kasey k. li, md, dds, facs stanford university sleep ... university sleep medicine program. ......

Pediatric OSA Treatment – Beyond T&A

Kasey K. Li, MD, DDS, FACSStanford University Sleep Medicine Program

Airway Imaging in Pediatric OSA

• The adenoid and tonsils are larger and the airway is most restricted where adenoid and tonsils overlap

• The volume of adenotonsillar tissues correlates with AHI

• The airway is smaller in children with OSA compared to controlsArens R, et al. Am J Respir CCM 2003;167:65-70.Arens R, et al. Am J Respir CCM 2001;164:698-703.

Pediatric Sleep Apnea Surgery Tonsillectomy/Adenoidectomy

Pediatric Sleep Apnea SurgerySurgical Outcomes

• T&A improves airway stability by reducing the collapsibility (measured by Pcrit)J Appl Physiol 1994;77:918-924.

• T&A improves QOL (sleep disturbance, physical symptoms, emotional symptoms, hyperactivity and daytime functioning)

Laryngoscope 2003;113:1639-1644.Arch Oto Head Neck Surg 2005;131:308-314.

• Pulmonary hypertension has normalized based on echocardiography assessment

Int J Pediatr Otorhinolaryngol 2001;59:41-46.Int J Pediatr Otorhinolaryngol 2000;11:21-26.

• T&A improves school performance

Eur J Paediatr 1996;155:56-62.Pediatrics 1998;102:616-620.

• T&A reduces health care utilization

Pediatrics 2004;113:351-356.


• The cure rate of T&A for OSA is 80% - 401 patientscumulative data from 11 studies

• RDI > 19 was more likely to have Post-op RDI > 5Shen et al. Arch Oto H N Surg 1995;44;51.

• Obese children, positive family history of OSA and African American Children are at high risk for having residual OSA after T&A

Morton S, et al. Sleep 2001;24;823.


• 110 children with OSA underwent T&A• 25% children achieve AHI ≤ 1, 46% AHI <5, 29% had

AHI ≥ 5• Obesity and AHI are the major determinant for outcome

Tauman R, et al. J Pediatr 2006;149:803-808.• 40 SDB children and 30 controls with F/U of 1 year• Serial PSG showed a trend toward increasing AHI w/ time• Velocity of weight gain, obesity and African American are

risk factors for recurrence Amin R, et al. Am J Respir CCM 2008;177:654-659.


• Retrospective review of 400 children treated surgically• Outcomes assessed with PSG 3 mos postoperatively• 68% (251/400) underwent T & A• 14.5% (58/400) had persistent SDB

Guilleminault C, et al. Laryngoscope 2004;114:132.

• Quality of life assessment pre/post T&A with OSA-18• Evaluation at pre-op, within 7 mos and 9-24 mos• Surveys #2 and #3 improved compared to #1• Domains of sleep disturbance and physical suffering were

significantly lower in survey #2 as c/w #3Mitchell RB, et al. Arch Otol 2004;130:409-12.

Pediatric Sleep Apnea SurgeryRecurrence

• 23 pubertal & postpubertal teenagers w/ prior T&A• 5 subjects (all boys) reported snoring, 3 with OSA• Mandibular deficiency/diminished posterior airway seen

with the OSA patientsGuilleminault C, et al. J Pediatrics 1989;114;997.

• 20 subjects followed 12 years after T&A (20 controls)• Increased snoring in the T&A group (50% vs. 20%)• Greater inspiratory effort in the T&A group in PSG• Diminished airway space persists 12 years after T&A

Tasker C, et al. Arch Dis Child 2002;86;34.

Pediatric Sleep Apnea Pediatric Sleep Apnea CPAPCPAP

• Retrospective study - 79 Children (6 mo-18 yr) • 65 (82%) accepted CPAP, (34 took 9-295 days)• 6-12 yr > 13-18 yr > below 6 yr• Mean follow up 207 days (8-979 days)• 50 (mean age 10 yr) had objective data (counter)• 78% had complicating medical disorder• 76% used CPAP at least half the days (≥ 1 hr)• Mean daily use 4.7 hrs

≤ 5 yo ≈ 7.2 hrs, 6-12 yo ≈ 4.2 hrs, 13-18 yo ≈ 3.6 hrs

O’Donnell AR, et al. Sleep 2006;29;651-658.


• Retrospective study - 46 Children (7-19 yr) • Mean age 13.6, mean BMI 39.8 (29 obese, 6 Down)• 27/46 (59%) pts had objective data• Mean follow up 18.1 mo (3 - 43 mo)• 19/27 (70%) compliant (adult criteria)• Parents over estimated usage

≤ 4 hrs ≈ 2 hrs > 4 hrs ≈ 0.5 hrs

Uong EC, et al. Pediatrics 2007;120;e1203-11.


