SURGERY

1. DR ROOHIA

2. SDB
 The SDB treatment is based in three types:
 Type 1: Behavioral
 Type 2: Devices to be worn
 Type 3: Surgery

3. PEDIATRIC OSA -SEVERITY
OSA
SEVERITY
LEVEL
AHI
MILD 1-4
MODERATE 5-10
SEVERE >10

4. Management Algorithm

5. MANAGEMENT
 Any child with AHI> 5
intervention is necessary.
Surgical
 Adenotonsillectomy – First Line of therapy
 Turbinate reduction
 Craniofacial surgery-
Mandibular advancement
Lefort osteotomies and maxillary distraction.
 Uvulopalatopharyngoplasty- Not a good idea !
 Tracheostomy
Medical
 Weight loss
 Continuous positive airway pressure
 Intranasal steroids (modest effect)-Mild patients
 Leukotriene antagonist- Mild patients
 Oral appliances
 Positional therapy
 Snore aids

6. Nonsurgical management
 Pharmacotherapy considered in less severe cases of
obstructive apnea.
 neonatal rhinitis, allergic rhinitis, and acute tonsillitis
 In cases of chronic upper airway obstruction,
mechanical correction by prostheses, positive airway
pressure, or weight loss may be worth consideration.
 In most patients, those with obesity or neuromuscular
disorders in which airway dynamics are affected,
surgical management is generally considered.

7. SURGICAL MANAGEMENT
 Patients at greatest risk include
 with severe obstructive sleep apnea syndrome;
 diminished neuromuscular tone (ie, cerebral palsy);
 morbid obesity;
 skeletal and craniofacial abnormalities, such as
hypoplasia of the midface or mandible or
nasopharyngeal vault; and
 very young children (younger than age 2–3 years

8.  Surgery is often considered to be the first-line
treatment for simple snoring and mild/moderate OSA.
 Surgery is considered successful when the AHI drops
at least 50% and is below 20 per hour in patients
whose presurgical AHI was greater than 20 per hour.

9. Nasal and nasopharyngeal
obstruction
 simple as a transoral, retropalatal approach for
adenoidectomy .
 marsupialization of nasolacrimal duct cysts,
 as complex as an anterior craniofacial approach for
encephalocele.
 may require aggressive resection

10.  Bilateral choanal atresia
and stenosis of the
pyriform aperture are
causes of obstructive
apnea in neonates and
require early
intervention
 early repair with
avoidance of
tracheotomy is always
desirable

11.  choanal atresia may be
approached by either the
transpalatal or the
transnasal route
 In small children, the
procedure is best
performed using a small
rigid rod-lens telescope
and a drill with a protected
shaft. Microdebriders
designed for intranasal
surgery

12. From: Single-Stage Choanal Atresia Repair in the Neonate
Single-stage choanal atresia repair (right side demonstrated). A, Atretic plate; B, puncture with suction; C, dilation with urethral
sounds; D, widening of opening with stapes curette; E and F, removal of posterior nasal septum with backbiter; and G, panoramic
view of nasopharynx.
Figure Legend:

13.  A 120-degree telescope placed in the
mouth with the palate retracted
affords the surgeon a view of the
nasopharynx so that a urethral
sound may be safely passed through
the atretic plate
 After creation of mucosal flaps with
a sickle knife or ablation of the
mucosa with the aid of a fiber-
delivered laser, the microdebrider
can be fitted with a small round bur
to initiate
bone removal, and subsequently
with choanal atresia
 The opened choanae may be treated
with mitomycin C to reduce the risk
of restenosis and stenting for
several weeks using endotracheal
tubes

14.  In cases of pyriform
aperture stenosis
offending bone may be
approached through a
sublabial approach and
reduced using similar
instrumentation

15.  Nasopharyngeal stenosis,
once a common complication
of syphilis, may result as a
complication of
adenotonsillectomy,
uvulopalatopharyngoplasty,
or surgery for cleft palate or
velopharyngeal insufficiency
 Simple release of the scarred
area results in recurrence,
and treatment must include
the movement of fresh, well-
vascularized tissue to cover
the denuded bed

16.  Laterally based pharyngeal flap
for correction of nasopharyngeal
stenosis.
 (A) A lateral incision is made
from velopharyngeal opening into
lateral scar on one side (top) and
deepened (bottom).
 (B) Mucosal flaps are elevated
from the scar inferolaterally and
the scar is excised.
 (C)A laterally based posterior
pharyngeal flap is incised
incorporating a back cut (top),
then elevated with the underlying
muscle (center).
 Points A1 and B1 are closed to
points A and B, respectively,
covering the denuded area

17.  Z-plasty laterally based pharyngeal flaps other
advancement and rotation flaps and radial forearm
and jejunal free flaps.
 the use of intralesional steroids and topical application
of mitomycin C to the surgical site to reduce the risk of
recurrence.
 Postoperative stenting with nasopharyngeal airways or
oropharyngeal prostheses
is mandatory

18. Adenotonsillar hyperplasia and
oropharyngeal obstruction
 Exclusion Criteria
 Children with BMI > 95th percentile.
 Children with developmental delay or neuromuscular
disease.
 Children with craniofacial syndromes or asthma.
 All children showed improvement in respiratory
parameters after surgery.
 82% of children had resolution of OSA (to AHI <5).
 Improvement in all fields of OSA.

