Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole and today we're highlighting surgical management of pediatric obstructive sleep apnea. Joining me is Dr. William Collins. He's the Department Chairman and Division Chief for Pediatric Otolaryngology in the Department of Otolaryngology Head and Neck Surgery at the University of Florida College of Medicine.

Dr. Collins, thank you so much for joining us today. As we get into the symptoms commonly associated with pediatric obstructive sleep apnea; I'd like you to start by telling us a little briefly, what is normal sleep patterns for children? How do we know if children are sleeping enough?

William O. Collins, MD, FACS, FAAP: Great. Thank you, Melanie. I appreciate the invitation to be here today. As a Pediatric Otolaryngologist, this is a very common type of patient that I see. The most common symptom that we will ask about and probably the best symptom to screen for these children, is snoring. And I always like to know, from the parent's perspective, does the child snore or not during sleep? Does it happen every night? Is it in just certain positions? And if it is happening, how long that has been going on? There's probably a small percentage of children who have obstructive sleep apnea that don't snore. But snoring is probably the most common symptom and is a good screening question, good screening tool for these patients.

In addition to that, you know, I like to inquire whether or not the child has disrupted sleep, and sometimes this can be very obvious to family and caregivers where the child will actually stop breathing or pause in their breathing for a few seconds at night. They can also gasp or choke. Often that can be accompanied by frequent awakenings at night.

 So that's kind of the first line of questioning and inquiry when I see these patients in clinic, if I'm evaluating them for obstructive sleep apnea.

Host: What are some of the complications of untreated sleep apnea in children? How can these sleep disorders be associated with growth, developmental and cardiopulmonary complications, attention problems, attention deficit issues. Tell us a little bit about that.

William O. Collins, MD, FACS, FAAP: You hit on a lot of them. One of the things I try to stress to the parents is if we can make the diagnosis of obstructive sleep apnea, why that is important. And it goes way beyond just a noisy, disruptive sleeper. If children are not getting a good night of sleep, both from a quality and a quantity standpoint, they can have some behavioral changes, that can manifest as a difficulty focusing at school, ADHD type of presentation, can affect academic performance as well.

There are some studies that highlight that and improved academic performance after treatment of the obstructive sleep apnea. It can affect growth and development as well. There are some cardiovascular complications, like you had in the most severe scenarios and we don't see this very often, but we at least probably once or twice a year, will see children that present with pulmonary hypertension and right heart strain, right ventricular hypertrophy from severe untreated obstructive sleep apnea.

 So we generally make it a point that when we make the diagnosis of obstructive sleep apnea, and there's different methods we can do that, that we recommend treatment for it. Some children can get worse over time and some children probably outgrow it, but it's very hard up front to pinpoint which kids will get better or which kids will get worse over time if left untreated.

Host: Dr. Collins, as we learn more about sleep and its relationship to diabetes and obesity, and as we said, attentional issues, developmental, behavioral, all of these things, and we're learning about that in adults, that in children, that could be magnified. And these issues would start earlier.

So tell us about diagnoses. We hear about sleep studies. We mostly hear about those with adults. And with kids, is this something that is difficult to do? Are we looking at at-home studies or in hospital studies? Tell us about that.

William O. Collins, MD, FACS, FAAP: Absolutely. So I think any diagnostic protocol starts with a good history and physical examination. And I mentioned some of those factors in the history that are particularly relevant and pertinent. On physical exam, we do a very systematic and thorough exam of the head and neck area. And that includes looking from the front of the nose through the nasal passages, back of the nose, back of the throat, tongue size, tonsil size, neck circumference, and all of those things can kind of pinpoint where the anatomic areas of airway obstruction may be occurring. In certain children, who are able to cooperate in clinic, we can do flexible nasopharyngoscopy and actually visualize those areas deeper in the nose, directly visualize the size of the adenoid tissue, which is in the nasopharynx and also get an assessment of their oropharynx and hypopharynx and where the tonsils sit in relation to the tongue base, the status of the lingual tonsils on the posterior third of the tongue, and also visualize the larynx from the level of the glottis or true vocal folds and more superiorly.

In some cases, the diagnosis is fairly obvious when the history and the physical exam match up and make sense, and if the parents and family are good historians and are confident in the symptoms they're reporting. In other cases, if there's some ambiguity with the history and physical exam findings or in children who have a more complex past medical history, children that may have underlying neuromuscular disease, Down syndrome, bleeding disorders, some type of condition that would make their operative risk higher; those are children that we likely would elect to get a formal sleep study or polysomnogram prior to making any decisions about potential treatment, including both medical and surgical treatments.

Host: So based on all of that, and we hear about treatments, so many, Inspire and dental things and obviously CPAP. But with kids, one of the treatment options out there is tonsillectomy. When does that become the discussion, the indications for an adenotonsillectomy? Because people think we're not even doing tonsillectomies anymore. But in the case of sleep apnea, this is a possibility.

William O. Collins, MD, FACS, FAAP: Absolutely. So for mild sleep apnea, if I have a sleep study and it documents mild sleep apnea, we can offer medical therapy which often includes nasal steroid sprays, sometimes montelukast or leukotriene inhibitors. But for mild obstructive sleep apnea patients who have failed medical treatment or moderate or severe obstructive sleep apnea, we start talking about surgical options.

And still by far, the most common surgical option that we offer in children is adenotonsillectomy with removal of both the tonsils in the back of the throat and the adenoids from the nasopharynx. We offer that option for children with either the symptoms of obstructive sleep apnea, or in children who have documented obstructive sleep apnea, as well as in children who have a history of recurrent streptococcal tonsillitis as well.