• Prospective study - 29 children (2 - 16 yr) at 3 centers• Randomly assigned CPAP/BiPAP• 8 (28%) dropped out in 6 mos• 21 with objective/subjective data• Mean nightly use 5.3 ± 2.5 hrs• Parents over estimated use (7.6 hrs vs 5.8 hrs)• 78% of parents admitted that CPAP not used nightly• Subjective improvement in daytime sleepiness• High drop out rate/suboptimal use

Marcus CL, et al. Pediatrics 2006;117;e442-51.

Obstructive Sleep Apnea SyndromeNasal Obstruction and OSA

• Nasal obstruction is a risk factor for OSA in childrenUrschitz, et al. Chest 126:790, 2004.Corbo GM, et al. Pediatrics 108:1149, 2001.Anuntaseree W, et al. Pediatr Pulmonl 32:222, 2001.

• Treatment of nasal obstruction improves OSAMansfield LE, et al. Ann Allergy 92:240, 2004.Nixon GM, et al. Am J Respir Med 1:159, 2002.

• Nasal obstructin leads to increased nasal resistance and mouth breathing, which can negatively affect facial growth

McNamara JA. Angle Orthod 50:269, 1981.Harvold EP, et al. Am J Orthod 79:359, 1981.

Pediatric Sleep Apnea• 26 snoring children studied by PSG and 26 controls• 96.2% of OSA children are mouth breathers• Vertical facial growth pattern identified in OSA group• Retroposition and postinclination of the mandible• 69% w/ labial incompetence and 52% w/ crossbite in OSA

group, none in controls• Diminished nasopharyngeal airway (enlarged adenoids) in

OSA groupZucconi M, et al. Eur Respir J 13;411, 1999.

• OSA children have craniofacial abnormalities (increase ant. lower facial height, retrognathic mandible )

Kawashina S, et al. Acta Paediatr 91;71, 2002.

Pediatric Sleep Apnea Maxillary Morphology

• 40 OSA patients and 21 controls• Dental casts, cephalometrics evaluated• 50% of OSA patients vs. 5% of controls with posterior

transverse discrepancies• OSA patients have narrower, more tapered and shorter

maxillary archSeto BH, et al. Eur J Orthod 23;703; 2001.

• 13 patients with Marfan’s (high arch palate) and 13 controls• Maxilla significantly narrower (ICD, IPD, IMD) in Marfan’s group• Nasal resistance abnormal in 12 Marfan’s and 4 controls• 7 in Marfan’s group with OSA, none in controls

Cistulli PA, et al. Chest 110:1184, 1996.

Pediatric Sleep Apnea Airway Evaluation

Nasal Airway & Rapid Maxillary Expansion

• Retrospective review of 10 children (6.5-15.5 y.o ) with h/o nocturnal enuresis who underwent RME

• All patients with nasal obstruction• NE improved, nasal breathing (subjective) improved in all

patients Timms DJ. Angle Orthod 60:229, 1990.

• Prospective study of 10 children (8-13 y.o) with NE• Six patients are mouth breathers, 8 Class II, 1 crossbite• NE improved in 7 patients, nasal resistance improved in all

Kurol J, et al. Angle Orthod 68:225, 1998.

Nasal Airway & Rapid Maxillary Expansion• Retrospective review of 237 patients• 91% improvement (subjective) of nasal breathing

Timms DJ. L Laryngol Otol 98:357, 1984.

• Prospective study of 26 patients (age 10-20) with RME• Nasal resistance evaluated by rhinomanometry • Amount of expansion 5-9 mm (1st molar)• Reduction of resistance in all (mean 36% improvement)• Weak correlation between improvement and expansion

Timms DJ. Br J Orthod 13;221, 1986.

Pediatric Sleep ApneaRapid Maxillary Expansion

• Prospective Study w/ 10 OSA patients (range 19-43 y.o)• All have maxillary constriction w/ dental crowding• 6 patients w/ surgically assisted RME• Mean expansion 12.1 mm at the appliance• 9/10 patients improved (RDI 19 to 7, LSAT 89% to 91%)

Cistulli PA, et al. Sleep 21:831, 1998.

Pediatric Sleep ApneaRapid Maxillary Expansion

• Prospective Study of 31 children with OSA• 19 boys, mean age 8.7 years, mean AHI 12.2 (5.7-21.1yo)• Maxillary constriction, no tonsillar hypertrophy (22 prior T/A)

• 9 Class I, 14 Class II and 8 Class III• RME- mean expansion 4.32 mm• All had increased nasal resistance (26 bi-, 5 unilateral)• AHI < 1 along w/ reduction in nasal resistance

Pirelli P, et al. Sleep 15;761-766, 2004.

