Chapters Transcript Video The Sounds of Sleeping: How to Assess Snoring or Apneic Children So we'll go ahead and get started. Thank you again for joining our topic. Today is pediatric sleep disorder, breathing from snoring to obstructive sleep apnea and presenting today is Doctor Grace Boni. She is a pediatric ologist and she cares for Children with ear, nose and throat conditions. She is particularly interested in cancerous and noncancerous head and neck growths including pediatric thyroid cancer and bronchial cleft cysts. She is also interested in complex airway disease such as sub subglottic and tracheal stenosis. In her research, Doctor Boni focuses on head and neck tumors in Children, particularly thyroid cancer. She leads an effort among several research centers to characterize the biology of pediatric thyroid cancer using cutting, cutting edge molecular and cellular testing. She is also studying the features and treatment of the condition with the goal of improving outcomes. Boni earned her medical degree with honors at the Case Western Reserve University School of Medicine and she completed a residency in head and neck surgery at Oregon Health and Science University and a fellowship in pediatric Oology at Children's Hospital of Philadelphia. Currently, Doctor Bonn sees patients at Mission Bay and coming soon in June, she will begin um Monday clinics at our Redwood Choice Practice. So thanks again for joining and I will let Doctor Boni take it away. Thanks so much for that introduction, Lauren. And uh thanks for the opportunity to be here. Um And for everyone for taking time out of their busy day to attend this webinar. Hopefully, there will be some information in here that's useful. Um And please, if there are any questions feel free to ask um at the end of the webinar or um you know, reach out to me um uh personally. So um we'll go ahead and get started. All right. Ok. So um the topic for today is um pediatric sleep disorder breathing, as Lauren mentioned. Um I have no disclosures and the objectives sort of my talk today are to number one, describe the clinical spectrum of um pediatric sleep disorder breathing, uh which ranges from simple snoring to obstructive sleep apnea. Um And then to identify kind of the signs symptoms and various risk factors that are associated with sleep disorder breathing. Uh Also to describe the studies and criteria that we use to diagnose and differentiate different um uh types of sleep disorder breathing and then to list the uh various medical and surgical management options and what are the indications for those? Um So we'll jump right into it. I'm gonna present um a few patient kind of case examples um of uh someone that you might see in your clinics to illustrate. Um, some of the key points of my talk today. The first one is a six year old male who presents a, his well child visit with a new complaint of snorting. Um, he tends to go to bed late and it's difficult to wake up in the morning. Mom notes that he's a pretty restless sleeper tosses and turns a lot. Um, but, you know, she doesn't sleep in the same room as him. And so she doesn't know if he has any other symptoms. Um He does have a past medical history that's significant for a DH D. And then uh mom mentions that her husband also snores very loudly. So this is a pretty typical uh patient that I'll see in my practice um as a referral and I think um leads into the kind of broad question of what is pediatric sleep disorder breathing. So, like I mentioned before, it's a spectrum um that is fundamentally characterized by disruption of normal respiratory patterns and ventilation during sleep and it's caused by some upper air resistance. Uh that can be due to either narrowing from an anatomical standpoint or um from hypotonia that's more related to um changes during sleep. And then it uh encompasses a few different um disease states. So there's something called habitual primary snoring. Um and then all the way to obstructive sleep apnea, it does not include other sleep disorders which are um typically in Children like insomnia, um hypersal and circadian disorders, et cetera. Um Those are sort of in a separate category. So I won't be covering those in my talk today. So when is it more than just snoring? Um So snoring alone or primary or habitual snoring is um is kind of diagnosed on the criteria of just snoring more than three nights a week. Um It becomes more than that when there are additional symptoms. So these are often, you know, they require additional studies to truly diagnose. Um but the other associated kind of sleep disorder, breathing um uh disorders that um fall into this category or sleep related hypo ventilation where you have hypercapnia in addition to snoring, hypoxemia, um in addition to snoring and then true obstructive sleep apnea where you're having in addition to snoring or other symptoms, um obstructive events or prolonged hypercapnia. There's also in the category of sleep disorder, breathing, central sleep apnea, um which is obstructive sleep apnea plus uh either diminished or absent respiratory effort that sort of falls more into the um purview of uh pediatric pulmonology or sleep medicine. And so I will not be covering that in my talk today and will focus more on kind of the obstructive sleep apnea. So, what is obstructive sleep apnea? Um by definition, according to um the classification of um sleep disorders, it's prolonged, either partial or intermittent co complete upper airway obstruction. Um It actually requires a sleep study to be diagnosed and on the sleep study, you're looking for an H I of one or more which is different than adults um or a uh CO2 level um that is elevated to 50 or more for greater than 25% of the sleep time. Um The most common causes in Children uh of OS A are tonsil and aid hypertrophy. And then um the long term effects which have been well established in um several large studies are cognitive and behavioral issues, failure to thrive hypertension, ventricular dysfunction and core pulmoni. So how does OS A present in Children? Everyone here, I'm sure is quite familiar. Um But some of the main symptoms that are associated strongly uh with OS A are snoring, labored breathing, including apneas or pauses. Often parents will describe sort of their child will um kind of gasp or choke or snore themselves awake. Um Even if they don't necessarily notice that they're stopping in their breathing, um they'll have cyanotic episodes in certain severe cases. Mouth