Search

Background: Children with achondroplasia often have breathing problems, especially during sleep. The most important treatments are adenotonsillectomy (for treating upper obstruction) and/or neurosurgery (for resolving cervicomedullar junction stenosis)., Data Sources: We reviewed the scientific literature on polysomnographic investigations which assessed the severity of respiratory disorders during sleep., Results: Recent findings have highlighted the importance of clinical investigations in patients with achondroplasia, differentiating between those that look for neurological patterns and those that look for respiratory problems during sleep. In particular, magnetic resonance imaging (MRI) and somatosensory evoked potentials are the main tools to evaluate necessary neurosurgery and over myelopathy, respectively., Conclusions: The use of polysomnography enables clinicians to identify children with upper airway obstruction and to quantify disease severity; it is not suitable for MRI and/or neurosurgery considerations.

The efficacy of adenotonsillectomy for treating obstructive sleep apnoea syndrome (OSAS) in children has been established, but its precise effects on inspiratory effort are not well documented.In 353 children enrolled in the Childhood Adenotonsillectomy Trial, randomised to undergo either early adenotonsillectomy (n=182) or a strategy of watchful waiting with supportive care (WWSC) (n=171), thoraco-abdominal asynchrony (TAA) was analysed during quiet, non-apnoeic and non-hypopnoeic breathing during sleep at baseline and at 7 months using overnight polysomnography.Children who underwent early adenotonsillectomy demonstrated a reduction in TAA post-surgery while the WWSC arm showed no change. On assessing TAA with regard to normalisation of clinical polysomnography findings at follow-up, TAA was reduced in children who had surgical resolution of OSAS (based on apnoea-hypopnoea index), but not in children who displayed spontaneous normalisation of apnoea-hypopnoea index. In the latter group, TAA was inversely correlated with quality of life.We conclude that adenotonsillectomy reduces TAA during quiet sleep. Monitoring of instantaneous TAA may yield additional insight in the dynamic changes of inspiratory effort. In combination with traditional indices of obstruction, TAA may more accurately characterise the degree of sleep-disordered breathing in children., (Copyright ©ERS 2017.)

Pediatric OSAS and craniofacial malformations present challenges that require innovative approaches and comprehensive treatment strategies. Synchronous airway lesions, craniofacial malformations, obstructive anomalies of the tongue base, nasal vault and choanae are commonly addressed by subspecialists from various clinical and surgical academic traditions who practice variable levels of required communication. This is not a mere social requirement but an important requisite for intelligent and effective airway management. Membership of dedicated airway, aero digestive or craniofacial teams are desirable but not required. I expect this clinical brief to help many brilliant clinicians in their pursuit of perfection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A combination of abnormal anatomy and physiology of the upper airway can produce its repetitive narrowing during sleep, resulting in obstructive sleep apnea (OSA). Treatment of sleep-breathing disorder ranges from lifestyle modifications, upper airway surgery, continuous positive airway pressure (CPAP) to the use of oral appliances. A proper treatment selection should be preceded by thorough clinical and instrumental examinations. The type and number of specific oral appliances are still growing. The mandibular advancement appliance (MAA) is the most common type of a dental device in use today. The device makes the mandible protrude forward, preventing or minimizing the upper airway collapse during sleep. A significant variability in the patients' response to treatment has been observed, which can be explained by the severity of sleep apnea at baseline and duration of treatment. In some trials, patients with mild OSA show a similar treatment effect after the use of CPAP or MAA. It is worthwhile to give it a try with an oral appliance of MAA type in snoring, mild-to-moderate sleep apnea, and in individuals who are intolerant to CPAP treatment.

Over the past few decades there has been a significant increase in research focusing on the pathophysiology, diagnosis, and treatment of sleep apnea. However, there is still a long way to go in creating standard evidence-based medical practice for the diagnosis, evaluation, and treatment of sleep apnea patients. Current and future directions of sleep surgery and other treatments are discussed here., (© 2017 S. Karger AG, Basel.)

Objective: To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD)., Design: A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice., Main Outcome Measures: We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons' evaluation of OSA and their approaches to VPD., Results: A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038)., Conclusions: Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.

The failure of traditional upper airway surgery such as uvulopalatopharyngoplasty has been attributed to lower airway obstruction related to base of tongue collapse. Multiple procedures, including glossectomy, tongue base radiofrequency, genioglossus advancement, and tongue suspension techniques, have been advocated to improve success rates. No consensus exists on which subsets of patients are best treated by individual approaches and direct comparative data are lacking. The selection of procedures must be based on individual patient needs and the relative potential benefits and risks., (© 2017 S. Karger AG, Basel.)

Sleep-related breathing disorders (SRBD) consist of a variety of clinical entities, ranging from primary snoring to severe obstructive sleep apnoea at the opposite extreme. Although it has no official definition, minimally invasive surgery infers surgery where the procedure is clinically less aggressive and may involve a much smaller incision or none at all. It also implies that such procedures may result in a quicker recovery and reduced morbidity, and that they are often conducted under local anaesthesia as day cases. Minimally invasive surgery in SRBD may be performed on its own or may be conducted in conjunction with other surgical procedures or in association with non-surgical treatment modalities such as oral appliances. Indeed, it may be considered in patients experiencing difficulty tolerating treatment with continuous positive airway pressure. This is with a view to improving the upper airway dimensions and thus reducing the pressure requirement with this type of treatment modality, hence improving its compliance and efficacy. Here we address the role of minimally invasive surgery in SRBD within various anatomical regions of the upper airway, namely the nose, soft palate, and the tongue., (© 2017 S. Karger AG, Basel.)

