Sleep Endoscopy and Cine Magnetic Resonance Imaging Evaluation of Children With Persistent Obstructive Sleep Apnea.

OBJECTIVE: To compare findings of same-day cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) and examine how each technique uniquely contributes to the evaluation of persistent obstructive sleep apnea following adenotonsillectomy. STUDY DESIGN: Retrospective cohort study. SETTING: Quaternary care center. METHODS: Chart review was performed for consecutive patients who underwent same-day cine MRI and DISE between 2015 and 2020. Descriptive statistics are reported, and Cohen kappa coefficients were calculated to evaluate the agreement between cine MRI and DISE for obstruction at the adenoids, lingual tonsils, and tongue base. RESULTS: There were 137 patients, the mean age was 10.4 years (95% CI, 3.2-16.7), and 62.8% were male. The most common sites of obstruction on DISE were the tongue base (86.9%), velum (78.7%), epiglottis (74.5%), inferior turbinate (68.6%), and lingual tonsil (61.3%). The most common sites of obstruction on cine MRI were the hypopharynx (56.3%), tongue base (44.8%), lingual tonsil (38.0%), and macroglossia (37.6%). There was moderate agreement for adenoid hypertrophy (κ = 0.53) and poor agreement for lingual tonsil hypertrophy (κ = 0.15) and tongue base obstruction (κ = 0.09). DISE identified more instances of multilevel obstruction when compared with cine MRI (94.9% vs 48.2%). CONCLUSION: DISE offered a better examination of nasal and supraglottic obstruction and is sensitive to partial vs complete collapse, while cine MRI offered better soft tissue resolution for lymphoid tissue hypertrophy and provided a global view of primary and secondary airway obstruction. Cine MRI and DISE are complementary modalities in the evaluation of children with persistent obstructive sleep apnea.

Safety and cost of drug-induced sleep endoscopy outside the operating room.

INTRODUCTION: Drug-induced sleep endoscopy (DISE) is used to assess site of obstruction for patients in a pharmacologically induced sleep-like state. It is traditionally performed in the operating room (OR), however, no data exists regarding the feasibility of this intervention outside the OR in children. The objective is to compare the safety of DISE performed in the MRI induction room to those performed in the OR. METHODS: Prospective case-series of patients undergoing DISE in the MRI induction room (study group) to those assessed in the OR (controls) in a single-institution pediatric tertiary care center. Consecutive patients undergoing DISE examination for persistent obstructive sleep apnea (OSA) after adenotonsillectomy from September 2016 to September 2017 were included. RESULTS: Overall, 118 patients (38 study patients, 80 controls) with a mean age of 10.6 years (95% confidence interval [CI], 9.3-11.9) underwent DISE; 39.8% (47/118) were female. The most frequent comorbidity was cardiac disease (22.0%, 26/118). The mean obstructive apnea-hypopnea index was 12.2 events/hour (95% CI, 8.8-15.6) for controls and 13.5 events/hour (95% CI, 8.7-18.3) for study patients (P = .76). No major complication or unplanned admissions occurred in either group. Induction time was similar (12 vs. 13 minutes, P = .7) as was total procedure time (12 vs. 14 minutes, P = .3) for procedures performed in both settings. CONCLUSION: There were no significant complications for DISE performed in the OR or the MRI induction room and procedure times were similar. Further assessment of patient outcomes and resource utilization is needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 2076-2080, 2020.

Slide tracheoplasty outcomes in children with congenital pulmonary malformations.

