Polysomnographic Characteristics of Sleep Architecture in Children With Obstructive Sleep Apnea.

BACKGROUND: The conventional measure of sleep fragmentation is via polysomnographic evaluation of sleep architecture. Adults with OSA have disruption in their sleep cycles and spend less time in deep sleep stages. However, there is no available evidence to suggest that this is also true for children and published results have been inconclusive. OBJECTIVE: To determine polysomnographic characteristics of sleep architecture in children with OSA and investigate effects relative to OSA severity. METHODS: Overnight polysomnograms (PSG) of children referred for suspected OSA were reviewed. Subjects were classified by apnea hypopnea index (AHI). PSG parameters of sleep architecture were recorded and analyzed according to OSA severity. RESULTS: Two hundred and eleven children were studied (median age of 7.0 years, range 4-10 years) Stage N1 sleep was longer while stage N2 sleep and REM sleep was reduced in the OSA group when compared to those without OSA (6.10 vs 2.9, P < .001; 42.0 vs 49.7, P < .001; 14.0 vs 15.9, P = .05). The arousal index was also higher in the OSA group (12.9 vs 8.2, P < .001). There was a reduction in sleep efficiency and total sleep time and an increase in wake after sleep onset noted in the OSA group (83.90 vs 89.40, P = .003; 368.50 vs 387.25, P = .001; 40.1 ± 35.59 vs 28.66 ± 24.14, P = .007; 29.00 vs 20.50; P = .011). No significant difference was found in N3 sleep stage (33.60 vs 30.60, P = .14). CONCLUSION: We found evidence that children with OSA have a disturbance in their sleep architecture. The changes indicate greater sleep fragmentation and more time spent in lighter stages of sleep. Future research is needed and should focus on more effective methods to measure alterations in sleep architecture.

Women Surgeons Who Contributed to the Development of Pediatric Otolaryngology in the United States.

OBJECTIVE: Our goal was to identify the early pioneering women surgeons in the United States who devoted their career or the majority of their practice to the care of otolaryngologic disorders in children. We sought to share their stories, recognize their contributions to the surgical subspecialty now known as pediatric otolaryngology, and acknowledge their vision and leadership. DATA SOURCES: Primary sources include books, published articles in the medical literature, newspaper articles, memorials/obituaries in both the medical literature and lay press, web logs, the John Q Adams Center for the History of Otolaryngology to include the Women in Otolaryngology, a number of otolaryngology departments, and children's hospitals nationwide. Interviews were conducted with former colleagues and senior pediatric otolaryngologists. REVIEW METHODS: Following review of all available information, women surgeons were included in this study if there was documentation of a clinical practice involving the otolaryngologic care of children in the United States before 1985 with demonstration of the education of others in this discipline. RESULTS: Six women surgeons were identified: Drs. Alice G Bryant, Margaret F. Butler, Ellen James Patterson, Emily Lois Van Loon, LaVonne Bernadene Bergstrom, and Joyce A. Schild. CONCLUSION: Six pioneering women surgeons in the United States have been identified who devoted their practice to the care of otolaryngologic disorders in children and mentored or trained other health care providers. The stories of their lives, their contributions to the care of otolaryngologic disorders in children, and their work as mentors or educators have been described. Laryngoscope, 134:40-46, 2024.

Pediatric Invasive Fungal Rhinosinusitis: A Comprehensive Analysis of Prognostic Factors for Survival.

OBJECTIVE: Pediatric invasive fungal rhinosinusitis (IFS) is a devastating infection that manifests almost exclusively in immunocompromised children. The goal of this work was to determine which clinical features carry prognostic value for survival. METHODS: A retrospective review of children with a histopathological diagnosis of IFS was performed at an academic tertiary care institution from 1990 to 2021. Clinical variables were collected to generate survival and life-table estimators at 6-months and 1-year. RESULTS: Eighteen patients were included in this analysis, with a mean age of 9.8 years (range, 1-17 years). Most children were neutropenic (n = 15, 83.3%), with acute lymphoblastic leukemia (n = 10, 55.6%) representing the most common primary diagnosis. A mean of 3.2 operations (range 1-7 operations) was performed per patient for either mucormycosis (n = 10, 55.6%) or aspergillosis (n = 8, 44.4%). The mean time to absolute neutrophil count recovery was 65.8 days (range 20-137 days), with a 6-month and 1-year survival rate of 47.6% and 41.7%, respectively. Gross total resection (p = 0.006, p < 0.001), number of antifungals (p = 0.0004, p = 0.0003), and total operation number (p = 0.0032, p = 0.0035), served as positive prognostic factors for 6-month and 1-year survival. Conversely, altered mental status (p = 0.0026), cerebral involvement (p = 0.0010), cranial neuropathies (p < 0.0001), hyperglycemia (p = 0.0445, p = 0.0208), and intensive care unit status (p = 0.0013) served as negative prognostic factors for 6-month and 1-year survival. CONCLUSION: Several key elements were identified and found to play a vital role in influencing survival for pediatric IFS. Early diagnosis, prompt medical therapy, and aggressive surgical intervention remain at the forefront in the treatment of this complex opportunistic infection. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1239-1250, 2023.