Surgical treatments for snoring., Objectives: To compare the results on snoring and sleepiness of different surgical treatments for sleep disordered breathing (SDB) including uvulopalatopharyngoplasty (UPPP), functional expansion pharyngoplasty (FEP), osteotomy, septoplasty with turbinoplasty, and somnoplasty., Methodology: Between May 2011 and December 2015, 329 patients presenting with SDB underwent a dedicated clinical examination, drug-induced sleep endoscopy (DISE), and polysomnography (PSG). Of these, 84 patients underwent surgical treatment. Treatments were evaluated through 4 questionnaires (snoring intensity, snoring severity, Epworth Sleepiness Scale [ESS], and global snoring score) before and 6 weeks and 6 months after treatment. Treatment success was defined as a global snoring visual analog scale score (VAS) ≤3 at 6 months., Results: The average age of the surgical group was 43 ± 11 years; the mean body mass index was 26 ±3 kg/m; and 88% were male. The snoring scores decreased significantly for every surgical technique at 6 weeks and 6 months. A higher reduction in the median snoring scores was observed in patients receiving UPPP/FEP and osteotomy compared to somnoplasty and septoplasty. Treatment was successful in 88% of the UPPP/FEP group, 92% of the osteotomy group, 61% of the septoplasty group, and 64% of the somnoplasty group., Conclusions: All surgical treatments effectively and persistently reduced snoring and sleepiness symptom scores. The highest rates of success were observed with osteotomies and UPPP/FEP procedures.

Background: To describe the process involved in developing a decision aid prototype for parents considering adenotonsillectomy for their children with sleep disordered breathing., Methods: A paper-based decision aid prototype was developed using the framework proposed by the International Patient Decision Aids Standards Collaborative. The decision aid focused on two main treatment options: watchful waiting and adenotonsillectomy. Usability was assessed with parents of pediatric patients and providers with qualitative content analysis of semi-structured interviews, which included open-ended user feedback., Results: A steering committee composed of key stakeholders was assembled. A needs assessment was then performed, which confirmed the need for a decision support tool. A decision aid prototype was developed and modified based on semi-structured qualitative interviews and a scoping literature review. The prototype provided information on the condition, risk and benefits of treatments, and values clarification. The prototype underwent three cycles of accessibility, feasibility, and comprehensibility testing, incorporating feedback from all stakeholders to develop the final decision aid prototype., Conclusion: A standardized, iterative methodology was used to develop a decision aid prototype for parents considering adenotonsillectomy for their children with sleep disordered breathing. The decision aid prototype appeared feasible, acceptable and comprehensible, and may serve as an effective means of improving shared decision-making.

Background: To explore the feasibility, the efficacy, and the mechanism of mandibular advancement devices (MAD) in the treatment of persistent sleep apnea after surgery., Methods: Nineteen patients who failed uvulopalatopharyngoplasty (UPPP) or UPPP plus genioglossus advancement and hyoid myotomy (GAHM) were given a non-adjustable MAD for treatment. All patients had polysomnography (PSG) at least 6 months post-UPPP with and without the MAD. Seventeen patients had computed tomography (CT) examinations., Results: After the application of MAD, the apnea hypopnea index (AHI) decreased significantly from 41.2 ± 13.1/h to 10.1 ± 5.6/h in the responder group. The response rate was 57.9 % (11/19). During sleep apnea/hypopnea acquired from sedated sleep, the cross-sectional area and anterior-posterior and lateral diameters of the velopharynx enlarged significantly from 4.2 ± 6.0 mm 2 to 17.5 ± 15.3 mm 2 , 1.9 ± 2.3 mm to 6.5 ± 4.1 mm, and 1.1 ± 1.3 mm to 2.6 ± 2.1 mm, respectively (P < 0.01) in the responder group with MAD. The velopharyngeal collapsibility also decreased significantly from 83.3 ± 21.8 % to 46.5 ± 27.1 %. The glossopharyngeal collapsibility decreased from 39.8 ± 39.1 % to -22.9 ± 73.2 % (P < 0.05)., Conclusion: MAD can be an effective alternative treatment for patients with moderate and severe OSAHS after surgery. The principal mechanisms underlying the effect of MAD are expansion of the lateral diameter of the velopharynx, the enlargement of the velopharyngeal area, the reduction of velopharyngeal and glossopharyngeal collapsibility, and the stabilization of the upper airway.

