Management of OSA in children. evaluation tools, contraversies , surgeries and challenges in OSA made by Dr Shashidhar Tatavarthy. head of ENT at artemis hospitals

1. Adenotonsillectomy and OSA
the easy and the tough ones
Dr Shashidhar Tatavarthy
Head , department of ENT and Head Neck surgery
Artemis hospitals

2. History of OSA
• 1837 – Dickens – describes
overweight/hypersomnolent boy in the Posthumous
papers of the Pickwick Club (term “pickwickian” used
by Osler)
• W. Hill -1889; “ The stupid -lazy child who frequently
suffers from headaches at school, breathes through
his mouth instead of his nose, snores and restless at
night and wakes up with a dry mouth in the morning
is well worthy of the solicitous attention of the Scholl
medical officer.”
1973-Guilleminault – opened the flood gates by T&A

3. Epidemiology
• Most studies showed 4% to 11% prevalence of parent-reported apnea.
• The prevalence of OSA among Indian children in on study 9.6% (95% CI: 8.1%-
11.7%) 1
• Depending on threshold of AHI to diagnose, the prevalence of
Pediatric OSA ranges from 1% to 4% in most studies.
• ( AHI> 2014 ) earlier studies – AHI>2 or AHI >5
• Overall prevalence of snoring in pediatric patient population has been
mentioned from 8 to 36 %.
Association of pediatric obstructive sleep apnea with poor academic performance: A school-based study from India Abhishek Goyal, Abhijit Pakhare, Girish Bhatt, Bharat Choudhary
and Rajesh Patil Lung India. 35.2

4. OSA symptoms
during night
• Symptoms vary by age-especially in
infants!
• Snoring-Volume does not correlate with
the degree of obstruction
• Observed apneic pauses
• Snorting / gasping / choking
• Restless sleep
• Diaphoresis
• Paradoxical chest wall movement
• Abnormal sleeping position
• Sweating
• Mouth Breathing
• Secondary enuresis
• Night terrors

5. Day time problems and comorbidities
Morning headaches
Difficulty awakening
in AM
Hyponasal Speech
Nasal congestion,
Chronic Rhinorhea
and sinusitis
Mouth breathing,
Dry Mouth
Frequent infections
of ears , decreased
hearing and dull
look
Difficulty
swallowing and
worsening of GERD
Poor appetite
Daytime
somnolence-7-10%
Mood changes
Internalizing
behaviors
Externalizing
behaviors
ADHD like
symptoms, School
problems

6. OSA with adeno tonsillar hypertrophy
effect on other diseases..
Worsening GERD
1
Increase in seizure
frequency in
predisposed children
2
Other CO-Morbid Sleep
problems
•-RLS,PLMS
•--Bedtime resistance ,
nightwakings
•Circadian problems
3
Worsening of IG A
nephropathy
4
New onset Asthma or
atopic disease
5
Dystonias and periodic
fever , apthous
stomatitis
6

7. Metabolic consequences
endothelial dysfunction, which is
characterized by reduced vasodilation,
enhanced vasoconstriction and
chronic inflammatory and
prothrombotic activity, contributing to
the development of atherosclerosis
and cardiovascular disorders-
early hypertension..
Reduced effectiveness of leptin, or
leptin resistance, secondary to obesity
contributes to a weakened ventilatory
response. Leptin acts as a respiratory
stimulant in collaboration with both
central and peripheral
chemoreceptors – may worsen obesity
Increase glucose intolerance and
insulin resistance -
type 2 DM higher – Odds ratio 2.1

8. Neurobehavioral
Consequences
• Deficits in learning, memory ,
vocabulary
• IQ loss of 5 points or more
• Apneic events inversely related
to memory and learning
performance
• Treatment of OSA likely improves
behavior, attention, quality of
life, neurocognitive functioning.
( not always as per meta analysis
– Chat trial)

9. AAP guidelines 2012
(1) All children/adolescents should be screened for snoring.
(2) Polysomnography should be performed in children/adolescents
with snoring and symptoms/signs of OSAS;
(3) Adenotonsillectomy is recommended as the first-line treatment of
patients with adenotonsillar hypertrophy.
(4) High-risk patients should be monitored as inpatients postoperatively.
(5) Re evaluate after surgery
(6) CPAP only if adenotonsillectomy is not performed or if OSAS persists
postoperatively.
(7) Weight loss is recommended in addition to other therapy in patients
who are overweight or obese.
(8) Intranasal corticosteroids are an option for children with mild OSAS in
whom adenotonsillectomy is contraindicated or for mild postoperative
OSAS.
Pediatrics 2012;130:576–584

