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} There are three types of Apnea: There are three types of Apnea: - Obstructive, - Obstructive, - Central, - Central, - Mixed. - Mixed.

Cont. Apnea Obstructive apnea – cessation of airflow for at least 10 seconds with respiratory effort 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 Central apnea – cessation of airflow for at least 10 seconds without respiratory effort Mixed apnea – characteristics of both for at least 10 seconds Mixed apnea – characteristics of both for at least 10 seconds Hypopnea – hypoventilation secondary to partial obstruction 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 85% of adult patients are male. 85% of adult patients are male. Men 4%, Female 2%. Men 4%, Female 2%. 2/3 rd obese. 2/3 rd obese. Contributes to HTN and cardiovascular disease. Contributes to HTN and cardiovascular disease. Increased motor vehicle accidents. Increased motor vehicle accidents.

Pathophysiology Pharyngeal collapse Pharyngeal collapse Decreased airway patency Decreased airway patency Increase in negative pressure Increase in negative pressure Becomes a vicious cycle. Becomes a vicious cycle.

Symptoms Snoring* Snoring* Excessive daytime sleepiness* Excessive daytime sleepiness* Restless sleep Restless sleep Personality changes Personality changes Headaches Headaches Sexual dysfunction Sexual dysfunction Job performance Job performance Sleep hygiene Sleep hygiene Bed partner ’ s input * Bed partner ’ s input *

Physical Exam Vital signs Vital signs Head & Neck exam Head & Neck exam Flexible endoscopy Flexible endoscopy

Vital signs Height Height Weight Weight Collar size Collar size Blood pressure Blood pressure Calculate BMI Calculate BMI Wt (kg) / Ht (meters) squared Wt (kg) / Ht (meters) squared Men >27.8, Women >27.3 Men >27.8, Women >27.3

Examination Tongue Tongue Palate Palate Uvula Uvula Tonsils Tonsils Nasal cavity Nasal cavity Hyoid Hyoid Mandible Mandible Maxilla Maxilla

Cephalometrics Standardized lateral radiographs Standardized lateral radiographs Examines bony and soft-tissue structure Examines bony and soft-tissue structure Two-dimensional evaluation Two-dimensional evaluation Lack of volumetric data Lack of volumetric data Maxillomandibular surgery, oral appliances Maxillomandibular surgery, oral appliances

Polysomnogram EEG EEG EKG EKG Submental EMG Submental EMG Anterior tibialis EMG Anterior tibialis EMG EOG EOG Nasal/oral airflow Nasal/oral airflow Pulse oximetry Pulse oximetry Respiratory movement Respiratory movement Sleeping position Sleeping position Esophageal manometry Esophageal manometry

Treatment Nonsurgical modalities Nonsurgical modalities Surgical modalities Surgical modalities

Nonsurgical Treatment Weight loss Weight loss Sleep hygiene Sleep hygiene Pharmacotherapy Pharmacotherapy Nasal continuous positive airway pressure Nasal continuous positive airway pressure Oral appliances Oral appliances

Nonsurgical Treatment Weight loss Weight loss Get below “trigger weight” Get below “trigger weight” Diet, exercise, bariatric surgery, medications Diet, exercise, bariatric surgery, medications Sleep hygiene Sleep hygiene Avoidance of sedatives Avoidance of sedatives Positional changes Positional changes

Pharmacotherapy Protriptyline – decreases REM sleep Protriptyline – decreases REM sleep Xanthine based drugs Xanthine based drugs Steroids Steroids Antibiotics Antibiotics Nasal medications Nasal medications

CPAP Titrated to limit all respiratory events Titrated to limit all respiratory events 50-90% acceptance – better if daytime symptoms improved 50-90% acceptance – better if daytime symptoms improved Side effects in 40-50% Side effects in 40-50%

Oral appliances Advances the mandible Advances the mandible Retains the tongue anteriorly Retains the tongue anteriorly

UPPP Fujita (1981) Fujita (1981) Most common procedure Most common procedure 1st line tx for retropalatal collapse 1st line tx for retropalatal collapse 10-50% success % success.

