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213

Upper During

Airway Sleep

Obstruction in Children

r

.

Anatomic

and

nosed

by plain

raphy.

These

recognition

physiologic

film studies

of the

placement

are

usually

[3-5,

blamed

Airway symptoms

and

Cinefluoroscopy

revision

April

27,

1 3, 1979;

accepted

after

1979.

Department of Radiology, University of Florida College of Medicine, Gainesville, FL 32610. AdI

dress reprint requests 2 Department

College

of Pediatrics,

of Medicine,

Department sity of Florida 32610.

to A. H. Felman. University

Gainesville,

of Florida

FL 32610.

of Ear, Nose, and Throat. Univer-

College

of Medicine.

Gainesville,

AJR 133:213-216, August 1979 0361 -8o3x/79/1332-o213 $00.00 © American Roentgen Ray Society

FL

that

Subjects

And

Nine

children,

disturbed

sleep

directly

caused

while

awake.

record

the

symptoms

and

presently

adenoids

used

cinefluoroscopic

obstruction of the

disclosed and

airways

an abnormal

intermittent

activity

With

attention

the has

complete

of the oral

and

the etiology

is

[1 2].

in adults

findings

airway

examinations

diag-

of the upper airway during sleep. in sleeping adults usually involves

similar

tonsils

often

xeroradiog-

in adults,

and

sleep partial

patients

syndrome

with

intermittent clinical

on

apnea

are

and/or

observe

our

during

airway

1 ]. In children

techniques report

suggested

radiographic collapse

that

on hypertrophied We

performed sleep

upper

tomography,

abnormalities airway function

7, 9-1

monitoring

in childhood.

usually

dynamic upper

of the

fluoroscopy,

hypersomnia

of devices

hypopharynx

abnormalities

radiography,

been focused on [1 -1 0]. Monitoring

February

.

Cinefluoroscopic findings are described in nine children with sleep-related upper airway obstruction who are asymptomatic while awake. Asleep, these patients show strikingly similar changes in the region of the hypopharynx. During inspiration, the tongue and hypopharyngeal soft tissues are approximate, obliterating the hypopharyngeal air space causing intermittent and almost complete obstruction to air flow. The value of cinefluoroscopic studies on sleeping children with clinical symptoms of airway obstruction during sleep is emphasized.

Alvin H. Felman,1 Gerald M. Loughlin,2 Clifton A. Leftridge, Jr.,2 and Nicholas J. Cassisi,3

Received

.

are difficult

in children during

sleep

while

awake

pattern airway

to perform

whose

clinical

and

in whom

were

normal.

of hypopharyngeal obstruction.

Methods aged

1 1 months

characterized

flow; bizarre movements;

to 1 1 years,

by loud,

and assumption

snoring

were

studied.

respirations;

of unusual sleeping

Initial intermittent

positions.

complaints obstruction

indicated to air

Right sided cardiac

failure, systemic hypertension, and growth failure were additional findings in some patients. All had previously normal laryngoscopy, bronchoscopy, and routine airway radiography. After a variable period of sleep deprivation they were placed on the fluoroscopic table in a darkened room and allowed to fall asleep in the most comfortable and natural position; most were prone or prone-lateral. One child, unable to sleep horizontally, was held upright by his mother during fluoroscopy. Videotape fluoroscopic recordings were made after the children were gently maneuvered into the lateral and occasional frontal position. They were then aroused and fluoroscoped while awake. In two patients, spot films as well as rapid sequence (6/sec) 70 mm exposures were made in addition to the videotape.

FELMAN

214 :

ET AL.

AJR:133,

Fig.

k

choscopy and mal: tonsillectomy failed to relieve

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,:

‘

:

‘

.,

laryngoscopy were norand adenoidectomy symptoms. A, Videotape

while awake shows widely patent oral and hypopharynx during inspiration. B, While asleep, almost complete obliteration of hypopharynx during inspiration.

..

