Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study

Am J Respir Crit Care Med. 2010 Sep 1;182(5):676-83. Epub 2010 May 6.

Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D,Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D.

Department of Pediatrics, University of Chicago, Comer Children's Hospital, 5721 S. Maryland Avenue, Chicago, IL 60637, USA.

Abstract

RATIONALE: The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined.

OBJECTIVES: To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS.

METHODS: A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI).

MEASUREMENTS AND MAIN RESULTS: Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children.

CONCLUSIONS: AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.

Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders.

J Oral Maxillofac Surg. 2010 Oct;68(10):2431-6. Epub 2010 Jul 21.

Demetriades N, Chang DJ, Laskarides C, Papageorge M.

Department of Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, Boston, MA 02111, USA. neophytos.demetriades@tufts.edu

Abstract

PURPOSE: Literature suggests that patients without pre-existing sleep-related breathing disorders who undergo orthognathic surgery for treatment of facial asymmetry may experience changes in their oropharyngeal airway. Mandibular retropositioning can compromise the posterior airway space, alter the physiologic airflow through the upper airway, and predispose patients to development of obstructive sleep apnea syndrome (OSAS).

PATIENTS AND METHODS: This study was a retrospective cohort analysis of 26 patients who underwent mandibular retropositioning with or without maxillary advancement within the past 5 years at Tufts University School of Dental Medicine. Pre- and postoperative lateral cephalometric radiographs were analyzed with digital DOLPHIN software (Dolphin Imaging, Chatsworth, CA) for evidence of changes to the posterior airway dimension. In addition, patients were evaluated postoperatively with SNAP polysomnography (model 4/6; SNAP Laboratories, Wheeling, IL) for evidence of OSAS.

RESULTS: Results indicated that mandibular retropositioning greater than or equal to 5 mm decreased the posterior airway space below 11 mm (30.75%, P = .03) and showed evidence of soft palate elongation greater than 32 mm (15.39%, P = .037) in a significant number of patients. However, as determined by cephalometric analysis, mandibular retropositioning greater than or equal to 5 mm in combination with maxillary advancement had no significant effect on the posterior airway space or soft palate.

CONCLUSION: Postoperative SNAP polysomnography showed higher incidence of mild to moderate OSAS in patients who underwent mandibular retropositioning greater than or equal to 5 mm (69.25%) compared with patients who underwent mandibular retropositioning in combination with maxillary advancement (38.46%, P = .039).

Copyright © 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Diagnostic accuracy of split-night polysomnograms.

J Clin Sleep Med. 2010 Aug 15;6(4):357-62.

Khawaja IS, Olson EJ, van der Walt C, Bukartyk J, Somers V, Dierkhising R, Morgenthaler TI.

Center for Sleep Medicine, Mayo Clinic, Rochester, MN 55905, USA.

Abstract

STUDY OBJECTIVES: American Academy of Sleep Medicine (AASM) practice parameters indicate that split-night polysomnograms (SN-PSG) may be performed when the apnea hypopnea index (AHI) is > or = 20 to 40, depending on clinical factors. The aim of this study was to determine the diagnostic accuracy of SN-PSG, including at the lower range of AHIs.

METHODS: We reviewed 114 consecutive full-night PSGs (FN-PSG) performed at our center between August 2006 and November 2008 on subjects enrolled in studies in which obstructive sleep apnea (OSA) was the sleep disorder of interest. We compared the AHI from the first 2 hours (2 hr-AHI) and 3 hours (3 hr-AHI) of sleep with the "gold standard" AHI from FN-PSG (FN-AHI), considering OSA present if FN-AHI > or = 5.

RESULTS: The 2 hr-AHI and 3 hr-AHI correlated strongly with the FN-AHI (concordance correlation coefficient [CCC] = 0.93 and 0.97, respectively). After adjusting for percentage of sleep in stage REM sleep and in supine position, the correlation of 2 hr- and 3 hr-AHI with FN-AHI remained strong (0.92 and 0.96, respectively). The area under the receiver operating curves (AUC) for 2 hr-AHI and 3 hr-AHI using FN-AHI > or = 5 were 0.93 and 0.95, respectively.

