G Model PEDOT 7109 No. of Pages 5

International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl

Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea Christopher T. Wootten *, Sivakumar Chinnadurai, Steven L. Goudy Department of Otolaryngology, Division of Pediatric Otolaryngology, Vanderbilt University, Nashville, TN, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 1 December 2013 Received in revised form 10 March 2014 Accepted 20 April 2014 Available online xxx

Objectives: In this study we determine the subjective and objective outcomes of pediatric patients with refractory OSA undergoing drug-induced sleep endoscopy (DISE)-directed surgical treatment. Methods: 31 consecutive children with OSA following TA underwent DISE. 26 completed DISE-directed operative management of the level(s) of ongoing upper airway obstruction. Pre- and postoperative OSA were assessed through a detailed history (of nighttime symptoms (NS) and daytime symptoms (DS)), physical examination, and polysomnography. Results: Age ranged 5–18 years (mean 9.7  3.4). Fourteen of 26 had trisomy 21 (51%). Operations were performed in the following frequencies: lingual tonsillectomy (LT) (22), midline posterior glossectomy (MPG) (16), revision adenoidectomy (11), inferior turbinate submucosal resection (7), uvulopalatoplasty (2), and supraglottoplasty (2). Overall, 92% reported subjective improvement. NS improved from 5.8  2.9 preoperatively to 2.1  2.5 postoperatively (p < 0.05), while DS improved from 2.1 1.3 preoperatively to 0.6  1.1 postoperatively (p < 0.05). Seventeen patients completed preoperative polysomnography, while only 11 of them also completed postoperative polysomnography. Mean OAHI fell from 7.0 (5.8) events/ hr to 3.6 (1.8) events/hr (t-test, p = 0.09). Conclusions: Individualized, multilevel, DISE-directed operative therapy was associated with substantial improvement in subjective measures of sleep. ã 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Sleep endoscopy MRI Apnea Obstructive sleep apnea Pediatric sleep Tonsillectomy

1. Introduction Obstructive sleep apnea (OSA) occurs in 1–10% of children [1,2], and the effects of untreated OSA range from cardiopulmonary dysfunction to neurocognitive delay and learning disabilities in the classroom [3]. Adenotonsillectomy is the first-line therapy for most children with OSA, with a wealth of data indicating a positive response [4]. Indeed, most patients with an abnormal sleep study based on the obstructive apnea-hypopnea index (OAHI) improve with adenotonsillectomy regardless of the size of the tonsils or the severity of the sleep symptoms reported by the guardians [5,6]. In contrast, for the children who fail to improve or have a substantial remission of their OSA after adenotonsillectomy based on

* Corresponding author at: Monroe Carell Jr. Children’s Hospital at Vanderbilt, Doctors’ Office Tower, 7th Floor, 2200 Children’s Way, Nashville, TN 37232-9307, United States. Tel.: +1 615 936 8176; fax: +1 615 875 0101. E-mail address: [email protected] (C.T. Wootten).

postoperative polysomnography, the treatment recommendations reported in the literature are highly disparate. Continuous positive airway pressure (CPAP) ventilation, multilevel operations in the pharynx, craniofacial framework surgery, and tracheotomy are all described, depending on the level(s) of ongoing collapse and other patient factors [7,8]. Some sense of the level(s) of collapse causing ongoing OSA can be diagnosed through a careful history and physical examination, including in-office endoscopic evaluation. However, sleep imaging and drug-induced sleep endoscopy (DISE) provide a more anatomically comprehensive and physiologic view of the entire upper airway during sleep [9,10], and they are well tolerated by the pediatric patient. Families of children with refractory OSA were offered sleep medicine consultation to consider CPAP and other nonsurgical therapies (montelukast, nasal steroids, and antihistamines in patients with upper airway obstruction worsened by atopic disease). Those who were unwilling to initiate CPAP or unsuccessful with CPAP or medical management were offered DISE and directed therapies. To delineate the level(s) of ongoing airway

http://dx.doi.org/10.1016/j.ijporl.2014.04.041 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: C.T. Wootten, et al., Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.041

