Polysomnographic and Clinical Findings in Children With Obstructive Sleep Apnea Joseph Leach, MD; Jerold Olson, MD; John Hermann, PhD; Scott Manning, \s=b\ A
retrospective study was conducted to determine which
types of children might have polysomnographic findings
that are most compatible with obstructive sleep apnea (OSA). The charts of 93 patients who were aged 18 months to 12 years were examined. All 93 patients had symptoms that were initially suggestive of OSA, and they underwent polysomnography. The types of presenting symptoms and associated illnesses were noted. Physical findings, including height, weight, and tonsil size, were examined. Of 93 patients with symptoms that were suggestive of OSA, 34 met sleep study criteria for OSA. In 44 patients, OSA was not demonstrated, and 15 patients had other results. On the basis of age, sex, and symptoms, no significant differences could be found between the group with OSA and the group with normal polysomnographic findings. Cor pulmonale, tonsil hypertrophy, and failure to thrive were associated with OSA. Surprisingly, obesity was not significantly associated with OSA. (Arch Otolaryngol Head Neck Surg. 1992;118:741-744) Sir William Osier1 used the "pickwickian" refer patients with findings that included obesity, In 1912, and obstruc¬ term
to
to
hypoventilation, hypersomnolence. Airway tion during sleep was later reported in such patients by Gastaut and colleagues.2 Other investigators described cor pulmonale in patients with similar findings.3,4 By 1965, the term "obstructive sleep apnea" (OSA) had been coined,5 and by 1978, polysomnography (PSG) had been estab¬ lished as a reliable method for diagnosing the disorder.6 By 1981, case series of children with OSA began to appear in the
literature,7 and it soon became evident that adenoton-
curative in a large number of these patients.6,8"11 Although the number of tonsillectomies per¬ formed for all reasons has declined in recent years, the number performed for OSA has risen at our institution. In the adult, OSA may manifest itself by a number of primary and secondary symptoms. Obesity is seen in the majority of adult patients with OSA.12 Other common include snoring, daytime hypersomnolence, poly-
sillectomy
was
findings
cythemia, hypertension, cardiac arrhythmias, nightmares, somnambulism, and twitching during sleep.12 Obstructive sleep apnea is also commonly seen in adults with short, thick necks and redundant soft palate tissue.8,12 In children, however, the presentation of OSA may be less clear. It has been shown that obese, hypersomnolent Accepted
for
publication
October 14, 1991.
Department of Otolaryngology, University of Texas Southwestern Medical School, Dallas (Drs Leach, Olson, and Manning), and the Sleep Disorders Center, Children's Medical Center, Dallas, Tex (Dr From the
Hermann).
Presented at the Annual Meeting of the American Society of Pediatric Otolaryngology, Waikoloa, Hawaii, May 11, 1991. Reprint requests to Department of Otolaryngology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75235 (Dr
Leach).
MD
children with cor hypertrophy will
pulmonale secondary to adenotonsillar likely benefit from a tonsillectomy and without adenoidectomy.13 Thisinsurgical procedure is not In morbidity, especially very young patients. patients with neuromuscular
or
craniofacial abnormalities and
OSA, adenotonsillectomy is not as effective, and tracheot¬
omy may be performed instead. For this reason, PSG has been used in other institutions to determine which children do indeed have OSA.1214,15 A complete sleep study requires that the child be mon¬ itored for a minimum of 4 hours of sleep, which usually requires an overnight stay in the hospital or sleep center. Polysomnography is expensive, and typically ranges in cost from $600 to $1000 per overnight session at our insti¬ tution. In an era of limited hospital resources and strict cost control, PSG should ideally be ordered only when there is a high index of suspicion for sleep disorder in children who would otherwise be at higher risk in undergoing adeno¬ tonsillectomy. Such children would include those who are very young, those with other problems that might increase the morbidity of surgery, or those in whom the diagnosis is in doubt (ie, the symptoms do not fit the physical find¬ ings). Unfortunately, the literature does not define the pa¬ tient for whom OSA can be diagnosed on the basis of his¬ tory and physical findings alone. This retrospective study was therefore conducted to determine which clinical aspects of OSA correlate most strongly with PSG manifes¬ tations of the disease. MATERIALS AND METHODS The charts of 93 patients who ranged in age from 18 months to 12 years were reviewed. These patients underwent PSG based on their symptoms that were suggestive of obstructive sleep pat¬ terns. Symptoms included snoring or other obstructive airway noises, observed apnea or cyanosis, hypersomnolence, parasomnias (sleepwalking, enuresis, and nightmares), and disturbed sleep patterns. Physical examination noted the height and weight percentiles for age and the presence of tonsillar hypertrophy, fa¬ cial dysmorphias, or neuromuscular disorders. Chest roentgeno¬ grams and electrocardiograms were obtained for those patients in whom symptoms were suggestive of cor pulmonale. Complete sleep studies were obtained in which the child was monitored for a minimum of 4 hours of sleep. During that period, a heart tracing, an electroencephalogram with a C3-C4 mastoid electrode, an electro-oculogram, and a pulse oximeter were mon¬ itored. Chin-cheek and intercostal electromyography was per¬ formed. Oral and nasal airflow was monitored. An esophageal pH probe was used in selected patients. Strain gauges were applied to the child's chest and abdomen, and a tape recording of the sounds produced by sleeping was obtained. The child was observed during sleep by a remote video camera. Obstructive episodes were defined as cessations of air movement past the pharynx in conjunction with continued chest and diaphragmatic activity that lasted longer than 2V¡ breaths each. Cessation of air movement through the mouth and nose for 2V4 breaths without chest wall or abdominal movement was defined as central apnea. Mixed apnea was defined as a combination of obstructive and
