Pediatric obstructive sleep apnea
syndrome : time to wake up
Veena Arali, Srinivas Namineni, Ch Sampath
IJCPD , JAN-APRIL 2012, 5 (1)
“On Some Causes Backwardness
• OSAS – 1966
• In 1976
Guilleminault et al jop
Obstructive Apnea: continued chest and abdominal
motion in the absence of airflow during sleep
Obstructive Hypopnea: decreased airflow and alveolar
ventilation in the presence of paradoxical motion of chest
Apnea-Hypopnea Index: # of events/hour
• Used to categorize severity of condition
• AHI > 1 abnormal, but clinically significant?
• Pathology in a snoring child not yet clearly defined
• OSAS in childhood, as defined by the American Thoracic
Society, is a 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.
Physiology of breathing and
• Upper air way resistance
Types of sleep
• There are five stages of sleep; four stages are
considered non-REM sleep and one stage of
What is REM sleep?
• Rapid eye movement..during a sleep period
(eyes dart from right to left) stimulates occular
• Called “active sleep” or “paradoxical sleep”;
• Respiration is irregular, heart rate is generally
faster, blood pressure is higher…brain waves
fast and shorter;
• Dreaming occurs;
Clinical evaluation & diagnosis of
1. The nose, one should look for asymmetry of the nares, a large
septal base, collapse of the nasal valves during inspiration, a
deviated septum or enlargement of the inferior nasal turbinates.
2. The oropharynx should be examined for the position of
the uvula in relation to the tongue.
3. The size of the tonsils should be compared with the size
of the airway.
4. The presence of a high and narrow hard palate, overlapping incisors,
a crossbite and an important overjet are indicative of a small jaw
and or abnormal maxilla-mandibular development
Objective confirmation of SDB
Testing during sleeping –SDB
Brouillette’s OSA questionnaire initially appeared
accurate in small sample, but on subsequent
studies was indeterminate in 47%
» Brouillette, J Pediatr, 1984
Parents cannot predict severity of OSA based on
» Preutthipan, Acta Paediatr, 2000
– lack specificity to distinguish OSAS from primary snoring.
» Lamm, Ped Pulm 1999
– sensitivity 94%, specificity 68%
» Sivan, Eur Respir J, 1996
• Polysomnography = sleep study
• “Gold standard”
• Only technique that allows comprehensive
monitoring of both cardiorespiratory function
and sleep noninvasively
• Polysomnography is the only test that may exclude the
diagnosis of SDB. It must always include monitoring of
sleep/wake states through electroencephalography (EEG),
electrooculography, chin and leg electromyography,
electrocardiography, body position and appropriate
monitoring of breathing.
• The American Thoracic Society has defined
their criteria for an abnormal PSG in children
• Apnea index (AI) 1/hour
• Apnea-hypopnea index 5/hour
• Peak end-tidal carbon dioxide 53 mm Hg or
• An end-tidal carbon dioxide tension 50 mm Hg for
10% of the sleep period and
• A minimum hemoglobin oxygen saturation 92%.
• The most common orofacial characteristics encountered include
a retrognathic mandible,
large neck circumference,
long soft palate (which leads to dentists’being unable to visualize the
entire length of the uvula when the patient’s mouth is open wide),
nasal septal deviation
and relative macroglossia.
• The following features are found in OSA patients on a cephalogram:
An increased incidence of maxillary retrusion (ANB < 0)
An increased incidence of mandibular retrusion(ANB > 0)
An increased incidence of maxillary and mandibular
retrusion (SNA and SNB)
The hyoid was more inferiorly and anteriorly placed
A thicker soft palate
A larger tongue; a longer pharyngeal length.
• Medical therapies
Insufflations of pharynx during sleep
Continuous positive airway pressure via nasal
• Adenotonsillectomy is the most common treatment
for childhood OSA
• Cure rate = 75-100%
» Suen, Arch Otolaryngol Head and Neck Surg, 1995
– post-op pain, poor oral intake and bleeding
– airway edema
– pulmonary edema
• 24 months of age
• OSA – 3wks of age
• Severe snoring & clinical symptoms- 6-24
• 6months of age.
• Rapid and slow maxillary distractions are performed
between 5 and 11 years of age.
• Distraction results in widening of the palate and the
nose; thus, these procedure remedies nasal occlusion
related to a deviated septum, for which little can be
done before 14 to 16 years of age.
• Surgeries, such as nasal septoplasty and other
maxillofacial surgeries, are indicated in some rare cases
but not usually seen in the pediatric population.
• Orthognathic surgery is normally postponed until 10 to
13 years of age.
• Two surgical techniques used in patients with SDB are
mandibular distraction osteogenesis
and maxillomandibular advancement
journal club Bilevel
positive airway pressure
Sequelae of OSAS in Children
– Right ventricular hypertrophy
– Left ventricular hypertrophy
– Pulmonary hypertension
– Systemic hypertension
– Cor pumonale
– Developmental delay
– Poor school performance
– Leaning problems
– Mood and behavior problems.
J. M. Battagel & P R. L'Estrange
• lateral cephalometric radiographs of 59
dentate, white, Caucasian males.
• 35patients with proven obstructive sleep
apnoea (OSA) &
• 24 –conrol
• Radiograph traced
• conventional cephalometric measurements
did not differ
European Journal of Orthodontics 18 (J996) 557-569
• significant reductions were found in the lengths
of the mandibular body and cranial base and in
cranial base angulation in OSA subjects.
• The combination of a short mandible and
intermaxillary space, with an enlarged soft palate
but decreased pharyngeal airway has relevance
to the effective management of OSA.
• Inselected patients, advancement of the lower
jaw by a nocturnal mandibular repositioning
splint may be indicated.
European Journal of Orthodontics 18 (J996) 557-569
Wilhelmsson B et al
• To compare – dental appliance &
uvulopalatopharyngoplasty for Rx of OSA
• RCT –UPPP or a dental appliance to achieve
mandibular advancement of 50% of max
• Apnea Index (AI) Apnea & Hypoxia Index(AHI)
Oxygen Distraction Index(ODI) & Snoring Index(SI).
oto laryngeal 1999; 119 : 503 -509
• Both groups show significant
AHI, ODI, & SI .
values of AI,
• dental appliance - adjunctive
Acta oto laryngeal 1999; 119 : 503 -509
• A diagnostic approach to suspected obstructive sleep
apnea in children journal of pediatrics Volume 105,
Issue 1, July 1984, Pages 10–14.
• Can parents predict the severity of childhood
obstructive sleep apnoea? Journal of acta pediatrecia
vol 89 ,issue 6 june 2000 ,708-712
• The cephalometric morphology of patients with
obstructive sleep apnoea European Journal of
Orthodontics 18 (J996) 557-569