G Model PEDOT 7109 No. of Pages 5

2

C.T. Wootten et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx

obstruction, we performed DISE in 26 consecutive children with persistent obstructive sleep apnea after adenotonsillectomy. Using DISE-directed multi-level operations to correct persistent OSA, a majority of patients achieved improvement in their OSA. 2. Methods Vanderbilt IRB approval was obtained to review the electronic medical records, and the following data were extracted: date of operation, type of operation, pre- and postoperative clinical symptoms, pre- and postoperative body mass index (BMI), preand postoperative polysomnographic (PSG) data, overall sense of improvement, medical comorbidities, and basic demographical data. Statistical analysis was performed on standard spreadsheet software. The technique of manual bolus drug-induced sleep endoscopy has been described elsewhere [11]. After temporarily maskventilating the patient under sevoflurane/nitrous oxide inhalational anesthetic to secure peripheral intravenous access, our anesthesiologists used propofol (1 mg/kg boluses throughout the DISE to maintain the appropriate plane) to achieve an “asleep but spontaneously breathing” state that mimicked natural supine sleep. Due to cost concerns for such a short procedure, a bispectral analysis monitor (BIS) was not employed. The flexible endoscope was then passed from the naris to the larynx on both sides without any topical premedication of the nasal, oral, or oropharyngeal passageways. A careful assessment was made of fixed obstructions (septal, turbinate, adenoid, and lingual tonsillar-based obstructions) as well as dynamic obstructions that were accentuated under a spontaneously breathing plane of anesthesia due to Bernoulli forces in the airway. Dynamic obstructions included posterior displacement of the palate seen on inspiration, glossoptosis, which may exist in isolation or exacerbate lingual tonsillar hypertrophy, and collapse of the supraglottic larynx. Static and dynamic obstructions that filled or nearly filled the airway at that level were deemed significant and were targeted for therapy. While the VOTE (Velum, Oropharynx/lateral walls, Tongue base, Epiglottis) classification system [12] was not specifically employed due to our study period predating that assessment scheme, similar observations were made. That is, DISE might find no obstruction, partial obstruction with airflow limitation, or complete obstruction with apnea. Partially obstructive lesions that vibrated and produced audible airflow reduction (a VOTE grade 1 obstruction) and fully obstructive lesions (a VOTE grade 2 obstruction) were deemed targets for surgical therapy. Both the DISE and the subsequent operations to correct levels of airflow obstruction were performed under the same anesthetic, and we counseled patients a priori about the risks and benefits of the definite procedure (DISE itself) and the possible procedures DISE might recommend. Therefore, levels of obstruction selected for operative intervention included nasal, nasopharyngeal, retropalatal, retrolingual, and supraglottic. Specifically, inferior nasal turbinates were reduced using a turbinate reduction blade affixed to a microdebrider (Medtronic, Minneapolis, MN). Following submucosal reduction, the turbinates were outfractured. Nasopharyngeal surgery consisted of revision adenoidectomy using a suction monopolar cautery. The retropalatal airspace was improved via a diamondshaped excision of the oral mucosa of the uvula and posterior soft palate with anterior rotation and suturing of the residual uvula onto the margin of the palatal incision. The retrolingual airspace was improved using lingual tonsillectomy (LT) and/or midline posterior glossectomy (MPG). A lingual tonsillectomy alone was performed if the patient had exophytic lingual tonsillar tissue and no additional glossoptosis or relative macroglossia that produced residual retrolingual airspace collapse after the LT. Likewise, MPG alone was performed when

Table 1 Daytime and nighttime symptoms assessed during pre- and postoperative clinic visits. The clinical weight assigned to each symptom is given in points (pts). Weighted value (pts) Daytime symptoms Daytime somnolence/intrusive naps Mouth-breathing Hyperactivity/attention deficit Learning difficulty Headache Growth failure Total possible Nighttime symptoms Snoring Gasping Pausing Fitful sleep Sleep walking Talking/moaning in one’s sleep Enuresis Difficult arousal in the morning Total possible

