OSA in Children
An ENTs Perspective
Haidy Marzouk, MD
Assistant Professor
Department of Otolaryngology
SUNY Upstate Medical Center
FINANCIAL DISCLOSURES
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None
OTHER DISCLOSURES
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Worried parents and tough questions make us
better
OUTLINE
Do we really have to do this?
 Will he/she behave better?
 Will he/she lose weight?
 How is the recovery like?
 What are the risks?
 Is tonsillectomy and adenoidectomy all you can
offer?
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DO WE REALLY HAVE TO DO
THIS?
INTRODUCTION
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Long term affects of sleep apnea include:
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T&A can improve – BP, inflammatory markers, and
correlation with reduction in asthma symptoms
shown
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pulmonary and cardiovascular changes
Failure to thrive in some
Impaired cognition, focus, behavioral disturbance
Increased inflammatory markers in the body
Abnormal bite
Impaired quality of life
Those who have preop PSG – 38% severe
BP and inflammatory markers don’t improve as much in
obese children
Won’t it affect his immune system??
Well can’t he/she just grow out of it?? It’s just mild…
It’s just mild Apnea
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Research has demonstrated poor correlation between
AHI and QOL
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Neither obstructive AHI or REM AHI correlates with
OSA-18 scores
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Exception is oxygen saturation
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Prospective study
Other PSG parameters don’t reflect burden on QOL in
children
Baldassari CM, Alam L, Vigilar M, Benke J, Martin C, Ishman S.
Otolaryngol Head Neck Surg. 2014 Oct;151(4):687-91
Baldassari CM, Alam L, Vigilar M, Benke J, Martin C, Ishman S.
Otolaryngol Head Neck Surg. 2014 Oct;151(4):687-91
It’s Just Mild Apnea
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For mild apnea specifically, T&A better than
watchful waiting
Studied retrospectively
 T&A group mean reduction in AHI from 3.5 to 2.69
 Observation group worsened from 3.09 to 5.18
 Average time for post op PSG 10 months
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Exception – obese children had no difference
between groups
 What’s mild?
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In this study, considered AHI between 1 and 5
What’s cure?
Trosman SJ, Eleff DJ, Krishna J, Anne S. Int J Pediatr Otorhinolaryngol.
2016 Apr;83:25-30
WILL HE/SHE GROW OUT OF IT ?
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Randomized control studies of children ages 5-9
PSG findings, QOL, neurocognitive functioning,
attention/executive function, behavior studied over 7
months
Groups early T&A vs. watchful waiting
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QOL and PSG findings?
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Kids did better in T&A group over time
Normalization of AHI - 79% vs. 46%, P<0.001
Some data shows watchful waiting kids who are younger
get worse over time
Marcus CL, etal. ; Childhood Adenotonsillectomy Trial (CHAT).N Engl J Med. 2013
Jun 20;368(25):2366-76
Garetz SL, Mitchell RB, Parker PD, Moore RH, Rosen CL, Giordani B, Muzumdar H,
Paruthi S, Elden L, Willging P, Beebe DW, Marcus CL, Chervin RD, Redline S.
Pediatrics. 2015 Feb;135(2):e477-86
BUT HIS/HER TONSILS ARE SMALL?!
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Retrospective and case control studies– no correlation
between tonsil size and OSA severity
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Kids with bigger tonsils had greater proportion of
resolution after surgery
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All sizes benefitted from surgery
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Tang A, Benke JR, Cohen AP, Ishman SL. Otolaryngol Head Neck Surg. 2015
Aug;153(2):281-5
Hwang SH1, Guilleminault C, Park CS, Kim TW, Hong SC. Otolaryngol Head
Neck Surg. 2013 Aug;149(2):326-34
WHAT ABOUT THE CENTRAL APNEAS?
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Children with OSA and mild CSA on preoperative PSG
showed significant improvement in CAI following
adenotonsillectomy
 73.3% resolution
CO2 retention and elevation?
Otolaryngology– Head and Neck Surgery 146(3) 487–490 Changes in
Central Apnea Index following Pediatric Adenotonsillectomy
CENTRAL APNEA
Improvement in Down’s Syndrome patients as well
Otolaryngology–Head and Neck Surgery2015, Vol. 153(4) 644–648
WILL HE/SHE BEHAVE BETTER?
CHAT STUDY 2013 NEJM
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464 children ages 5 to 9 randomly assigned to early
T&A versus watchful waiting
Studied at baseline and 7 months later
Developmental Neuropsychological Assessment – no
difference
Significantly greater improvements in overall
behavioral and QOL measures
Previous studies found benefits maintained longer
term (2.4-3.6 years)
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Change not as great over time, but still significant
N Engl J Med. 2013 June 20; 368(25): 2366–2376
Chung S, Hodges EK, Ruzicka DL, Hoban TF, Garetz SL, Guire KE,
Felt BT, Dillon JE, Chervin RD, Giordani B. Int J Pediatr
Otorhinolaryngol. 2016 Jan;80:21-5
NEUROCOGNITION
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2016 meta-analysis on patients ages 2.5-14
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Improved neurocognitive function and IQ
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Case controlled
Some of the studies conflicted
Correlated to AHI improvement
Especially with preschool children
 Neuroplasticity
Song SA, Tolisano AM, Cable BB, Camacho M. Int J Pediatr
Otorhinolaryngol. 2016 Apr;83:205-10
Compared low IQ versus high IQ children
 Both have the same improvement
 Findings independent of BMI
Chung S, Hodges EK, Ruzicka DL, Hoban TF, Garetz SL,
Guire KE, Felt BT, Dillon JE, Chervin RD, Giordani B.
