Surgery for paediatric sleep apnea

SURGERY FOR PAEDIATRIC SLEEP APNEA

DR ROOHIA

SDBThe SDB treatment is based in three types:Type 1: BehavioralType 2: Devices to be wornType 3: Surgery

PEDIATRIC OSA -SEVERITY OSA SEVERITY LEVEL

AHI

MILD 1-4

MODERATE 5-10

SEVERE >10

Management Algorithm

MANAGEMENTAny 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

Nonsurgical managementPharmacotherapy considered in less severe cases of

obstructive apnea.neonatal rhinitis, allergic rhinitis, and acute

tonsillitisIn 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.

SURGICAL MANAGEMENTPatients 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

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.

Nasal and nasopharyngeal obstructionsimple 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

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

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

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:

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

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

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

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 (bottom).

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

Adenotonsillar hyperplasia and oropharyngeal obstructionExclusion 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.

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.

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

Macroglossia and the ptotic tongueChildren with

macroglossia generally have Beckwith-Wiedemann syndrome(macroglossia, omphalocele, visceromegaly, cytomegaly of the adrenalcortex);

Down syndrome; or vascular malformation

of the tongue

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

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

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

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

Hypoplasia of the midface and mandibleUpper 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

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

Distraction osteogenesisFirst 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

Distraction osteogenesisadvantage of the rapid healing and capacity

for growth in the pediatric SkeletonPREOP -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.

Distraction osteogenesis is divided into four phases:

(1) surgery, (2) distraction,(3) consolidation, (4) removal

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

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.

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.

TracheostomyTracheostomy 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

AAP GUIDELINESScreening of all children for snoringSpecialty referral of complex high-risk

patients Urgent evaluation of cardio-respiratory

failurePSG as Gold Standard for diagnosisAdenotonsillectomy as first-line treatmentInpatient monitoring of high-risk patientsPost-operative reevaluation to determine if

additional treatment is required

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