Surgery for Pediatric Sleep Apneadocencianestesia.com/uploads/1/3/1/6/13162488/surgery...Surgery for Pediatric Sleep Apnea David H. Darrow, MD, DDSa,b,* aDepartments of Otolaryngology

Otolaryngol Clin N Am

40 (2007) 855–875

Surgery for Pediatric Sleep Apnea

David H. Darrow, MD, DDSa,b,*aDepartments of Otolaryngology and Pediatrics, Eastern Virginia Medical School,

825 Fairfax Avenue, Norfolk, VA 23507, USAbChildren’s Hospital of The King’s Daughters, 601 Children’s Lane,

Norfolk, VA 23507, USA

The pathologies responsible for sleep-related breathing disorders (SRBD)in children are more diverse than those in adults. Although most affectedadults and older children experience obstruction at the pharyngeal level, of-ten caused by hyperplasia of the tonsils and adenoid and pharyngeal soft tis-sues, younger individuals may be affected at a variety of sites in the upperrespiratory tract. In small children, the distance between these sites maybe quite small, resulting in stertor or stridor or both, and the source ofthe noisy breathing may be difficult to localize.

Generally speaking, SRBD are characterized by episodic obstruction ofairflow through the upper airway during sleep. In children, SRBD may re-sult from decreased caliber of the airway caused by nasal obstruction in anobligate nasal breather, compromised skeletal anatomy, excessively compli-ant or hyperplastic pharyngeal or laryngeal soft tissues, or neuromuscularcompromise, complicated by the diminished muscle tone and neurophysio-logic changes that typically accompany sleep. Attempts to overcome the ob-struction by increasing respiratory effort often exaggerate collapse of theairway, resulting in a paradoxical increase in resistance to airflow. The phys-iologic sequelae may include hypoxemia, hypercapnia, and acidosis, whichin turn signal central and peripheral chemoreceptors and baroreceptors toinitiate the arousals and sudden pharyngeal dilation that characterizeSRBD.

Successful management of sleep apnea in children depends on accurateidentification of the site of obstruction and the severity of obstruction.Only then can appropriate surgical and nonsurgical remedies be considered.

* Department of Otolaryngology, Eastern Virginia Medical School, 825 Fairfax Avenue,

Norfolk, VA 23507.

E-mail address: [email protected]

0030-6665/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.otc.2007.04.008 oto.theclinics.com

mailto:[email protected]

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Diagnosis of sleep-related breathing disorders in children

With the exception of acute life-threatening events usually caused by re-flux-induced laryngospasm, the presenting symptom in pediatric SRBD isnoisy breathing. Stridor, a term used to describe turbulent airflow throughthe larynx and lower sites in the airway, is rare because lesions in these areasare not often affected by the dynamic changes that occur during sleep. Con-versely, stertor, a term used to describe sonorous breathing in the upper air-ways, is quite common. In most studies, snoring occurs during sleep in 3%to 12% of children [1], although some studies suggest prevalence as high as27% [2]. Only those with hypoventilation, apnea, hypoxemia, or repeatedarousals, however, are considered to have SRBD.

In its mildest form, SRBD presents as upper airway resistance syndrome.Affected children demonstrate episodic arousals resulting from partial ob-struction of the upper airway, associated with symptoms of heroic snoring,mouth breathing, sleep pauses or breathholding, gasping, perspiration, andenuresis. Daytime manifestations of sleep disturbance include morningheadache, dry mouth, halitosis, and most significantly behavioral and neu-rocognitive disorders [3–6]. Hypersomnolence may occur in older childrenand adolescents. Other signs and symptoms include audible breathingwith open mouth posture, hyponasal speech, and chronic nasal obstructionwith or without rhinorrhea. Approximately 40% of children who snoredemonstrate more significant degrees of obstruction characteristic ofobstructive hypopnea syndrome or obstructive sleep apnea syndrome asdefined later [1]. The most severely affected patients may develop cor pulmo-nale, right ventricular hypertrophy, congestive heart failure, alveolar hypo-ventilation, pulmonary hypertension, pulmonary edema, or failure to thrive,and are at risk for permanent neurologic damage and even death.