Int J Pediatr Otorhinolaryngol. 2016 Jan;80:21-5
OSA AND DEPRESSION
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2013 meta-analysis
11 studies
 n=894
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Medium relationship between OSA and
depressive symptoms
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Independent of BMI
Medium improvement in symptoms after T&A
 Recommendation that children with depression
get screened for SDB
 In both primary snoring and OSA symptoms
were similarly elevated
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ADHD AND OSA
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Systematic review and meta-analysis
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Case controlled analysis
n=1113 in treatment group, n=1405 in watchful waiting
 Mean age 8 years old
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Medium relationship between OSA and ADHD
symptoms
 Medium relationship effect with T&A
 13 month follow up
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Sedky K, BeAmiri S, AbdollahiFakhim S, Lotfi A, Bayazian G,
Sohrabpour M, Hemmatjoo T. Int J Pediatr Otorhinolaryngol.
2015 Aug;79(8):1213-7
Bennett DS, Carvalho KS. Sleep Med Rev. 2014 Aug;18(4):349-56
WHAT ABOUT HIS/HER WEIGHT?
WEIGHT GAIN OR LOSS
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Children usually GAIN weight greater than
expected after T&A compared to watch and wait
group
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Contrary to previous thinking
When compared to kids without apnea…
Obese kids tend to gain more weight compared to
their obese peers
 Normal weight kids don’t tend to gain more in one
study
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Children of all categories of baseline weight
 Children of all severities of apnea
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Katz ES, Moore RH, Rosen CL, Mitchell RB, Amin R, Arens R, Muzumdar
H, Chervin RD, Marcus CL, Paruthi S, Willging P, Redline S. Pediatrics.
2014 Aug;134(2):282-9
THEORIES
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Decreased work of breathing at night creates less
calorie burning
They’re less hyperactive and burning less calories
It’s easier to eat without large tonsils and
appetite increases
SHOULD OBESE CHILDREN GET T&A?
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Chance of cure less
~26% for AHI <1.5
 ~50% for AHI <5
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Still a significant AHI reduction even in severely
obese children
 MRI findings of obese kids after T&A shown to
have tendency for residual NP fullness
 However, these children are at risk for further
weight gain, which can influence OSA as well
 Is it worth it to operate for mild apnea??
 Still not enough evidence to not treat with T&A
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HOW IS THE RECOVERY?
WHAT ARE THE RISKS?
RECOVERY/RISKS
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My part is the easy part
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9% risk of respiratory compromise
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Increased risk with: severity of OSA, low body
weight, young age
2-4% risk of bleeding – lasts for 2 weeks
 Dehydration
 PAIN
 Recovery period about 2 weeks
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De Luca Canto G, Pachêco-Pereira C, Aydinoz S, Bhattacharjee R,
Tan HL, Kheirandish-Gozal L, Flores-Mir C, Gozal D. Pediatrics.
2015 Oct;136(4):702-18
PARTIAL INTRACAPSULAR
TONSILLECTOMY (PITA)
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Tonsil “debulking” leaving a small amount of tonsil
behind
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Biological dressing
Efficacy equivalent with regards to OSA
Less pain
Less risk of dehydration
Faster return to diet and activity
Less risk of bleeding
Shorter admissions (less cost?)
Risk of regrowth - ~3.5%
Risk of recurrent tonsillitis equivalent to nontonsillectomy group
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Acevedo JL, Shah RK, Brietzke SE. Otolaryngol Head Neck
Surg. 2012 Jun;146(6):871-9
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Ericsson E, Graf J, Lundeborg-Hammarstrom I, Hultcrantz E. J
Otolaryngol Head Neck Surg. 2014 Jul 27;43(1):26
IS TONSILLECTOMY THE ONLY
INTERVENTION? WHAT ABOUT
THE NOSE?