Sleep positions in children with Down syndrome and obstructive sleep apnea.

OBJECTIVES: To assess sleep positions in children with both Down syndrome (DS) and obstructive sleep apnea (OSA) and determine if there is a preferred sleep position by severity of apnea. METHODS: A single-center retrospective review of patients with both DS and OSA was performed. Caregivers reported sleep position utilized greater than 50% of observed sleep time. Accuracy of this report was confirmed through review of hypnograms from polysomnography studies. RESULTS: Eighty-two patients met inclusion criteria. Median body mass index (BMI) was 26.6 and 56% of patients had a prior tonsillectomy and/or adenoidectomy. The mean obstructive AHI (OAHI) was 25.33 with 90.4% having severe OSA, 9.6% having moderate OSA, and no patients having mild OSA. Reported sleep positions were skewed towards lateral/decubitus (82.9%) compared to prone (11.0%) and supine (6.1%). This was consistent with hypnogram data where 71% of total sleep time in lateral/decubitus positions compared to prone (13%) and supine (6%). The median changes in sleep position per patient was 5 (IQR: 3-6). Lower BMI (p < 0.001, 95% CI: 0.32-1.13) and tonsillectomy (p < 0.001, 95% CI: 7.7-18.19) were associated with lower OAHI. Sleep position was not associated with age (p = 0.19), sex (p = 0.66), race (p = 0.10), ethnicity (p = 0.68) nor history of tonsillectomy (p = 0.34). Preferred sleep position was not correlated with OAHI (p = 0.78, r = 0.03) or OSA severity (p = 0.72, r = 0.03). CONCLUSIONS: This study highlights the possibility that children with DS may have preferential sleep positions that cater to optimized airflow in the context of OSA although further prospective study is needed.

Prospective Evaluation of a Smartphone Otoscope for Home Tympanostomy Tube Surveillance: A Pilot Study.

OBJECTIVES: Recent technological advances have led to the capability of performing high resolution imaging of the tympanic membrane. Smartphone technologies and applications have provided the opportunity to capture digital images and easily share them. The smartphone otoscope device was developed as a simple system that can convert a smartphone into a digital otoscope. This device has the prospective ability to improve physician-patient communication and assist with the diagnosis and management of ear disease. Our objective was to evaluate the feasibility and physician/parental satisfaction using the Cellscope® smartphone attachment for at home tympanostomy tube monitoring. METHODS: Children between 6 months and 15 years of age at an urban tertiary children's hospital that were scheduled for bilateral tympanostomy tube insertion or underwent bilateral tympanostomy tube surgery were prospectively enrolled in the study. Comparisons were made between parental home-recorded videos and findings during in-office otoscopy. Two independent otolaryngologists reviewed the videos and concordance between inter-rater agreements was calculated. Acceptability and use questionnaires were administered to physicians and parents. RESULTS: There was good intra-rater agreement between traditional otoscopy and video-otoscopy for tube extruding, tube blocked and tube extruded with at least 80% agreement (P < .05) and excellent inter-rater agreement between physicians for nearly all tube variables (P < .0001) There was a high degree of satisfaction with this mode of surveillance. Parents and physicians agreed that the CellScope® smartphone was easy to use, helpful with the occurrence of acute events, and appeared to improve quality of care. CONCLUSIONS: The CellScope® smartphone is feasible for use in tympanostomy tube surveillance. Use of the device may allow otolaryngologists to easily follow a child's tympanostomy tube remotely over time and offer greater parental satisfaction.