Physical examination of children with SRBD should include assessmentof the patient’s weight and body habitus, a complete examination of thehead and neck with attention to potential sites of obstruction, and ausculta-tion of the patient’s heart and lungs. Findings of nasal dyspnea or mouthbreathing, hyponasal speech, mandibular hypoplasia, drooling, neuromus-cular deficit, and tonsillar hyperplasia all suggest some degree of upper air-way obstruction. Fiberoptic assessment of the nasal vault, the adenoid pad,and the distal pharynx and larynx may be useful in selected cases. Ancillarystudies including chest radiography and electrocardiography should be per-formed in severely obstructed children. In many cases of nasal obstructionin infants and young children, CT scanning is desirable to define the bonyanatomy and to assess the relationship of nasal masses to the sinonasal tractand the central nervous system. At some institutions, cross-table lateral fluo-roscopy may be performed during sleep to aid in localizing the site ofobstruction.

When a history of severe symptoms of sleep disturbance correlates withobvious physical findings of airway obstruction, additional studies to

857SURGERY FOR PEDIATRIC SLEEP APNEA

establish a patient’s candidacy for surgical intervention may be superfluous.Studies suggest, however, that in most cases accurate diagnosis of SRBDcannot be established solely on the basis of a history and physical examina-tion [7–14]. SRBD occurs primarily during REM sleep when children areless likely to be observed by their parents [15], and in many cases of upperairway resistance syndrome and obstructive hypopnea syndrome parentsmay misinterpret the symptoms only as snoring in the absence of obstruc-tion. In addition, although hyperplasia of the tonsils and adenoid likely pre-dispose to airway obstruction, airway dynamics during sleep cannot bedetermined by static examination in the office setting. Furthermore, fiberop-tic assessment of the airway is useful in determining anatomic obstructionbut offers a distorted wide-angle view of obstructing tissues and does notdemonstrate the dynamics of the nasopharynx during sleep. Similarly, ra-diographic assessment of the adenoid tissue and tongue base may be difficultto interpret [16–19]. In such cases, polysomnography remains the gold stan-dard for objective correlation of ventilatory abnormalities with sleep-disor-dered breathing [8]. This test and its interpretation are described in greaterdetail elsewhere in this issue.

Unfortunately, the expense and scheduling difficulties associated withpolysomnography make this a cumbersome method of assessment inmany otolaryngology practices. Other techniques of assessment includingaudiotaping [9,11], videotaping [20], and home polysomnography [21]have demonstrated favorable results, but require further study. Abbreviatedpolysomnography (ie, overnight oximetry or nap polysomnography) hasdemonstrated a high positive predictive value and a low negative predictivevalue, suggesting that patients with negative results may still require addi-tional studies [22–24].

Causes of sleep-related breathing disorders in children

Causes of SRBD in children may be grouped on the basis of age, simpli-fying the differential diagnosis for a given patient (Box 1). Neonates and in-fants rarely have significant lymphoid hyperplasia, and SRBD in thesechildren are usually related to their immature respiratory physiology or tocongenital obstructing lesions. In premature babies, neural pathways thatcontrol ventilation, coordination of the larynx and diaphragm, and chemo-receptor responses are not yet fully developed. In such children, hypoventi-lation, central apnea, and periodic breathing are common, resulting in reflexbradycardia. Hypoxemia and hypercapnia, which are less common becauseof the short duration of the apneic events, do not reliably evoke compensa-tory mechanisms. Apnea in infants may also be associated with gastroesoph-ageal reflux, either as a direct result of soiling of the upper airway or becauseof vagally mediated reflexes that inhibit inspiration. In such cases, manage-ment by medical therapy or Nissen fundoplication may be warranted.