 So tonsillectomy is, it's still our mainstay of surgical treatment for pediatric obstructive sleep apnea, but it's also important to recognize it's not as much of a one size fits all solution as we used to think it might be.

Host: Well then share with us anything that's exciting as far as tonsillectomy in this day and age. I mean, I had mine 40, 50 years ago. What are we doing now that's different? What's different for these kids that are going through this procedure? I'd like you to speak to other providers about any technical considerations or exciting equipment, any advancements in the technology.

William O. Collins, MD, FACS, FAAP: Yeah. So there's been advancements both in the technology used as well as in the surgical technique for tonsillectomy. There is is a range of surgical techniques for complete removal of the tonsils. This is what we would classify as an extra capsular tonsillectomy, where we actually dissect out the entire tonsillar tissue, separate from the underlying pharyngeal musculature.

This can be done either with, with what we call COLD technique, which is a scalpel and snares. It can be done with electrocautery, where you're using heat to cut the tissue and seal off the blood vessels. There are also a number of newer technologies, one of the most common being radio frequency ablation. That produces a highly charged ionic plasma field that dissociates the tissue and also seals the blood vessels with the advantage being that it accomplishes the same end goal with removal of the tissue and control of bleeding, but at a much lower temperature at the tissue level, which results in less thermal injury and less postoperative pain.

 The postoperative pain is considerable with any extracapsular tonsillectomy technique, but some of these newer technologies can mitigate that to some degree. There is also a technique of intracapsular tonsillectomy. This technique, instead of removing the entire tonsil, you shave down the tonsil and leave a very, very thin capsule of tissue overlying the pharyngeal muscular bed. And the advantage of this technique is that the pain is much less. The bleeding rate is much less than with the traditional technique, but you are leaving some tonsil tissue behind with a small risk of regrowth of that tonsil tissue. So there are different ways to do this and we will sometimes tailor it to a particular patient depending on their patient factors and family concerns.

Host: Dr. Collins, what age are we talking about, up to what age is this a possibility for sleep apnea?

William O. Collins, MD, FACS, FAAP: So we really don't have hard criteria for minimum age or maximum age. I'd say the peak age range that we are seeing is toddler, preschool, early elementary age, for these patients. That's usually when the adenotonsillar tissue undergo maximum enlargement and hyperplasia is in that age group.

And they kind of expand more rapidly than the child can grow, and it crowds off the upper air digestive tract. Now, that being said, certainly we will see it in some older children. Teenagers are a little bit tricky, as teenagers tend to go. Sometimes you have to treat them like children, and sometimes you have to treat them like adults.

And adult obstructive sleep apnea is, really a kind of almost a different disease entirely. So again, you have to tailor the surgical approach to the individual patient.

Host: Well, that's certainly true and thank you for sorting that out for us. If this treatment isn't the complete treatment for this, if they still have a little residual sleep apnea afterwards, are there other options? What then are we looking at?

William O. Collins, MD, FACS, FAAP: After a tonsillectomy, we will give the children several months, usually at least three months, before we would consider even repeating a sleep study, for example. The healing time is, and the healing process is prolonged. But if children still have persistent symptoms at that point, then, you know, we go back to our history and physical.

One of the common things we see is uncontrolled allergies and you can still get nasal congestion, turbinate, inferior turbinate hypertrophy in the nasal passages, from untreated or undertreated allergies that can manifest as obstructive sleep apnea. Sometimes we will address that at the same time as tonsillectomy, and we can do a procedure called a turbinate reduction where we shrink the size of the mucous membranes, the turbinates inside the nasal passages.

In more severe cases, if children have documented severe obstructive sleep apnea postoperatively, those are situations we may schedule them to undergo what's called a drug induced sleep endoscopy or a DICE procedure. And that is a procedure that we do in the operating room under sedation, where we try to as much as possible, mimic physiologic sleep.

And we examine the child's upper aerodigestive tract with a flexible bronchoscope or flexible nasopharyngoscope and see where is that obstruction coming from? Is it coming from the palate level? Is the soft palate exceptionally long and redundant? Is the tongue base prolapsing posteriorly?

 Could there be other lesions? Could there be laryngomalacia or something, kind of unexpected in these patients. And the DICE will give us a pretty good assessment of where any sites of residual anatomic airway obstruction may be occurring. And it may be in multiple sites. And then we can tailor future treatments, based on the findings of that exam.

Host: This is really an interesting topic and you've given us a lot to think about. For other providers, primary care, pediatricians that are seeing these children, sometimes for the first time hearing about this from parents; what would you like them to know as referring physicians about pediatric obstructive sleep apnea and why it's important to look to the specialists at UF Health Shands Hospital?

William O. Collins, MD, FACS, FAAP: Yeah. I think sleep is one of those physiologic functions that we're just starting to understand and are really only learning the tip of the iceberg. It's one of the things people do every night and kind of take it for granted. But we're really understanding much better the consequences and implications of untreated sleep disorders.

And in children, obstructive sleep apnea is one of those more common conditions. And it's important to recognize there are multiple treatment options. And for these children, both medical, surgical, there's different surgical techniques. Inspire technique, which has recently been approved for children with Down syndrome that are 13 and older.

So, the field is advancing and our understanding of the disruptions in sleep is advancing as well with the surgical techniques, adapting to that new body of knowledge.

Host: Thank you so much, Dr. Collins, for joining us and sharing your incredible expertise today. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, please visit UFhealth.org/medmatters.

That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.