Background: Airway obstruction due to enlargement of tonsils and adenoids is a common pediatric problem resulting in sleep disordered breathing. The cause for the relatively abnormal growth of tonsils and adenoids is poorly understood., Methods: Non-acutely ill children undergoing tonsillectomy and adenoidectomy (T&A) for various reasons were enrolled prospectively in a study to determine the frequency of asymptomatic respiratory viral infections in each lymphoid tissue and to relate the number and types of virus to the degree of airway obstruction. Molecular techniques were used to detect 9 respiratory viruses while Brodsky scores and measurements of percentages airway obstruction were used to estimate the degree of airway compromise due to the tonsil and adenoid, respectively., Results: Viruses were detected in 70.9% of tonsils and 94.7% of adenoids, p < 0.001. Adenovirus was the most common virus detected at 71.1%. Adenoids had an average of 2.4 viruses compared to 0.92 for tonsils, p < 0.001. Higher Brodsky scores were only associated with EBV in tonsils, p = 0.03, while greater percentages of airway obstruction in the adenoids were associated with adenovirus, EBV, corona virus, parainfluenza virus and rhinovirus, p ≤ 0.005., Conclusions: Asymptomatic viral infections are common and directly related to the degree of airway obstruction significantly more often in adenoids than tonsils., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To compare post-operative pain severity, analgesic intake, and complications in children undergoing tonsillectomy and adenoidectomy with bipolar radiofrequency ablation (Coblation) vs. pulsed-electron avalanche knife (PEAK) technology., Materials and Methods: This was a prospective, non-randomized, non-blinded comparative cohort study in a private practice setting with three fellowship-trained pediatric otolaryngologists. Patients aged 3 to 12years undergoing tonsillectomy and adenoidectomy were assigned to surgery with either bipolar radiofrequency ablation or pulsed electron avalanche knife instrumentation. Daily telephone contact for the first 14 post-operative days obtained the following data: validated proxy pain scale scores, number of post-operative analgesic medication doses consumed, and occurrence and severity of post-operative hemorrhage., Results: One-hundred adenotonsillectomy subjects were enrolled (50 bipolar radiofrequency ablation, 50 pulsed-electron avalanche knife). There were no clinically relevant differences in post-operative pain scores between the two surgical groups on all post-operative days. Total doses of non-narcotic and narcotic analgesics were similar between the groups, with the exception of less acetaminophen doses being consumed in pulsed-electron avalanche knife patients on post-operative days 9, 10, and 12. Post-operative hemorrhage episodes resulting in re-operation and/or hospitalization were equivalent between the two groups. However, bipolar radiofrequency ablation patients were 2.33 times more likely to experience minor bleeding events at home (that did not require medical intervention)., Conclusion: Pulsed-electron avalanche knife surgery was found to be an adequate technique for pediatric adenotonsillectomy, with similar amounts of post-operative pain and clinically relevant hemorrhage when compared to bipolar radiofrequency ablation., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Although tonsillectomy is one of the most common surgeries performed in pediatric, it has potential major complications such as pain and bleeding. This study aimed to compare the bleeding and pain after tonsillectomy in bipolar electrocautery tonsillectomy versus cold dissection., Methods: This double blind clinical trial was conducted on 70 pediatric patients who were candidate of tonsillectomy. Patients were divided into two groups of including bipolar cautery (BC) and cold dissection (CD). operation time, intraoperative blood loss, and postoperative bleeding and pain were evaluated in the current study., Results: In both of the CD and BC groups, no significant difference was found in terms of sex and age. The average amount of the intraoperative blood loss in BC group was 14.086 ± 5.013 ml and in CD group was 26.14 ± 4.46 ml (p. v = 0.0001). The mean time of operation in BC group was 19 ± 2.89 min and in CD group was 29.31 ± 5.29 min (p. v = 0.0001). patients were evaluated in terms of pain on the first, third, fifth, and seventh days after the operation. No statistically significant difference was found between two groups. Moreover, Compared pain scores in all times across two groups, no significant difference was found. In terms of postoperative bleeding, none of the patients in both groups had bleeding during follow-up., Conclusion: Our study showed that bipolar electrocautery tonsillectomy can significantly reduce the operation time and intraoperative blood loss; however, postoperative pain and blood loss were similar in both techniques. We recommend bipolar electrocautery as the most suitable alternative method for tonsillectomy, especially in children., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Snoring sounds generated by different vibrators of the upper airway may be useful indicators of obstruction sites in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). This study aimed to investigate associations between snoring sounds, obstruction sites, and surgical responses (≥50% reduction in the apnea-hypopnea index [AHI] and <10 events/hour) in patients with OSAHS. This prospective cohort study recruited 36 OSAHS patients for 6-hour snoring sound recordings during in-lab full-night polysomnography, drug-induced sleep endoscopy (DISE), and relocation pharyngoplasty. All patients received follow-up polysomnography after 6 months. Fifteen (42%) patients with at least two complete obstruction sites defined by DISE were significantly, positively associated with maximal snoring sound intensity (40-300 Hz; odds ratio [OR], 1.25, 95% confidence interval [CI] 1.05-1.49) and body mass index (OR, 1.48, 95% CI 1.02-2.15) after logistic regression analysis. Tonsil obstruction was significantly, inversely correlated with mean snoring sound intensity (301-850 Hz; OR, 0.84, 95% CI 0.74-0.96). Moreover, baseline tonsil obstruction detected by either DISE or mean snoring sound intensity (301-850 Hz), and AHI could significantly predict the surgical response. Our findings suggest that snoring sound detection may be helpful in determining obstruction sites and predict surgical responses.

In the last several years, a variety of novel approaches to the treatment of sleep-disordered breathing have emerged. This new technology holds promise in serving to re-engage with patients who have previously been lost to follow-up due to continuous positive airway pressure intolerance. With more tools at our disposal, in turn more options can be offered to patients' growing demand for alternatives that are tailored to their individual needs. The key to proper deployment of alternative therapies will often depend on identification of certain phenotypic traits that trend toward a reasonable response to a given therapy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Our objective was to determine the developmental status of young children with sleep-disordered breathing (SDB) as measured by the Ages and Stages Questionnaire (ASQ-3) and to evaluate improvement after treatment., Methods: The ASQ-3 was completed at entry, 3 months and 6 months after adenotonsillectomy or adenoidectomy. The questionnaire consists of 30 items that assess five domains: communication, gross motor, fine motor, problem solving and personal-social. Domain scores were compared with normative values: abnormal ≥2 SDs and borderline ≥1 but <2 SDs below the mean., Results: 80 children, mean (SD) age 3.0 (0.94) years, 62.5% male, 77.5% African American, were enrolled. Median (range) apnea-hypopnea index (AHI) was 12.6 (1.4-178.5). At entry, 22 (27.5%) children scored in the abnormal range in at least one developmental area and an additional 23 (28.8%) had at least one borderline score. A generalized linear model including gender, AHI, maternal education and prematurity showed that only prematurity was an independent predictor of at least one abnormal or borderline entry score (likelihood ratio test p < 0.001). Adjusting for covariates and excluding children with a history of prematurity, the prevalence of at least one abnormal or borderline score (based on 112 observations of 70 children) was estimated at 49% (95% CI [37, 62]) at baseline; 34% (95% CI [17, 56]) at 3 months; and 22% (95% CI [10, 41]) at 6 months. Post-hoc pairwise comparison of time points showed the baseline versus 6-month difference to be statistically significant (p = 0.015)., Conclusions: The 27.5% baseline prevalence of abnormal ASQ scores in children with SDB indicates it is a risk factor for developmental delay. Significant improvements in score classifications were found 6 months after surgery., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives/hypothesis: To investigate the relationship between sleep-disordered breathing (SDB) and nocturnal enuresis (NE) in children and to prospectively evaluate the effectiveness of adenotonsillectomy on resolving enuresis in indicated SDB patients with NE., Methods: We prospectively collected data from 183 children (121 males, mean age 8.17 ± 2.84 years) who underwent adenotonsillectomy to treat SDB between July 2011 and July 2013, and analyzed the prevalence of NE. Before and 3 months after surgery, all parents were requested to answer a self-reported SDB scale questionnaire (22 questions, 0-22 points) and a NE questionnaire (episodes of enuresis per month). Paired t test, Student t test, and Chi-square test were used to analyze the data., Results: Overall prevalence of NE was 9.3% (17 patients) preoperatively and 1.5% postoperatively (four patients). After adenotonsillectomy, prevalence of NE and the mean SDB scale were significantly decreased (both P values < 0.001). After adenotonsillectomy, 13 of the 17 NE patients (76.5%) showed complete resolution. There was significantly higher prevalence of NE in patients with obstructive sleep apnea (OSA) than those without OSA (13.1%, 14 of 107 vs. 3.9%, 3 of 76; P = 0.036)., Conclusion: There is strong association between NE and SDB, and adenotonsillectomy can markedly improve enuresis in the majority of children with NE and SDB., Levels of Evidence: 4. Laryngoscope, 126:1241-1245, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Sleep-disordered breathing in children is often associated with tonsillar hypertrophy. For many years, total tonsillectomy (TE) was the treatment of choice, but performing an intracapsular tonsillotomy (TT) is becoming increasingly widespread. In this Danish study, we have investigated the long-term results on efficacy and parent satisfaction after TT performed on children., Methods: This was a retrospective study based on a questionnaire that was sent to the parents of 335 children who underwent TT due to sleep-related obstructive symptoms., Results: A total of seven children had unilateral re-TT due to tonsillar regrowth, leaving a total of 342 operations performed. The response rate was 71% and the median follow-up was 90 months. None of the patients in this study ex-perienced post-operative bleeding requiring medical assistance. A total of 97% of parents reported total or partial relief of all symptoms, whereas 3% experienced no effect of treatment on preoperative symptoms. A total of 5% of the children later underwent tonsillectomy after their primary TT. The majority of parents (89%) would choose the operation again in a similar situation., Conclusions: TT has previously been shown to have a lower morbidity and risk of post-operative bleeding and a better recovery than TE. In this study, we found it to be a long-term efficient and safe treatment for children with obstructive symptoms during sleep and it was associated with a high degree of parent satisfaction., Funding: none., Trial Registration: This was a retrospective study.