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Because babies depend primarily on nasal breathing, obstruction of thenose or nasopharynx has more significance than in older children. Commoncauses include neonatal rhinitis, pyriform aperture stenosis, choanal atresia,dacryocystoceles, and nasal-choanal stenosis related to craniofacial condi-tions, such as Apert’s syndrome or Crouzon’s disease. Dermoids, teratomas,gliomas, and encephaloceles of the nose and nasopharynx are seen less fre-quently. Oropharyngeal obstruction in this age group is usually related tomicrognathia or macroglossia. Micrognathia may be syndromic, as in chil-dren with Treacher Collins or Nager syndromes, or developmental, as inPierre Robin syndrome. Relative macroglossia is common in Down syn-drome and Beckwith-Wiedemann syndrome. Venous and lymphatic malfor-mations of the pharynx and tongue and congenital cysts of the vallecula andtongue may also cause obstruction in this age group (Fig. 1). Laryngeal ab-normalities, such as laryngomalacia, more often result in severe stridor whileawake rather than in collapse of soft tissues during sleep. Neuromusculardisorders, which may be complicated by impaired pharyngeal tone, impairedexcursion of the diaphragm, or effects of medical therapy, begin to cause

Box 1. Causes of sleep-related breathing disorders in children

Neonates and infantsNasal aplasia, stenosis, or atresiaNasal or nasopharyngeal massesCraniofacial anomalies

Hypoplastic mandible (Pierre Robin, Nager, or TreacherCollins syndromes)

Hypoplastic maxilla (Apert’s syndrome, Crouzon’s disease)Macroglossia (Beckwith-Wiedemann syndrome)Vascular malformations of tongue and pharynxCongenital cysts of the vallecula and tongueNeuromuscular disorders

Toddlers and older childrenRhinitis, nasal polyposis, septal deviationSyndromic narrowing of nasopharynx (Hunter’s, Hurler’s, or

Down syndromes; achondroplasia)Adenotonsillar hyperplasiaObesityMacroglossia (Down syndrome)Vascular malformations of tongue and pharynxNeuromuscular disorders

IatrogenicNasopharyngeal stenosis


obstruction in this age group and often progress as the child ages because ofadenotonsillar enlargement.

Toddlers and older children are more affected during sleep by disordersthat have had an opportunity to progress. Hyperplasia of the tonsils and ad-enoid is unquestionably the most common cause of upper airway obstruc-tion in children resulting in sleep-disordered breathing. Severe allergicrhinitis may also develop in children, causing airway obstruction or compli-cating obstruction caused by other causes. Sinonasal polyposis caused bycystic fibrosis may appear in children in this age group. Similarly, weightgain becomes an issue in older children, and the accumulation of fat inthe fascial planes surrounding the pharynx of obese individuals may bea cause of surgical failure following adenotonsillectomy. Some childrenare affected by syndromes involving progressive reduction of the pharyngealairway, such as Down syndrome, achondroplasia, and the mucopolysac-charidoses (Hunter’s and Hurler’s syndromes). In the latter group, surgicalintervention may actually precipitate deposition of mucopolysaccharide.

In adolescence, lymphoid hyperplasia becomes a less important cause ofSRBD as the pharynx increases in size and the tonsils and adenoid recede.As in adults, sleep-disordered breathing is more commonly associated withredundant pharyngeal tissues, obesity, macroglossia, and septal deviation.Progression of neuromuscular disorders may also necessitate surgical inter-vention in this age group.

Iatrogenic stenosis of the nasopharynx following adenotonsillectomy,uvulopalatopharyngoplasty, or surgery for cleft palate or velopharyngeal in-sufficiency may result in significant sleep apnea. Corrective surgical interven-tion for this disorder is often complicated by recurrence.

