cavity and oropharynx, DISE is better suited for the evaluation of nasal and laryngeal obstruction. Four studies of pediatric DISE have reported the effectiveness of this technique to identify at least one site of obstruction, and three of these studies have reported identification rates of 100%. The fourth study identified sites of obstruction in 100% of children with Down syndrome, but in only 52% of children without Down syndrome.

2.2 Cine MRI

Cine MRI yields detailed information on both anatomy and dynamic airway motion. Consecutive images of the upper airway are acquired over a 2-minute period. These high-resolution images are then displayed in a format that creates an active “movie” of airway motion and collapse during sleep. In contrast to DISE, this technique is able to simultaneously examine multiple levels of the airway, and is more likely to identify primary and secondary sites of obstruction. Additionally, due to the brightness of lymphoid tissue on T2-weighted images, adenoidal and lingual tonsillar hypertrophy are easily identified and quantified. Limitations of cine MRI include poor visualization of obstruction at the nose and larynx and the willingness of the anesthesiologist to assist with this technique.

3 Medical Therapies

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