2 2 1 1 1 1 8

1 2 3 1 1 1 2 1 12

glossoptosis and/or macroglossia partially or fully obstructed the retrolingual airspace in the setting of nominal lingual tonsil tissue. When both large lingual tonsils and glossoptosis/relative macroglossia were present simultaneously, both operations were performed. Lingual tonsillectomy was performed using a Coblator Evac70 wand (ArthroCare, Austin, TX) on settings of 7 ablate and 3 coagulate to contour the hypertrophic lingual tonsillar tissue. Midline posterior glossectomy was performed after a Doppler device was used to isolate and mark the lingual arteries. A midline incision was made with monopolar cautery starting approximately 2 cm anterior to the circumvallate papilla and continuing posteriorly towards the vallecula. The wound was distracted open with retraction sutures, while a Coblation wand was used to remove tongue muscle submucosally between the boundaries of the lingual arteries and 1–1.5 cm deep into the tongue. The midline wound was primarily closed at the end with interrupted absorbable sutures. At the level of the larynx, significant supraglottic collapse was treated with a supraglottoplasty, using microlaryngeal scissors to release aryepiglottic folds and excise bulky supra-arytenoid tissue. A clinical index was created prior to data compilation and analysis to describe daytime and nighttime symptoms related to sleep-disordered breathing as observed by the patients’ guardians based on standard questions asked during each clinical encounter (Table 1). These symptoms were assigned point values. Specifically, for the nighttime symptoms, pausing (3 points) was deemed worse than gasping (a partial airflow obstruction worth 2 points), which was worse than simple snoring (worth 1 point). Because enuresis has been associated with OSA independent of obesity [13], the occurrence of secondary enuresis was given 2 points, while the remaining parasomnias received one point. Concerning the daytime symptoms, mouth-breathing and intrusive naps have been shown to be associated with OSA with a higher specificity than other daytime symptoms [14], and these were given a greater weight. The same questions were asked pre- and postoperatively to each patient’s guardian, and the change in symptom severity was assessed by comparing the change in points. 3. Results Thirty-one patients underwent DISE for OSA refractory to or recurrent after adenotonsillectomy. After hearing the risks, benefits, and alternatives to multilevel sleep operations 5/31 families elected to undergo DISE only to assess what levels of

Please cite this article in press as: C.T. Wootten, et al., Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.041

G Model PEDOT 7109 No. of Pages 5

C.T. Wootten et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx Table 2 The types of operations performed following DISE and their frequencies in 26 children with refractory OSA. DISE-directed operations

Number performed in 26 patients

Lingual tonsillectomy Midline posterior glossectomy Revision adenoidectomy Inferior turbinate reduction Uvulopalatoplasty Supraglottoplasty

22 16 11 7 2 2

obstruction were ongoing. These 5 opted for nonsurgical management of the obstruction(s) DISE discovered, and their outcomes data are not analyzed herein. Data is available for 26/31 children who underwent both DISE and multilevel sleep operations directed by DISE. The mean age at operation was 9.3 (3.4) years. Males and females were evenly present in the study (13 each). The mean BMI at operation was 24.7 (6.3) kg/m2 (median = 24 kg/m2, range 16.5–35.3 kg/m2). Mean Z-score adjusted BMI at operation was >1.66 (0.61). The mean last recorded BMI was 24.3 (6.3) kg/ m2. Fourteen (54%) had Down syndrome (DS), and 1 patient had a 22q11.2 deletion syndrome (Opitz G/BBB). The remaining 11 patients were nonsyndromic. The range of time between adenotonsillectomy and DISE-directed therapies was 1–5 years. The range of followup since DISE-directed therapies is 5 months to 4 years. All 31 DISE evaluations were performed by the same surgeon (C. W.). Sleep endoscopy typically revealed multilevel collapse, and 3/ 26 patients underwent only single-level operation (2 underwent LT; 1 underwent MPG). Twenty-three patients underwent multilevel operation. Operations were performed in the following frequencies: LT (22), MPG (16), revision adenoidectomy (11), inferior turbinate submucosal resection (7), uvulopalatoplasty (2), and supraglottoplasty (2) (Table 2). Significant intraoperative bleeding occurred during one LT, which was controlled with oropharyngeal packing and treated with endovascular coagulation with Onyx (Covidien, Plymouth, MN). The patient was intubated overnight and suffered no additional consequences. No other patient left the operating room intubated, and none required reintubation in the postoperative phase. The longest hospital stay was 2 nights.

3

Table 3 Data set including age, BMI and Z-score at operation, pre- and postoperative obstructive index (AHI) and postoperative outcomes for 11 patients who completed pre- and postoperative PSG. Age (years)

BMI (kg/ m 2)

Z-score

Preop. obstructive index (events/hr)

Postop. obstructive index (events/hr)

Outcome

13

27.7

>1.8

5.1

6.1

6

17.5

>1.3

6.0

6.3

13 11 6 5 6 11 4 4 10

35.3 16.5 19.4 20.1 17.2 26.0 20.9 17.5 30.2

>2 > 0.5 >1.8 >2 >1.1 >1.9 >2 >1.4 >2

7.5 23.8 2.8 6.5 3.8 5.0 4.7 3.5 8.5

1.5 3.9 2.8 2.1 3.8 0.6 3.5 4.4 5.0

Attempted CPAP Attempted CPAP Observation Observation Observation Observation Observation Observation Observation CPAP CPAP