Fig. 1. Vallecular cyst (arrow), demonstrated on lateral neck radiograph (A), causing prolapse

of the epiglottis into the laryngeal inlet (B), stented by an endotracheal tube (arrow). This infant

presented with inspiratory stertor.

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Management of sleep-related breathing disorders in children

Nonsurgical management

Treatment of SRBD in children is tailored to the etiology of the airwayobstruction. Medical management, such as thioxanthines and methylpheni-date, may be useful in cases of central apnea. Pharmacotherapy may also beconsidered in less severe cases of obstructive apnea, or when surgical inter-vention does not address the pathology. Examples of such disorders includeneonatal rhinitis, allergic rhinitis, and acute tonsillitis. In cases of chronicupper airway obstruction, mechanical correction by prostheses, positive air-way pressure, or weight loss may be worth consideration. In most patients,however, such as those with obesity or neuromuscular disorders in whichairway dynamics are affected, surgical management is generally consideredbefore use of positive airway pressure or oral prostheses, because these in-terventions are rarely tolerated in children and are often ineffective. Suchmethods of management should be entertained, however, to address residualobstruction following surgery. Rarely, in the most severe or refractory cases,tracheotomy must be considered.

Surgical management

Preoperative planning is an essential component of the surgical manage-ment of patients with SRBD. Postoperative respiratory distress is commonafter surgery for SRBD because of effects of anesthesia, bleeding, edema,and residual airway compromise. Patients at greatest risk include thosewith severe obstructive sleep apnea syndrome; diminished neuromusculartone (ie, cerebral palsy); morbid obesity; skeletal and craniofacial abnormal-ities, such as hypoplasia of the midface or mandible or nasopharyngealvault; and very young children (younger than age 2–3 years) [24–28]. As a re-sult, high-risk individuals who are undergoing even routine procedures, suchas adenotonsillectomy, should be admitted to a high-visibility bed in thehospital with continuous cardiac and oxygen saturation monitoring. Intra-operative use of steroids and postoperative placement of nasopharyngealairways may reduce the risk of airway compromise after surgery. Narcoticsand sedatives should be used sparingly in severely obstructed children.Obese patients and those with reduced neuromuscular tone may benefitfrom airway support with positive airway pressure. In the most extremecases, overnight endotracheal intubation may be desirable.

Nasal and nasopharyngeal obstructionSRBD caused by nasal and nasopharyngeal masses is best addressed by

removal of the mass. Depending on the pathology, the procedure may beas simple as a transoral, retropalatal approach for adenoidectomy or mar-supialization of nasolacrimal duct cysts, or as complex as an anterior cranio-facial approach for encephalocele. Nasal and nasopharyngeal neoplasms


may require aggressive resection, and preoperative embolization (juvenilenasopharyngeal angiofibroma) or postoperative radiation therapy or che-motherapy (malignancies).

Bilateral choanal atresia and stenosis of the pyriform aperture are causesof obstructive apnea in neonates and require early intervention (Fig. 2).Such infants can be temporized with oropharyngeal airways, but shouldnot leave an intensive care setting until a secure airway is established by tra-cheotomy or repair of the bony defect. Timing of surgery is controversial;early repair with avoidance of tracheotomy is always desirable; however,children several weeks to several months old better tolerate bleeding andbetter accommodate instruments used in the nasal cavity.