breathing is another common symptom. And then in older kids who have um who have moved past diapers, having aures, um and uh and then restless sleep, um failure to thrive, particularly in younger um Children with OS A and then daytime hyperactivity, which is often more common in Children than um in adults. You would often see fatigue as um the more um common energy uh concern and then behavioral issues and attention issues. So that brings me to the second patient um case, which is a four year old male who again, again is presenting with snoring. Um But in his case, his nose always seems blocked and mom says he's a constant mouth breather. Um He does have a past medical history that's significant for um Trisomy 21 and also had a V S D um in the past uh that was repaired and then um has kind of ongoing mild dysphagia issues. Um He has no other family history. So that brings me to the next topic, um which is which Children are at risk for OS A. So, um in general, in the general population of healthy Children, it's gonna affect mostly ages 2 to 6 year old um Children. And uh it's a very, very prevalent uh disease. 1 to 5% of all Children have OS A. So the A P actually recommends that all Children should be screened um for signs and symptoms and it relevant to the um patient I just presented. It's important to know that patients with Trisomy 21 have um very high risk of uh developing OS A at some point in their lives. Up to 80% of these Trisomy, 21 patients actually have OS A and so they actually have slightly more aggressive um screening recommendations which is to undergo um a sleep study by the um by the age of five. And then other risk factors for OS A um include patients who may be presenting with just consular android hypertrophy. Um obesity is a big risk factor, uh which we'll talk about a little bit later. Um smoke exposure and African American race um as well as other comorbidities. So, cranial facial anomalies including trice me 21 but also beck with Weedman with um macroglossia issues. Uh Prater Willy um related to some of their uh sort of um skull structure here, Roan, um where they have uh you know, post your tongue bla based displacement as well as potentially a cleft palate, um achondroplasia and then uh cruz on and craniofacial dys um and then neuromuscular disorders. So, uh duen muscular dystrophy is a very common um condition in which I always say presents and then pr malformation. So this is a common question that I'll get um from patients, which is does OS A run in families. Um So studies have actually demonstrated an increased prevalence of first degree relatives of os A patients um developing OS A. So, uh the rates and the magnitude of risk are a little bit more variable in the literature, but range anywhere from um you know, 21% to 84% of re first degree relatives and then, uh you know, 2 to 40 plus fold increase in risk. But unfortunately, the studies, the data isn't great. There's a lot of confounding variables um that could lead to OS A um affecting multiple members of a family. Um Now, the next step you know, after assessing for symptoms and risk factors in your patient would be to do a physical exam and the important things to pay attention to on physical exam for um these patients is really number one, their weight on their vitals. Um and uh and then their blood pressure to screen for hypertension as um a consequence of OS A and then their tonsil size. Um So if you look on the right here, this image demonstrates our typical tonsil or grading scale that we use the broad ski scale. And so um the picture A is one plus tonsils, you can sort of barely see the tonsils peeking out from the FAA here, the UBI here, midline and palate um here anteriorly. And then two is considered to sort of be um visible kind of outside of the tonsillar pillars. Whereas three is uh is more like 75% obstruction or so. And then four um would be tonsils that are completely obstructing the orals or touching in the middle. Um You would also want to pay attention to any like dysmorphic faces, um any cleft palate or high arched palates um which can be associated with Os A and then micro or retro. Um and then the other thing to pay attention to on sort of like your anti rhinoscopy or looking in the nose, um exam is enlarged, inferior turbinate. Um So the photo here shows um kind of a normal, this is actually the right side of the nose when you're looking at it. Um And you can see the, the turbinate on the left side of the photo and the septum on the right side. Um And then the photo below it shows pretty significant um inferior turbinate hypertrophy uh where the turbinate is actually contacting the septum. So how, how is OS a a diagnosed um like I mentioned earlier in order to truly diagnose it, you need to have a sleep study and in Children, um the gold standard is an overnight in laboratory sleep study. Um There have been a lot of studies that show that clinical history and physical exam, um even those that are performed by ologists um are pretty inaccurate, so only accurate about 50% of the time. Um And you know, the sleep study um is recommended to be done in laboratory because uh at home sleep studies or oxy sort of the light versions of sleep studies that have been um that have been implemented in adults have not actually been validated in Children. Um And the only problem is that sleep studies um you know, are often quite booked out um sometimes for months out and that's something that's a problem that's across the country. Um So you have sometimes significant limitations due to scheduling um as well as the cost and inconvenience. So, in practice, nowadays, um at least in the pediatric or laryngology community, some um places will be using questionnaires in lieu of sleep studies to sort of point us towards whether or not a child, um, is likely to have OS A or not based on their symptoms. Um, and so there's two main questionnaires that we use. One is the OS A 18, which, uh, has been shown to have a sensitivity of, um, of 40% in some studies up to 70% in others. Um, and then the P S Q or pediatric sleep questionnaire, which has a slightly higher sensitivity of 78%. Um So, you know, these questionnaires, obviously they aren't perfect. Um but they sometimes are a better alternative to waiting, you know, sometimes up to six months for a sleep study. Um There are some specific indications though where I will uh wait no matter how long it takes to get a sleep study before considering doing