Tracheostomy of symptoms.

terior PP

studied using this or hypopharyngeal

In adults,

hypersomnia

during sleep are dramatically

In the

normal

vertebral riorly.

soft

tissue

In all nine

geal airway During sleep palate ing

patient

fell

the

ration, The

does

of our

remained several

and

canal

not

thicken

patients,

the

the

the

tongue

of the

nasal

pharynx, interrupted

posterior

antepharyn(fig. the

1 A). soft

occludrespi-

breath.

abnormality

moved

and

snoring, for

The pre-

protrude

posterior

causing gasping

common

and oral

was

popharynx. In the lateral projection, mained open during expiration but of

movement

patent while awake occurred. In some,

against and

occasional

more

is minimal

widely changes

backward

nasal

there

the hypopharynx during sleep [1 3]. in its normal anterior position and the

observed

in the

the hypopharynx on inspiration the

and

the

prevertebral

hyreback soft

of tongue,

posterior

U

glottis,

=

relief pos-

tip of uvula, wall, E =

=

pharyngeal

G

=

A

arytenoid.

=

Discussion sleep

under intense investigation ing etiology seems related Results

resulted in complete M = mandible, T

edge =

epiglottis,

soft tissues of tongue remains

1979

1 -11-month-old black boy with obstruction during sleep. Bron-

airway

.4

Three children without sleep apnea were technique. No evidence of airway obstruction collapse was observed.

August

“

has

[2,

and

animals

as measurements have

[3-5,

7, 9-1

used.

strated increased airway hypopharyngeal muscles Walsh et al. [2] reported with

during

the

‘ ‘

patients’

resistance, These

still

symptoms

produced

by the

posterior

pharyngeal

observation

with

monitoring muscles, as well

flow

rates,

observations

and

have

pres-

demon-

resistance and laxity of supporting during sleep. fluoroscopic findings in two adult

hypersomnia apneic

1]. Direct

and electromyographic other pharyngeal

of airway been

patients

is

of upper airway obstruction during sleep with various monitoring devices in adult

endoscopic instruments of the genioglossus and sures

syndrome

important underlyairway obstruction

3, 6, 7, 9-1 1 ]. Most relieved by tracheostomy.

The mechanism been studied

humans

apnea

but the most to incomplete

phase tongue wall.

sleep

apnea

upper retracting The

syndrome.

airway into

In both,

obstruction apposition

obstruction

was with

recurred

the

rhyth-

tissues thickened and protruded forward. The approximation of these tissues partially occluded the hypopharynx and opening to the larynx (figs. 1 B and 2). In the frontal projec-

mically with each ineffective inspiratory effort and finally terminated with a loud snore as the soft palate fluttered. After several ineffective inspirations the cycle recurred”

tion the lateral in the midline.

[2].

caused from curred

the sleep. during

pharyngeal Intermittent

children

to gasp

Considerable these

for

breath

and

snoring

and

noisy

episodes.

after tracheostomy, the complete approximation ynx.

walls moved medially complete occlusion

In three

hypopharynx of the tongue

to oppose of air flow

arouse

slightly

breathing

children

oc-

restudied

remained closed and posterior

with phar-

The

tion

authors

coincides

Smith et al. hypersomnia fluoroscoped lished. sefzadeh ysostosis

published with

Their

[1 4] described sleep apnea during sleep description

et al. [1 5] recently in whom

no radiographs

the fluoroscopic

sleep

but their

descrip-

in our

children.

findings

an achondropiastic syndrome whose but no radiographs also

parallels described

fluoroscopy

child pharynx were

our

findings.

a child

with

showed

with was pubYou-

pyknod-

hypopharyn-

AJR:133,

August

Fig. ied

2-2-year-old

upright

black

while

asleep

arms. A, Expiratory ryngeal airway patent

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Inspiration. obliterated soft tissue.

UPPER

1979

child in

AIRWAY

OBSTRUCTION

DURING

215

SLEEP

stud-

mother’s

phase. Hypophabut narrowed. B,

Hypopharyngeal air column by apposition of surrounding Borderline hypertension and

cardiomegaly

present

but tracheostomy

deferred.

A

B ideal.

In children

and

sleep-related

dude

airway

with

hypersomnia

breathing obstruction

from

the child is awake or from With proper preparation

apnea

during airway

Therapeutic

symptoms

one

radiographs

laryngoscopy and care

examined fluoroscopically mains patent, sleep related be excluded.

sleep

disturbance,

cannot

ex-

exposed and

most

while

bronchoscopy. children can

be

sleep. If the airway reobstruction can probably

decisions

including

tracheostomy must be based on graphic findings with other clinical

correlation parameters.

the

need

of the

for

radio-

REFERENCES 1

.