Although choanal atresia may be approached by either the transpalatal orthe transnasal route, improvements in endoscopic and powered instrumenta-tion have made the transnasal approach the first choice for most otolaryn-gologists [29,30]. In small children, the procedure is best performed usinga small rigid rod-lens telescope and a drill with a protected shaft. Microde-briders designed for intranasal surgery (Fig. 3) are well-suited for this pur-pose. A 120-degree telescope placed in the mouth with the palate retractedaffords the surgeon a view of the nasopharynx so that a urethral soundmay be safely passed through the atretic plate. After creation of mucosalflaps with a sickle knife or ablation of the mucosa with the aid of a fiber-de-livered laser, the microdebrider can be fitted with a small round bur to initi-ate bone removal, and subsequently with choanal atresia or Silver Bullet(Medtronic/Xomed, Jacksonville, Florida) burs to expand the opening(Fig. 4). Standard suction blades (2.9 or 3.5 mm) used for sinus surgery fa-cilitate the removal of soft tissue and thin bone. Back-biting forceps areused to remove the posterior portion of the vomer. The opened choanaemay be treated with mitomycin C to reduce the risk of restenosis [31], andstenting for several weeks using endotracheal tubes or Albouker-type stentmay be indicated in some cases. In cases of pyriform aperture stenosis, the

Fig. 2. Comparison of CT scans of patients with choanal atresia (A) and pyriform aperture

stenosis (B, arrows).

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offending bone may be approached through a sublabial approach and re-duced using similar instrumentation [32,33].

Nasopharyngeal stenosis, once a common complication of syphilis, mayresult as a complication of adenotonsillectomy, uvulopalatopharyngoplasty,

Fig. 3. The Straight Shot microdebrider (Medtronic/Xomed, Jacksonville, Florida) facilitates

choanal atresia surgery by removing bone and soft tissue without injury to the nasal vestibule.

Fig. 4. Drilling of the atretic plate may be accomplished with a pediatric round bur (top),

followed by a choanal atresia bur (center), or Silver Bullet blade (bottom).


or surgery for cleft palate or velopharyngeal insufficiency. This disorderoften causes obstruction of the upper airway that is even more significantthan the disorder the original surgery was intended to correct. Typically,cicatrix forms circumferentially in the nasopharynx as a result of removalof excessive removal of mucosa from opposing surfaces. Simple release ofthe scarred area results in recurrence, and treatment must include themovement of fresh, well-vascularized tissue to cover the denuded bed. A va-riety of techniques has been recommended, including Z-plasty [34],laterally based pharyngeal flaps (Fig. 5) [35], other advancement and rota-tion flaps [36–38], and radial forearm and jejunal free flaps [38,39]. Manyauthors advocate the use of intralesional steroids and topical applicationof mitomycin C to the surgical site to reduce the risk of recurrence. Postop-erative stenting with nasopharyngeal airways or oropharyngeal prostheses[40] is mandatory, although the necessary duration of such stenting iscontroversial.

Adenotonsillar hyperplasia and oropharyngeal obstructionAdenotonsillectomy is generally considered first-line therapy in most

patients with SRBD, providing they have at least mild adenotonsillarhyperplasia. Improvements in snoring and polysomnography may be antic-ipated postoperatively in such patients [12,13,41–46]. Even obese childrenseem to have reduced obstruction after surgery [47–49]; however, availablestudies lack long-term follow-up and symptoms may return in those whodo not additionally pursue weight loss. Children with SRBD who exhibitabnormalities in body growth preoperatively often demonstrate increasedbody mass after surgery [50–52]. Improvement following adenotonsillarsurgery has also been demonstrated in children with preoperative enuresis[53–56], orthodontic abnormalities [57], and behavioral issues [3–6,58–62]before surgery, including those who are obese [63,64]. Validated surveys sug-gest an overall improvement in quality of life after adenotonsillectomy[49,65,66].

Several new techniques of tonsillectomy and adenoidectomy have beenproposed in recent years as technology has evolved. For decades, guillotineand cold steel removal of the tonsils were fraught with complications ofbleeding and postoperative pain. The use of electrocautery in these proce-dures reduced the problem of surgical blood loss considerably and decreasedoperating time, but postoperative pain remained a significant morbidity[67,68].

