4/11/2013. Objective

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1 Sleep nasopharyngoscopy py in children: rationale and facts Hamdy El-Hakim FRCS(Ed) FRCS(ORL) Associate Professor Pediatric Otolaryngology Division of Otolaryngology Head & Neck Surgery The Stollery Children s Hospital & The University of Alberta Hospitals Edmonton (Alberta) Canada 2013 Objective Introduce more modern concepts on the pathogenesis of SDB Discuss the rationale behind the use of endoscopy under pharmacologically induced sleep Demonstrate the findings in some high risk group patients 1

2 Sensory impairment Neuro-motor dysfunction Upper airway dysfunction Structural alteration Tauman R & Gozal D. Paediatric Respiratory Reviews (2006) Aims of approach Identify operable situations (T&A and others) Avoid operating on high risk patients who unlikely to benefit Interpret a structured examination in the light of the individual diagnosis or risk group Have a plan B Counsel on the achievable 2

3 Reports on adenotonsillectomy resolving sleep disordered breathing 14 studies (n 355), success rate 82.9% 22 studies (n 1079), success as defined per individual study 66.3% (24-100%) Brietzke SE and Gallagher D. The effectiveness of T&A in the treatment of pediatric OSAHS: A meta-analysis. Otolaryngology Head and Neck Surgery (2006) 134, Friedman M et al. Systematic review of T&A for pediatric OSAHS. AA-OHNS Chicago Sept 2008 How otolaryngologists reach the diagnosis Do not use routinely polysomnography Neither symptoms nor the awake examination can predict or relate to the gold standard Weatherly RA et al. Identification and evaluation of OSA prior to T&A in children: a survey of practice patterns. Sleep Medicine 2003;4(4): Brietzke SE et al. Can history and physical examination reliably diagnose pediatric OSAHS? A systematic review of the literature. Otolaryngol Head Neck Surg 2004;131:

4 Literature on modalities that identify surgical targets Do not use routinely polysomnography Neither symptoms nor the awake examination (included X-ray) can predict or relate to the reference standard Weatherly RA et al. Sleep Medicine 2003 Brietzke SE et al. Otolaryngol Head Neck Surg 2004 Questionnaires Tools for Tools for Screening (PSQ) QOL assessment (OSA 18) The sensitivity of any individual symptom or combination was low The specificity of snoring, sleepiness and learning disabilities was high in some studies 4

5 Tonsil size (0-4) and OSAS The association between subjective pediatric tonsil size using 0-4 scale and objective OSAS severity is weak at best. Level 4 Nolan & Brietzke OHNS 2011 Cine MRI Statistically significant differences in upper airway measurements and collapse between 16 children with OSA and controls Down Syndrome relative macroglossia (74%); glossoptosis (63%), recurrent & enlarged adenoids (63%); enlarged lingual tonsils (30%), & hypopharyngeal collapse (22%) Lane et al. Radiology Shott & Donnelly. Laryngoscope Guimaraes et al. Pediatric Radiology

6 Cine MRI Excellent demonstration of collapses and obstructions of the airway Digitized volumetric assessment Delineation of soft tissues and parapharyngeal structures, and Does not expose the child to radiation. Still requires anaesthesia or sedation, Expensive Not readily accessible. Literature on sleep endoscopy in children 6

7 An early description Sher AE, Shprintzen RJ, and Thorpy MJ. Endoscopic observations of obstructive sleep apnea in children with anomalous upper airways: predictive and therapeutic value. Int J Pediatr Otorhinolaryngol. 1986;11(2): Awake examination Four types of obstruction / collapse were described. Type1 Type 2 Type 3 Type 4 7

8 Sleep endoscopy in the literature Croft CB et al. Endoscopic evaluation and treatment of sleep associated upper airway obstruction in infants and young children. Clin Otolarynol 1990; 14; Contencin P et al. Pharyngolaryngeal fibroscopy under general anesthesia in children.technique and indications in sleep apnea and hypopnea. Ann Otolaryngol Chir Cervicofac 1991;108(7):373-7 Myatt HM & Beckenham EJ. The use of diagnostic nasoendoscopy in the management of children with complex upper airway obstruction Clin Otolaryngol 2000, 25(3):200-8 No correlation to reference standard Valera FC et al. OSAS in children: Correlation between endoscopic and polysomnographic findings. Otolaryngol Head Neck Surg 2005;132:

9 More recently Multi-level problems post T&A: (n 13) nose, tongue base, adenoidal re-growth VOTE; velum, oropharyngeal lateral walls, tongue base, and/or epiglottis Truong et al: velum, oropharynx, tongue base, and supraglottis Durr et al. Archives of Otolaryngology, Head and Neck Surgery 2012;138(7): Truong et al. International Journal of Pediatric Otorhinolaryngology 2012;76(5): Adult literature DISE (drug induced sleep endoscopy). Two validation studies; two expert sleep endoscopists Collapse may predict failure of surgical treatment as was recently claimed Rodriguez-Bruno K et al. Otolaryngology - Head and Neck Surgery 2009;140: Kezirian E et al. Archives of Otolaryngology Head and Neck Surgery 2010;136(4):393 Koutsourelakis I et al.. Laryngoscope

