Adult and Pediatric
Obstructive Sleep Apnea
Prof. Dr. Jehad Al-Baba
Chief of E.N.T Department
Everyone has brief pause in his or her breathing
pattern called Apnea , the word comes from
the Greek word meaning
“Without
Breathing”
{Respiratory pause that exceeds 3 standard
deviation of the mean breath time for an
infant or a child at any particular age}
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There are three types of Apnea:
 - Obstructive,
 - Central,
 - Mixed.
Cont. Apnea
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Obstructive apnea – cessation of airflow for
at least 10 seconds with respiratory effort
Central apnea – cessation of airflow for at
least 10 seconds without respiratory effort
Mixed apnea – characteristics of both for at
least 10 seconds
Hypopnea – hypoventilation secondary to
partial obstruction
Disorder Of breathing during sleep
characterized by prolonged partial upper
airway obstruction and /or intermittent
complete obstruction (obstructive apnea)
that disrupts normal ventilation during
sleep and normal sleep patterns.
Obstructive Sleep Apnea
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85% of adult patients are male.
Men 4%, Female 2%.
2/3rd obese.
Contributes to HTN and cardiovascular
disease.
Increased motor vehicle accidents.
Pathophysiology
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Pharyngeal collapse
Decreased airway patency
Increase in negative pressure
Becomes a vicious cycle.
Symptoms
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Snoring*
Excessive daytime sleepiness*
Restless sleep
Personality changes
Headaches
Sexual dysfunction
Job performance
Sleep hygiene
Bed partner’s input *
Physical Exam
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Vital signs
Head & Neck exam
Flexible endoscopy
Vital signs
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Height
Weight
Collar size
Blood pressure
Calculate BMI
Wt (kg) / Ht (meters) squared
 Men >27.8, Women >27.3
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Examination
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Tongue
Palate
Uvula
Tonsils
Nasal cavity
Hyoid
Mandible
Maxilla
Cephalometrics
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Standardized lateral radiographs
Examines bony and soft-tissue structure
Two-dimensional evaluation
Lack of volumetric data
Maxillomandibular surgery, oral appliances
Polysomnogram
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EEG
EKG
Submental EMG
Anterior tibialis
EMG
EOG
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Nasal/oral airflow
Pulse oximetry
Respiratory
movement
Sleeping position
Esophageal
manometry
Treatment
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Nonsurgical modalities
Surgical modalities
Nonsurgical Treatment
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Weight loss
Sleep hygiene
Pharmacotherapy
Nasal continuous positive airway pressure
Oral appliances
Nonsurgical Treatment
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Weight loss
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Get below “trigger weight”
Diet, exercise, bariatric surgery, medications
Sleep hygiene
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Avoidance of sedatives
Positional changes
Pharmacotherapy
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Protriptyline – decreases REM sleep
Xanthine based drugs
Steroids
Antibiotics
Nasal medications
CPAP
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Titrated to limit all respiratory events
50-90% acceptance – better if daytime
symptoms improved
Side effects in 40-50%
Oral appliances
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Advances the mandible
Retains the tongue anteriorly
UPPP
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Fujita (1981)
Most common procedure
1st line tx for retropalatal collapse
10-50% success.
Mandibular Osteotomy with
Genioglossus Advancement
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Enlarges the retrolingual airway without
disturbing dentition
Prevents retrolingual collapse
Tongue reduction
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Lingual tonsillectomy
Laser midline glossectomy
Lingualplasty
Radiofrequency volumetric tissue reduction
Nasal surgery
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Improved symptoms and CPAP
 Septoplasty
 Turbinate reduction
 Functional nasal reconstruction
Tracheostomy
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Bypasses all areas of obstruction
Virtually 100% effective
Two indications
 Temporary procedure during airway
reconstruction
 Severe OSA when CPAP refused,
ineffective, or not tolerated or if other
conditions exacerbated by the apneas
Line the tract with skin flaps
Lack of social acceptance
Apnea in Childhood
 OSA result from:
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Adenotonsillar hypertrophy.
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Neuromuscular diseases.
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Craniofacial abnormalities .
 True OSA result in:
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Neurocognitive impairment.
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Behavioral problems.
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Failure to thrive.
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Cor pulmonal , particularly
in sever cases.
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Enuresis.
OSA Presented with the following
symptoms
Habitual (nightly) snoring.
 Disturbed sleep .
 Daytime neurobehavioral problems.
 Daytime sleepness may occur but is
uncommon in young children.
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 Anatomic factors :
That narrow the upper airway.
Adenotonsillar hypertrophy.
 Trisomy 21(down syndrome) .