The incidence of revision adenoidectomy: A comparison of four surgical techniques over a 10-year period.

Approximately 130,000 adenoidectomies are performed each year in the United States. Few studies have examined adenoid regrowth and the incidence of revision surgery or have compared four different surgical instruments commonly used for adenoid surgery within the same institution. This study aimed to determine the incidence of revision adenoidectomy after the use of microdebrider, Coblation, suction cautery, and curette instruments over a 10-year period at a single major tertiary children's center in the United States. A retrospective chart review was performed for all patients who underwent primary and/or revision adenoidectomy at the Children's Hospital Los Angeles (CHLA) between August 2004 and August 2014. During the 10-year study period, a microdebrider was used in 212 cases, Coblation in 382, suction cautery in 1,926, and curette in 3,139 adenoidectomies. The percentages of revision adenoidectomy were 1.42% (3 patients) for microdebrider, 0.79% (3 patients) for Coblation, 0.36% (7 patients) for suction cautery, and 0.03% (1 patient) for curette. The cumulative incidence of revision adenoidectomy for initial surgeries performed at CHLA was 0.2% for the 10-year study period. Pearson chi-square analysis showed statistically significant differences between the surgical techniques (p < 0.0001). In conclusion, regrowth of adenoid tissue requiring revision surgery occurs very infrequently irrespective of the instrument used for the primary procedure, and the most common indication for revision adenoidectomy is to improve eustachian tube dysfunction rather than nasal obstruction due to adenoid hypertrophy.

Bone-Anchored Hearing Aid vs. Reconstruction of the External Auditory Canal in Children and Adolescents with Congenital Aural Atresia: A Comparison Study of Outcomes.

OBJECTIVES/HYPOTHESIS: Congenital aural atresia is a rare condition affecting 1 in 10,000-20,000 children a year. Surgery is required to restore hearing to facilitate normal development. The objective of this study was to compare outcomes in hearing, complications, and quality of life of surgical reconstruction of the external auditory canal reconstruction (EACR) and bone-anchored hearing aid (BAHA) in a pediatric population with congenital aural atresia. STUDY DESIGN: Subjects were children who had a diagnosis of congenital aural atresia or stenosis and who received either BAHA or EACR. METHODS: The medical records of 68 children were reviewed for operative complications and audiometric results. A quality of life questionnaire was prospectively administered to a subset of subjects. RESULTS: Pre-operatively, air conduction threshold was not significantly different between groups at 500, 1000, 2000, and 4000 Hz (p > 0.05). Post-operatively, the BAHA group (44.3 ± 14.3 and 44.5 ± 11.3) demonstrated a significantly larger hearing gain than the EACR group (20.0 ± 18.9 and 15.3 ± 19.9) in both the short and long-term periods (p < 0.001). Overall, the incidence of complications and need for revision surgery were comparable between groups (p > 0.05). Quality of life assessment revealed no statistical significance between the two groups (p > 0.05). CONCLUSION: Although the quality of life and incidence of surgical complications between the two interventions was not significantly different, BAHA implantation appears to provide a better, more reliable audiologic outcome than EACR.

Vallecular cyst as a cause of obstructive sleep apnea in an infant.

A 3-month-old baby was diagnosed with obstructive sleep apnea (OSA) on polysomnography (PSG) with a high apnea hypopnea index (AHI). On further investigations he was found to have a vallecular cyst that was successfully treated. We discuss the clinical presentation of vallecular cysts and the importance of polysomnography in identifying this rare condition.

Age specific differences in pediatric obstructive sleep apnea.

