Adult and Pediatric

Obstructive Sleep Apnea

Prof. Dr. Jehad Al-Baba

Chief of E.N.T Department
Everyone has brief pause in his or her breathing
pattern called Apnea , the word comes from
the Greek word meaning “Without
Breathing”
{Respiratory pause that exceeds 3 standard
deviation of the mean breath time for an
infant or a child at any particular age}
 There are three types of Apnea:
 - Obstructive,

 - Central,

 - Mixed.
 Cont. Apnea
 Obstructive apnea – cessation of airflow for
at least 10 seconds with respiratory effort
 Central apnea – cessation of airflow for at
least 10 seconds without respiratory effort
 Mixed apnea – characteristics of both for at
least 10 seconds
 Hypopnea – hypoventilation secondary to
partial obstruction
Disorder Of breathing during sleep
characterized by prolonged partial upper
airway obstruction and /or intermittent
complete obstruction (obstructive apnea)
that disrupts normal ventilation during
sleep and normal sleep patterns.
 Obstructive Sleep Apnea
 85% of adult patients are male.
 Men 4%, Female 2%.
 2/3rd obese.
 Contributes to HTN and cardiovascular
disease.
 Increased motor vehicle accidents.
 Pathophysiology
 Pharyngeal collapse
 Decreased airway patency
 Increase in negative pressure
 Becomes a vicious cycle.
 Symptoms
 Snoring*
 Excessive daytime sleepiness*
 Restless sleep
 Personality changes
 Headaches
 Sexual dysfunction
 Job performance
 Sleep hygiene
 Bed partner’s input *
 Physical Exam

 Vital signs
 Head & Neck exam
 Flexible endoscopy
 Vital signs
 Height
 Weight
 Collar size
 Blood pressure
 Calculate BMI
 Wt (kg) / Ht (meters) squared
 Men >27.8, Women >27.3
Examination
 Tongue
 Palate
 Uvula
 Tonsils
 Nasal cavity
 Hyoid
 Mandible
 Maxilla
 Cephalometrics
 Standardized lateral radiographs
 Examines bony and soft-tissue structure
 Two-dimensional evaluation
 Lack of volumetric data
 Maxillomandibular surgery, oral appliances
 Polysomnogram
 EEG  Nasal/oral airflow
 EKG  Pulse oximetry
 Submental EMG  Respiratory
 Anterior tibialis movement
EMG  Sleeping position
 EOG  Esophageal
manometry
 Treatment

 Nonsurgical modalities
 Surgical modalities
 Nonsurgical Treatment

 Weight loss
 Sleep hygiene
 Pharmacotherapy
 Nasal continuous positive airway pressure
 Oral appliances
 Nonsurgical Treatment
 Weight loss
 Get below “trigger weight”
 Diet, exercise, bariatric surgery, medications

 Sleep hygiene
 Avoidance of sedatives
 Positional changes
 Pharmacotherapy
 Protriptyline – decreases REM sleep
 Xanthine based drugs
 Steroids
 Antibiotics
 Nasal medications
 CPAP

 Titrated to limit all respiratory events

 50-90% acceptance – better if daytime
symptoms improved
 Side effects in 40-50%
 Oral appliances
 Advances the mandible
 Retains the tongue anteriorly
 UPPP
 Fujita (1981)
 Most common procedure
 1st line tx for retropalatal collapse
 10-50% success.
 Mandibular Osteotomy with
Genioglossus Advancement
 Enlarges the retrolingual airway without
disturbing dentition
 Prevents retrolingual collapse
 Tongue reduction
 Lingual tonsillectomy
 Laser midline glossectomy
 Lingualplasty
 Radiofrequency volumetric tissue reduction
 Nasal surgery
 Improved symptoms and CPAP
 Septoplasty

 Turbinate reduction

 Functional nasal reconstruction

 Tracheostomy
 Bypasses all areas of obstruction
 Virtually 100% effective
 Two indications
 Temporary procedure during airway

reconstruction
 Severe OSA when CPAP refused,

ineffective, or not tolerated or if other

conditions exacerbated by the apneas
 Line the tract with skin flaps
 Lack of social acceptance
Apnea in Childhood
 OSA result from:
 Adenotonsillar hypertrophy.
 Neuromuscular diseases.
 Craniofacial abnormalities .
 True OSA result in:
 Neurocognitive impairment.
 Behavioral problems.
 Failure to thrive.
 Cor pulmonal , particularly
in sever cases.
 Enuresis.
 OSA Presented with the following
symptoms

 Habitual (nightly) snoring.

 Disturbed sleep .

 Daytime neurobehavioral problems.

 Daytime sleepness may occur but is

uncommon in young children.

 Anatomic factors :
That narrow the upper airway.
 Adenotonsillar hypertrophy.
 Trisomy 21(down syndrome) .