 Other genetic or craniofacial syndromes.
associated with
 (Midface hypoplasia, Small nasopharynx,
Choanal atresia or stenosis, Macroglossia,
Micrognathia or retrognathia and cleft
palate).
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 Anatomic factors :
 Obesity.
 Nasal obstruction.
 Laryngomalacia.
 Sickle cell disease.
 Velopharyngeal flap repair
Neurologic factors :
That decreased pharyngeal muscular dilator
activity.
Medications.
 Sedative.
 General anaesthesia.
Brain stem disorders.
 Chiari-malformation.
 Birth asphyxia.
Neuromuscular diseases.
 Muscular dystrophy.
 Cerebral palsy.
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OSA occurs in children of all ages from
neonates to adolescents.
It is thought to be most common in preschoolage children (which is the age when the tonsils
and adenoids are the largest in relation to the
underlying airway size).
Occurs equally among boys and girls.
The estimated prevalence of snoring in
children is 3 to 12 %.
OSA affect 1 to 10 %.
Sedation
anesthesia
Muscle
Weakness
Sleep onset
Decreased upper airway
muscle activity
Decreased CO2
Increased O2
Upper airway narrowing
Relief of obstruction
Restoration of airflow
Obstructive,Hypoventilation
&Apnea
Increased upper airway
muscle activity
Hypoxemia
Hypercapnia
Arousal from
sleep
Obesity
Small
Airway
Enlarged tonsil
& Adenoids
Craniofacial
anomalies
Increased ventilatory effort
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To identify patients who are at risk for
adverse outcomes.
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Avoid unnecessary intervention in
patients who are not at risk for adverse
outcomes.
Evaluate which patients are at increased
risk of complications resulting from
adenotonsillectomy, so that appropriate
precaution can be taken.
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HISTORY
 In children younger than five years.
Snoring is the most common complaint.
Symptoms reported by parents:
 Mouth breathing
 Diaphoresis
 Paradoxicrib-cage movements
 Restlessness
 Frequent awakenings
α In children five years and older.
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Enuresis
Behavior problems
Deficient attention span
Failure to thrive
In addition to snoring
α Compared with adult.
α Fewer children with OSA report excessive
daytime somnolence, with the exception of
obese children.
 In extreme cases of OSA in children.
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Cor pulmonal and Pulmonary hypertension
may be the presenting problems.
 Poor growth and FTT are more common in
children with sleep-disordered breathing.
Growth velocity increases after
adenotonsillectomy
 Decreased production of growth hormone
during fragmented sleep may contribute
further to poor growth.
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Obstructive Sleep Apnea Screening Quiz
Do your children have any of the following symptoms that can
be associated with sleep apnea?
continuous loud snoring
episodes of not breathing at night (apnea)
failure to thrive (weight loss or poor weight gain)
mouth breathing
enlarged tonsils and adenoids
problems sleeping and restless sleep
excessive daytime sleepiness
morning headaches
daytime cognitive and behavior problems, including
problems paying attention, aggressive behavior and
hyperactivity, which can lead to problems at school
Evaluation of the childs general apperance,with careful attention
to craniofacial characteristics, such as:
α Midface hypoplasia
α Micrognathia
Evaluation for nasal obstruction depends on the child's age.
α Septal deviation
α Naso-lacrimal cysts
α Choanal atresia
α Nasal aperture stenosis Must be considered in infants
2-Lateral neck radiography.
fig 2
Arrows indicate
prominent adenoidal
tissue in the posterior
nasopharynx, resulting
in upper airway
narrowing
WHAT
ABOUT
MANAGMENT
MEDICAL
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CPAP
Antibiotics
Weight loss
Nasal steroids
Systemic steroids
SURGICAL
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Adenotonsillectomy
Uvulopalatopharyngoplast
y
Tracheotomy
OSA is more common in children with craniofacial
syndromes.
1-Children who have syndromes with
craniosynostosis:
-Apert's syndrome,
-Crouzon's disease,
-Pfeiffer's syndrome,
-Saether-Chotzen syndrome,
-abnormalities of the skull base,
-Accompanying maxillary hypoplasia,
May have nasopharyngeal obstruction
2-Children with syndromes that involve
micrognathia:
-Treacher collins syndrome,
-Pierre Robin syndrome,
-Goldenhar's syndrome,
Become obstructed at the hypo pharyngeal level
3-Children with Trisomy 21 :
A narrow upper airway combined with Macroglossia
and hypotonic musculature predispose them to
OSA
The surgical management of craniofacial
syndromes and OSA in children frequently
requires
more
than
standard
adenotonsillectomy.
In children with midfacial hypoplasia,
craniofacial advancement may be indicated.
Glossopexy, mandibular distraction or
advancement, or tongue suspension should
be considered in patients with micrognathia