10. Tools for
screening
OSAS and
outcomes

11. Tools for
screening
OSA
OSA- 18

12. Diagnostic
modalities

13. Tongue base and lingual hypertrophy

14. Turbinate hypertrophy , tubal tonsils

15. Obese kids- Prader willi sequence

16. MPS – challenges

17. Cerebral palsy

18. Mobeius syndrome and melkerson Rosenthal

19. Achondroplasia

20. Morbid obesity

21. Nasal adenoids

22. Downs syndrome- macroglossia

23. Infective and Obstructive tonsils

24. Central sleep apnea- phox 2b gene

25. PSG

26. Procedure adenoidectomy

27. Potential complications

28. Adenoidectomy with debrider

29. Tonsillectomy – cold steel versus powered

30. Airway surprises – do MLB when dise normal

31. Dise assessment

32. Dise
OSAS persists in one third
of children treated with
T&A and 20% of pediatric
OSA may not have
adenotonsillar
hypertrophy
M. Friedman, M. Wilson, H.C. Lin, et al., Updated
systematic review of tonsillectomy and adenoidectomy
for treatment of pediatric obstructive sleep apnea/
hypopnea syndrome, Otolaryngol. Head Neck Surg. 140
(2009) 800–808

33. Our experience
• Total of 570 Adenoidectomy and tonsillectomies
(combined or either ) in last 5 years.
• All bipolar tonsillectomies –
• 320 – coblation adenoids and 120 with debrider
• Revision adenoid surgery – 9 (2 ours and 7
outside)
• Obstructive indications 425 – snoring , mouth
breathing and nose block.
• Adjunctive procedures-
• Turbinoplasty- 45
• Septoplasty – 15
• Supraglottoplasty- 6
• Palatoplasty -14
• FESS - 16

34. Serious Complications
• Neck pain – 6, 1/6 managed by neck collar for 4 weeks
• Tonsillar haemorrhage requiring re exploration -2
• Transient quadriparesis -1
• Major vessel bleed – requiring intervention or carotid ligation =0
• Post surgery cpap use or ventilation – 2
• Mortality – none

35. Risk Factors for
Postoperative Respiratory
Complications in Children
with OSAS undergoing
Adenotonsillectomy
– Age Younger than 3 years
– Severe OSAS on PSG, AHI>10
– Pulmonary hypertension
– Congenital heart disease
– Failure to Thrive
– Prematurity, CLD.
– Recent URI
– Morbid Obesity
– Trisomy 21
– Craniofacial abnormalities
– Neuromuscular disorders, Cerebral
Palsy
– Asthma
– Seizures

36. What else if adeno
tonsillectomy is not adequate
• Any child with AHI> 5 intervention is necessary.
• Less of a consensus regarding AHI 1-5.
• Surgical
• Adenotonsillectomy – First Line of therapy
• Turbinate reduction and/ or septoplasty
• Palatoplasty – anterior /zeta modified /
expansion
• Tongue base reduction
• Midline glossectomy
• Craniofacial surgery-
Mandibular advancement/ Maxillary
distraction.
• Lingual Tonsillectomy/ Epiglottopexy
• Hyoid Suspension
• Tracheostomy

37. Non surgical
treatment
• Intranasal steroids and montelukast
provide a less invasive treatment than
surgery or CPAP . Suitable for mild to
moderate OSA 1
• Weight loss
• Mandibular appliances
• Cpap – best compliance- 41% , institute -
71%. 2.1 hours average use.
1.Kheirandish-Gozal L, Bhattacharjee R, Bandla HP, Gozal D. Antiinflammatory therapy outcomes for mild OSA in children. Chest.
2014;146:88–95

38. CPAP
• Almost always an alternative to surgery
• Surgical failure
• Morbid Obesity
• Complex OSA
• Non-Surgical candidates
• FDA approved for children > 30 kg

39. Benefits of surgery and treatment
 Efficacy
 AHI
 Quality of life
 Cognition
Pediatric Sleep Questionnaire
IQ Test
 Cardiovascular Parameters
Cerebral blood flow
Hemoglobin Saturation
Pulse Rate
Pulse variability
 School performance
Significant improvement in grades from 1st to 2nd grade in cohort that underwent adenotonsillectomy.
No significant change in control group and group that chose not to have adenotonsillectomy..
 Enuresis/Incontinence
Children with OSA have increased risk for enuresis.
Possibly related to increased levels of BNP?
Significant decrease in nocturnal enuresis and voids/day after adenotonsillectomy.

40. Unanswered questions and hot topics of
research in peds OSA.
• Best screening tool and who should get a PSG
• End organ markers – which can predict the morbidity and mortality
of OSA in children
• Criteria for defining success of medical and surgical treatment in
OSA.
• which children are most likely to benefit from pharmacologic
treatments either before, in combination with, or in lieu of surgery.

41. Conclusion
• All snoring kids are potential OSA and evaluate them
• Assessment with Dise , CT scan , MRI and PSG offer more insights in
treatment
• Adenotonsillectomy is the gold standard of treatment and assess if it
may be suboptimal and plan accordingly.
• Surgical failure and need for further treatment should be evaluated

42. Thank you for
your patience
tbshashi@gmail.com
ph: 9810669116