Safar the

P, Escarraga

LA, Chang F: Upper airway obstruction in J App! Physiol 1 4 : 760-764, 1959 RE, Michaelson ED, Harkleroad LE, Zighelboim A, Sack-

unconscious

2. Walsh ner

MA:

Upper

disturbance

Fig. 3.-Spot

film of hypopharynx in normal child while asleep for renal biopsy. Widely patent hypopharynx, normal thickness of prevertebral soft tissue, and anterior tongue. Configuration unchanged during all phases of respiration.

patient.

airway and

obstruction

in obese

Ann

somnolence.

patients

Intern

Med

with

sleep

76:185-192,

1972

3.

Lugaresi

F, Coccagna

Snoring.

G, Farneti

Electroencephalogr

P, Mantovani Clin

M, Cirignotta F: 39 : 59-64,

Neurophysiol

1975

4.

geal

obstruction

tient

also

similar

had

an elongated

In normal found the

sleeping

that

to our patients. uvula

the

nasopharyngeal

oropharyngeal

passage

tongue

to the

palate.

that we observed during children

all

phases showed

The

airway three

of respiration widely

patent

was necessary adenoidectomy,

Kemp

(fig.

3).

but

51 :1 60-1

Orem

J, Netick

ance

to breathing

Clin

Neurophysiol

during

children

intermittent

airways

micrognathia.

JAMA

Guilleminault

C,

Our

sleep

apnea

while

7.

awake,

improved but is still under observation. Dynamic abnormalities of the upper airway ied with noninvasive techniques; videotape

tonsilwell and

WA,

8.

Kravath

sleep 9. 1

0.

one

upper

RE,

stud-

1 1

is

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WC:

Increased

sleep

in the

.

during

sleep: Exp

muscle.

upper cat.

CP,

who

have

airway

FL,

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Borowiecki

Hypersomnolence

and

caused

by

1977 A,

Simmons

B,

Dement

airway obstruction1 37 : 296-300, 1977

B: Hypoventilation

lymphoid

resist-

E!ectroencepha!ogr

obstruction-occurrence

237:2740-2742,

Eldridge

Pollak

in children

airway

obstruction

during treated

by tube and T and A. Pediatrics 59:865-871 , 1977 Orem J, Norris P, Lydic A: Laryngeal abductor activity during sleep. Chest [suppl] 73 : 300-301 , 1978 Remmers JE, deGroot WJ, Sauerland EK, Anch AM: Pathogenesis of upper airway occlusion during sleep. J App! Physiol 44:931-938,

are best fIuoroscoy

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WC: Sleep apnea syndrome due to upper a review of 25 cases. Arch Intern Med

control. in children bears some similarapnea syndrome in adults but Our patients all demonstrated obstruction during sleep but in only four. Following four are completely

Conway

human

the

43 : 1 4-22, 1977 Bower GC, Barnes ME:

sleeping

6.

The of

70, 1976

A, Dement

of

only

the

AM:

activity

apposition

nasopharyngeal

airways

Neuro! 5.

[13]

patent

EK, Harper

electromyographic

pa-

mandible.

and remains

by normal

patent

their

hypoplastic

Ardran

closes

had widely

with each acting as his own Sleep airway obstruction ities to the hypersomnia sleep has been less well studied. symptoms of upper airway tracheostomy lectomy and

and

newborns,

However,

Sauerland

1978

Borowiecki

B, Pollak

Fibro-optic

study

CP, Weitzman

of pharyngeal

airway

ED, Rakoff during

5, Imperato sleep

in patients

J:

216

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hypersomnia obstructive sleep-apnea syndrome. Laryngoscope 88:1310-1313, 1978 Guilleminault C, Eldridge FL, Simmons FB, Dement WC: Sleep apnea in eight children. Pediatrics 58:23-30, 1976 Ardran GM, Kemp FH: The nasal and cervical airway in sleep in the neonatal period. AJR 108:537-542, 1970 with

12.

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13.

ET AL.

14.

15.

AJR:133,

August

1979

Smith TH, Baska RE, Francisco CB, McCray GM, Kunz S: Sleep apnea syndrome: diagnosis of upper airway obstruction by fluoroscopy. J Pediatr 93:891-892, 1978 Yousefzadeh DK, Agha AS, Reinertson J: Radiographic studies of upper airway obstruction with cor pulmonale in a patient with pycnodysostosis. Pediatr Radio! 8:45-47, 1979