CONCLUSIONS: The AHI derived from the first 2 or 3 hours of sleep is of sufficient diagnostic accuracy to rule-in OSA at an AHI threshold of 5 in patients suspected of having OSA. This study suggests that the current recommended threshold for split-night studies (AHI > or = 20 to 40) may be revised to a lower number, allowing for more efficient use of resources.

Snoring and obstructive sleep apnea.

Med Clin North Am. 2010 Sep;94(5):1047-55.

Ulualp SO.

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9035, USA. seckin.ulualp@utsouthwestern.edu

Abstract

Obstructive sleep apnea (OSA) may be associated with myriad clinical consequences such as increased risk of systemic hypertension, coronary vascular disease, congestive heart failure, cerebrovascular disease, glucose intolerance, impotence, obesity, pulmonary hypertension, gastroesophageal reflux, and impaired concentration. Nonetheless, OSA remains undiagnosed in 82% of men and 93% of women with the condition. Early identification and treatment of OSA provides significant relief for individuals, prevents complications of OSA, and reduces overall health care costs. Better understanding of the pathogenesis, risk factors, diagnosis, and treatment of OSA has the potential to improve early recognition of OSA and prevention of adverse effects on the individual and society.

Prader-Willi syndrome: sorting out the relationships between obesity, hypersomnia, and sleep apnea

Current Opinion in Pulmonary Medicine:

November 2010 - Volume 16 - Issue 6 - p 568–573

Bruni, Oliviero

doi: 10.1097/MCP.0b013e32833ef547

Sleep and respiratory neurobiology: Edited by Lee K. Brown

Purpose of review: Although several studies in the last years have evaluated obesity, obstructive sleep apnea (OSAS), and excessive daytime sleepiness (EDS) in patients with Prader–Willi syndrome (PWS), their pathophysiologies and interactions and the role of treatment with growth hormone are not completely understood. The present review analyzes the contributing role of obesity, OSAS, and sleep structure abnormalities in determining the EDS and the role of specific treatment in improving the clinical outcome.

Recent findings: The studies on sleep structure of PWS patients show abnormalities of rapid eye movement (REM) sleep and a decrease in non-REM sleep instability, corroborating the hypothesis of the presence of a primary disorder of vigilance and the similarities with obstructive sleep apnea. These sleep alterations might also be linked to the action of mediators of inflammation (i.e. adiponectin or cytokines) determined by obesity. Obesity and hypothalamic dysfunction could be responsible for the primary abnormalities of ventilation during sleep that, in turn, might contribute to EDS. Although EDS seems to resemble narcolepsy, PWS patients do not present the other typical symptoms of narcolepsy.

Summary: The most consistent hypothesis for linking the three different symptoms of PWS is a primary central hypothalamic dysfunction. Further research is needed to evaluate the contribution of the upper airway resistance syndrome in the pathogenesis of EDS, the role of the alterations of sleep microstructure, the relationships between PWS and narcoleptic phenotype, the involvement of orexin/hypocretin, and the effects of drugs acting on REM sleep and/or wakefulness.

Electrical stimulation of the hypoglossal nerve in the treatment of obstructive sleep apnea

Sleep Medicine Reviews , 

Eric J. Kezirian, An Boudewyns, David W. Eisele, Alan R. Schwartz, Philip L. Smith, Paul H. Van de Heyning, Wilfried A. De Backer

Volume 14, Issue 5, Pages 299-305 (October 2010)

Upper airway occlusion in obstructive sleep apnea has been attributed to a decline in pharyngeal neuromuscular activity occurring in a structurally narrowed airway. 

Surgical treatment focuses on the correction of anatomic abnormalities, but there is a potential role for activation of the upper airway musculature, especially with stimulation of the hypoglossal nerve and genioglossus muscle. 

We present evidence from research on upper airway neuromuscular electrical stimulation in animals and humans. We also present results from eight obstructive sleep apnea patients with a fully implanted system for hypoglossal nerve stimulation, demonstrating an improvement in upper airway collapsibility and obstructive sleep apnea severity. 

Future research, including optimization of device features and stimulation parameters as well as patient selection, is necessary to make hypoglossal nerve stimulation a viable alternative to positive airway pressure therapy and upper airway surgical procedures.