Initial reports of tonsillectomy using lasers yielded variable and occa-sionally disappointing results [69–72]. With the report by Krespi and Ling[73] of serial tonsillectomy with carbon-dioxide laser in the outpatient set-ting, however, came the notion that partial tonsillectomy was safe andless painful than traditional tonsillectomy for patients with tonsil hyperpla-sia. It is theorized that the exposure of muscle resulting from removal of thetonsil capsule is the cause of pain associated with tonsillectomy, and that

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Fig. 5. Laterally based pharyngeal flap for correction of nasopharyngeal stenosis. (A) A lateral

incision is made from velopharyngeal opening into lateral scar on one side (top) and deepened

(bottom). (B) Mucosal flaps are elevated from the scar inferolaterally and the scar is excised. (C)

A laterally based posterior pharyngeal flap is incised incorporating a back cut (top), then ele-

vated with the underlying muscle (center). Points A1 and B1 are closed to points A and B, re-

spectively, covering the denuded area (bottom). (From Cotton RT, Nasopharyngeal stenosis.

Arch Otolaryngol 1985;111:146–48; with permission. Copyright � 1985, American Medical

Association. All rights reserved.)


leaving some small portion of the tonsil behind may vastly diminish this se-quelae [74]. Proposed many years ago, the technique had been abandonedbecause of the risk of tonsil regrowth at a time when most such procedureswere performed for recurring infection. Studies suggest that single-stage in-tracapsular tonsillectomy, or ‘‘tonsillotomy,’’ using the carbon-dioxide laseris safe, rapid, and effective with little loss of blood [75,76]. The microde-brider has been a more popular instrument for this procedure, however,given its greater efficiency and lower cost. Randomized studies comparingmicrodebrider intracapsular tonsillectomy with complete electrocauterytonsillectomy generally suggest a modest advantage in pain reduction, par-ticularly otalgia, and return to normal activity; other outcomes yielded lessconsistent results [77–80]. The procedure involves a slight increase in dura-tion and blood loss.

Other technologies developed over the last 20 years have competed forsupremacy in adenotonsillectomy with the promises of decreased pain, de-creased bleeding, and decreased operative time. No one device seems tohave definitively accomplished these goals. The Harmonic scalpel (EthiconEndo-Surgery, Cincinnati, Ohio) is an instrument that uses ultrasonic tech-nology to cut and coagulate with minimal tissue damage. Recent random-ized studies of tonsillectomy using this device suggest that there is noadvantage in pain reduction or hemorrhage rate, and that surgical timemay be somewhat longer and the cost of the disposable blade is high[80–82]. Radiofrequency devices, such as the Somnoplasty system (SomnusMedical Technologies, Sunnyvale, California) and the ArthroCare Cobla-tion system (ArthroCare, Sunnyvale, California) have been studied in smalltrials that suggest modest reduction in pain compared with electrocautery,with further decrease in postoperative pain when the tonsil is reduced ratherthan excised [47,83–90]. There is some controversy about increased hemor-rhage rates using this technology [91,92].

Techniques of adenoidectomy include curettage, suction electrocauteryablation, and removal by power-assisted devices. Traditional curettage is in-expensive but is the least precise of these techniques and is associated withhemorrhage that must be controlled before leaving the operating room.Electrocautery dissection, by definition, is associated with less bleedingand is also a precise and inexpensive device [93–95]. High settings are re-quired on the cautery device, however, with the potential for thermal injuryto deep structures. Surgical times have been variable. Studies of power-assis-ted (microdebrider) techniques have demonstrated excellent precision withrapid removal of tissue and minimal additional time for cautery; however,the disposable blades add significant expense [96,97].

Uvulopalatopharyngoplasty is not commonly performed in children, per-haps because most children with sleep apnea do not demonstrate the redun-dant tissue found in adults with similar symptoms. Several studies havedemonstrated that the procedure is efficacious in the most difficult-to-treatpatients with SRBD, particularly those with obesity [98], neurologic

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impairment [99–101], or Down syndrome [102–104]. These reports are retro-spective, however, and it remains unclear whether resection of the palateand uvula add significantly to tonsillectomy with plication of the tonsil pil-lars, which is usually performed simultaneously. In addition, nasopharyn-geal stenosis remains a significant risk when the procedure is performed atthe same time as adenoidectomy [38,105].