Mean = 8.1 Mean = 22.6 Mean > 1.5 Mean = 7.0 SD = 3.5 SD = 6.3 SD = 0.74 SD = 5.8

Mean = 3.6 SD = 1.8

Outcomes measured included changes in daytime symptoms, nighttime symptoms, change in obstructive AHI (OAHI), nadir oxygen saturation and overall satisfaction with postsurgical improvement in airflow. Daytime symptoms fell from 2.5 (1.6) preoperatively to 0.8 (1.0) postoperatively (t-test, p < 0.001). Nighttime symptoms fell from 6.0 (2.7) preoperatively to 1.9 (2.2) postoperatively (t-test, p < 0.001) (Fig. 1). A sub-analysis of daytime and nighttime symptoms lacked power to be conclusive. Eleven patients had a complete pre- and postoperative polysomnography data set (Table 3). Mean OAHI fell from 7.0 (5.8) events/hr to 3.6 (1.8) events/hr (t-test, p = 0.09). Likewise, nadir oxygen saturation changes did not reach statistical significance. Overall patient satisfaction with postsurgical improvement in airflow (measured as a “yes” or “no” binary response) was 92% (Fig. 2). Two families did not feel sleep-disordered breathing and/or daytime symptoms improved following operation, and for the 1 patient that completed postoperative polysomnography, the PSG

Fig. 1. Mean daytime and nighttime symptom scores associated with sleep-disordered breathing and measured in points both improved from preoperatively to postoperatively (p < 0.001) in 26 children undergoing DISE-directed operations for obstructive sleep apnea.

Please cite this article in press as: C.T. Wootten, et al., Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.041

G Model PEDOT 7109 No. of Pages 5

4

C.T. Wootten et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx

Fig. 2. Overall patient satisfaction with improvement in airflow during sleep as reported by the caregivers of 26 children who underwent DISE-directed operations for obstructive sleep apnea.

was worse postoperatively. Two additional patients with “satisfactory” results also demonstrated worsening on polysomnography. These 4 patients underwent MPG + LT, LT + adenoidectomy, LT + adenoidectomy, and MPG + adenoidectomy. Two of the 4 failures were syndromic (one patient had Down syndrome and another had 22q11.2 deletion syndrome). Overall, a Fisher exact test was performed to determine whether the presence of Down syndrome or male sex were associated with a higher failure rate by symptom score or PSG, and there was no statistically significant correlation. 4. Discussion While PSG confirms the presence of OSA, it does nothing to elucidate the level(s) of airway collapse. In our series, druginduced sleep endoscopy diagnosed levels of obstruction from the nasal passageways to the larynx and directed operative treatment in 26 pediatric patients with OSA that recurred or persisted following adenotonsillectomy. Operative management of each individual’s level(s) of airway collapse resulted in an overall satisfaction rate of 92% at the time of followup. DISE appears to be useful in children with ongoing OSA after adenotonsillectomy. The subjective success rate of these secondary surgeries indicated by DISE is similar to the subjective and objective success rates observed for the treatment of OSA by adenotonsillectomy in unselected populations. Stated another way, the primary OSA operation, adenotonsillectomy, fails to resolve OSA in at least 5– 15% of children [15,16]. The incidence of residual OSA after adenotonsillectomy is elevated in the setting of a high preoperative OAHI [2], a syndrome and/or obesity [17]. The present study addresses this failure group to some extent (half of our patients were syndromic) with DISE-directed multilevel surgery for residual or recurrent OSA. Our study suggests that the majority of these children benefit from secondary operations, but again around 8% will subjectively fail to improve and will go on to require a tertiary therapy. DISE is a useful tool to assess the anatomy of residual/recurrent OSA after adenotonsillectomy. In a large adult series examining the level(s) of residual/recurrent obstruction after tonsillectomy + some additional palate or palate + tongue-related surgery, retropalatal obstruction was seen in a majority of patients [10]. In the same study, retrolingual obstruction (termed “hypopharyngeal obstruction”) was nearly universal. Excepting patients who had undergone prior palate surgery with hyoid suspension, the tongue base was felt to cause hypopharyngeal obstruction in a majority of treatment failures. While this study established DISE as a means to determine anatomically how patients fail upper airway operations for OSA, another adult study went further and