19. Powered Intracapsular
Tonsillectomy & Adenoidectomy
(PITA)
 Advantages
 Decreased pain compared to
extracapsular tonsillectomy.
 Reduced dehydration.
 Reduced need for analgesics
(narcotics).
 Earlier return to normal diet.
 Lower risk of hemorrhage.
 Fewer exposed blood vessels.
 Improves PSG and OSA scores.
 Disadvantages
 Risk of tonsil re-growth.
 Risk of recurrent tonsillitis.
 Longer surgery.
 Four minutes.
 More blood loss.
 Fifteen cc.

20.  Risk Factors for Postoperative Respiratory Complications in Children with
OSAS undergoing Adenotonsillectomy
 Age Younger than 3 years
 Severe OSAS on PSG
 Obesity
 Prematurity
 Recent URI
 Craniofacial abnormalities
 Neuromuscular disorders

21. Macroglossia and the ptotic tongue
 Children with
macroglossia generally
have Beckwith-
Wiedemann
syndrome(macroglossia,
omphalocele,
visceromegaly, cytomegaly
of the adrenalcortex);
 Down syndrome; or
 vascular malformation of
the tongue

22.  Complications of macroglossia include aberrant dental
eruption and malocclusion, maldevelopment of the
maxilla and mandible, excessive drying of the tongue
with ulceration, and airway obstruction

23.  resection of the lingual
margin or a wedge resection
with or without aggressive
resection at the foramen
cecum
 suture suspension of the
tongue and radiofrequency
ablation
 Lymphatic malformations
that are limited to the
superficial layers of the
tongue (lymphangioma
circumscriptum) may be
ablated using a carbondioxide
laser

24.  venous malformations of the tongue may be reduced
considerably using a combination of superficial and
intralesional neodymium:yttrium-aluminum-garnet
laser therapy, alcohol sclerosis, or excision

25.  Ductal cysts of the vallecula may present with sleep-
disordered breathing in neonates
 Lateral radiograph of the upper airway may be useful
when the diagnosis is suspected. The lesion is
managed by marsupialization using cold steel, laser, or
microdebrider; laser applied to the base helps to
control hemorrhage

26. Hypoplasia of the midface and
mandible
 Upper airway obstruction caused by hypoplasia of the
midface and mandible is usually associated with
craniofacial syndromes
 Micrognathia caused by Pierre Robin syndrome often
improves within the first 2 years of life without
surgical intervention for the mandible

27.  symptoms are more severe,
temporary repositioning of
the ptotic tongue by
labioglossopexy
 procedure carries the risks
of dehiscence, tongue
lacerations, and
deformation of the lip and
speech impairment caused
by scar formation
 Subperiosteal release of
the floor of the mouth has
also been reported

28. Distraction osteogenesis
 First described in 1969 by Ilizarov and Lediaev [116] in
the treatment of limb length discrepancies, osteotomy
with distraction of bone is now widely accepted as the
procedure of choice in the early management of airway
obstruction caused by craniofacial disproportion

29. Distraction osteogenesis
 advantage of the rapid healing and capacity for growth
in the pediatric Skeleton
 PREOP -undergo airway endoscopy and craniofacial
assessment by three-dimensional CT scanning.
 Airway patency is estimated in relaxed and jaw-thrust
positions, and precise bony measurements are taken
from the scan.

30.  Distraction osteogenesis
is divided into four
phases:
 (1) surgery,
 (2) distraction,
 (3) consolidation,
 (4) removal

31.  After a lag phase of 24 to 72
hours, distraction is started.
Distraction may progress at a
rate of 1 to 2 mm per day, with
adjustments of 1 mm every 12 to
24 hours.
 Once the desired length of the
mandible has been achieved,
adequacy of the airway is
verified by flexible or rigid
laryngoscopy before
consolidation.
 In children who already have a
tracheostomy, downsizing and
bedside occlusion can be
performed

32.  The consolidation phase
is approximately 8
weeks, but should last at
least two times as long as
the distraction period.
 The hardware may be
left in place during this
time. The final stage is
removal of the hardware
and minor scar revision.

33.  Patients with Pierre Robin sequence or mandibular
hypoplasia have shown significant improvement in flow
limitation with mandibular advancement.
 Large meta-analysis of 1185 patients included 88
tracheotomized patients for poor airways.
 78.4% decannulation rate after distraction.
 97% of children and 100% of adults with OSA were cured of
symptoms.
 Patients with high-arched palates or craniofacial
abnormalities resulting in maxillary narrowing benefit
from Lefort osteotomies and maxillary distraction.
 Can be curative.
 Enlarges nasal cavity.
 Enlarges lateral diameter of palate and oropharynx.

34. Tracheostomy
 Tracheostomy is an effective for upper airway obstruction.
 Often avoids a difficult postoperative course.
 Provides an immediate improvement in symptoms.
 Can be used as a temporizing measure in patients until skeletal
expansion and soft-tissue reduction can be performed.
 Syndromic patients
 Craniosynostosis patients
 Not perfect.
 Complications
 Stoma narrowing
 Plugging
 Accidental decannulation
 Deleterious effect on psychosocial function of patients and families

35. AAP GUIDELINES
Screening of all children for snoring
Specialty referral of complex high-risk patients
Urgent evaluation of cardio-respiratory failure
PSG as Gold Standard for diagnosis
Adenotonsillectomy as first-line treatment
Inpatient monitoring of high-risk patients
Post-operative reevaluation to determine if additional
treatment is required

36. THANK YOU