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undergoing T&A have shown that those who undergo turbinate reduction at the
same time as T&A have greater reductions in AHI than those undergoing T&A
alone [114–116].
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7.12.3 Surgical Treatment—Oropharyngeal/Tongue
While uvulopalatopharyngoplasty (UPPP) has been reported to be successful in
40% to 80% of adults, depending on their physical exam characteristics, there is
limited information regarding the effectiveness of UPPP in children [117].
Expansion sphincter pharyngoplasty (ESP) with T&A has been studied in children
with severe OSA and compared to ESP alone; they found that children who underwent both procedures had lower postoperative AHI and higher cure rates than those
in the group who underwent ESP alone [118].
Lingual tonsil hypertrophy is a common nding in children with persistent
OSA.A meta-analysis showed that removal of lingual tonsils resulted in a reduction
of the AHI of 6.6 with an overall success rate of 52% [119, 120]. A review of the
adverse effects of lingual tonsillectomy notes that these are similar to those for T&A
and include bleeding, poor oral intake, and scarring [121]. This procedure may be
performed independently or in association with tongue base procedures like tongue
suspension or partial midline glossectomy.
Tongue suspension is intended to prevent the base of the tongue from falling
back (glossoptosis) during sleep and involves a heavy suture that goes around the
base of the tongue and is anchored anteriorly to the inside of the mandible. When
performed in combination with radiofrequency to the base of tongue, it has been
shown to have a 61% success rate in children [122]. Midline posterior glossectomy
entails the removal of midline tongue tissue when the tongue is falling back and
obstructing the airway or pushing the palate up and back into the nasal and upper
pharyngeal airway. Small studies in children have reported improvements in AHI
and symptoms when performed alone or in combination with lingual tonsillectomy
[91, 123, 124]. Associated rare complications include dysphagia, minor bleeding,
and taste disturbance as well as the possibility of bleeding from the lingual artery.
Tongue-lip adhesion is used to treat infants with glossoptosis who have micrognathia. It is intended to pull the tongue forward toward the lower lip and is typically used for children with Pierre–Robin sequence. A 2016 meta-analysis of
children undergoing tongue-lip adhesion showed an improvement in AHI of 15.4
events/h (30.8–15.4) [125].
Genioglossal advancement is rarely considered in children as they need to have
permanent teeth in order to safely perform the procedure. This procedure entails
moving the genioglossal muscle attachment to the mandible and a surrounding portion of bone forward to open up the airway space behind the tongue. Because the
tooth roots can be affected, it is not carried out in children until they have adult teeth.
Hypoglossal nerve stimulation therapy has been used to treat adolescents with
Down syndrome and persistent OSA.The device stimulates the hypoglossal nerve
during sleep, and this results in tongue contraction and anterior movement that may
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or may not be coordinate with breathing, depending on the type of simulator
implanted. Results for children with Down syndrome suggest that it is effective as
salvage surgery for most children, and at 12months, the mean decrease in AHI was
15.1events/h, and 55% had an AHI<5 while 75% had an AHI under 10 [126].
S. Ishman
7.12.4 Surgical Treatment—Laryngeal
Epiglottopexy is considered for children with epiglottic prolapse causing airway
obstruction. A 2020 summary of epiglottopexy reported a success rate of 53.6%
[127]. Supraglottoplasty is performed for infants with OSA due to laryngomalacia
as well as older children who develop sleep-state dependent laryngomalacia (i.e.,
laryngomalacia that is only seen during sleep). A meta-analysis found that supraglottoplasty was effective for both groups of patients, with signicant improvements in both the AHI and the oxygen saturation nadir [128].
7.12.5 Surgical Treatment—Craniofacial andTracheotomy
In children with craniofacial abnormalities, mandibular and maxillary surgery may
be used to expand the skeletal structure and thus the pharyngeal airway. While benets have been shown in adults, outcomes in children are limited and optimal timing
for surgery is unknown [129–131]. Mandibular distraction osteogenesis is commonly used for young children with retrognathia and has been shown to be very
effective in alleviating OSA, with a 73.4% success rate in the AHI in a 2018 systematic review [132].
Tracheotomy continues to be a useful procedure for children with severe OSA
that is most commonly used for children with multilevel obstruction or infants without other obvious anatomic solutions. In a review of 29 children who underwent
tracheotomy for severe OSA, the majority had associated neuromuscular comorbidity and craniofacial abnormalities [133].
7.13 Conclusion
The diagnosis and management of pediatric OSA continue to evolve as we work to
nd more accessible and broadly available assessment option. T&A remains the
rst-line therapy for children with OSA.Still, children with OSA after T&A should
be assessed for the recurrence of tonsil tissue if partial tonsillectomy was performed
or regrowth of adenoids. Additional assessments may include drug-induced sleep
endoscopy and cine MRI to understand sites of obstruction. Both medical and surgical options should be considered for patients, and the impact of growth and development is crucial as you consider treatment for children.
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135
Take-Home Message
• Adenotonsillectomy is rst-line thereapy for children with OSA.
• For children with persistent OSA, drug-induced sleep endoscopy or cine MRI
are used to assess for sites of collapse that may contribute to OSA. Medical and
surgical options should be considered for children with persistent OSA and per-
sonalize therapy should be discussed.
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Obstructive Sleep Apnea andSystemic
https://t.me/medicina_free
Autoimmune Diseases
PhilippeChalem
Systemic inammatory diseases of autoimmune origin constitute a heterogeneous
group of diseases from the pathophysiological point of view. From a clinical perspective, they often present marked differences, determined by manifestations that
are considered specic to each. However, they frequently share common clinical
features that could make it difcult to establish a differential diagnosis.
This is the case of the pain and inammation of the joints, a common denominator in many systemic autoimmune diseases. Constitutional symptoms such as fever,
weight loss and chronic fatigue are frequent, nonspecic and often confusing
manifestations.
Fatigue is one of the common denominators in many rheumatic conditions and is
often considered a symptom that may indicate the inammatory activity of the disease. This symptom is critical and is included in the evaluation scales of diseases
such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus and
Sjögren’s syndrome [1–4].
However, inammatory activity in rheumatic diseases is not always documented
when there is fatigue. When that happens, the presence of comorbidities, nutritional
disorders, states of anxiety and depression or sleep disorders should be assessed.
Obstructive sleep apnea is found within this last group [5].
Patients who suffer from systemic autoimmune diseases such as rheumatoid
arthritis, ankylosing spondylitis and other seronegative spondyloarthritis, systemic
lupus erythematosus, Sjögren’s syndrome, progressive systemic sclerosis, inammatory myopathies and vasculitides suffer from obstructive sleep apnea more frequently than the general population (Table8.1) [5–12].
This raises the need to address the following questions: (1) Are there common
pathophysiological pathways between obstructive sleep apnea and systemic
8
P. Chalem (*)
Centro de Investigación en Reumatología y Especialidades Médicas, Bogotá, Colombia
Clínica del Country, Bogotá, Colombia
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. M. Baptista et al. (eds.), Obstructive Sleep Apnea,
https://doi.org/10.1007/978-3-031-35225-6_8
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