evaluated the success of DISE directed operations for refractory OSA. Fifty-three percent of patients were nonresponders to DISEdirected operations for OSA that included palatal surgery and/or radiofrequency ablation of the tongue base and/or hyoid suspension [18]. Our study attempts to answer similar questions in a pediatric population – whether DISE directed therapies, including multilevel upper airway operations for refractory OSA work. At the time of writing, our subjective results seem more encouraging, with 92% reporting improvement. There are few common characteristics among the 4 patients that either subjectively or objectively failed to improve after DISEdirected surgery. All 4 patients required tongue base operations, but LT and MPG were common procedures in this series. Two patients were syndromic (22q11.2 deletion syndrome, Down syndrome), while the remaining 2 were nonsyndromic. Tongue base obstruction occurred at a higher frequency in children with Down syndrome than in controls in a previously published report of DISE for OSA [19]. A single published report exists describing OSA in a patient with 22q11.2 deletion syndrome that failed to resolve after tonsillectomy, and tongue base obstruction secondary to micrognathia was causally implicated [20]. Neither of these studies provides long-term outcomes regarding the success or failure of tongue base operations in children with certain syndromes who had failed adenotonsillectomy. In our study, 1 of the patients who reported subjective improvement but demonstrated a slight increase in OAHI postoperatively had markedly different electroencephalographic data on the two studies. The patient’s initial PSG demonstrated 4.5% REM sleep, while the followup study demonstrated 19% REM sleep. As such, the preoperative study may have simply underestimated the OAHI, explaining the patient’s sense of improvement postoperatively, where the OAHI was slightly worse. Certainly, the present study is not without limitations. The data are uncontrolled, and well-designed studies on the natural history of OSA in children eligible for adenotonsillectomy demonstrate objective “normalization” of PSG across 7 months of watchful waiting in 46% [17]. It is difficult to estimate the frequency of OSA improvement without operation or CPAP that can be expected in a group that has already failed adenotonsillectomy. Further, our followup interval is as little as 5 months for a few individuals, and no more than 4 years for any in the study. Therefore, the durability of the benefit conferred by these DISE-directed operations remains in question. As an example, uvulopalatopharyngoplasty (UPPP) and MPG were performed simultaneously in 34 adult patients with severe OSA. At 6 months, 79% were “cured” by normalization of AHI, while that number had fallen to 20% at 5 years [18]. If a similar decline in benefit is seen over time in our study population, the value of improved sleep and its potential benefit to daytime cognitive function in growing, school-aged children may still outweigh the cost of an operation that is statistically likely to fail over a period of years. Furthermore, objective improvements in the OAHI are not demonstrated in the present study, as the mean OI, which improved from 7.0 (5.8) events/hr preoperatively to 3.6 (1.8) events/hr postoperatively, failed to reach statistical significance (ttest, p = 0.09). Too few patients in the study had a complete (preoperative and postoperative) PSG data set to render these data meaningful. This stems from several factors: the study is retrospective, PSGs obtained outside of the medical system were not always available in our EMR for review, and some families with children who symptomatically improved postoperatively did not wish to undergo the trouble of a postoperative study. In addition, 3 patients with symptoms of severe sleep-disordered breathing, Down syndrome and autism had attempted PSG only to have the studies aborted due to intolerance of the montage. Finally, the present study was limited by the operative repertoire we were

Please cite this article in press as: C.T. Wootten, et al., Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.041

G Model PEDOT 7109 No. of Pages 5

C.T. Wootten et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx

willing or able to employ. For example, no patient was offered the option of mandibular and/or midface advancement or hyoid suspension, and no patient was counseled to undergo tracheotomy at the time of DISE. With a broader repertoire of more-invasive operations that target the craniofacial skeletal anatomy, a different success rate may be observed. 5. Conclusions DISE is an effective tool to delineate the level(s) of airflow obstruction in children with obstructive sleep apnea who have already undergone adenotonsillectomy. Furthermore, the operations guided by DISE seem to produce subjective benefits for most children when performed under the same anesthetic. A trend towards objective benefit was also demonstrated, but the change in the obstructive index failed to reach significance, with too few patients having a complete PSG data set. A prospective trial is needed to evaluate the objective benefits, held against the standard of preoperative and postoperative polysomnography and validated clinical instruments Conflict of interest The authors have no conflicts of interest to disclose. References [1] J.C. Lumeng, R.D. Chervin, Epidemiology of pediatric obstructive sleep apnea, Proc. Am. Thorac. Soc. 5 (February (2)) (2008) 242–252. [2] M.S. Schechter, Section on Pediatric Pulmonology SoOSAS. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome, Pediatrics 109 (April (4)) (2002) e69. [3] A.C. Halbower, E.M. Mahone, Neuropsychological morbidity linked to childhood sleep-disordered breathing, Sleep Med. Rev. 10 (April (2)) (2006) 97–107. [4] S.L. Ishman, Evidence-based practice: pediatric obstructive sleep apnea, Otolaryngol. Clin. North Am. 45 (October (5)) (2012) 1055–1069. [5] R.D.V. Mandavia, K. Kapoor, A. Rachmanidou, Quality of life assessment following adenotonsillectomy for obstructive sleep apnoea in children under three years of age, J. Laryngol. Otol. 126 (12) (2012) 5.