any additional interventions. And our um our oology guidelines recommend that whenever there's discordance between the reported symptoms and their tonsil size. So if you have a patient who is having a lot of um symptoms concerning for severe os A but their tonsils are only one plus, for example, um that's an instance where I would order a sleep study, um patients who have obesity or um comorbidities. So trice 21 craniofacial abnormalities, neuromuscular disorders, as well as sickle cell disease and Neco polysaccharide doses where um they have kind of an inclination to have large um tonsils and adenoids. Those are also indications for sleep studies. And really what you're trying to do is not only diagnose sleep apnea but also determine the severity of the sleep apnea, which helps us figure out in terms of management in the perioperative and postoperative setting. Um What's the safest thing to do for these patients? So I'll briefly go over, um, how do you interpret a, a sleep study? This is um maybe a little bit beyond the, the scope of um you know, once practiced. But um and you know, the sleep medicine doctors are really the experts at this, but sort of a primer in how to interpret a sleep study. Um So the main number that we typically pay attention to is actually the A I. So the number of apnea um plus the number of hypotneas events per hour and apnea is defined as um a greater than 90% reduction in air flow lasting greater than or equal to 10 seconds or two respiratory cycles. Uh hypoxia is basically a lesser reduction. So 30% or more reduction in air flow and doesn't necessarily have a time or respiratory cycle limit to it. But um is associated with either a des saturation or arousal from sleep. Typically. Um Other key measurements to pay attention to on the sleep study um report are the 02. So the lowest 02 value that they um get to when they're sleeping and then the peak CO2 value that uh, they get to and those are things that we use to, um, get a sense of in addition to just their age, I number how severe the, um, their sleep apnea is the, the strict kind of criteria we use for grading OS A. Severity is based on A I. Um, and so, uh, mild Os A is gonna be 1 to 5, um, events per hour, moderate is 5 to 10 and then severe is anything greater than 10. Now, there's some other helpful studies that um I will sometimes order to help with um my assessment of a patient who I'm suspecting Os A in and those are lateral neck x-rays. Um This is really helpful for assessing um the uh the adenoids and you can actually also see the palatine um tonsils in uh in many kids. Um Sometimes they're masked by the angle of the mandible. Um But uh you can see them in a lot of cases over here on the right, you'll see. So the anos are this um kind of hyper um lucent signal on the uh on the right here right along the skull base. Um And then you can actually see the palatine tonsils right here. Um And the important thing about lateral neck x-rays is that they should be done um with a patient in neck extension um to as a a adequately assess the anos basically. Um and what you're looking for is an ada nasal pyx ratio. In terms of the width of greater than 0.8. Um and that's pretty highly diagnostic for um A aid hypertrophy. That being said ratios that are less than 0.8 are um still significant in terms of having mild or moderate aid hypertrophy. Um Other things that you can use to uh help with your um diagnosis of OS A would be C T scans. Um We don't use those very commonly because it's a little bit overkill often. Um They, you know, have the radiation risk associated with them and usually you can diagnose um OS A with other less invasive measures. Um But that being said in some Children who have other comorbidities, for example, or other concerns, you may use AC T scan. Um And then a newer technology which is a CE MRI. So it's basically like a real time MRI where they're taking several photos kind of back to back um uh as they're in the MRI machine. Um And that helps you get um a sense of their um changes, their night dynamic changes in their airway as they're sleeping, um or they're just breathing as well. Um And that can help with assessing the airway, the degree of airway obstruction, but I will say that C MRI has in the literature been shown to maybe not be as great um As uh another study that I'll mention in a second here, but um it's not as great for assessing sort of like the dynamic airway narrowing. Um It's really, really helpful and valuable in assessing the lingual um tonsils and the tongue base and distinguishing the two. So the modality that's actually quite superior to the A MRI. Um for assessing the airway is something called drug induced sleep endoscopy. This is something that we um over the past 10 years, I would say have really incorporated into our practice of Zal laryngologist for the assessment of O A. Um Basically what it involves is taking the um, child to the operating room and then putting them to sleep with either um dex Metodine or propofol. Um And it's t treated pretty carefully to where they're just snoring, just starting to have obstructions and not in a real like deep kind of anesthetic um level of sedation. And then we look with our flexible lary laryngoscope through their nostrils, um and assess uh their airway. There are sort of five main um airway kind of levels that we like to assess and are indicative of obstructive sleep apnea. The first one actually being the nasal cavity and um looking for uh enlarged turbinates or a deviated septum. And then the next level is the soft palate or the, um And uh so we'll look at the degree of collapse where the palate is contacting the poster Riri wall. We'll look at whether it's circumferential or just in one uh dimension. We'll then look at the oral pyx, lateral walls and what you're looking for here is mostly kind of the tonsils and how much the back of the tonsils are um protruding into the oral and obstructing that portion of the airway. And then we look at the tongue base looking for um kind of uh you know, in a micro naic or retro naic patients displacement of the tongue base. Um And finally, the Epilady or super glo airway to see if there's any um laryngomalacia or other um anatomical component of their obstructive sleep apnea. That's lower down. Um The indications for using uh dice are um, patients similar to uh A P S G when there's sort of a discordant exam um and symptoms and then P S G findings. So, um when their sleep study is