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/02/2015
central apnea. Hypopnea was defined as a reduction of upper airflow by at least 50% for 2Vz breaths. Hypopneas were also subcategorized as obstructive, central, or mixed. Other indications of OSA or an obstructive respiratory process included oxygen desaturations or hypercapnia in conjunction with one of the fol¬ lowing: (1) paradoxing (opposite motion of the chest and abdo¬
men); (2) snoring; (3) increasing respiratory effort, leading to arousal; (4) chest retractions; (5) disrupted sleep patterns second¬ ary to obstruction (this included an increased number of arousals, increased stage I sleep, decreased stages III and IV sleep, de¬
creased rapid eye movement sleep, and increased awakenings); and (6) cardiac arrhythmias. Findings that were addressed by PSG were then recorded. Statistical analysis of these variables was then carried out by 2 techniques.
RESULTS Of the 93 charts that were reviewed, 34 patients were found to have OSA, 44 had normal PSG findings, five had gastroesophageal reflux, five had central apnea, one had pa¬ vor nocturnus, one had obstructive hypoxia, and three could not be tested due to failure to obtain recordable sleep wave tracings. The Table gives the demographics, symptoms, an¬ atomic and neurologic disorders, and physical findings for all of the patients; these five items are discussed below. Sex and
Age
Obstructive sleep apnea did not appear to be more prevalent in any age or gender group. Of the group with
OSA, 59% (20/34)
were male, and 41% (14/34) were female. Of the group without OSA, 54% (34/59) were male, and 46% (25/59) were female. The average age of the OSA group was 4.4 years. The mean age of the group without OSA was 4.5 years.
Race Of the group with OSA, 38% (13/34) were black, 44% (15/34) were white, and 18% (6/34) were Hispanic. Of the group without OSA, 19% (11/59) were black, 67% (40/59) were white, and 14% (8/59) were Hispanic. This was sig¬ nificant at the P
retrospective study was conducted to determine which
types of children might have polysomnographic findings
that are most compatible with obstructive sleep apnea (OSA). The charts of 93 patients who were aged 18 months to 12 years were examined. All 93 patients had symptoms that were initially suggestive of OSA, and they underwent polysomnography. The types of presenting symptoms and associated illnesses were noted. Physical findings, including height, weight, and tonsil size, were examined. Of 93 patients with symptoms that were suggestive of OSA, 34 met sleep study criteria for OSA. In 44 patients, OSA was not demonstrated, and 15 patients had other results. On the basis of age, sex, and symptoms, no significant differences could be found between the group with OSA and the group with normal polysomnographic findings. Cor pulmonale, tonsil hypertrophy, and failure to thrive were associated with OSA. Surprisingly, obesity was not significantly associated with OSA. (Arch Otolaryngol Head Neck Surg. 1992;118:741-744) Sir William Osier1 used the "pickwickian" refer patients with findings that included obesity, In 1912, and obstruc¬ term
to
to
hypoventilation, hypersomnolence. Airway tion during sleep was later reported in such patients by Gastaut and colleagues.2 Other investigators described cor pulmonale in patients with similar findings.3,4 By 1965, the term "obstructive sleep apnea" (OSA) had been coined,5 and by 1978, polysomnography (PSG) had been estab¬ lished as a reliable method for diagnosing the disorder.6 By 1981, case series of children with OSA began to appear in the
literature,7 and it soon became evident that adenoton-
curative in a large number of these patients.6,8"11 Although the number of tonsillectomies per¬ formed for all reasons has declined in recent years, the number performed for OSA has risen at our institution. In the adult, OSA may manifest itself by a number of primary and secondary symptoms. Obesity is seen in the majority of adult patients with OSA.12 Other common include snoring, daytime hypersomnolence, poly-
sillectomy
was
findings
cythemia, hypertension, cardiac arrhythmias, nightmares, somnambulism, and twitching during sleep.12 Obstructive sleep apnea is also commonly seen in adults with short, thick necks and redundant soft palate tissue.8,12 In children, however, the presentation of OSA may be less clear. It has been shown that obese, hypersomnolent Accepted
for
publication
October 14, 1991.
Department of Otolaryngology, University of Texas Southwestern Medical School, Dallas (Drs Leach, Olson, and Manning), and the Sleep Disorders Center, Children's Medical Center, Dallas, Tex (Dr From the
Hermann).