Mandibular Osteotomy with Genioglossus Advancement Enlarges the retrolingual airway without disturbing dentition Enlarges the retrolingual airway without disturbing dentition Prevents retrolingual collapse Prevents retrolingual collapse

Tongue reduction Lingual tonsillectomy Lingual tonsillectomy Laser midline glossectomy Laser midline glossectomy Lingualplasty Lingualplasty Radiofrequency volumetric tissue reduction Radiofrequency volumetric tissue reduction

Nasal surgery Improved symptoms and CPAP Improved symptoms and CPAP Septoplasty Septoplasty Turbinate reduction Turbinate reduction Functional nasal reconstruction Functional nasal reconstruction

Tracheostomy Bypasses all areas of obstruction Bypasses all areas of obstruction Virtually 100% effective Virtually 100% effective Two indications Two indications Temporary procedure during airway reconstruction Temporary procedure during airway reconstruction Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas Line the tract with skin flaps Line the tract with skin flaps Lack of social acceptance Lack of social acceptance

Apnea in Childhood

 OSA result from:  Adenotonsillar hypertrophy.  Neuromuscular diseases.  Craniofacial abnormalities.

 True OSA result in:  Neurocognitive impairment.  Behavioral problems.  Failure to thrive.  Cor pulmonal, particularly in sever cases. in sever cases.  Enuresis.

 Habitual (nightly) snoring.  Disturbed sleep.  Daytime neurobehavioral problems.  Daytime sleepness may occur but is uncommon in young children. OSA Presented with the following symptoms

 Anatomic factors : That narrow the upper airway. 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).

 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.

 OSA occurs in children of all ages from neonates to adolescents.  It is thought to be most common in preschool- age 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 %.

Sleep onset Decreased CO2 Increased O2 Decreased upper airway muscle activity Arousal from sleep Increased upper airway muscle activity Relief of obstruction Restoration of airflow Hypoxemia Hypercapnia Obstructive,Hypoventilation &Apnea Upper airway narrowing Increased ventilatory effort Sedation anesthesia Muscle Weakness Obesity Small Airway Enlarged tonsil & Adenoids Craniofacial anomalies

 To identify patients who are at risk for adverse outcomes.  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.

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. ζEnuresis ζBehavior problems ζDeficient attention span ζFailure to thrive ζIn addition to snoring α Compared with adult. αFewer children with OSA report excessive daytime somnolence, with the exception of obese children.

 In extreme cases of OSA in children.  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.

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: 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

fig 2 Arrows indicate prominent adenoidal tissue in the posterior nasopharynx, resulting in upper airway narrowing 2-Lateral neck radiography.

WHATABOUTMANAGMENT

 MEDICAL  CPAP  Antibiotics  Weight loss  Nasal steroids  Systemic steroids  SURGICAL  Adenotonsillectomy  Uvulopalatopharyngoplast y  Tracheotomy

OSA is more common in children with craniofacial syndromes. 1-Children who have syndromes with craniosynostosis: -Apert's syndrome, -Apert's syndrome, -Crouzon's disease, -Crouzon's disease, -Pfeiffer's syndrome, -Pfeiffer's syndrome, -Saether-Chotzen syndrome, -Saether-Chotzen syndrome, -abnormalities of the skull base, -abnormalities of the skull base, -Accompanying maxillary hypoplasia, -Accompanying maxillary hypoplasia, May have nasopharyngeal obstruction

2-Children with syndromes that involve micrognathia: -Treacher collins syndrome, -Treacher collins syndrome, -Pierre Robin syndrome, -Pierre Robin syndrome, -Goldenhar's 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 Glossopexy, mandibular distraction or advancement, or tongue suspension should be considered in patients with micrognathia