uh quite severe, um but their exam is again like one plus tonsils. Um and it doesn't quite line up for the classic tonsil adenoid hypertrophy related os A. Then we'll often use a dice um, before then proceeding with um dice targeted interventions for their sleep apnea. Um We'll use it if there's a concern particularly in Children with comorbidities like neuromuscular disorders. Um, a concern for multilevel obstruction and then also, um for uh patients who have had a tonsil toy and noid toy for Os A but are still having persistent symptoms and um, disease on their sleep study. All right. So then a slight kind of um, side topic that I wanted to bring up here. Um, just because I am an laryngologist is some of the interactions that you might see um between OS A and other areas of the head and neck. And so other complaints basically that these patients might um come to you with in addition to OS A symptoms. So, um as you can imagine, there's a lot of interplay between Os A and the nose related to the adenoids and the aids, um being a main cause of OS A um but also of nasal obstruction. And so, um you know, Anno hypertrophy in general will present in like ages 2 to 6 year olds. And then the anodes theoretically should be regressing on their own and atrophied by the age of 16 in a normal child. Um But there has been studies um that have shown that in patients who have OS A, um they often have persistent hypertrophy, the anodes that persist, you know, even into adulthood. Um And then the uh instances where you might be concerned um that there is uh that there is something more than just um you know, classic nasal obstruction going on would be um if you're having chronic nasal congestion, that's not going away in between illnesses or chronic nasal drainage rhea. Um and then a hyponasal voice and this is um these are some images of uh aids that are hypertrophied. So, um what we're looking at here on the left grade, one is the aid superiorly. And then actually the E station tube, you can see um the opening which is called the torus um Tiberius, that's on the right side of that little um graphic and then the poster for wall um and the uh the palate in the back of the nose um at the inferior aspect of that image. So that's grade one um aid hypertrophy all the way to, you know, grade three and grade four. We're having near complete obstruction of the nasal, um the back of the nasal cavity from enlarged anos. Um often you'll have patients who have OS A as well as ear symptoms. Um And again, it's, it's kind of about the aids um and caused by the anodes. And so that's sort of the missing link here where enlar anos in addition to causing nasal obstruction and sleep issues can actually block the U station two. Um And here's the image again of the anodes in the back of the nasal cavity and the U station tubes. And so you can see the proximity and when you have complete obstruction from like four plus ADOS, um you can imagine how the U station tube would also be blocked. And what that can result in is issues with like recurrent acu titi media, chronic otitis media and then mutation two dysfunction, which often presents with kind of this nebulous like oral fullness or plug sensation in their ears with in the absence of other um of ear, other ear abnormalities. Um So when to be concerned about um ear issues in addition to OS A issues. So our criteria where we start to think about intervening um recommends if a child had more than three ear infections in six months or four ear infections in 12 months. Um as well as if they've had persistent middle ear fluid, um not necessarily an infection but just an infusion or fluid in their ear that's lasted for longer than three months. Um Or if they have any hearing concerns or abnormal audiogram, that would be a good time to refer them um on to E N T, which brings me to the next question of when should I refer a child with either suspected or confirmed OS A to an E N T. Um So they don't necessarily have to have confirmed OS A to be a candidate for a referral if you have a patient basically who has snoring plus something else going on. Um Then uh you know, those symptoms of Os A that we talked about earlier, labored breathing apneas, things like that. Um Or if you have any symptoms that are concerning that they have a noid hypertrophy. Um So these other nose or ear concerns that I just mentioned, those would be very good patients to refer on to E N T for further evaluation. Um And then if they have other risk factors for Os A, so other comorbidities, for example, obesity, um if you see that they have enlarged tonsils. Um And then obviously, if they have confirmed OS A on a sleep study, um then that's a good reason to refer them. Um If you have a concern for something that's not a sleep um related breathing disorder, then that's a patient that you would probably actually want to refer to pulmonology or sleep medicine rather than E N T since we don't um specialize in that area. And then how is OS A treated? So once the patient comes to us, um the kind of first line therapy that we um use is Tonsil toy and aid Omy. Um And that is actually um that's sort of irrelevant uh to their tonsil size studies have shown that regardless of whether they have one plus tonsils or four plus tonsils. Um Tonsil toy and annoy can still be beneficial um for the treatment of OS A and is, is generally the most effective treatment. Um We have evolved quite a bit over the past, I would say again, like tw 10, 20 years um where we used to be doing a lot of these extra capsule total tonsil tonsil omy um involving removing the entire tonsil. These had, you know, decent rates of um pain and bleeding after the surgery. Uh sometimes bleeding rates up to like 7 to 10% historically. Um But what we have found is actually that if you do an inter capsular tonsil toy, where you actually leave a little bit of the rind of the tonsil tissue behind. Um that can be just as effective as doing a total tonsil elect that significantly decreases the pain after the procedure. Um as well as the um the postoperative bleeding rates. Um And so, with inter capsular techniques of which there's a few different varieties. Um one of which you're seeing here in the photo demonstrating a cob blader inter capsular um tonsil toy, the bleeding rates go from, um, you know, like I mentioned historically, up to 10% down to less than 100.5%. And typically these Children rather than being out of school and in severe pain where they might