BACKGROUND: Some have suggested that younger children have a more severe form of obstructive sleep apnea than older children and therefore are at a higher risk for respiratory compromise after tonsillectomy and adenoidectomy. However, at present there are few studies that have identified any significant correlation between age and severity of obstructive sleep apnea. OBJECTIVE: To determine if age specific differences in obstructive sleep apnea are present in children. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: The records of children (1-18 years of age) with obstructive sleep apnea diagnosed by overnight polysomnography between January 1998 and January 2001 were reviewed. Children included in the study also had evidence of adenotonsillar hypertrophy and had no other co-existing medical problems. MAIN OUTCOME MEASURES: Overnight polysomnography was performed in all children. Apnea-hypopnea index (AHI), baseline and lowest O(2) saturation, baseline and peak end tidal CO(2), and total number of obstructive apneas, hypopneas, central apneas and mixed apneas were measured during each polysomnogram. Children were subdivided into the following age groups: 1-2, 3-5, 6-11 and 12-18 years. Polysomnograms were classified into normal, mild, moderate and severe categories. RESULTS: Three hundred and sixty-three children were studied; 45 children were ages 1-2 years, 159 children were ages 3-5 years, 137 children were 6-11 years and 22 children were 12-18 years. Although there appears to be a trend towards a greater mean number of obstructive apneas, hypopneas, central apneas, mixed apneas, a higher mean AHI, lower mean SaO(2) nadir, and a higher mean PETCO(2) in the younger age groups when compared to the older groups, a Student's t-test demonstrates that there is no statistical significance for most OSA parameters. An analysis of variance using the F-test reveals statistical significance (p<0.01) when children ages 1-2 were compared to those 3-5, 6-11 or 12-18 years of age for the variables AHI, mean number of central apneas, hypopneas and mixed apneas. When comparing patients in the various severity categories, children ages 1-2 years show a distinct distribution with a larger percentage in the moderate to severe categories. Chi square analysis reveals a significant difference between the frequency distribution of children in age group 1-2 years and that of the other age groups (p<0.01). CONCLUSION: There is a predilection for children less than 3 years of age to have more severe obstructive sleep apnea as documented by polysomnography. Central apnea also appears to be more common in this age group. These findings may be explained by anatomic and physiologic differences related to age and support a period of observation following adenotonsillectomy in younger children.

Antimicrobial therapy for children with adenotonsillar hypertrophy and obstructive sleep apnea: a prospective randomized trial comparing azithromycin vs placebo.

OBJECTIVE: Multiple clinical trials demonstrate the value of administering antibiotics for recurrent tonsillitis. However, there is no consensus as to the role of antibiotics in the management of adenotonsillar hypertrophy and obstructive sleep apnea (OSA). It has been suggested that antibiotics may reduce adenotonsillar size, improve obstructive symptoms, and obviate the need for surgery. The goal of this pilot study was to evaluate the efficacy of a broad-spectrum antibiotic in the management of adenotonsillar hypertrophy and OSA. METHODS: Twenty-two children ages 2 through 12, with evidence of OSA, were enrolled in this double-blinded, prospective clinical trial. Children were randomly assigned into 1 of 2 groups. Group I received azithromycin for a 30-day period (12 mg/kg on days 1-5; the regimen was repeated on days 11-15 and days 21-25). Group II received a placebo administered in the same regimen for a 30-day period. Overnight polysomnography was performed before and within 2 weeks after drug administration. RESULTS: Polysomnographic indices of OSA severity appear to indicate an improvement in the antibiotic as compared to the placebo group, but a comparison of mean +/- standard error for each parameter failed to demonstrate statistical significance using the paired t test. Only 1 of 11 (9%) children had normalization of their polysomnographic parameters. CONCLUSIONS: These results suggest that a course of a broad-spectrum antibiotic may be effective in temporarily improving OSA due to adenotonsillar hypertrophy, but does not appear to obviate the need for surgery.

Pediatric total tonsillectomy using coblation compared to conventional electrosurgery: a prospective, controlled single-blind study.

OBJECTIVE: Postoperative recovery after tonsillectomy using Coblation excision (CES) was compared with conventional electrosurgery (ES). STUDY DESIGN AND SETTING: Patients aged 3 to 12 years from 3 clinical sites were randomly assigned and blinded to receive tonsillectomy using CES (n = 44) or ES (n = 45). RESULTS: Operative parameters did not differ between groups. Return to normal diet, activity, and pain-free status were similar, although fewer CES patients contacted the physician regarding postoperative complications (33% vs 54%; p = 0.081), experienced nausea (35% vs 62%, p = 0.013), or had localized site-specific swelling (p < 0.05) during the 2 weeks after surgery. In addition, CES children tended to discontinue prescription narcotics 1 day earlier than ES patients (7 vs 8 days, p = 0.071) and took one half as many daily doses. More CES than ES parents rated the postoperative experience as 'better than expected' (79% vs 60%, p = 0.055). CONCLUSION AND SIGNIFICANCE: Children who received CES tonsillectomy appeared to experience a better quality postoperative course, with no detriment to operative benefits of conventional electrosurgery.