Unlabelled: Primary snoring (PS) is considered as the most benign form of sleep-disordered breathing (SDB), and treatment is usually not prescribed. Studies suggest that PS may not be as benign as had formerly been considered. We aimed to investigate the natural history of PS in children with adenotonsillar hypertrophy, and compare those who underwent adenotonsillectomy (AT) with those who did not., Material and Methods: Children diagnosed with PS based on polysomnographic findings were included in the study. Information retrieved from their medical records, including medical history, physical examination, anthropometric measures, and polysomnography (PSG) results, was reviewed. A telephone interview was conducted 4-6 years following the PSG evaluation. The interview included the Pediatric Sleep Questionnaire Sleep-related Breathing Disorder (PSQ-SRBD) scale, demographics, anthropometric measures, and history of AT., Results: A total of 248 children (56% males) were studied (mean age: 5.4 ± 3.4 years). Telephone interviews were conducted 5.3 ± 1.1 years following PSG. Sixty-four children (26%) underwent AT/adenoidectomy (A) following PSG. Of the 184 children who did not undergo surgery, 62 (34%) had positive PSQ-SRBD scores five years after diagnosis. Children with PS who underwent AT had better PSQ-SRBD scores at five years post diagnosis than the nonoperated children., Conclusions: A significant proportion of children with PS persist with SDB symptoms even five years following the diagnosis. In our cohort, a considerable percentage of children with a PSG diagnosis of PS underwent AT despite non-supportive sleep study results. Surgical intervention may have beneficial effects on some children with PS. Further studies using objective measures of sleep and incorporating the effect of SDB duration are required., (Copyright © 2015. Published by Elsevier B.V.)

Background: Few data are available about obesity surgery in adolescent patients., Objective: To assess long-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients <18 years., Setting: University Hospital, Europe., Methods: A retrospective study of prospectively collected data of patients <18 years (childhood group; ChG) (n = 28) treated by LRYGB of which 19 were available for follow-up between 2.4 and 10.2 years (mean 7.2 years). This group of patients was matched with an adult control group (AdG) of randomly chosen patients with similar characteristics who underwent LRYGB during the same period. The extensive survey included a telephonic questionnaire., Results: 19 (12 females) of the 28 patients (67.9%) were available for follow-up. Preoperatively, 3 had type 2 diabetes mellitus (T2DM), 1 arterial hypertension, 5 dyslipidemia and 1 sleep apnea. In the ChG, average BMI after 7 years dropped from 38.9 kg/m2 preoperatively to 27.5 kg/m2. In the AdG, average BMI decreased from 39.4 to 27.1 kg/m2 in the same time period (nonsignificant between groups). One patient in the ChG needed a reoperation (internal hernia) versus 3 patients in the AdG (1 leak, 2 obstructions). All patients resolved their initial comorbidities. Two of 12 female patients in the ChG became pregnant 6 and 8 years after surgery, respectively, despite seemingly adequate oral contraception. Compliance with postoperative guidelines was good in 16/19 patients in ChG and in 14/18 patients in the AdG. Overall degree of satisfaction was high: 8.2/10 (SD 1.2, range 6-10) in the ChG and 8.9/10 (SD 1.7, range 5-10) in the AdG., Conclusion: LRYGB seems to be safe, provide good weight loss, and cure comorbidities in an adolescent population. Satisfaction degree is high. Inadvertent pregnancy despite conventional contraception is a possible issue., (© 2016 S. Karger GmbH, Freiburg.)