Macroglossia and the ptotic tongueChildren with macroglossia generally have Beckwith-Wiedemann syn-

drome (macroglossia, omphalocele, visceromegaly, cytomegaly of the adre-nal cortex); Down syndrome; or a vascular malformation of the tongue.Complications of macroglossia include aberrant dental eruption and maloc-clusion, maldevelopment of the maxilla and mandible, excessive drying ofthe tongue with ulceration, and airway obstruction. Unfortunately, surgicalreduction of the tongue is generally effective only for the first three indica-tions, and less so for airway obstruction. The procedure usually consists ofa resection of the lingual margin or a wedge resection with or without ag-gressive resection at the foramen cecum [106], and fails to address obstruc-tion at the distal oropharynx and tongue base (Fig. 6). As a result, airwayobstruction persists in many children undergoing tongue reduction for mac-roglossia [107]. Regrowth of tongue tissue following the procedure has alsobeen reported [108].

Other methods of managing macroglossia include suture suspension ofthe tongue and radiofrequency ablation. Successful use of the tongue suspen-sion suture technique has been reported in a single pediatric case [109], butanecdotally the procedure is not well tolerated. To date, only case reportsdocument the success of radiofrequency ablation for pediatric macroglossiacaused by Down syndrome (E.A. Mair, personal communication, 2006).

Vascularmalformations of the tongue are generally of lymphatic or venousorigin. Lymphatic malformations that are limited to the superficial layers ofthe tongue (lymphangioma circumscriptum) may be ablated using a carbon-dioxide laser. Microcystic disease causing the tongue to be both wide andthick, however, is extremely difficult to treat. Limited success has been re-ported using radiofrequency and coblation technology [110,111]. Manysuch patients retain a tracheotomy indefinitely. Conversely, venous malfor-mations of the tongue may be reduced considerably using a combination ofsuperficial and intralesional neodymium:yttrium-aluminum-garnet laser ther-apy, alcohol sclerosis, or excision [112].

Ductal cysts of the vallecula may present with sleep-disordered breathingin neonates (see Fig. 1). These lesions are thought to result from mucousgland obstruction, but the etiology has not been definitively elucidated.The diagnosis may be difficult to make endoscopically because of the posi-tion of the mass. Lateral radiograph of the upper airway may be useful whenthe diagnosis is suspected. The lesion is managed by marsupialization using


cold steel, laser, or microdebrider; laser applied to the base helps to controlhemorrhage and theoretically reduces the risk of recurrence.

Hypoplasia of the midface and mandibleUpper airway obstruction caused by hypoplasia of the midface and man-

dible is usually associated with craniofacial syndromes. Micrognathiacaused by Pierre Robin syndrome often improves within the first 2 yearsof life without surgical intervention for the mandible. In cases of mild air-way obstruction, children with competent caretakers may be managed byprone positioning and nasopharyngeal stenting by nasal trumpet or similardevice [113]. When symptoms are more severe, temporary repositioning of

Fig. 6. Approaches to surgical reduction of the tongue. None of these methods reliably treats

disorders in children. (From Darrow DH, Weiss DD. Management of sleep-related breathing

disorders in children. Operative Techniques in Otolaryngology-Head and Neck Surgery

2002;13:111–18; with permission.)

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the ptotic tongue by labioglossopexy (Fig. 7) has been advocated [114]. Re-sults from this procedure are variable, however, and the procedure carriesthe risks of dehiscence, tongue lacerations, and deformation of the lip andspeech impairment caused by scar formation [115]. Subperiosteal release


of the floor of the mouth has also been reported but has not been usedwidely. Temporary tracheotomy seems to be the most reliable and least mor-bid means of airway management providing the patient shows signs of man-dibular ‘‘catch-up’’ growth within the first few months. When this is not thecase, distraction osteogenesis should be considered.