get dehydrated, not wanna eat any solids. Um, for up to two weeks are feeling better when they have intra capps, toomy and mostly back to normal by one week if not within a few days of the surgery. Um So, uh, the, the patients that we, um, that we do a little bit, um, more work up in and are a bit more concerned about, um, in order to manage them a little bit more intensively, um, around the time of their toomy and ectomy are ones that are less than three years old. Um, those who have severe OSA on their sleep studies. So an age I of greater than 10 or 02 major of less than 80%. Um, these patients are at increased risk of per operative complications. And so we, we will typically admit them to the floor or pick you postoperatively for um just one night most commonly um to have them on continuous pulse ox symmetry. Um But the vast majority of healthy Children over the age of three, who are getting their tonsils and AIDS out actually go home the same day. Um And I wanted to mention so the um the chat trial, the childhood a Toomy trial, this was really where a lot of the data um that shows that aid Toomy is um should, is and should be. The first line therapy for OS A came from. This was a landmark study that was published in um any New England Journal of Medicine in 2013. Um It was a multi center effort, um where 464 school age Children were um randomized to either a trial of watchful waiting or um, Toomy and annoy. Um These were Children with confirmed Os A who 76% of the um group that underwent surgery had normalization. Um So their os a completely resolved uh after surgery, whereas um only 46% of the watchful waiting group had resolution. Um And then they also demonstrated that there were significant improvements in behavioral and quality of life outcomes in the group that underwent um, ectomy and annoy, whereas these weren't um seen in the watchful waiting group. Interestingly. So this was actually the primary end point of this trial was uh assessment of cognitive outcomes. Um They did not find a significant change um in the uh cognitive outcomes um between the watchful waiting groups, um and the Anno toil groups. Um and there are some subsequent follow up studies that have been in progress that are looking at why that's the case. There's also an ongoing study that's sort of a spinoff of the chat trial, which is called the pediatric Anno toy trial for snoring or pets. Um, and that is assessing for, um, the, uh, benefits of doing toomy and admin toy in the very mild, um, os a group. And, uh, that's a sort of a subset of the chat trial that, um, is particularly interesting, um, because there are some other options out there besides surgery that, um, have been shown to, to have efficacy in that group. Um, so to see what really is the optimal first line treatment for those patients. Um, this is a common question that I get asked, uh, when I'm discussing tonsil toy and Aidy, what are the long term effects of the surgery? So there's a lot of conflicting evidence out there. And I think, um, that part of it is, um, due to a study that was published in 2018 in, uh, geo laryngology, which is a very reputable journal, um, in our field, uh, it looked at a large danish, it was sort of like a population based, um, uh, study and it found, um, a threefold increased risk of upper respiratory infections after having tons anatomy done um with confidence interval of 1.5 to 4.8. Um So the study was problematic in a lot of ways. Um And I think unfortunately, um uh has contributed to quite a bit of misinformation out there. Um But the uh study actually did not control for the indication for why these Children were undergoing tonsil toy and Ain toy, which places them at a super high risk of sampling bias. Um And so we don't know if the and why there's such a high risk of upper respiratory infections after tonsil select toy and annoy in these Children is because they were, you know, kind of undergoing a surgery for frequent tonsilitis episodes or if they had OS A or other risk factors that um that would incline them to, to have respiratory infections both before and after surgery. Um There has been a large meta analysis that is sort of um kind of more helpful. Um And uh that was done in 2015 and really showed that there was no clinically significant um negative effect. There were some uh kind of laboratory abnormalities in terms in terms of um levels of different um uh cytokines and things that were detected um in on a basic science level and um patients who had Tonia and annoy done. Um but on a clinical level, there was no significant um data that was uh found. So a little bit more about per um, special populations who have OS A and may need to undergo a time a Toomy. Um, so when I have a patient that has been referred, who also has obesity, um I will also typically refer them to the G I um, uh providers for help with, um, weight loss and weight management. And that's something that certainly as, um, a pediatrician is something you could kind of, um try to optimize even before referring to uh E N T. Um, there's been some very, very strong data that shows that there's a link between obesity and os A as well as um losing weight being beneficial for improvement in um, in A H I. So, um there is also an increased risk in obese patients for having persistent os A after um tons and Aidy. Um And so kind of a lot of good reasons um to, to try to aggressively control their weight, um, patients who have bleeding disorders. Uh So these patients kind of really need to have their bleeding disorder work up and complete before we take them for toomy and annoy because of the high risk of bleeding associated with the surgery. Um And so at a bare minimum, they should have a CBC P T P TT and bleeding time. Um, you know, ideally within like the past month or two of when uh they're going through surgery and then some patients I refer as well to hematology um for assistance with per operative management, particularly those with like fond willow brands or um any factor um disorders and then patients with sickle cell anemia. Um so they uh you know, they're at very high risk of um acute crises if you administer steroids, which is something that we actually do routinely um in patients who are undergoing endo toomy to help with postoperative pain and swelling. Um So this is a special population where we avoid the steroids. Um And then they also potentially need to have postoperative or preoperative rather transfusions to prevent them