NASAL OBSTRUCTION AND SLEEP
Nasal obstruction, irrespective of cause
contributes to sleep quality of life
 Allergic rhinitis is a risk factor for OSA and
decreases long term QOL after T&A
 Receptors present in the nasopharynx to control
muscle tone in upper airway
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Muscle tone higher with nasal breathing during sleep
Obese children have higher anterior nasal
resistance
 The most accurate way to diagnose nasal
obstruction severity in correlation with
symptoms is through nasal endoscopy
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Alkhalil M1, Lockey R. Ann Allergy Asthma Immunol. 2011
Aug;107(2):104-9
TREATMENT OF NASAL OBSTRUCTION
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Mometasone
Improves snoring
 Improves scores on OSA 18
 Shrinks adenoids with 4 week trials
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Inferior turbinate reduction
Improves nocturnal breathing
 When appropriate and performed with T&A, creates
further improvement than T&A alone
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Diagnose and treat obstruction and don’t assume
adenoidectomy alone is sufficient
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Chohan A, Lal A, Chohan K, Chakravarti A, Gomber S. Int J Pediatr
Otorhinolaryngol. 2015 Oct;79(10):1599-608
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Jung et al. Clin Exp Otorhinolaryngol. 2011 Mar;4(1):27-32
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Cheng PW, Fang KM, Su HW, Huang TW. Laryngoscope. 2012
Dec;122(12):2850-4
CONCLUSIONS
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Adenotonsillectomy remains a first line and
effective treatment for pediatric sleep apnea
Partial Intracapsular tonsillectomy has become a
valid option for treatment of pediatric OSA
Considerations and appropriate counseling must
be given to the obese pediatric patient with
regards to surgery
Nasal obstruction must be part of the treatment
plan for OSA
THANK YOU
OTHER SOURCES
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
Mangiardi J, Graw-Panzer KD, Weedon J, Regis T, Lee H, Goldstein NA. Int J
Pediatr Otorhinolaryngol. 2010 Dec;74(12):1361-6
Odhagen E, Sunnergren O, Hemlin C, Hessén Söderman AC, Ericsson E, Stalfors J. Eur Arch
Otorhinolaryngol. 2016 Jan 4
Stucken EZ1, Grunstein E, Haddad J Jr, Modi VK, Waldman EH, Ward RF,
Stewart MG, April MM. Laryngoscope. 2013 Nov;123(11):2868-72
Mostovych N, Holmes L, Ruszkay N, LaHurd A, Heinle R, Nardone H. JAMA
Otolaryngol Head Neck Surg. 2016 Feb 1;142(2):150-6
Vicini C, Eesa M, Hendawy E, Pari M, D'Agostino G, AlGhamdi S, Meccariello G.
Int J Pediatr Otorhinolaryngol. 2015 Jul;79(7):1106-10
Mukhatiyar P, Nandalike K, Cohen HW, Sin S, Gangar M, Bent JP, Arens R.
JAMA Otolaryngol Head Neck Surg. 2016 Jan 1;142(1):25-31
Duarte VM1, Liu YF, Shapiro NL. Laryngoscope. 2014 Aug;124(8):1959-64
Lee CH, Hsu WC, Chang WH, Lin MT, Kang KT.
Clin Otolaryngol. 2015 Oct 5
Van M1, Khan I1, Hussain SS1. J Laryngol Otol. 2016 Mar;130(3):214-8.
Burstein DH1, Jackson A, Weedon J, Graw-Panzer KD, Fahmy S, Goldstein NA.
Int J Pediatr Otorhinolaryngol. 2013 Apr;77(4):525-9
Jeyakumar A, Fettman N, Armbrecht ES, Mitchell R. Otolaryngol Head Neck
Surg. 2011 Feb;144(2):154-8
Com G, Carroll JL, Tang X, Melguizo MS, Bower C, Jambhekar S. J Clin Sleep
Med. 2015 Apr 15;11(4):467-74
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
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
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Levi J, Leoniak S, Schmidt R. Arch Otolaryngol Head Neck Surg. 2012 Oct;138(10):897-901
Lewis TL, Johnson RF, Choi J, Mitchell RB. Otolaryngol Head Neck Surg. 2015
Apr;152(4):734-9
Nandalike et al. Sleep. 2013 Jun 1;36(6):841-7
Mitchell R, Boss E. Sleep. Dev Neuropsychol. 2009;34(5):650-61
Segal S, Eviatar E, Berenholz L, Kessler A, Shlamkovitch N.Am J Rhinol. 2003 MarApr;17(2):69-73
Isaac A, Major M, Witmans M, Alrajhi Y, Flores-Mir C, Major P, Alsufyani N, Korayem M,
El-Hakim H. JAMA Otolaryngol Head Neck Surg. 2015 Jun;141(6):550-5
Cheng PW, Fang KM, Su HW, Huang TW. Laryngoscope. 2012 Dec;122(12):2850-4
Alkhalil M1, Lockey R. Ann Allergy Asthma Immunol. 2011 Aug;107(2):104Sin S1, Wootton DM, McDonough JM, Nandalike K, Arens R. Laryngoscope. 2014
Nov;124(11):2640-4
Kim DK1, Han DH2. Int Forum Allergy Rhinol. 2015 Aug;5(8):741-6
Otolaryngology–Head and Neck Surgery146(6) 871–879
Otolaryngology–Head and Neck Surgery147(3) 538–543
Otolaryngology–Head and Neck Surgery 2015, Vol. 152(5) 931–940
Elisabeth Ericsson a,b,*, Inger Lundeborg c, Elisabeth Hultcrantz International Journal of
Pediatric Otorhinolaryngology 73 (2009) 1254–1262