Objectives: To examine whether high intellectual ability, in comparison to average or lower performance, reflects the consequences of sleep-disordered breathing and limits behavioral benefit observed 6 months after adenotonsillectomy., Methods: Children aged 3-12 years (n=147) recruited from otolaryngology practices at two hospitals and assessed with Conners' Parent Rating Scales and an age range-appropriate intellectual measure, the Stanford-Binet Intelligence Scale at baseline and 6 months after clinically-indicated adenotonsillectomy. Subjects were classified as having high (IQ≥110), average (90≤IQ<110), or low (IQ<90) cognitive ability., Results: After adenotonsillectomy, improvements in Conners' internalizing, externalizing, hyperactivity, and cognitive domains were observed across IQ groups (main effects for time, all p<0.01 or better), with no evidence for differential improvements among the groups (no significant time by IQ group interactions). The magnitude of behavioral improvement among children with high IQ resembled that observed among the other two groups. Changes in the Conners' domains were not significantly correlated with baseline IQ, age, socioeconomic status, body mass index z-score, or respiratory disturbance index., Conclusion: Behavioral function can improve after adenotonsillectomy even among children with relatively high intellectual ability at baseline. Diagnosis and treatment with expectation of neurobehavioral benefit should be considered among high-performing children as readily as it is more traditionally among their lower-performing peers., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Many clinicians are concerned about possible airway or respiratory complications following adenotonsillectomy for sleep related breathing disorder (SRBD), and routinely admit such patients for overnight monitoring. However, published guidelines suggest this is unnecessary in some cases. This study firstly aimed to establish current UK practice, and secondly to investigate whether children with mild/moderate SRBD experience respiratory problems during the first post-operative night., Methods: To establish current UK practice, we carried out a telephone survey asking if the procedure was carried out as a day-case, and admission criteria. For the second aim, a prospective study of children admitted following adenotonsillectomy for mild/moderate SRBD was carried out to investigate occurrence of respiratory complications on first post-operative night., Results: Forty-two UK ENT doctors responded to the telephone survey, 50% routinely admitted patients having adenotonsillectomy for SRBD. Discharge criteria included stable observations and eating and drinking (14 hospitals), no bleeding (1), stable oxygen saturations (1) and age above 5 years (1); four had no specific criteria. Of 51 children admitted following adenotonsillectomy for mild/moderate SRBD, 11 (21.6%) experienced oxygen desaturations overnight. Of these, nine were under 4 years old, and two older children had asthma. Irrespective of comorbidities, 9/27 (33.2%) children under 4 years old experienced desaturations. The only children aged more than 4 years that had desaturations were ones that had additional comorbidities., Conclusion: Half of surveyed doctors admit all children following surgery for SRBD. The number of admissions could be reduced, because same-day discharge for otherwise-healthy children over 4 years old having adenotonsillectomy for mild/moderate SRBD appears to be safe., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Sleep-disordered breathing (SDB) in children could be resolved by adenotonsillectomy (T&A). However, incomplete results are often noted post-surgery. Because of this partial resolution, long-term follow-up is needed to monitor for reoccurrence of SDB, which may be diagnosed years later through reoccurrence of complaints or in some cases, through systematic investigations. Children undergoing T&A often have small upper airways. Genetics play a role in the fetal development of the skull, the skull base, and subsequently, the size of the upper airway. In non-syndromic children, specific genetic mutations are often unrecognized early in life and affect the craniofacial growth, altering functions such as suction, mastication, swallowing, and nasal breathing. These developmental and functional changes are associated with the development of SDB. Children without genetic mutations but with impairment of the above said functions also develop SDB. When applied early in life, techniques involved in the reeducation of these functions, such as myofunctional therapy, alter the craniofacial growth and the associated SDB. This occurs as a result of the continuous interaction between cartilages, bones and muscles involved in the growth of the base of the skull and the face. Recently collected data show the impact of the early changes in craniofacial growth patterns and how these changes lead to an impairment of the developmental functions and consequent persistence of SDB. The presence of nasal disuse and mouth breathing are abnormal functions that are easily amenable to treatment. Understanding the dynamics leading to the development of SDB and recognizing factors affecting the craniofacial growth and the resulting functional impairments, allows appropriate treatment planning which may or may not include T&A. Enlargement of lymphoid tissue may actually be a consequence as opposed to a cause of these initial dysfunctions., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Previous research on SDB in children has focus edprimarily on OSA, whereas there is an increasing body of evidence to suggest that children with a spectrum of SDB symptoms may be at risk for perioperative and postoperative adverse events. To this end, it is imperative that these children are identified before surgery so that anesthesia and postoperative pain management plans can be optimized to mitigate risk. Although PSG remains the gold standard as a means to screen for SDB preoperatively,there are now clinically valid tools that can be used as part of the preanesthetic interview to identify children at risk. However, although recent work suggests that implementation of such screening tools may be important in identifying at-risk children and reducing perioperative adverse events through changes in anesthetic management, there is still much to be done with respect to changing the culture of standard postoperative opioid dosing. Perianesthesia nurses are thus in a unique position to help encourage a culture in which SDB in children is recognized asa significant risk for both perioperative and potentially deadly postoperative sequelae.

Adenotonsillectomy is one of the most common surgical procedures performed in children, with more than half a million procedures performed annually. We provide a review of the procedure, including indications, contraindications, perioperative issues, and current controversies. A more in-depth discussion of indications for sleep-disordered breathing and recurrent throat infections is performed. We provide a reasonable approach to these conditions for the general pediatrician. Finally, we discuss selected areas of current controversies: the role of preoperative polysomnogram, postoperative weight gain, and effects on immune function.

Study Objective: Sleep disordered breathing (SDB) in preschool-aged children is common, but long-term outcomes have not been investigated. We aimed to compare sleep and respiratory parameters in preschool children to examine the effects of treatment or non-treatment after 3 years., Methods: Children (3-5 years) diagnosed with SDB (n = 45) and non-snoring controls (n = 30) returned for repeat overnight polysomnography (39% of original cohort), 3 years following baseline polysomnography. Children with SDB were grouped according to whether they had received treatment or not. SDB resolution was defined as an obstructive apnea hypopnea index (OAHI) ≤ 1 event/h, no snoring detected on polysomnography and habitual snoring not indicated by parents on questionnaire., Results: Fifty-one percent (n = 23) of the children with SDB were treated. Overall, SDB resolved in 49% (n = 22), either spontaneously (n = 8) or with treatment (n = 14). SDB remained unresolved in 39% (n = 9) of those treated and 64% (n = 14) of the children who were untreated. Two of the non-snoring controls developed SDB at follow-up. The treated group had significantly lower OAHI (p < 0.01), respiratory disturbance index (p < 0.001), total arousal and respiratory arousal indices (p < 0.01 for both) at follow-up compared with baseline. There were no differences between studies for the untreated group., Conclusions: Although treatment resulted in an improvement in indices related to SDB severity, 39% had SDB 3 years following diagnosis. These findings highlight that parents should be made aware of the possibility that SDB may persist or recur several years after treatment. This is relevant regardless of the severity of SDB at baseline and the treatment given., (© 2015 American Academy of Sleep Medicine.)