from going into an acute crisis at the time of surgery. Um And then any family history of anesthetic complications uh where we would need to avoid certain anesthetic agents. So those are, that's kind of a surgical like the main surgical management option that we use for OS A. But um I wanted to also cover uh some of the non surgical management options. Um One of which is watchful waiting, um which is uh totally fair for kind of milder os A. Um patients, you can do that for up to six months according to our guidelines. Um and that's totally reasonable. There's also some medical therapies that can be tried. These tend to be more effective actually in the older population. So patients who are older than age seven, um and the two main ones that have good data behind them are nasal steroid sprays. So, um fluticasone is the one that we commonly use bin is another one. Um, but these have been shown to, um, reduce the A I, uh, approximately 50% in Children after a six week course. And I always counsel when I'm, uh, doing a trial of nasal steroid sprays, I always counsel the patients that they need to be using Flonase. Um, it on like sort of a religious basis every single day for six weeks to really see the full effect of it. And there have been uh studies that show that if you use it for less than three or four weeks and you actually don't get any benefit of it. Um And then the other uh main non-surgical management option that's used for OS A is Mono LECA or Leuco trine inhibitors. Um because there's been uh data suggesting that there's increased levels of kind of generalized inflammation in the tonsillar, um FASA and in the tonsils as well as anos in patients with OS A. And so, um there was a fairly large study that showed um after a 12 week course of mono lou cast, there was approximately uh 50% or more reduction in A H I and um the majority of Children. So 65% of Children and then the other option um is positive airway pressure. So either CPAP or BIPAP, which we'll talk about a little bit later. So what can you try before referring um patients who you're concerned about either sleep disorder breathing or OS A. Um, and so if they have pretty mild, again, mild signs and symptoms, a trial of nasal steroid sprays. So I typically use Vera for ages less than two and felonies for um, older Children. Um, a child mono Lucas would totally be reasonable as well. Um, or you could order a sleep study, um, if you feel comfortable with that or it's always um, fine to just refer them on to E N T and, and not do any additional work up. Um And so, you know, if you have a patient who has snoring and apneas and you're concerned, then totally reasonable to just send them along to E N T. And the next question would be, how should you refer these patients to E N T? So, um some general guidelines, if they have mild to moderate symptoms, typically, that's a routine referral um and will be seen, you know, sometime around, hopefully like within a month or or so. Um and then if they have more severe signs and symptoms. So, for example, if they're less than three years old, um or are having cyanotic episodes, failure to thrive severe os a on their sleep study um or any other respiratory symptoms when they're awake. Um That's a patient who probably um warrants an urgent referral and will be seen within a couple of weeks by E N T. And so that brings me to my last case which is a five year old male who presents a story. Um Now, this patient actually had a ton ectomy and Aidid toy at age two. Um, his symptoms improved for a couple of years afterwards, but then have over the past year or so started to gradually worsen again. He also pauses when he, he's breathing several times a night every single night, um, per mom and dad. Um, and uh, he does have a past medical history that's significant for obesity. Um and was found to have moderate OS A when he had his original sleep study. So, what about persistent disease? Um So up to 30% of Children actually have persistent Os A after tonsil toy and aid Omy. And the most common reason is due to persistent upper airway obstruction. Um also in a minority of Children, sorry, in a minority of Children, they can have tonsil or a noid regrowth. Um I would say that's probably less than uh less than 10%. 5 to 10% of these Children have regrowth as the the cause of of persistent os A. Um The risk factors that have been demonstrated in the literature for persistent disease after surgery are patients who start with moderate to severe os A those who are age less than two um obese patients like I mentioned and then those with other comorbidities. So, craniofacial anomalies and neuromuscular disorders, Children who are deemed preoperatively to have kind of a, a higher risk for persistent disease. Um, we will routinely do a repeat sleep study about three months postoperatively, which is when you would expect to see the full effect of the surgery. Um, oftentimes they will continue to snore and have other symptoms for up to three months after having their tons out. And that's just related to the progression of kind of healing and scarring, um, and opening up of their airway after the surgery. So, um if they, but if they're at high risk for having persistent disease, we'll go ahead and get a repeat sleep study and then a little bit more about the role of positive pressure. So, um CPAP or BIPAP, both are fine, bipap is sometimes better tolerated um in Children. Uh because, um you know, the, the support is decreased during expiration. Um And so it's a little bit easier to breathe out and maybe a little bit more comfortable. Um But unfortunately, um you know, any positive pressure involves some sort of appliance being placed on the face, which Children as you can imagine don't love, particularly those who have other um you know, developmental delays or issues like that. Um And so non-compliance rates are kind of very high, greater than 50 per 50%. Um for, for positive pressure, we use them in patients who are poor surgical candidates. Um And then also in the setting um of persistent or residual disease where it's not surgically amenable. Um It does require undergoing additional sleep studies on a sort of a routine basis to titrate positive pressure. And so that's one criteria um that also leads to noncompliance is not being able to cooperate with the sleep study. Um And then there are concerns um there's some data out there that suggests that you can have long term cranial facial changes, including