2015 HSC Section 1 Book of Articles

Reprinted by permission of Curr Opin Otolaryngol Head Neck Surg. 2012; 20(6):518-521.

C URRENT O PINION

Management of sleep apnea in the cleft population

Harlan R. Muntz

Purpose of review Obstructive sleep apnea is prevalent in children with facial clefts. As there are increasing concerns that sleep disordered breathing and obstructive sleep apnea may lead to cognitive difficulties, it is imperative that the otolaryngologist and cleft surgeon be aware of the concerns for sleep disorders and implement appropriate interventions for the management. Recent findings Micrognathia associated with Robin Sequence has long been understood to have significant potential for sleep apnea. Positioning, nasopharyngeal airway, tongue–lip adhesion and mandibular distraction have been used to improve the breathing in this set of children. Screened by symptoms, a large proportion of children with clefts will have a positive sleep study. Syndromic children seem to be more prone to this, even though nonsyndromic children are also at risk. Children who have had secondary management of velopharyngeal insufficiency with pharyngeal flap and sphincter pharyngoplasty seem to be at greater risk of sleep disorder. Specific directed therapies should provide the optimum results for the correction including tonsillectomy with partial adenoidectomy, revision pharyngoplasty, maxillary advancement and continuous positive airway pressure for sleep. Summary Awareness of the risk of sleep disorders and the possible treatments in children with cleft deformities is very important for the otolaryngologist. Keywords cleft lip, cleft palate, mandibular distraction, obstructive sleep apnea, Robin Sequence, sleep disordered breathing, tongue–lip adhesion, tonsillectomy and adenoidectomy

INTRODUCTION The awareness of sleep issues in the pediatric popu- lation has increased over the years. The snoring child is no longer just cute but a sign of obstruction that can lead to cognitive and behavioral difficul- ties. Many studies have been done to look at these issues. One large study by Bonuck et al. [1] looked at 12 447 children and found that symptoms of snor- ing and observed apnea were common. Habitual snoring was as high as 25% and apnea 15%, whereas ‘always’ snoring was seen in over 7% and apnea in 2%. In this study, the peak for symptomatic sleep disordered breathing was at about 3.5 years. Perhaps spurred by the increasing awareness of sleep disordered breathing in the population, a number of studies have looked at this problem in the cleft population. In many cases, it seems the awareness has focused the clinician to ask the right questions. Identification of historical symptoms that define sleep apnea has not been successful in the general population, but questioning of the cleft population seems to have a higher rate of return. In Muntz et al. [2], over 90% of sleep studies performed

on children with clefts were positive. The decision to order the sleep study was based on the presence of multiple symptoms related to obstructive sleep apnea. Unfortunately, using varied weighting schemes in both linear and cubic formulas, they could not suggest severity using multiple factors [2]. The MacLean study was similar in that 85% had positive sleep studies after referral for sleep symp- toms, 28% of which suggested severe sleep apnea [3] and Robison andOtteson [4] suggested the same with 83.1% having obstructive sleep apnea. Syndromes are common in children with clefts and more so in those with isolated cleft palate. The risk of significant obstructive sleep apnea was Division of Otolaryngology - Head and Neck Surgery, Primary Children’s Medical Center, University of Utah, Salt Lake City, Utah, USA Correspondence to Harlan R. Muntz, MD, FAAP, FACS, Primary Children’s Medical Center, #4500, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, USA. Tel: +1 801 662 5666; fax: +1 801 662 5662; e-mail: harlan.muntz@imail.org Curr Opin Otolaryngol Head Neck Surg 2012, 20:518–521 DOI:10.1097/MOO.0b013e3283585685

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