Presented at the Annual Meeting of the American Society of Pediatric Otolaryngology, Waikoloa, Hawaii, May 11, 1991. Reprint requests to Department of Otolaryngology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75235 (Dr
Leach).
MD
children with cor hypertrophy will
pulmonale secondary to adenotonsillar likely benefit from a tonsillectomy and without adenoidectomy.13 Thisinsurgical procedure is not In morbidity, especially very young patients. patients with neuromuscular
or
craniofacial abnormalities and
OSA, adenotonsillectomy is not as effective, and tracheot¬
omy may be performed instead. For this reason, PSG has been used in other institutions to determine which children do indeed have OSA.1214,15 A complete sleep study requires that the child be mon¬ itored for a minimum of 4 hours of sleep, which usually requires an overnight stay in the hospital or sleep center. Polysomnography is expensive, and typically ranges in cost from $600 to $1000 per overnight session at our insti¬ tution. In an era of limited hospital resources and strict cost control, PSG should ideally be ordered only when there is a high index of suspicion for sleep disorder in children who would otherwise be at higher risk in undergoing adeno¬ tonsillectomy. Such children would include those who are very young, those with other problems that might increase the morbidity of surgery, or those in whom the diagnosis is in doubt (ie, the symptoms do not fit the physical find¬ ings). Unfortunately, the literature does not define the pa¬ tient for whom OSA can be diagnosed on the basis of his¬ tory and physical findings alone. This retrospective study was therefore conducted to determine which clinical aspects of OSA correlate most strongly with PSG manifes¬ tations of the disease. MATERIALS AND METHODS The charts of 93 patients who ranged in age from 18 months to 12 years were reviewed. These patients underwent PSG based on their symptoms that were suggestive of obstructive sleep pat¬ terns. Symptoms included snoring or other obstructive airway noises, observed apnea or cyanosis, hypersomnolence, parasomnias (sleepwalking, enuresis, and nightmares), and disturbed sleep patterns. Physical examination noted the height and weight percentiles for age and the presence of tonsillar hypertrophy, fa¬ cial dysmorphias, or neuromuscular disorders. Chest roentgeno¬ grams and electrocardiograms were obtained for those patients in whom symptoms were suggestive of cor pulmonale. Complete sleep studies were obtained in which the child was monitored for a minimum of 4 hours of sleep. During that period, a heart tracing, an electroencephalogram with a C3-C4 mastoid electrode, an electro-oculogram, and a pulse oximeter were mon¬ itored. Chin-cheek and intercostal electromyography was per¬ formed. Oral and nasal airflow was monitored. An esophageal pH probe was used in selected patients. Strain gauges were applied to the child's chest and abdomen, and a tape recording of the sounds produced by sleeping was obtained. The child was observed during sleep by a remote video camera. Obstructive episodes were defined as cessations of air movement past the pharynx in conjunction with continued chest and diaphragmatic activity that lasted longer than 2V¡ breaths each. Cessation of air movement through the mouth and nose for 2V4 breaths without chest wall or abdominal movement was defined as central apnea. Mixed apnea was defined as a combination of obstructive and
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/02/2015
central apnea. Hypopnea was defined as a reduction of upper airflow by at least 50% for 2Vz breaths. Hypopneas were also subcategorized as obstructive, central, or mixed. Other indications of OSA or an obstructive respiratory process included oxygen desaturations or hypercapnia in conjunction with one of the fol¬ lowing: (1) paradoxing (opposite motion of the chest and abdo¬
men); (2) snoring; (3) increasing respiratory effort, leading to arousal; (4) chest retractions; (5) disrupted sleep patterns second¬ ary to obstruction (this included an increased number of arousals, increased stage I sleep, decreased stages III and IV sleep, de¬
creased rapid eye movement sleep, and increased awakenings); and (6) cardiac arrhythmias. Findings that were addressed by PSG were then recorded. Statistical analysis of these variables was then carried out by 2 techniques.
RESULTS Of the 93 charts that were reviewed, 34 patients were found to have OSA, 44 had normal PSG findings, five had gastroesophageal reflux, five had central apnea, one had pa¬ vor nocturnus, one had obstructive hypoxia, and three could not be tested due to failure to obtain recordable sleep wave tracings. The Table gives the demographics, symptoms, an¬ atomic and neurologic disorders, and physical findings for all of the patients; these five items are discussed below. Sex and
Age
Obstructive sleep apnea did not appear to be more prevalent in any age or gender group. Of the group with
OSA, 59% (20/34)
were male, and 41% (14/34) were female. Of the group without OSA, 54% (34/59) were male, and 46% (25/59) were female. The average age of the OSA group was 4.4 years. The mean age of the group without OSA was 4.5 years.
Race Of the group with OSA, 38% (13/34) were black, 44% (15/34) were white, and 18% (6/34) were Hispanic. Of the group without OSA, 19% (11/59) were black, 67% (40/59) were white, and 14% (8/59) were Hispanic. This was sig¬ nificant at the P