• 14 treated children achieved significant reduction of AHI and improvement of symptoms

Villa MP, et al. Sleep Med 8:128-134, 2007.

Pediatric Sleep ApneaOrthopedic effect of RME w/ maxillary processes opening in

a triangular fashion-base at the palatal vaultAm J Orthod Dentofac Orthop 107;268, 1995.

Pre R.M.E Post R.M.E

CT VOLUME RENDERING OF MAXILLA

PRE R.M.E. POST R.M.E.

Orthodontic Widening for Pediatric OSACase Presentation

• 7 year old boy with snoring, daytime fatigue and family history of OSA

• PSG – RDI 6.1 events/ hour– LSAT 95%

• PSG orthodontic widening– RDI 3.2 events/ hour– LSAT 96%

• Improved school performance• Resolution of afternoon

fatigue and irritability

Before After

Obstructive Sleep Apnea Maxillomandibular Expansion by Distraction

MME by Distraction Osteogenesis for OSAGuilleminault and Li. Laryngoscope 114:893, 2004

PatienPatientt

SexSex AgeAge PrePreRDIRDI

PostPostRDIRDI

PrePrePesPes

PostPostPesPes

Pre Pre O2O2

PostPostO2O2

Size Size (mm)(mm)

F/U F/U (mo)(mo)

11 FF 2424 4.34.3 00 --1313 --55 9292 9696 77 1111

22 MM 1818 2.22.2 1.61.6 --1414 --77 8989 9393 1212 252533 MM 99 99 0.70.7 -- -- 8888 9191 77 303044 MM 1818 0.80.8 1.91.9 --3333 --1212 9090 9090 1212 25255566

MMFF

21214343

21.421.441.241.2

8.48.41515

----

----

84848686

86869292

121277

131355

MeanMean 2222 13.213.2 4.54.5 --2020 --88 8888 9191 9.59.5 1818

Maxillomandibular Advancement

Pediatric Sleep Apnea SurgeryPediatric Sleep Apnea Surgery• 18 children (12 boys) – persistent OSA• All non-obese, non-syndromic

– Mean age 14.7 ± 2 (10-17 yr)– Mean RDI 26.7 ± 17.5 (9-65.6)– Mean LSAT 89.8 ± 1.2% (88-91%)– CPAP recommended as initial tx– 10 refused CPAP and 8 failed CPAP– 16 MMA, 2 mandibular advancement

Pediatric Sleep Apnea SurgeryPediatric Sleep Apnea Surgery

Variables Pre-Tx Post-Tx• RDI 26.7 17.5 3.9 3.1 • Lowest SaO2 89.8 1.2 91.8 1.3• No complications encountered• Daytime fatigue and sleepiness improved in

all patients but two patients continue to have residual symptoms

• Follow up 26.7 17.5 months

Pediatric Sleep Apnea SurgeryCase Presentation (1998)

• 16 year old boy with long history of daytime fatigue. Does not remember when he is not tired. Behavior problems and lives with grandparents

• Completed phase I and II ortho treatment, scheduled for debanding in 2 days

• PSG– RDI 65.6 events/hour– LSAT 90%

Pediatric Sleep Apnea SurgeryCase Presentation

Pediatric Sleep Apnea SurgeryCase Presentation (2007)

• 15 year old girl with significant daytime fatigue and tiredness over the past several years.

• Mother: Our orthodontist was able to fix the bite without the need of surgery-7 year treatment.

• PSG– AHI 62 events/ hour– LSAT 84%

• Tried CPAP for 4 months


• 10 year old boy• Long history of daytime

fatigue. • Behavior, social and

school problems • PSG

– RDI 22 events per hour– LSAT 89%

• Struggling with PAP for the past 4 years


Case #1:• PSG: RDI-1, LSAT 94%• Improvement of quality of sleep as well daytime

fatigueCase #2:• PSG: RDI-2, LSAT 92%• Improvement of behavior, social and school issuesCase #3:• PSG: RDI-6, LSAT 92%• Resolution of all symptoms


• Patient #3 -14 years old• Continues to do well• Early facial skeletal

surgery adversely affects growth

• Planning for second mandibular advancement at age 17

ConclusionsConclusions• Significant number of pediatric patients have

continual problems and symptoms following Adenotonsillectomy

• Majority of children are unable to tolerate CPAP• Most children are suboptimally treated with

CPAP therapy• Improvement of nasal airway, skeletal expansion

by orthodontic or surgery provide additional treatment options for patients beyond adenotonsillectomy

kasey k. li, md, dds, facs stanford university sleep ... university sleep medicine program. ......

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