midface retrusion related to the use of of the masks. So what are some other management options then? Besides our kind of standard um mentum. So, uh these are much, I would say much, much less commonly used in Children and sort of in special circumstances, always with um uh dice or some other evaluation to make sure that these are significantly contributing to their um OS A. But uh something that can be tried, that's not a surgical intervention would be an oral appliance and these are typically um prescribed by uh the dental um team and can help with sort of helping the jaw um protrude out a little bit. Um and then uh and bring the tongue base um anteriorly and open up the airway in the oral pharynx that way. Um And then there's other surgeries such as Maxillary expansions uh where you're actually widening the palate um for those with narrow arch palates, um There's Malo Mandibula Advancements where you're um doing cuts in the um in the jaw and also in the um in the mix to bring the upper dentition and the mandible forward and then um and open up the airway that way. Um There's several different variations of Fingal. So surgeries on the back of the mouth, on the palate. Um and on the tonsillar um uh in the tonsillar area where we reorganize tissue to open up that area. Um lingual tonsil elect toy. So in the graphic on the right, you can see the lingual tonsils are at the back of the tongue, kind of right up against where the base of the tongue is. Um And those are one of the most common culprits for people who have persistent um OS A after having their tonsils and anos out and then the gloomy to reduce um enlarged tongues and then super glydo plasty if it's indicated because they have uh you know, epiglottic or other collapse. Um And then kind of the the nuclear option is tracheostomy in patients who really, you just can't control their OS A, they have severe disease and um and uh so a tracheostomy just bypasses all um of the upper airway and then I'll finish with. So just uh kind of a teaser of what's on the horizon in terms of managing OS A. Um So there is a device that's called the Inspire Hypoglossal nerve stimulator. Um This is something that's surgically implanted and there's um a implanted generator in the chest wall that has leads that go to um the intercostal region and then also up to the um the hypoglossal nerve, which is located in the submandibular area of the neck. Um And basically what it involves is timing stimulation of the hypoglossal nerve which actually controls protrusion of the tongue um to the respiratory cycle. Um And so it basically causes the patients to stick their tongue out when they are breathing in to open up their airway. And has been shown particularly in patients with um trice 21 uh to potentially have some significant improvement in their um A H I. So, uh the main study out of Harvard showed that um there was a median of 85% reduction in A H I at 12 months post postoperatively in these trisomy, 21 patients, which is huge because this is a really refractory population where essentially nothing works and they can't tolerate positive pressure often. So that's something that is in the process of being studied and implemented widely. Um and is kind of the next um frontier I would say in the management of really of your os A and so with that, that uh is the conclusion of my talk today. And I'm happy to um take any questions. Thanks so much for, again, for your attention and for attending. Thanks everyone. Ok. So let me start with, if a child benefits from flo's use after six weeks, can they be weaned off of it or is it best to continue? And for how long and then could there be any rebound? Hypertrophy or return of symptoms once clones is discontinued. Yeah, that's a great question. So, um, so the answer is, it depends. So, I think if, um, if the child is really benefiting from uh the Flonase, it's, it's actually safe to use almost in perpetuity. The main downside of using Flo's long term is uh risk of nose bleeds. Um And, um, and that's pretty easily resolved. I always tell my patients to point the Flonase towards their ear rather than towards their septum when they are spraying it. Um But uh I think it's also reasonable if you know, if this patient kind of had other symptoms of like seasonal, um seasonal congestion and seasonal worsening of their OS A um to try to wean the Flonase if it's out of season and um and see if they, they do well. Um the theoretically they should have kind of um they should have shrinkage of their aid tissue. That's the hope with the Flonase. And so in the absence of other factors that would um cause them to get inflamed again, then it would be reasonable to try to uh weaning of the clones. Thank you. Next question is, hello. How can we differentiate hypo versus hyper nasal sounds on physical examination? That's um that's a great question as well. So, uh you know, so hyper nasal speech, um which is related to kind of obstruction, um uh or sorry, hyponasal speech which is related to obstruction. Um is really that sound of like having a plugged nose, um, when they're talking, uh, that sort of muffled sound, um, when they're having hyper nasal speech, that means that they're, um, there is air escaping, um, through like the, the Lowry, so the back of the nose, um, and that's more, that's more commonly due to issues with like a pallet. So a cleft palate or um, a submucous cleft palate where they're not having complete closure in the Velox. And so they end up having this kind of breathy quality um to, to their voice that if there's any, you know, if there's any kind of question of it that you're not able to discern, that's something that uh referral to speech therapy for further evaluation. We would totally be fair. Great. OK. This question came up a couple of times. What is the youngest age we can do with sleep study? Most of the Children do not cooperate for the sleep study? Yeah, I mean, there is no absolute lower limit to the age that you can do a sleep study. So we do sleep studies even on um you know, on patients like neonates um who are, you know, pre that are in the N U will do sleep studies on them. Um So there's no lower limit. There is definitely uh a component of child development and ability to, to tolerate the sleep study. Um But that's something where they have lots and lots, especially you know, at U CS F in our pediatric sleep labs, they have a lot of experience with, with trying to, um, meet Children where they're at