Mild Obstructive Sleep Apnea in Children: What Is the Best Management Option?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope. May 2019

Background

Pediatric obstructive sleep apnea (OSA) is characterized by upper airway obstruction, poor sleep, and daytime sequelae such as hyperactivity. Although controversy exists regarding the ideal evaluation for children with sleep-disordered breathing, the severity of OSA is currently determined by full-night polysomnogram (PSG). Mild OSA is defined by an apnea-hypopnea index (AHI) > 1 and <5. The majority (approximately 85%) of healthy school-aged children evaluated by otolaryngologists for tonsil hypertrophy and obstructive symptoms have either primary snoring or nonsevere OSA.

The treatment of mild OSA in children is controversial. There is a lack of data on the natural history of mild sleep apnea. Furthermore, a poor correlation exists between quality of life (QOL) scores and OSA severity; mild OSA in children may have a significant impact on their general health and well-being. High-quality studies comparing observation, medical management, and surgery for mild pediatric OSA are just beginning to emerge. Many of these studies use varied measures to assess outcomes. Thus, it may be difficult for providers treating children with mild OSA to counsel parents on the optimal treatment for their child.

Best Practice

Multiple therapeutic options may be effective for treating mild pediatric OSA including observation, management with anti-inflammatory medications, and surgery (Table 1). Validated instruments that assess symptom burden and the impact of OSA on QOL may be useful in determining which treatment option is most appropriate for the child. Shared decision making between caregiver, child (when appropriate), and physician may be useful in developing a management strategy for mild OSA. Data on the sequelae of mild OSA in children, including the impact of obstruction on cardiovascular parameters and neurocognition, are lacking. Future research is needed to compare long-term outcomes for the different treatment options for mild OSA in children (Laryngoscope. 2018;128:2671–2672).

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UAS Successful Treatment for OSA When Compared with TORS

How do transoral robotic surgery (TORS) and upper airway stimulation (UAS) compare for treating tongue base obstruction contributing to obstructive sleep apnea (OSA)?

Bottom line: UAS is successful in treating OSA, showing improved outcomes, length of stay, and readmission compared to TORS.

Background: TORS tongue base reduction utilizes robotic instrumentation to perform a lingual tonsillectomy combined with midline glossectomy and supraglottoplasty. With UAS, the hypoglossal nerve is selectively stimulated to induce muscle tone in the upper airway, relieving obstruction and reducing apnea and hypopnea burden; there is also evidence that it improves obstruction at the velum through coupling of the palatoglossus muscle.

Study design: Retrospective review of 100 patients (24 TORS, 76 UAS) from the senior authors’ surgical database who were treated between January 2011 and July 2017.

Setting: Thomas Jefferson University, Philadelphia.

Synopsis: Thirty-seven TORS and 94 UAS were performed. In the TORS cohort, 16 underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 35.70 and 80.50, respectively. In the UAS cohort, 14 patients underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 36.64 and 80.27, respectively. The mean postoperative AHI and O2 desaturation nadir in the TORS cohort were 20.05 and 84.10, respectively. The surgical success rate, patients who reached an AHI less than 15, and patients who reached and AHI less than 5 were 54.17%, 50.00%, and 20.83%, respectively. The mean postoperative AHI and O2 desaturation nadir of the UAS cohort were 7.20 and 88.77, respectively. Surgical success rate, patients who reached an AHI less than 15, and patients who reached an AHI less than 5 were 86.84, 89.47, and 59.21, respectively. TORS cohort patients had a mean length of hospital stay of 1.33 days; four patients had a 30-day unplanned readmission for dehydration and pain control. All UAS cohort patients underwent ambulatory surgery, and no patients were readmitted to the hospital. There were no major complications in either group. Limitations included a less-direct comparison between UAS and TORS due to the multilevel nature of UAS.

Citation: Huntley C, Topf MC, Christopher V, et al. Comparing upper airway stimulation to transoral robotic base of tongue resection for treatment of obstructive sleep apnea. Laryngoscope. 2019;129:1010–1013.

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