 Other genetic or craniofacial syndromes.

associated with
 (Midface hypoplasia, Small nasopharynx,

Choanal atresia or stenosis, Macroglossia,

Micrognathia or retrognathia and cleft
palate).
 Anatomic factors :

 Obesity.
 Nasal obstruction.
 Laryngomalacia.
 Sickle cell disease.
 Velopharyngeal flap repair
Neurologic factors :
That decreased pharyngeal muscular dilator
activity.
Medications.
 Sedative.
 General anaesthesia.

Brain stem disorders.

 Chiari-malformation.
 Birth asphyxia.

Neuromuscular diseases.
 Muscular dystrophy.
 Cerebral palsy.
 OSA occurs in children of all ages from
neonates to adolescents.
 It is thought to be most common in preschool-
age children (which is the age when the tonsils
and adenoids are the largest in relation to the
underlying airway size).
 Occurs equally among boys and girls.
 The estimated prevalence of snoring in
children is 3 to 12 %.
 OSA affect 1 to 10 %.
 Sedation Sleep onset
anesthesia

Muscle
Weakness
Decreased upper airway Decreased CO2
muscle activity Increased O2
Obesity

Upper airway narrowing Relief of obstruction

Small Restoration of airflow
Airway

Enlarged tonsil Obstructive,Hypoventilation Increased upper airway

& Adenoids
&Apnea muscle activity

Craniofacial
anomalies Hypoxemia Arousal from
Hypercapnia sleep

Increased ventilatory effort

 To identify patients who are at risk for
adverse outcomes.

 Avoid unnecessary intervention in

patients who are not at risk for adverse
outcomes.
 Evaluate which patients are at increased
risk of complications resulting from
adenotonsillectomy, so that appropriate
precaution can be taken.
 HISTORY
 In children younger than five years.
 Snoring is the most common complaint.

 Symptoms reported by parents:

 Mouth breathing

 Diaphoresis

 Paradoxicrib-cage movements

 Restlessness

 Frequent awakenings
α In children five years and older.
ζ Enuresis
ζ Behavior problems
ζ Deficient attention span
ζ Failure to thrive
ζ In addition to snoring
α Compared with adult.
α Fewer children with OSA report excessive
daytime somnolence, with the exception of
obese children.
 In extreme cases of OSA in children.
 Cor pulmonal and Pulmonary hypertension
may be the presenting problems.
 Poor growth and FTT are more common in
children with sleep-disordered breathing.
 Growth velocity increases after
adenotonsillectomy
 Decreased production of growth hormone

during fragmented sleep may contribute

further to poor growth.
 Obstructive Sleep Apnea Screening Quiz
Do your children have any of the following symptoms that can
be associated with sleep apnea?
continuous loud snoring
episodes of not breathing at night (apnea)
failure to thrive (weight loss or poor weight gain)
mouth breathing
enlarged tonsils and adenoids
problems sleeping and restless sleep
excessive daytime sleepiness
morning headaches
daytime cognitive and behavior problems, including
problems paying attention, aggressive behavior and
hyperactivity, which can lead to problems at school
 Evaluation of the childs general apperance,with careful attention
to craniofacial characteristics, such as:
α Midface hypoplasia
α Micrognathia
Evaluation for nasal obstruction depends on the child's age.
α Septal deviation
α Naso-lacrimal cysts
α Choanal atresia
α Nasal aperture stenosis Must be considered in infants
2-Lateral neck radiography.

fig 2

Arrows indicate
prominent adenoidal
tissue in the posterior
nasopharynx, resulting
in upper airway
narrowing
 WHAT
ABOUT
MANAGMENT
MEDICAL  SURGICAL 

 CPAP  Adenotonsillectomy
 Antibiotics  Uvulopalatopharyngoplast
 Weight loss y
 Nasal steroids  Tracheotomy
 Systemic steroids
OSA is more common in children with craniofacial syndromes.
1-Children who have syndromes with craniosynostosis:
-Apert's syndrome,
-Crouzon's disease,
-Pfeiffer's syndrome,
-Saether-Chotzen syndrome,
-abnormalities of the skull base,
-Accompanying maxillary hypoplasia,
May have nasopharyngeal obstruction
:Children with syndromes that involve micrognathia-2
,Treacher collins syndrome-
,Pierre Robin syndrome-
,Goldenhar's syndrome-

Become obstructed at the hypo pharyngeal level

3-Children with Trisomy 21 :

A narrow upper airway combined with Macroglossia and

hypotonic musculature predispose them to OSA
The surgical management of craniofacial
syndromes and OSA in children frequently
requires more than standard
adenotonsillectomy.

In children with midfacial hypoplasia,

craniofacial advancement may be indicated.
Glossopexy, mandibular distraction or
advancement, or tongue suspension should
be considered in patients with micrognathia