Persistent Obstructive Sleep Apnea After Tonsillectomy Mary Frances Musso, DO Pediatric Otolaryngology Learning Objectives Recognize indications for tonsillectomy List patients at risk for persistent OSA Identify methods used to evaluate sites of persistent obstruction Discuss treatment modalities for persistent OSA 1
Sleep Related Upper Airway Obstruction Primary Snoring 10% of children Sleep Disordered Breathing 25% to 40% in obese children Obstructive Sleep Apnea Syndrome 1-4% of children Untreated Effects of OSA:What We Know Cardiovascular effects Hypertension Right sided heart failure / cor pulmonale / Pulmonary HTN Ventricular remodeling Neurocognitive problems Behavioral consequences Enuresis Somatic growth retardation 2
Many Things We Don t Know. Guidelines 3
Tonsillectomy Indications for Recurrent Tonsillitis Criterion Minimum Frequency of Sore Throat Episodes Clinical features Treatment Documentation Definition At least 7 episodes in the previous year, at least 5 episodes in each of the 2 previous years, or at least 3 episodes in each of the previous 3 years Sore throat plus at least 1 of the following features qualifies as a counting episode: Temperature greater than 100.9 (38.3) Cervical adenopathy (tender lymph nodes or lymph node size greater than 2 cm) Tonsillar exudate Culture positive for group A β-hemolytic streptococcus Antibiotics administered in the conventional dosage for proved or suspected streptococcal episodes Each episode of throat infection and its qualifying features substantiated by contemporaneous notation in a medical record If the episodes are not fully documented, subsequent observance by the physician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with the initial history* Who Needs a Sleep Study Before Surgery? 4
Tonsillectomy Indications for OSA OSA Severity No OSA <1 Mild >1 to <5 PSG Criteria (AHI;; events/h) Moderate >5 to <10 Severe >10 Abnormal PSG in a child: Pulse oximetry levels less than 92% AHI >1 AHI >5 may warrant tonsillectomy Otolaryngology Head and Neck Surgery144(1S) S1 S30 2011 Pediatric OSA Most common cause of upper airway obstruction remains adenoid & tonsil hypertrophy If hypertrophic tonsil & adenoid tissue are present adenotonsillectomy (T&A) first line treatment 5
Other Indications for Tonsillectomy Multiple antibiotic allergy/intolerance PFAPA Periodic fever, aphthous stomatitis, pharyngitis, adenitis History of peritonsillar abscess PANDAS-Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections Poorly validated clinical indications halitosis, febrile seizures, malocclusion of teeth Post-tonsillectomy Healing Day 1 Day 5 Day 7 Day 17 Isaacson G. et al. Pediatrics Vol. 130 No. 2 August 1, 2012 pp. 324-334 6
Persistent OSA Published 2006 14 studies included- 355 subjects Treatment success of T&A 82% Excluded: craniofacial syndromes, neuromuscular disorders, morbid obesity Included: subjects up to 18 years of age Published 2009 23 studies included-1079 subjects Treatment success of T&A was 66% Excluded : craniofacial syndromes, chromosomal disorders & neuromuscular disorders Included : obese subjects, up to 20 years of age Risk Factors for Persistent OSA after T&A Craniofacial/ mandibular anomalies (Pierre Robin sequence, Treacher Collins) Obesity Neuromuscular disorders Genetic disorders Severe OSA prior to surgery Asthma in non-obese children 7
Where is the Persistent Obstruction?? PSG provides data on degree of OSA, does not identify level or levels of obstruction Anatomic sites where obstruction can occur 1. Nose and nasopharynx 2. Posterior oropharynx 3. Lateral pharyngeal walls 4. Level of hypopharynx / obstruction of BOT 5. Larynx Radiographic Studies Cine MRI Current Opinion in Otolaryngology & Head and Neck Surgery 2011, 19:449 454 8
Drug Induced Sleep Endoscopy (DISE) + Flexible laryngoscope DLB set 9
DISE Findings DISE Patient: 4 y/o M with h/o CHARGE/Goldenhar Syndrome S/p T&A at 2 years of age Recent PSG Mild OSA-0 obstructive apneas, 2 central apneas, 29 obstructive hypopneas, AHI 5.76, oxygen nadir was 90% H/o allergic rhinitis currently taking Zyrtec and Flonase Has not tried CPAP Has recurrent bronchitis 10
1/23/18 Video Areas addressed: supraglottoplasty, adenoid remnant, turbinate reduction Future consideration: lingual tonsils and laryngeal cleft injection 11
DISE Patient: 12 y/o with Trisomy 21 s/p PDA ligation PSG Severe OSA- AHI 31, oxygen nadir 82%(0.2 % time under 90%) 0 obstructive apneas, 1 mixed apneas, 16 central apneas, 238 obstructive hypopneas Recurrent pneumonias: 2 pneumonias, one of which was RSV No tonsil hypertrophy on PE Areas addressed: adenoids, inferior turbinates, lingual tonsils Future consideration: tonsils, AE folds 12
Treatment of Persistent OSA Nonsurgical Options MEDICATIONS: Intranasal corticosteroid sprays Fluticasone, Budesonide Leukotriene inhibitors Montelukast Key Points Up to 40% of children can have persistent OSA after T&A Children that continue to be symptomatic and children who are at higher risk for persistent OSA should undergo a sleep study after T&A DISE and Cine MRI are the most common tools used to identify sites of obstruction for children with persistent OSA Surgical and nonsurgical modalities are generally needed to treat persistent OSA 13
Single Visit Surgery Who: Children with recurrent ear infections Where: Texas Children s Hospital West Campus When: Why: How: Offered two times a month on Fridays by Dr. Musso and Dr. Raynor One visit more efficient for patients and parents Can call WC nurses line directly to schedule an appointment 832 227-1420 option 2 14