Sleep apnea represents a relative indication for posterior fossa decompression in pediatric patients with Chiari malformation type 1. Duraplasty was associated with improvement of sleep apnea in 100% of patients and dural splitting with improvement in 50% of patients. Duraplasty and dural splitting were associated with a similar reduction in tonsillar herniation on radiographic imaging of 58% (37% excluding tonsillectomy) and 35%, respectively. Longitudinal follow-up studies of patients with either neurologic deficits or severe symptoms will further elucidate the natural history of Chiari malformation type 1 and more appropriately gauge the risk-benefit tradeoff of surgical intervention., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: This study aimed to measure changes in disease-specific quality of life in children following tonsillectomy or adenotonsillectomy., Methods: A multicentre prospective cohort study was performed involving seven ENT departments in England. A total of 276 children entered the study over a 2-month period: 107 underwent tonsillectomy and 128 adenotonsillectomy. Forty-one children referred with throat problems initially managed by watchful waiting were also recruited. The follow-up period was 12 months. Outcome measures were the T14, parental impressions of their child's quality of life and the number of days absent from school., Results: One-year follow-up data were obtained from 150 patients (52 per cent). The mean baseline T14 score in the non-surgical group was significantly lower (T14 = 23) than in the tonsillectomy group (T14 = 31) or the adenotonsillectomy group (T14 = 35; p < 0.001). There was a significant improvement in the T14 scores of responders in all groups at follow up. The effect size was 1.3 standard deviations (SD) for the non-surgical group, 2.1 SD for the tonsillectomy group and 1.9 SD for the adenotonsillectomy group. Between-group differences did not reach statistical significance. A third of children in the non-surgical group underwent surgery during the follow-up period., Conclusion: Children who underwent surgical intervention achieved a significant improvement in disease-specific quality of life. Less severely affected children were managed conservatively and also improved over 12 months, but 1 in 3 crossed over to surgical intervention.

Background and Aims: Obstructive sleep apnoea (OSA) is a well recognised clinical disorder in which there is narrowing and repeated collapse of the upper airway during sleep resulting in the cessation of breathing. Patients with mild to moderate sleep apnoea are often provided with mandibular advancement splint (MAS) therapy as a form of first line or definitive treatment. The aims of this audit were to evaluate patient satisfaction and success of MAS therapy., Methods: 93 patients diagnosed with sleep apnoea and suitable for a splint were recruited prospectively at Queen Victoria Hospital, East Grinstead between January 2009 and October 2010. A patient satisfaction questionnaire was developed by health professionals involved in the care of patients with sleep apnoea and assessed for face and content validity and reliability. Participants completed the questionnaire six weeks after the splint was fitted., Results: 44% who previously experienced snoring now reported no snoring and 47% reported less snoring since wearing the MAS appliance. 69% reported complete resolution of sleep apnoea symptoms. 37% experienced aching teeth and 33% experienced having a dry throat when wearing the appliance. 86% of sleeping partners felt that their quality of sleep was improved following their partners treatment., Conclusions: The standards set for each criteria in this audit were met. MAS treatment has a key role to play in the management of obstructive sleep apnoea with high rates of patient satisfaction and the majority of patients partners reporting a significant improvement in their own and their partners sleep quality., (Copyright © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Objectives: A number of otolaryngic conditions such as chronic tonsillitis, adenoid hypertrophy, and obstructive sleep apnea are associated with oxidative stress and elevated levels of serum oxidants. The objective of this study is to measure changes in urine biomarkers of oxidative stress in children after adenotonsillectomy., Methods: Twenty-two children with sleep disordered breathing (SDB) with tonsil and adenoid hypertrophy were enrolled prior to adenotonsillectomy. Controls consisted of 20 healthy children. Urine samples were collected from all patients. Levels of three urinary biomarkers for oxidative status, 8-hydroxy-2-deoxyguanosine (8-OxodG), F(2)-isoprostane, and malondialdehyde (MDA) were measured using high performance liquid chromatography. For the study group, urine samples were repeated 3 weeks after surgery., Results: In the study group, preoperative urinary levels of 8-OxodG were higher than in controls (p=0.015). Levels decreased after surgery compared to preoperative levels (p=0.002), and reached control levels (p=0.167) at 3 weeks. Levels of urinary F(2)-isoprostane were similar in both groups (p=0.252), but decreased significantly after surgery (p=0.020)., Conclusions: Children with SDB have elevated levels of urinary 8-OxodG, a marker of oxidative stress. Adenotonsillectomy results in decreased 8-OxodG and F(2)-isoprostane. These findings suggest that urine analysis may represent a valuable tool for the measurement of oxidative stress., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Oxidative stress plays a crucial role in impairing endothelial function in sleep disordered breathing (SDB) but the underlying mechanism is still undefined. The objective of this study was to evaluate the interplay between oxidative stress, assessed by serum isoprostanes (8-iso-PGF2α) and soluble NOX2-dp (sNOX2-dp), and endothelial function, assessed by flow-mediated dilation (FMD), in children with SDB and healthy controls (HC)., Methods: One-hundred forty-four children including 45 with primary snoring (PS), 22 with obstructive sleep apnea (OSA) and 67 HC were recruited in this study; in 15 out of 22 OSA children FMD, serum 8-iso-PGF2α and sNOX2-dp were assessed before and after one month post adeno-tonsillectomy (AT)., Results: Compared with HC, OSA and PS children had significantly higher sNOX2-dp and serum 8-iso-PGF2α levels and lower FMD; compared with PS, FMD was significantly lower in OSA children. No significant difference for sNOX2-dp and serum 8-iso-PGF2α was observed between OSA and PS children. FMD was inversely correlated with sNOX2-dp levels (p<0.001) and with serum 8-iso-PGF2α (p<0.001). In multiple linear regression analysis, sNOX2-dp (p<0.001) and serum 8-iso-PGF2α (p<0.001) were the only independent predictive variables associated with FMD. AT significantly decreased sNOX2-dp and serum 8-iso-PGF2α levels (from 38.2±8.8 to 22.4±11.1 pg/ml, p<0.001, and from 281.4±69.7 to 226.0±66.4 pg/ml, p<0.001, respectively); conversely, FMD significantly increased after AT in OSA children (from 3.0±1.5 to 8.0±2.8%, p<0.001)., Conclusion: This study suggests that NOX2-derived oxidative stress is involved in artery dysfunction in SDB children. Such hypothesis is reinforced by FMD improvement after AT coincidentally with oxidative stress lowering., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02247167., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Hemoglobinopathies involving Hemoglobin S, like Hemoglobin SC disease, are characterized by anemia and vaso-occlusive crises. Vaso-occlusive crises can range in severity from localized pain to acute chest syndrome and myocardial infarction. These crises are usually brought on by stressors that induce hypothermia, hypoxia or acidosis, such as surgery [1]. Here we report a case of acute chest syndrome in a child with Hemoglobin SC disease following adenotonsillectomy and review of the literature regarding acute chest syndrome following adenotonsillectomy., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Tonsillotomy has gained popular acceptance as an alternative to the traditional tonsillectomy in the management of sleep-disordered breathing in children. Many studies have evaluated the outcomes of the two techniques, but uncertainty remains with regard to the efficacy and complications of tonsillotomy versus a traditional tonsillectomy. This study was designed to investigate the efficacy and complications of tonsillotomy versus tonsillectomy, in terms of the short- and long-term results., Methods: We collected data from electronic databases including MEDLINE, EMBASE, and the Cochrane Library. The following inclusion criteria were applied: English language, children, and prospective studies that directly compared tonsillotomy and tonsillectomy in the management of sleep disordered breathing. Subgroup analysis was then performed., Results: In total, 10 eligible studies with 1029 participants were included. Tonsillotomy was shown to be advantageous over tonsillectomy in short-term measures, such as a lower hemorrhage rate, shorter operation time, and faster pain relief. In long-term follow-up, there was no significant difference in resolution of upper-airway obstructive symptoms, the quality of life, or postoperative immune function between the tonsillotomy and tonsillectomy groups. The risk ratio of SDB recurrence was 3.33 (95% confidence interval = 1.62 6.82, P = 0.001), favoring tonsillectomy at an average follow-up of 31 months., Conclusions: Tonsillotomy may be advantageous over tonsillectomy in the short term measures and there are no significant difference of resolving obstructive symptoms, quality of life and postoperative immune function. For the long run, the dominance of tonsillotomy may be less than tonsillectomy with regard to the rate of sleep-disordered breathing recurrence.

