This document discusses pediatric obstructive sleep apnea syndrome (OSAS). It provides definitions of OSAS and reviews the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment options. Regarding treatment, adenotonsillectomy is discussed as the most common initial treatment for childhood OSAS, while CPAP, oral appliances, orthodontic interventions, and other surgical procedures are also reviewed. The document concludes by discussing sequelae of untreated OSAS in children and references several studies on OSAS diagnosis and management.

1. Pediatric obstructive sleep apnea
syndrome : time to wake up
Veena Arali, Srinivas Namineni, Ch Sampath
IJCPD , JAN-APRIL 2012, 5 (1)

2. Introduction
“On Some Causes Backwardness
In Children”
11/22/2013
journal club
2

3. History
• OSAS – 1966
• PMC
• In 1976
11/22/2013
journal club
Guilleminault et al jop
3

4.  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
and abdomen
 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
11/22/2013
journal club
4

5. Definition
• 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.
11/22/2013
journal club
5

6. Epidemiology
• 8-12%
• 1-3%
• 5-6%
11/22/2013
journal club
6

7. Physiology of breathing and
sleep
• Upper air way resistance
11/22/2013
journal club
7

8. Types of sleep
• There are five stages of sleep; four stages are
considered non-REM sleep and one stage of
REM sleep
11/22/2013
journal club
8

9. What is REM sleep?
• Rapid eye movement..during a sleep period
(eyes dart from right to left) stimulates occular
muscles;
• 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;
11/22/2013
journal club
9

10. EPIDEMIOLOGY
•
11/22/2013
journal club
10

11. Pathophysiology
11/22/2013
journal club
11

12. Pathophysiology
• Role of the Tonsils & Adenoids
11/22/2013
journal club
12

13. Role of upper airway
neuromotor tone
• Children with OSAS – ventilatory drive
• Neuromotor function- abnormal
• Accessory muscles- hypoxemia , hypercapnia
11/22/2013
journal club
13

14. • Role of Arousal
• Role of structural factors
• Role of genetic factors
11/22/2013
journal club
14

15. Clinical Symptoms
• Vary with the age
11/22/2013
journal club
15

16. 11/22/2013
journal club
16

17. Clinical evaluation & diagnosis of
SDB
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
11/22/2013
journal club
17

18. Objective confirmation of SDB
•
•
•
•
•
Testing during sleeping –SDB
Questionnaires
Home monitoring
Ambulatory monitoring
Polysomnography
11/22/2013
journal club
18

19. • Questionnaires
 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
their observations
» Preutthipan, Acta Paediatr, 2000
11/22/2013
journal club
19

20. Home monitering
Audiotapes
– lack specificity to distinguish OSAS from primary snoring.
» Lamm, Ped Pulm 1999
Videotapes
– sensitivity 94%, specificity 68%
» Sivan, Eur Respir J, 1996
11/22/2013
journal club
20

21. Diagnosis
PSG
• Polysomnography = sleep study
• “Gold standard”
• Only technique that allows comprehensive
monitoring of both cardiorespiratory function
and sleep noninvasively
11/22/2013
journal club
21

22. Polysomnography
• 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.
11/22/2013
journal club
22

23. • The American Thoracic Society has defined
their criteria for an abnormal PSG in children
as follows:
• 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%.
11/22/2013
journal club
23

24. 11/22/2013
journal club
24

25. Orofacial implications
11/22/2013
journal club
25

26. • The most common orofacial characteristics encountered include
 a retrognathic mandible,
 narrow palate,
 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),
tonsillar hypertrophy,
 nasal septal deviation
 and relative macroglossia.
11/22/2013
journal club
26

27. • 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.
11/22/2013
journal club
27

28. Treatment
• Adenotonsillectomy
• Medical therapies
 Nasopharyngeal airway
Insufflations of pharynx during sleep
Continuous positive airway pressure via nasal
mask
• Tracheostomy
11/22/2013
journal club
28

29. • Pharmacological
– Topical nasal steroids
– Antibiotics
– Nasal decongestant
– Weight loss
• Other surgical therapies
– Craniofacial surgical procedures
– Mandibular/maxillary plastic surgical procedures
– Stenting procedures for nasal stenosis
– Cleft palate revision procedures
– Uvulopalatopharyngoplasty
11/22/2013
journal club
29

30. Adenotonsillectomy
• Adenotonsillectomy is the most common treatment
for childhood OSA
• Cure rate = 75-100%
» Suen, Arch Otolaryngol Head and Neck Surg, 1995
• Complications
– anesthetic
– post-op pain, poor oral intake and bleeding
– airway edema
– pulmonary edema
11/22/2013
journal club
30

31. • 24 months of age
• OSA – 3wks of age
• Severe snoring & clinical symptoms- 6-24
months
• 6months of age.
11/22/2013
journal club
31

32. Orthodontic treatment
• RMD
• SMD
• 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.
11/22/2013
journal club
32

33. Oral appliances
11/22/2013
journal club
33

34. Surgical treatment
• 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
11/22/2013
journal club
34

35. CPAP
11/22/2013
journal club Bilevel
positive airway pressure
35

36. Sequelae of OSAS in Children
• Cardiopulmonary:
– Right ventricular hypertrophy
– Left ventricular hypertrophy
– Pulmonary hypertension
– Systemic hypertension
– Cor pumonale
– Polycythemia
11/22/2013
journal club
36

37. • Neurodevelopmental:
– Developmental delay
– Hypersomnolence
– Poor school performance
– Leaning problems
– Hyperactivity
– Mood and behavior problems.
11/22/2013
journal club
37

38. 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
11/22/2013
journal club
38
European Journal of Orthodontics 18 (J996) 557-569

39. • 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.
11/22/2013
European Journal of Orthodontics 18 (J996) 557-569
journal club
39

40. 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
protrusive capacity.
• Apnea Index (AI) Apnea & Hypoxia Index(AHI)
Oxygen Distraction Index(ODI) & Snoring Index(SI).
11/22/2013
journal Acta
club
oto laryngeal 1999; 119 : 503 -509
40

41. • Both groups show significant
AHI, ODI, & SI .
values of AI,
• dental appliance - adjunctive
11/22/2013
journal club
Acta oto laryngeal 1999; 119 : 503 -509
41

42. Conclusion
11/22/2013
journal club
42

43. References
• 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
11/22/2013
journal club
43

44. 11/22/2013
journal club
44