5

[6] R.B. Mitchell, Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography, Laryngoscope 117 (October (10)) (2007) 1844–1854. [7] S.R. Shott, Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy, Curr. Opin. Otolaryngol. Head Neck Surg. 19 (December (6)) (2011) 449–454. [8] C.H. Won, K.K. Li, C. Guilleminault, Surgical treatment of obstructive sleep apnea: upper airway and maxillomandibular surgery, Proc. Am. Thorac. Soc. 5 (February (2)) (2008) 193–199. [9] M.J. Ravesloot, N. de Vries, One hundred consecutive patients undergoing drug-induced sleep endoscopy: results and evaluation, Laryngoscope 121 (December (12)) (2011) 2710–2716. [10] E.J. Kezirian, Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy, Laryngoscope 121 (June (6)) (2011) 1320–1326. [11] A. De Vito, V. Agnoletti, S. Berrettini, E. Piraccini, A. Criscuolo, R. Corso, et al., Drug-induced sleep endoscopy: conventional versus target controlled infusion techniques – a randomized controlled study, Eur. Arch. Otorhinolaryngol. 268 (March (3)) (2011) 457–462. [12] E.J. Kezirian, W. Hohenhorst, N. de Vries, Drug-induced sleep endoscopy: the VOTE classification, Eur. Arch. Otorhinolaryngol. 268 (August (8)) (2011) 1233– 1236. [13] J.G. Barone, C. Hanson, D.G. DaJusta, K. Gioia, S.J. England, D. Schneider, Nocturnal enuresis and overweight are associated with obstructive sleep apnea, Pediatrics 124 (July (1)) (2009) e53–e59. [14] Z. Xu, D.K. Cheuk, S.L. Lee, Clinical evaluation in predicting childhood obstructive sleep apnea, Chest 130 (December (6)) (2006) 1765–1771. [15] P. Nieminen, U. Tolonen, H. Lopponen, Snoring and obstructive sleep apnea in children: a 6-month follow-up study, Arch. Otolaryngol. Head Neck Surg. 126 (April (4)) (2000) 481–486. [16] J.S. Suen, J.E. Arnold, L.J. Brooks, Adenotonsillectomy for treatment of obstructive sleep apnea in children, Arch. Otolaryngol. Head Neck Surg. 121 (May (5)) (1995). [17] R.B. Mitchell, J. Kelly, Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children, Otolaryngol. Head Neck Surg. 137 (July (1)) (2007) 43–48. [18] I. Koutsourelakis, F. Safiruddin, M. Ravesloot, S. Zakynthinos, N. de Vries, Surgery for obstructive sleep apnea: sleep endoscopy determinants of outcome, Laryngoscope 122 (November (11)) (2012) 2587–2591. [19] E. Fung, M. Witmans, M. Ghosh, D. Cave, H. El-Hakim, Upper airway findings in children with Down syndrome on sleep nasopharyngoscopy: case–control study, J. Otolaryngol. Head Neck Surg. (Le Journal d’otorhino-laryngologie et de chirurgie cervico-faciale) 41 (April (2)) (2012) 138–144. [20] C.L. Heike, A.M. Avellino, S.K. Mirza, Y. Kifle, J. Perkins, R. Sze, et al., Sleep disturbances in 22q11.2 deletion syndrome: a case with obstructive and central sleep apnea, Cleft Palate Craniofac. J. 44 (May (3)) (2007) 340– 346.

Please cite this article in press as: C.T. Wootten, et al., Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.041

Beyond adenotonsillectomy: outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea.

In this study we determine the subjective and objective outcomes of pediatric patients with refractory OSA undergoing drug-induced sleep endoscopy (DI...
405KB Sizes 0 Downloads 5 Views