Sleep Apnea & Tongue Tie

Question 1

What % of children have Sleep Disordered Breathing (SDB)

Answer 1

5-10%

Question 2

What % children have OSA?

Answer 2

1-3%

Question 3

Why is there a increase in OSA among preschool children?

Answer 3

Relative increased in size of tonsils and adenoids compared to pharyngeal airway

Question 4

Contributing Factors to Pediatric Sleep Apnea (2):

Answer 4

Tonsil hypertrophy (75% of children)

Obesity (20% of children, mostly in older kids) –> not as big a contributor

Question 5

Clinical Signs of Sleep Apnea in kids:

Answer 5

Snoring

Witness apnea

Restless sleep

Chronic Nasal Symptoms (runny nose, allergies)

Question 6

Michigan Pediatric Sleep Questionaire, 22questions. What % indicates apnnea?

Answer 6

33+%

Question 7

In Children there is a link between sleep apnea and ___

Answer 7

ADD/ADHD

Question 8

What is stertor?

Answer 8

heavy snoring upon inspiration, noise from the upper airways

Question 9

Anatomical features with OSA risk?

Answer 9

Large Nasal turbinates

Glossoptosis (tongue fell posteriorly)

Big tonsils

Retro/Micro gnathic

Question 10

Tonsil Grading

Answer 10

0 no tonsils
1 tonsils in pillars
2 tonsils extending to pillars
3 tonsils beyond pillars
4 tonsil touching at midline

Question 11

What type of sleep patient profile may NOT require additional testing?

Answer 11

SDB patient with obvious reason (e.g. Grade 3/4 tonsils)

Question 12

What sort of sleep patient should have further testing?

Answer 12

SDB patient with small tonsils, other symptoms like epistaxis, dysphagia (AKA abnormal clinical presentation)

–> assess Adenoids, Tongue base, pharynx

Question 13

What is the gold standard for OSA diagnosis for children?

Answer 13

In lab sleep study

(FYI: Not absolutely necessary before tonsillectomy)

Question 14

Do you have to have a sleep study to perform a tonsillectomy?

Answer 14

NO. Witnessed apnea by a caregiver is enough.

Question 15

Diagnosis of Sleep Apnea in Children

Answer 15

Apnea = no airflow for 2 breaths (5)

Hypopnea = 50% reduction in airflow associated with arousal (30%) or desat of 3% (4%)

Question 16

OSA grading children

Answer 16

Mild: AHI 1-5 (5-15) per hour
Moderate: AHI 5-10 (15-30) per hour
Severe: AHI >10 (>3) per hour

Question 17

Why isn’t CPAP used regularly in kids?

Answer 17

Long term use can alter growth of the midface

Poor compliance

Question 18

What are medical therapies for OSA/SDB?

Answer 18

good for mild apnea

Intranasal steroids –> Systemic Montelukast –> shrink adenoids tissue
Black box: neurocognitive issues

Question 19

When is a sleep endoscopy indicated?

Answer 19

Persistent snoring after T&A

Question 20

Which anatomical structure contribute to sleep apnea?

Answer 20

Tonsils & Adenoids

Base of Tongue

Larynx

Nose

Question 21

How effective is T&A surgery?

Answer 21

Cures 65% of pediatric OSA

Question 22

What is the most successful surgery to cure sleep apnea?

Answer 22

Orthognathic surgery

Question 23

Which kids need to stay overnight after tonsil surgery?

Answer 23

<3yo; but ok to go home after adenoidectomy

Question 24

Which patients req sleep study prior to surgery?

Answer 24

BMI >98%
Neuromuscular disorder
Sickle Cell Anemia
Craniofacial disorder
Storage disease (mucopolysach)
Down Syndrome

AHI>10; sat nadir <80%
To assess if overnight admission is required

Question 25

What is the gold standard in tonsillectomy?

Answer 25

"Extracapsular" tonsillectomy --> removal of entire palatine tonsil, no regrowth 2-5% post-op bleeding rate

Question 26

Considerations for intracapsular tonsillectomy:

Answer 26

Partial debulking of tonsil <3% chance of regrowth Lower risk of post-op bleeding Faster recovery Higher risk of symptom recurrence (~5%)

Question 27

Adenoidectomy overview

Answer 27

Low Risk of bleeding Higher recurrence risk in <2yo patients, concurrent allergic rhinitis

Question 28

Management of patient with tongue base obstruction?

Answer 28

T&A still first line - hyponia, down syndrome Exception: Pierre Robin Sequence

Question 29

Pierre Robin Sequence presentation

Answer 29

Micrognathia Glossoptosis (tongue fell back) + airway obstruction Cleft palate

Question 30

Mandibular Distraction Osteogenesis

Answer 30

--> relieve airway obstruction micrognathia/glossoptosis CI: Neuromuscular disorder, pulmonary disease

Question 31

Distraction osteogenesis work flow

Answer 31

1) Place device 2) Wait a few days 3) increase 0.75m 2x/day for 10 days 4) 6 weeks healing, remove device

Question 32

Risks associated with distraction osteogenesis

Answer 32

1) Damage to teeth 2) Cyst formation