10 Bottom line messages Reserve for special populations and after T&A Inhalational abandoned for TIVA Concerns regarding pharmacological sleep No validation Tonsil and adenoid size irrelevant Technique 10

11 Symptoms of SDB Indication 12 months (except infants) Trialed medical treatment if appropriate With or without planned surgery Uniform algorithm Flexible bronchoscope (2.2 mm) Topical anesthesia (1% Lignocaine) - only nasal Intravenous General anesthesia (Propofol / Remifentanyl - infusion or bolus) Minimal application of drugs Does not mimic physiological sleep Remifentanyl 2-2.5mcg/ml and infusion rates of Propofol varied from mcg/kg/min depending on response to stimulation 11

12 Endoscopic examination from nose to larynx Reporting the findings Obstruction chronic hypertrophic rhinitis deviated nasal septum, oropharyngeal tonsils, laryngeal, tracheal or bronchial Tongue T E Collapse lateral hypopharyngeal wall or circumferential, tongue base, laryngeal, tracheal, bronchial C 12

13 Ordinal scale 1 or 0 Collapse: any paradoxical movement reducing the lumen > 50% Obstruction: any encroachment on the airway caliber > 50% Normal tone 13

14 Sleep nasopharyngoscopy patterns & findings How did clinical & endoscopic examination agree on tonsillar obstruction? 14

15 Kappa value 0.44 (95% CI ) n 248 (moderate agreement according to Landis & Koch 1977) SNP Clinic Obstructive Non obstructive Obstructive Non obstructive Sites of pathology: 49 patients had single level Lateral collapse Circumferential collapse Larynx/trachea Tongue collapse Tonsils Deviated septum Chronic rhinits Adenoids years Mean age 5.9 years ( yrs) N of patients (total 241) M:F is 132:109 15

16 An index lesion The prevalence of laryngomalacia in children presenting primarily with SDB 3.9%- 358 consecutive patients 8.2%- 75 consecutive 3 years old 16

17 Patterns in high risk populations Current beliefs on obese patients Existing information suggest a non dynamic obstruction unique to obese individuals Horner RL, et al. Eur Repir J, 1989 Sakakibara H, et al. Eur Respir J Welch KC, et al. Sleep, 2002 Monahan KJ, et al. Am J Respir Crit Care Med 2002 Kulnis Ret al. Chest 2000;118: Gozal Det al. Am J Respir Crit Care Med 2004;169:163-7 Arens R, et al. American Journal of Respiratory and Critical Care Medicine, 2003 Only one study using respiratory gated MR demonstrates wide variation in cross sectional area of the upper airway Arens R et al. American Journal of Respiratory and Critical Care Medicine,

18 Investigating obese airways and comparing them to age and gender matched controls Case control Compared proportions of collapse, obstruction & mixed patterns 70 obese children 15 were excluded (missing height / weight; no matching controls; syndromic & other confounders) Distribution of patterns Groups Obstruction Mixed Collapse only only Obese Control Fisher s exact P <

19 Young children or early onset SDB Higher incidence of respiratory complications Poor response to adenotonsillectomy Scant research identified GERD as a potential association Mitchell RB, Kelly J. Outcome of T&A for OSA in children under 3 years of age. Otolaryngol Head Neck Surg May;132(5): Walker P, Whitehead B, Gulliver T. PSG outcomes of T&A for OSA in children under 5 years old. Otolaryngol Head Neck Surg Jul;139(1):83-6 Stratham MM, Elluru RG, Buncher R., Kalra m. T&A for OSA in young children: prevalenceof pulmonary complications. Arch Otolaryngol Head Neck Surg May;132(5): Joshua B, Bahar G, Shlkes T, Shpitzer, Raveh E, Adenoidectomy: long term follow up. Otolaryngol Head and Neck Surg 135 (2006) Diagnoses linked to SDB via pharyngeal dysfunction Gastroesophageal reflux disease (GERD) / Eosinophilic Esophagitis (EE) Prematurity Hypotonia Swallowing Respiration Phonation M. Bortolotti et al, OSA is treated by the prolonged treatment of GERD with omeperazole, Dig. Liver Dis. 38 (2) (2006), pp Alkhalil M et al. J Clin Sleep Med Feb 15;5(1):71-8. Review. Schwartz AR, et al. Obesity and OSA pathogenic mechanisms and therpaeutic approaches pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc Feb 15;5(2): Review. 19

20 Causes of Pharyngeal Dysfunction GERD / Prematurity Swallowing Asthma Obesity EE Dysfunction Early Onset n=73 Control I n=75 Control II n= Table 2: Causes of pharyngeal dysfunction are significantly different between groups Proportions of patterns Groups Obstruction Mixed Collapse only only Obese Early onset Control

21 Latest work Inter rater Weighted kappa Observed SE % CI Proportions of agreement Observed 0.73 Maximum Chance % CI Conclusions SNP demonstrates more operable sites It shows some agreement to the gold standard Its patterns are different in various groups of interest & that these patterns may correlate to the severity of the SDB Taken in context of individual risk groups it suggests that other elements may override structural alterations 21

22 Lingual tonsillectomy Powered turbinoplasty 22

23 Declaration No conflict of interest No financial support ERB obtained for all projects 23