Tomasz Lis, *Lidia Zawadzka-Głos
Treatment and management of a child with obstructive sleep apnea: an overview
Leczenie i postępowanie z dzieckiem z obturacyjnym bezdechem sennym: przegląd
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Obturacyjny bezdech senny (OBS) jest częstym schorzeniem u dzieci charakteryzującym się nawracającymi epizodami obturacji górnych dróg oddechowych w trakcie snu. Może to prowadzić do wielu negatywnych konsekwencji zdrowotnych dotykających układu sercowo-naczyniowego, poznawczego i metabolicznego. Dziecko ze zdiagnozowanym OBS powinno jak najszybciej otrzymać odpowiednie leczenie aby zapobiec poważnym negatywnym skutkom zdrowotnym. W tym artykule przeglądowym omawiamy dostępne zabiegowe i niezabiegowe metody leczenia OBS i kiedy ich użyć. Chirurgicznym leczeniem pierwszego rzutu pozostaje adenotonsillektomia, następuje jednak szybki rozwój innych metod w zależności od poziomu obturacji górnych dróg oddechowych. Postępowanie zachowawcze jest oparte na użyciu leków przeciwzapalnych (takich jak sterydy donosowe i lek wpływający na leukotrieny montelukast), dodatniego ciśnienia w drogach oddechowych, leczeniu ortodontycznym (włączając szybkie poszerzanie szczęki i aparaty wysuwające żuchwę) jak rózwież inne leczenie wspomagające. Obecne i nowe chirurgiczne i niechirurgiczne metody leczenia są ciągle rozwijane i mogą być użyte szczególnie u złożonych pacjentów z wielopoziomową obturacją oraz tych z przetrwałym OBS.
Summary
Obstructive sleep apnea (OSA) is a common disorder in children characterized by recurrent episodes of upper airway obstruction while asleep. It can lead to many adverse health consequences affecting cardiovascular, neurocognitive and metabolic systems. Child with diagnosis of OSA should receive an appropriate management without delay to prevent serious negative health consequences. In this review article we discuss available surgical and non-surgical OSA treatment modalities and when to use them. First-line surgical treatment remains adenotonsillotomy, yet other surgical techniques are beeing introduced, depending on the level of airway obstruction. Non-surgical approach is based on using anti-inflammatory medications (such as intranasal corticosteroids and leukotriene modifier montelukast), positive airway therapy, orthodontics (including rapid maxillary expansion and mandibular advancement devices) as well as other adjucant therapies. Current and new surgical and non-surgical treatment modalities are still beeing developed and may be used to treat especially complex patients with multi-level obstruction or these with persitent OSA.
Introduction
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete and/or partial upper airway obstruction which results in abnormal ventilation. OSA in children is associated with behavioral, neurocognitive and academic consequences (1, 2) as well as metabolic (3) and cardiovascular derangements (3, 4). It is assumed universally that each mentioned condition should benefit from adequate treatment of OSA, even though in many cases there is a lack of randomized controlled trials providing compelling proof of it. In previous study (5) we focused on diagnosis and evaluation of a child suspected for OSA. The aim of this particular study was to present different approaches of treating OSA in children, depending on the cause of it.
Management
Management of a child with OSA may be surgical or non-surgical. Depending on OSA severity and pre-existing risk factors, each child suffering from OSA, especially persistent one, should be treated using an individualized strategy.
Surgical management
Adenoidectomy and tonsillectomy/tonsillotomy
The traditional first-line treatment of OSA has been adenotonsillectomy (T&A) – surgical removal of the tonsils and adenoid. Partial tonsillectomy, or tonsillotomy is a more limited procedure in which the majority of tonsillar tissue is removed but the tonsillar capsule remains in place. This intracapsular procedure has fewer complication rates compared to standard tonsillectomy (6). However it exhibits a much higher risk of OSA recurrence since it carries a risk of tonsillar regrowth especially in younger children (7). There are many surgical techniques of tonsils removal, but according to American Academy of Pediatrics guidelines, the current data is insufficient to recommend one surgical technique over the other (8). Risk factors of persistent OSA after T&A include age > 7, severe disease, asthma, and obesity (9).
Fig. 1. Intracapsular tonsillectomy
Other surgical techniques
Surgical procedures beyond T&A are typically reserved for children with multi-level obstruction or these with residual OSA after T&A. Potential causes of airway obstruction at a certain level with a designated procedure, are presented in table 1.
Tab. 1. Surgeries considered for OSA patient by level of obstruction (based on (13))
| Source | Procedure |
| Nasal cavity | |
| Septal deviation | Septoplasty |
| Enlarged turbinates | Turbinate reduction |
| Nasopharynx | |
| Adenoid hypertrophy | Adenoidectomy |
| Maxillary hypoplasia | Maxillary advancement |
| Oropharynx | |
| Tonsillar hypertrophy | Tonsillectomy/tonsillotomy |
| Soft palate redundancy | Uvulopalatopharyngoplasty |
| Tongue | |
| Lingual hyperthropy | Lingual tonsillectomy |
| Retroglossal narrowing | Posterior midline glossectomy |
| Glossoptosis | Tongue suspension, hyoid myotomy and suspension |
| Micrognathia/retrognathia | Genioglossal/mandibular advancement |
| Larynx | |
| Laryngomalacia | Supraglottoplasty |
Nasal obstruction may result from e.g. a deviated nasal septum or enlarged nasal turbinates. Although nasal obstruction is rarely the primary cause of OSA, it could contribute to OSA. Treatment of nasal blockage in affected children may therefore be favorable.
