Pediatric Airway Disorders G. Paul Digoy, M.D. Director of Pediatric Otolaryngology OU Health Sciences Center Paul-Digoy@ouhsc.edu Office: 405 271-5504 Speaker Disclosure Speakers, moderators, or panelists in an accredited CME Activity, are required to disclose to participants: I, G. Paul Digoy, M.D., have no financial relationships or affiliations with the sponsors/exhibitors of this meeting to disclose. Outline Background on causes of pediatric airway obstruction Age based differential diagnosis of upper airway obstruction Understanding sleep apnea in children The role of adenotonsillectomy 1
Background Dynamic vs. Fixed obstruction younger vs. older Sleep apnea is a form of dynamic airway obstruction and the source of obstruction cannot always be diagnosed in clinic Fixed Dynamic 2
How to Diagnose Dynamic Airway Obstruction in Children? Diagnostic Airway Endoscopy in Children Intermittent Apnea 3
Spontaneous Ventilation (Higher Level of Sedation) Spontaneous Ventilation (Lower Level of Sedation) Overview of the More Common Causes of Upper Airway Obstruction in Children 4
Differential is Always Based on Age at Presentation At Birth After Birth 7 mo 8 mo 24 mo Obstruction at Birth Nasal Obstruction Vocal Cord Paralysis Pierre Robin Sequence Rare Congenital Nasal Obstruction At Birth Choanal Atresia Pyriform Aperture Stenosis 5
Bilateral Vocal Cord Paralysis in Children Second most common cause of stridor in infancy (10-20% of cases) 58% present within 12 hours of birth (Cohen et al. 1982) 50% of VC paralysis in children is congenital Bilateral Vocal Cord Paralysis in Children Management Tracheostomy vs. Close Observation 50% need a tracheostomy (most authors) Reversible allows time for potential nerve recovery Pierre Robin Sequence small lower jaw (micrognathia) a tongue which tens to ball up at the back of the mouth and fall back towards the throat (glossoptosis) breathing problems cleft palate 6
Mandibular Growth after TLA *Laryngomalacia After Birth to 6 mo *Subglottic Stenosis Tracheomalacia Other Laryngomalacia 7
Laryngomalacia Most common cause of stridor in infants Stridor Staccato (less common: high pitched and musical ) Onset Pattern of progression Associated symptoms (GERD) Laryngomalacia: Management Supine position is more aggravating than prone position Treatment for GERD Surgery (12%) Supraglottoplasty Tracheostomy 8
SUB GLOTTIC OR GLOTTIC STENOSIS Subglottic Stenosis - Management 9
*Croup 6 mo 24 mo *Airway Foreign Body *Respiratory Papillomas SGS: congenital/aquired Effect Of Edema Poiseuille s law Not all that barks is croup! 10
Recurrent Respiratory Papillomatosis Treatment Options: Surgical Debulking Microdebrider vs. Laser Cidofovir injections Microdebrider for Airway Papillomas Injection with Cidofovir 11
Prevention is Key 6 mo 24 mo Airway Foreign Bodies Aint nothin like history Three diagnostic tools History Imaging Physical exam 12
Sensitivities/Specificities of Diagnostic Tools History Sensitivity: 81-97% Specificity: 33 82% Physical Exam Sensitivity: 24 81% Specificity: 12 64% Radiography Sensitivity: 49 88% Specificity: 9 71% Articles Ciftci et al. Emir et al. *Zerella et al. Hoeve et al. Svedstrom et al. Barrios et al. Metrangolo et al. Lea et al. Hyperinflation of the right lung. Airway Foreign Bodies A good rule of thumb: diagnostic bronchoscopy should be performed if any one of the three diagnostic tools is considered positive When the diagnosis is in question: consider repeating the radiograph and physical exam after a 24 hour period 13
Obstructive Sleep Apnea Adenotonsillar Hypertrophy Laryngomalacia Obesity Nasal obstruction Rare Congenital/ Neuromuscular Primary Snoring (PS) Where does disordered breathing begin?? UARS? UARS Obstructive Sleep Apnea (OSA) -Restless Sleep -Enuresis -Daytime Hyperactivity -ADHD -Learning Problems -Daytime Sleepiness -Disruptive Behavior -Nigh-time Arousals -Witnessed Apneas Should you get a Sleep Study? Very controversial subject AAP vs. AAO Must consider: Cost Sleep lab availability Child s comfort How it may affect our clinical decision 14
SDB Behavior and Cognition Before and After T&A 78 Children scheduled for T&A were evaluated (ages 5 12) Control subjects (number 27): age, sex, and socioeconomic matching Tests: Polysomnography Behavior: Conners Parent Rating scale, Child Symptom Inventory-4: Parent Checklist Chervin et al. Pediatrics April 2006 SDB Behavior and Cognition Before and After T&A Tests continued: Sleepiness: Multiple Sleep Latency Test Psychiatric: ADHD based on DSM-IV Cognitive-Attention index: 100 pt scale Integrated Visual and Auditory Continuous Performance Test Children s Memory Scale Chervin et al. Pediatrics April 2006 SDB Behavior and Cognition Before and After T&A Analysis: Primary Outcome: behavioral hyperactivity index (AT versus Control) Second Analysis: separates children with sleep apnea from those without Chervin et al. Pediatrics April 2006 15
SDB Behavior and Cognition Before and After T&A Results: Otolaryngologists predicted OSAS 51% of time based on clinic evaluation 28% of T&A subjects had ADHD and only 7% of controls (p=0.03) 50% no longer met criteria for ADHD 1 yr after T&A 1 year later: no difference between control and T&A group (p-0.23) Chervin et al. Pediatrics April 2006 SDB Behavior and Cognition Before and After T&A Polysomnographic assessment of baseline SDB and its subsequent amelioration did not clearly predict either baseline neurobehavioral morbidity or improvement in any area other that sleepiness. Chervin et al. Pediatrics April 2006 Are you done yet? 16
Unresolved OSA/Sleep Disorder After T/A Pediatric OSA Prevalence of pediatric OSA is in the 1-4% range. Adenotonsillectomy can resolve symptoms of OSA in up to 80% of cases (27-80%). Complete normalization of sleep disordered breathing may be less common. Unresolved OSA after T/A Sources of obstruction: Nasal Laryngeal Palatal Lingual tonsils Diffuse hypotonia Obesity Other 17
Sleep Endoscopy Performed via light general anesthesia At stage II anesthesia, dynamic breathing and pharyngo-laryngeal muscle movements are examined. Sleep Endoscopy Sleep Endoscopy and Laryngomalacia 18
Sleep Endoscopy Tongue Base Obstruction Limitations of Sleep Endoscopy Not natural sleep Positioning Methods of sedation Reproducibility Comfort of anesthesiologist Nasal obstruction Significant source of pediatric OSA Rule out: Allergic rhinitis iti Piriform aperture narrowing Polypoid turbinates 19
Lingual Tonsils and OSA Can contribute significantly to OSAS in Children. Also source of: Dysphagia Globus Palatal Obstruction Conclusion Dynamic airway endoscopy in children is a critical tool for airway assessment Age is a crucial factor in establishing a differential diagnosis i All that barks is not croup Primary Snoring in Children is likely NOT a benign process 20
Conclusion Cont. When the source of pediatric OSA is unknown - Sleep endoscopy should be considered Thank You 21