First described in 1969 by Ilizarov and Lediaev [116] in the treatment oflimb length discrepancies, osteotomy with distraction of bone is now widelyaccepted as the procedure of choice in the early management of airway ob-struction caused by craniofacial disproportion [117–120]. The proceduretakes advantage of the rapid healing and capacity for growth in the pediatricskeleton. Distraction osteogenesis has been used for over a decade toadvance the mandible in cases of retrognathia and micrognathia, but indica-tions have expanded to include neuromuscular disorders. With modifica-tions to the expansion devices, distraction of the midface is also beginningto replace Leforte osteotomies with bone grafting [120,121].

Before surgery, all candidates for mandibular distraction undergo airwayendoscopy and craniofacial assessment by three-dimensional CT scanning.Airway patency is estimated in relaxed and jaw-thrust positions, and precisebony measurements are taken from the scan.

Distraction osteogenesis is divided into four phases: (1) surgery, (2) dis-traction, (3) consolidation, and (4) removal. The surgical approach recom-mended is illustrated in Fig. 8. After a lag phase of 24 to 72 hours,distraction is started. Distraction may progress at a rate of 1 to 2 mm perday, with adjustments of 1 mm every 12 to 24 hours. Once the desired lengthof the mandible has been achieved, adequacy of the airway is verified byflexible or rigid laryngoscopy before consolidation. In children who alreadyhave a tracheostomy, downsizing and bedside occlusion can be performed.The consolidation phase is approximately 8 weeks, but should last at leasttwo times as long as the distraction period. The hardware may be left inplace during this time. The final stage is removal of the hardware andminor scar revision. Avoidance of or decannulation from tracheotomy in

Fig. 7. Labioglossopexy for glossoptosis. Modified labioglossopexy. This technique, described

by Routledge, incorporates muscle into the lip-tongue adhesion. (A) After T-shaped incisions

are made on the anterior ventral tongue and lower lip, the wound edges on both incisions

are undermined to create mucosal flaps and the underlying tongue and orbicularis oris

muscles are exposed. (B) A small periosteal elevator is used to tunnel along the anterior aspect

of the mandible and to detach the genioglossus muscle. (C, D) A spinal needle passed through

the soft tissue along the anterior and posterior surfaces of the mandible through the skin of the

mentum facilitates placement of a circummandibular stay suture passed through muscle. (E)

The two ends of the suture are then placed into the tongue muscles in a location that allows

approximation of the muscle directly to the alveolar ridge incision. (F) The ventral tongue mu-

cosal flaps are then matched to the flaps of the lower lip and approximated using a 4-0 chromic

gut suture. (From Schraff S, Darrow DH. Labioglossopexy and epiglottopexy. Operative Tech-

niques in Otolaryngology-Head and Neck Surgery 2005;16:203–8; with permission.)

=

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appropriately selected patients undergoing distraction of the mandible isgreater than 80% [118,119,121].

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Fig. 8. Technique of mandibular distraction. (A) Planned bone cuts and pin placement for

mandibular distraction. Bone cuts are designed as in a bilateral sagittal split osteotomy. Two

pins are placed on either side of the osteotomy. In neonates, one pin is passed straight through

from one side of the mandible to the other. (B) The medial osteotomy is prepared by scoring the

bone. The bone is released with a gentle twist of the osteotome. (C) The multivector distractor is

applied to the inserted pins. Distraction may proceed at a rate of 1 to 2 mm per day. (FromDar-

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Surgery for Pediatric Sleep Apneadocencianestesia.com/uploads/1/3/1/6/13162488/surgery...Surgery for Pediatric Sleep Apnea David H. Darrow, MD, DDSa,b,* aDepartments of Otolaryngology