Background: To evaluate intranasal administration of butorphanol on postoperative pain and early postoperative cognitive dysfunction in old patients undergoing H-uvulopalatopharyngoplasty (H-UPPP)., Methods: A total of 260 male patients (65 to 77 years old) with obstructive sleep apnea hypopnea syndrome and scheduled for H-UPPP were divided randomly to receive intranasal butorphanol, intravenous butorphanol, intranasal fentanyl, or intravenous saline (controls). The definition of preemptive analgesia is that the tested drugs are given before anesthesia induction. Visual analog scale (VAS) and Bruggrmann comfort scale (BCS) scores were recorded at postoperative 1, 6, 12, 18, 24, 36, and 48 h. Postoperative cognitive dysfunction (POCD) was evaluated by Mini-Mental State Examination (MMSE) scores assessed one day before, and 1, 3, and 7 days postsurgery., Results: Compared with control group, those given preemptive analgesia required significantly less sufentanil during surgery, had less pain at postoperative 6-12 h; those given butorphanol experienced less nausea and vomiting, less pain at postoperative 6-24 h, and less POCD. Compared with patients given fentanyl, those given butorphanol required significantly less postoperative fentanyl, had less pain at postoperative 18-24 h, less nausea and vomiting, and less POCD. Compared with patients given intravenous butorphanol, those who received butorphanol by nasal route required significantly less postoperative fentanyl, had less pain at 36 and 48 h, and less POCD., Conclusion: Intranasal administration of butorphanol is safe and effective, reducing postoperative usage of analgesics and the incidence of POCD in old patients undergoing H-UPPP., Trial Registration: ChiCTR-TRC-14004121.

Importance: Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT)., Objective: To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB., Design, Setting, and Participants: Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up., Main Outcomes and Measures: Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups., Results: A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) (P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001)., Conclusions and Relevance: Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.

This article reports the case of a 44-year-old male with skeletal Class III, Angle Class III malocclusion and unilateral crossbite with concerns about obstructive sleep apnea syndrome (OSAS), esthetics and functional problems. To correct the skeletal deformities, the maxilla was anteriorly repositioned by employing LeFort I osteotomy following pre-surgical orthodontic treatment, because a mandibular setback might induce disordered breathing and cause OSAS. After active treatment for 13 months, satisfactory occlusion was achieved and an acceptable facial and oral profile was obtained. In addition, the apnea hypopnea index (AHI) decreased from 18.8 preoperatively to 10.6 postoperatively. Furthermore, after a follow-up period of 7 months, the AHI again significantly decreased from 10.6 to 6.2. In conclusion, surgical advancement of the maxilla using LeFort I osteotomy has proven to be useful in patients with this kind of skeletal malocclusion, while preventing a worsening of the OSAS.

Objective: To explore the application of polysomnography (PSG) and lateral cephalometric radiographs (LCR) in the diagnosis and treatment of sleep-disordered breathing (SDB) in children., Method: To select 157 cases of children suffering from SDB, 115 cases with primary snoring (PS) and 42 cases with obstructive sleep apnea hypopnea syndrome (OSAHS). After bilateral tonsillectomy and adenoidectomy, preoperative and postoperative LCR and PSG of measure were observed for statistical analysis., Result: Compared the group PS and group OSAHS; the thickness of adenoids was significantly different(P<0. 01). The preoperative oblique diameter of nasopharyngeal airway was significantly different (P<0. 05). There were significant differences on the preoperative and postoperative nasopharyngeal airway oblique diameter and oropharyngeal airway anteroposterior diameter in group PS and group OSAHS (all, P<0. 01). There were significant differences on the preoperative and postoperative AHI and LSaO2 in the group OSAHS (both, P<0. 01). The total effective rate of group PS was 97. 4% (112/115), and the total effective rate of group OSAHS was 97. 6% (41/42)., Conclusion: PSG and LCR have a very important role in the diagnosis and treatment of SDB in children. Bilateral tonsillectomy and adenoidectomy are the primary means of treatment in children with SDB.

Radiofrequency ablation (RFA) is used in the treatment of sleep disordered breathing (SDB), particularly in the alleviation of snoring. The literature provides evidence that the short-term results are promising; however, the long-term efficacy is a matter of contention. In this article, we present the results of a literature search of studies that use RFA in the treatment of SDB which have a follow-up time of greater than a year. RFA was found to be a safe technique with minimal morbidity. The overall Visual Analogue score from six studies showed the overall mean improvement to be 4.3 (confidence intervals 3.4-5.12). Apnea Hypopnea Index (AHI), improved significantly in five of the studies analysed. Epworth Sleepiness Score (ESS), improved significantly in six of the studies analysed. In conclusion, the evidence suggests that RFA for SDB results in a significant improvement in follow-up times of at least a year. Since RFA can be applied in a clinic setting and leads to minimal disruption to daily life, this treatment option can be considered for those unwilling to participate in the more traditional surgical options for SDB.