developmentally. And so there's lots of tips and tricks that they can use, um, to get them to comply with the sleep study. And so it's worth at least referring them for a sleep study and then, and then they would let you know if, if the child was not able to. Ok. Can you comment on the use of lasers to shrink soft tissues? Yeah. Um So I don't think lasers are, are um you know, super widely used or um kind of uh validated in the data. Um I I'm not sure if there's a specific indication that you're thinking of or specific soft tissue that you're thinking of for the um use of lasers. But uh the more typical kind of modalities that we'll use are either um Coteries, Cotter or um or Coblation, which is sort of like a um low frequency radio ablation um or uh you know, just cold steel cutting things out or um using a microdebrider, which essentially is like a, a little bit of a rotor router um that we use to take away tissue. Ok. A few more. You mentioned two meds for D I S E one is Propofol. What is the name of the other med used for sedation? Yeah, it's called um Dex Metodine or Precedex. Thank you. What is the difference in regrowth after I think this is inter v extra capsule. Yeah. Sure. Yeah. So there is um a slightly higher risk of regrowth um in intra capsular Tolectin definitely because you're leaving tissue behind. Um I generally, so it it depends on how you're performing your intra capsular tonsil omy. I generally will essentially remove all of the tonsil or tissue down to the very capsule rind of um the tonsil. Some people will leave actual tonsil or tissue. Um And that has been shown to be just as effective as total tonsil toy in many cases. But um there's certainly a higher risk of regrowth. The more tonsil tissue leave behind in my hands where I'm basically removing almost all the tonsil tissue. I'd say the regrowth rate is somewhere around um like 5 to 10%. But uh the very, very vast majority of those patients actually don't have um to go through surgery again for their regrowth. It's just kind of there, right? Do you see any impact on growth or height with long term nasal corticosteroid use? Um So that has been, that's definitely been studied. And um and the data seems to indicate that there's no um significant systemic absorption um of nasal steroids. And so, uh no significant effect on on overall growth trajectory would love thoughts on mouth breathing and adenoidal hypertrophy management in a 12 month old. Yeah. So, you know, if, if there aren't really any other sleep disorder breathing symptoms in that particular patient. And it's just that they have big annoys, they're congested and their mouth breather, breathers, they aren't snoring or having apneas or other things like that. Um, then I think it's, uh, I think it's reasonable to do a trial of, um, nasal steroid spray. So I would do Vera mist. Um, and, uh, and then if that failed and, you know, if it was causing other issues for that patient to where it's really problematic, um then certainly referring to E N T for consideration of just taking out their adenoids would be reasonable. How do you think about the role of allergic rhinitis in os A slash snoring? Should all patients of concern receive a trial of nasal steroids? Um So there is definitely an an interplay there um related to allergic rhinitis, um causing inferior turbinate hypertrophy as well as a hypertrophy in some cases. Um You know, we, we sort of, we try to tease apart um how much the nasal cavity obstruction from allergic rein is, is contributing to their sleep issue um when we see them during our visits and if it seems like there is a large component of um turbinate hyper and they have otherwise like smaller tonsils, um Then that would be a patient, I would consider just trying nasal steroids in. Um And uh you could also try sending them to allergy. I'll do that in some patients where they have pretty severe allergies for testing and um management of that. But we often will do um we'll still go ahead and proceed with doing a tonsil toy and annoy in those patients without necessarily waiting for resolution of their allergic rhinitis. Ok. Would excessive drooling signal any association with OS A or aid hypertrophy? Yeah. So, um, drooling, I think I see often as um more of a consequence of mouth breathing in Children who otherwise are healthy. So, otherwise don't have some other um neuromuscular disorder developmental disorder. Um It's usually because they're just constantly mouth breathing. Um and that is potentially related to nasal obstruction, potentially from either the adenoids or from their inferior turbinate's being hypertrophied. Could you comment on symptoms and management of deviated nasal septum? Yeah. Um So deviated nasal symptoms in Children is um is a bit of a tricky area because um we know that if you do anything to the septum at too early of an age, typically before they reach puberty, um that can actually affect the development of their mid face. Um and craniofacial. Um And, and so in general, we don't recommend unless they have some other like for example, cleft um liver palate if they're healthy and they have a deviated nasal septum, we don't recommend doing anything to that um until they reach puberty. So 16 or older. Um but uh there are other things that you can do to help optimize their nasal cavities and decongest them mainly nasal steroid sprays, um, that hopefully will buy them enough room. Um, aside from directly correcting their septum. Ok, two more questions. The mechanism of OS A in C P and other neuromuscular disorders. Is it the hypotonia? Yeah. Um, it, it usually is mostly the hypotonia. Um, and, uh, and they can, I mean, they can certainly have large tonsils and anos as well. But, um, in these patients, these are really good candidates for going to the O R to do a dice before doing any intervention on. Um because they will often have like at the level of their palate, for example, they'll just have kind of complete circumferential collapse because they're losing tone to such an extreme degree um in, on all sides of their airway um when they sleep. Ok. Final question is, do you suggest using nasal steroids due to chronic nasal congestion? Yeah. In patients who have chronic nasal congestion, um you know, with or without uh sleep disorder, breathing symptoms, it's absolutely reasonable to do a trial of, of nasal steroids. And that's probably kind of the most potentially beneficial um uh intervention that we have for that. Created by