Obstruction at the level of oropharynx, besides tonsils may be influenced by soft palate redundancy. Published articles reporting the usefulness and success of uvulopalatopharyngoplasty as a method of treatment in children, are limited to case series.
Tongue base obstruction in children can be addressed using a number of procedures with the most common one – lingual tonsillectomy. Besides above mentioned surgery, the efficacy of most of these procedures is better documented in the adult literature.
Supraglottoplasty is the procedure that may be performed in children with OSA and either sleep exclusive laryngomalacia or congenital laryngomalacia. It has been proven that this procedure improves respiratory indices but in most cases does not fully cure OSA (10).
In severe multi-level airway obstruction morbidities, more extensive surgical approaches may be needed, although in children there is limited evidence available. In one study of 48 children, Prager et al. described an 8.2% incidence of oropharyngeal scarring and stenosis, multilevel surgery that included lingual tonsillectomy (11).
Tracheotomy is the definitive surgical treatment for severe OSA in patients who have failed to respond to other treatment approaches or do not qualify for them. Such patients have either severe craniofacial abnormalities or neuromuscular disorders (12). Although such children remain tracheostomy dependent, the procedure can also be considered as a temporary measure to manage severe OSA while awaiting other surgical treatment.
Non-surgical treatment
Medications
As pediatric OSA is mostly caused by lymphatic tissue overgrowth, inhibition of adenotonsillar proliferation and inflammation, may be beneficial for especially mild OSA patients. Anti-inflammatory medications comprise nasal corticosteroids, and the leukotriene modifier montelukast. Recent meta-analysis has shown that montelukast improved the apnea-hypopnea index by 55% when used alone and by 70% when used in combination with intranasal corticosteroids in children with mild OSA (14). These therapies may be proposed as an alternative to surgery in mild uncomplicated OSA in children.
Positive airway pressure
Among children who are not surgical candidates, e.g. because of no evidence of enlarged tonsils and adenoids, those who have persistent OSA after T&A, or whose parents decline surgery, positive airway pressure (PAP) therapy during sleep should be considered. The application of positive pressure prevent upper airway collapse and therefore maintains airway patency. Effectiveness of this therapy has been widely reported in adults but also in selected group of children (15). Unfortunately PAP therapy in most cases has suboptimal adherence in children. Also besides obvious compliance problems (e.g. mask discomfort, air leaks) it is described that long-term use of the PAP can even lead to facial flattening because of the longstanding pressure of the mask on growing facial structures (16).
Orthodontics
There are few dental procedures that by widening intraoral and upper airway introitus space, can improve upper airway patency. These comprise rapid maxillary expansion (RME) and therapies using mandibular advancement devices (MAD). The above-mentioned are thought to reduce or eradicate OSA in some children with dentofacial abnormalities. RME is based on increasing the width of the hard palate using a dental appliance fixed to opposing maxillary teeth. This device has an expansion system used to open the midpalatal suture, therefore using it, is only possible prior to midline fusion of the maxilla and usually after eruption of at least part of permanent dentition. Although the current evidence on the effects of using RME is limited and based on small uncontrolled studies with a relatively short follow-up period, this therapy hold promise as potential treatment for patients with malocclusion or high-arched palate and OSA (17). MAD is an oral appliance that moves the tongue and mandible forward, thus increasing airway diameter. It can be used in selected children with OSA and e.g. retrognathia, although efficacy of its usage is supported by insufficient evidence in children (18).
Adjunct therapies
Since obesity is considered to be a major contributing factor to OSA, obese children with OSA may benefit from weight loss (19). Environmental agents such as tobacco smoke or allergens may cause nasal congestion and increased upper airway resistance in susceptible patients. Avoiding these factors may be beneficial as adjunct therapy of OSA. Besides these obvious proceedings, there are others with much less proofs, especially in children among which data is scarce. These include positional therapy (avoidance of certain position during sleep, mostly prone), myofunctional therapy (specific focused oropharyngeal exercises). In some patients nocturnal supplemental oxygen could also be a temporal solution until adequate therapy is provided (20).
Conclusions
To prevent short-term and potentially long-term adverse effects of pediatric OSA, current and new treatment modalities should be intensively investigated. Undoubtedly, T&A remains the first line of treatment in a large majority of patients, but other approaches are becoming more widely applied, especially in persistent OSA children. Either it is surgical or non-surgical approach, more outcomes research is needed to determine which patients are best treated with each treatment method.
Piśmiennictwo
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