Objectives/hypothesis: To evaluate the effect of radiofrequency surgery of the soft palate on daytime sleepiness in snoring men with mild or no sleep apnea., Study Design: Randomized controlled trial., Methods: Thirty-five men were recruited from consecutive patients referred to the Ear, Nose, and Throat Clinic due to snoring and complaints of daytime sleepiness. The inclusion criteria were an apnea-hypopnea index (AHI) of ≤ 15, male gender, and age 18 to 65 years. Patients were randomized to either radiofrequency or sham surgery of the soft palate. All but one chose and received the option of three treatments. All patients participated in a follow-up, including an overnight sleep apnea recording and questionnaires 12 months after the last treatment. The primary outcome was daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) and other questionnaires. Secondary outcomes were effects on the AHI and subjective snoring., Results: Thirty-two of 35 patients-19 of 20 patients in the radiofrequency surgery group and 13 of 15 patients in the sham surgery group-completed the study. No differences between the two groups in relation to the ESS or AHI were found at follow-up., Conclusion: Radiofrequency surgery of the soft palate has no effect on daytime sleepiness, snoring, or apnea frequency in snoring men with mild or no sleep apnea 1 year after surgery., Level of Evidence: 1b. Laryngoscope 124:2422-2426, 2014., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

DiGeorge Syndrome (DGS) may be associated with airway abnormalities including laryngomalacia and suprastomal collapse of the trachea (SCT), which may lead to sleep disordered breathing (SDB). We present a 4-year-old boy with DGS, SCT, and SDB by polysomnography (PSG) while the tracheostomy tube was capped. The patient underwent anterior tracheal wall suspension (ATWS) with concurrent tracheostomy decannulation. Following the repair, the patient experienced improved airway patency visually and by PSG with resolution of obstructive sleep apnea and hypoventilation. ATWS is an effective method to repair SCT in selected patients and may lead to early decannulation and improvement of SDB., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

A 38-year-old man (BMI 31) underwent bilateral tonsillectomy for sleep apnea syndrome under general anesthesia without any airway difficulty. On the fifth post-operative day excessive bleeding occurred suddenly. Emergency tracheostomy was planned, not under local anesthesia but general anesthesia in the presence of otolaryngologists for urgent tracheostomy, since the patient could not lie in the supine position. Tracheal intubation was tried using rapid sequence technique. However, excessive bleeding in the oral cavity did not allow successful direct laryngoscopy, resulting in CICV situation. When CICV situation was con- firmed associated with SpO2 91%, surgical cricothyrotomy was started by otolaryngologists. SpO2 decreased to 13% associated with heart rate of 38 beats · min-1 immediately before restoration of ventilation and oxygenation. After hemostasis, he showed uneventful post-operative course. On the occasion of airway management for excessive laryngopharyngeal bleeding, emergency surgical crycothyrotomy should be performed immediately before the fall of oxygen tension, if rapid sequence tracheal intubation had failed.

This article reviews current knowledge of the science of pediatric tonsillectomy-developmental anatomy of the tonsil, physiology of the operation, and wound healing after surgery. It outlines indication for surgery and best practices for intraoperative and postoperative care as described in the American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline: Tonsillectomy in Children. Finally, it discusses areas of uncertainty in the field and opportunity for future improvement., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to investigate the degree of impact of obstructive sleep apnea hypopnea syndrome (OSAHS) severity on pediatric psychological and behavioral abnormalities., Material and Methods: Fifty-one children aged 5-12 years with a confirmed diagnosis of OSAHS were divided into 3 groups according to the severity of OSAHS. They underwent bilateral tonsillectomy plus adenoidectomy or adenoidectomy alone. Repeated polysomnography and integrated visual and auditory continuous performance testing (-IVA-CPT) was performed to assess full-scale response control quotient (FRCQ), full-scale attention quotient (FAQ), and hyperactivity (HYP) before surgery and 3 and 6 months after surgery., Results: Mean FRCQ, FAQ, and HYP significantly improved over time in the 3 groups (FRCQ, F=292.05; FAQ, F=258.27; HYP, F=295.10, all P<0.001). FRCQ and HYP were not significantly different among the groups at the 3 time points. FAQ was significantly different among the groups (F=3.89, P<0.05). For FRCQ, FAQ, and HYP, there was no interaction between time and disease severity. Within groups, the effect of time on the apnea-hypopnea index (AHI) and lowest oxygen saturation (LaSO2) were significant for each group and they were significantly different among the 3 groups at each time point (all P<0.001)., Conclusions: These results suggest that OSAHS may have a significant impact on self-control, attention, and hyperactivity in children, which is gradually alleviated after surgery. Disease severity was not closely related to preoperative mental and psychological function or postoperative recovery. Thus, we find it difficult to determine the impact degree of OSAHS severity on mental and psychological function or predict postoperative recovery by using OSAHS severity alone in children.

Objectives/hypothesis: To determine the prevalence of severe obstructive sleep apnea (OSA) in a pediatric population who underwent indicated surgery for sleep disordered breathing (SDB)., Study Design: Retrospective chart review., Methods: We reviewed the charts of patients aged 2 to 18 years who underwent tonsillectomy or adenotonsillectomy over a 4-year period. Indications for preoperative polysomnography (PSG), PSG results, and perioperative complications were recorded., Results: Two hundred and thirty-five patients were included in the final analysis. Of these, 160 patients had preoperative PSG performed. The overall prevalence of severe OSA was 38%. The prevalence in patients for whom preoperative PSG was indicated or for which it should have been advocated according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guideline was 45% and 40%, respectively, whereas the prevalence in patients with no indication for preoperative PSG was 34%. There was no significant difference between groups (P = 0.39). The overall complication rate was 11%, with the rate being significantly lower (P = 0.0022) in patients who did not have preoperative PSG performed (0%) when compared to those who did (16%)., Conclusions: The prevalence of severe OSA in this pediatric population was high. Specifically, a significant percentage of children who would not have received preoperative PSG under the AAO-HNS recommendations had severe OSA and were consequently admitted for overnight observation. Our results suggest that preoperative PSG should be obtained for all pediatric patients with sleep disordered breathing., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)