OBJECTIVES/HYPOTHESIS: Evaluate and compare surgical outcomes of slide tracheoplasty for the treatment of congenital tracheal stenosis in children with and without pulmonary malformations. STUDY DESIGN: Retrospective chart review at a tertiary care pediatric medical center. METHODS: We identified patients with tracheal stenosis who underwent slide tracheoplasty from 2001 to 2014, and a subset of these patients who were diagnosed with congenital pulmonary malformations. Hospital course and preoperative and postoperative complications were recorded. RESULTS: One hundred thirty patients (18 with pulmonary malformations, 112 with normal pulmonary anatomy) were included. Pulmonary malformations included unilateral pulmonary agenesis (61%) and hypoplasia (39%). Children with pulmonary malformations had a greater median age compared to their normal lung anatomy counterparts. Preoperatively, patients with pulmonary malformations more frequently required preoperative mechanical ventilation (55.6% vs. 21.3%, P = .007), extracorporeal membrane oxygenation (ECMO) (11% vs. 0.9%, P = .05), and tracheostomy (22.2% vs. 3.6%, P = .01). Postoperatively, patients with pulmonary malformations more frequently required mechanical ventilation >48 hours (78% vs. 37%, P =.005) and ECMO use (11% vs. 0.9%, P = .05). Pulmonary malformation patients and children with normal anatomy did not differ in terms of postoperative tracheostomy (16.7% vs. 4.4%, P > .05), dehiscence (6% vs. 0%, P > .05%), restenosis (11% vs. 6%, P > .05) or postoperative figure 8 deformity (6% vs. 3%, P > .05). Mortality, however, was significantly increased (22.2% vs. 3.6%, P = .01) in children with pulmonary malformations. CONCLUSIONS: Although slide tracheoplasty can be successfully performed in patients with abnormal pulmonary anatomy, surgeons and families should anticipate a more difficult postoperative course, with possible associated prolonged mechanical ventilation, ECMO use, and higher mortality than in children with tracheal stenosis alone. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1283-1287, 2017.

Nasal polyps: pathogenesis and treatment implications.

Nasal polyps (NPs) represent a common clinical end point for a myriad of inflammatory disease processes involving the paranasal sinuses. Chronic rhinosinusitis is the most common cause for NPs, but not all NPs are created equally. This article outlines the current understanding of pathogenesis in nasal polyposis and discusses the implications on therapy.

Obstructive sleep disorders in Prader-Willi syndrome: The role of surgery and growth hormone.

OBJECTIVE: To review the effectiveness and safety of surgical intervention for obstructive sleep apnea in Prader-Willi syndrome. BACKGROUND: The muscle hypotonia and obesity associated with Prader-Willi syndrome (PWS) result in a high rate of obstructive sleep apnea (OSA). The use of growth hormone therapy in these patients has been associated with sudden death, raising concerns that such treatment may exacerbate obstructive sleep apnea. As a result, it has been suggested that children with PWS be evaluated for OSA and indications for adenotonsillectomy prior to instituting growth hormone therapy. The true effectiveness of surgical intervention in these cases, however, remains in doubt. METHODS: Retrospective review of patients with a diagnosis of PWS who underwent adenoidectomy or adenotonsillectomy from January 2001 to July 2009 at a regional, tertiary care children's hospital. Patients underwent pre-operative and post-operative polysomnography. Differences between pre-operative and post-operative body-mass index (BMI), apnea-hypopnea index (AHI), and median oxygen saturation and oxygen saturation nadir were analyzed. RESULTS: Five patients were identified during the study period. Three patients underwent adenotonsillectomy, 1 patient adenoidectomy alone, and another adenotonsillectomy with uvulopalatopharyngoplasty (UPPP). While median AHI was found to have decreased from 16.4 to 4.4, no statistically significant change could be demonstrated (p=0.274). Mean O(2) and nadir O(2) saturation also improved, but without reaching statistical significance. No intra-operative complications were noted. CONCLUSIONS: Our series, and other small case series, have demonstrated that complete resolution of sleep apnea in PWS patients is difficult to obtain with upper airway surgery alone. It is suggested that children with PWS being considered for growth hormone therapy undergo assessment for OSA by polysomnography. Patients identified with OSA should be referred for management by tonsillectomy and/or continuous positive airway pressure (CPAP) and then reassessed for residual airway obstruction prior to instituting hormonal therapy.

Systemic therapies in managing sinonasal inflammation.

Chronic rhinosinusitis (CRS) is a condition characterized by persistent inflammation due to intrinsic mucosal hypersensitivity or persistent infection. Proper medical treatment with antibiotic, leukotriene modifiers, oral corticosteroids, or even aspirin desensitization for the sinus inflammation can prevent the need for surgical intervention. The key to delineating the specific medical application is to determine the cause of the sinus mucosa dysfunction and its specific inflammatory pathway. Such targeted antiinflammatory medical therapy will lead to improved efficacy in the management of CRS. Even if surgical intervention is required, postoperative medical treatment is essential to minimizing the intrinsic mucosal inflammation and therefore preventing revision endoscopic procedures.