September 2019 HSC Section 1 Congenital and Pediatric Problems

Research Original Investigation

Ultrasonographic Evaluation of Upper Airway Structures in Children With Obstructive Sleep Apnea

themusclelayerscanbeidentifiedwellbyUSinchildren.Another method limitation is that the position of the neck during US examinationwas not exactly the same as the patient’s sleeping position; the slight neckextensionduringUSexaminationcould exposedeepercervicalsoft-tissuestructuresthatmaybepartially shadowedby themandible. 25 Even though the clinical utility of the Müller maneuver is controversial, we still tried to use the forced deep-inspiration technique to induce the maximum collapsibilityof theLPWandparapharyngeal content under US. However, it was very important to ensure cooperation on the partofthechildrenduringtheexamination,sothisstudyneeded to be conducted with the children awake.

Conclusions Ultrasonography of the head and neck is useful for evalua- tion of the upper airway structures in children. Using this imaging method, we found that the tonsillar volume esti- mated by US was not associated with AHI in children. How- ever, the LPW was thicker in children with OSA than in their counterparts with primary snoring. Therefore, LPW thick- ness may be an independent predictor of OSA in children. Measurement of the upper airway structures using US can help to clarify the role of the LPW in pediatric sleep apnea.

3 . Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc . 2008;5(2):242-252. doi: 10.1513/pats.200708 -135MG 4 . Li HY, Lee LA. Sleep-disordered breathing in children. Chang Gung Med J . 2009;32(3):247-257 . 5 . Ryan CM, Bradley TD. Pathogenesis of obstructive sleep apnea. J Appl Physiol (1985) . 2005;99(6):2440-2450. doi: 10.1152/japplphysiol .00772.2005 6 . Enciso R, Nguyen M, Shigeta Y, Ogawa T, Clark GT. Comparison of cone-beam CT parameters and sleep questionnaires in sleep apnea patients and control subjects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod . 2010;109(2):285-293. doi: 10.1016/j.tripleo.2009.09.033 7 . Arens R, McDonough JM, Costarino AT, et al. Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med . 2001;164(4): 698-703. doi: 10.1164/ajrccm.164.4.2101127 8 . Arens R, Sin S, McDonough JM, et al. Changes in upper airway size during tidal breathing in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med . 2005;171(11):1298-1304. doi: 10.1164/rccm.200411-1597OC 9 . Truong MT, Woo VG, Koltai PJ. Sleep endoscopy as a diagnostic tool in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol . 2012;76(5): 722-727. doi: 10.1016/j.ijporl.2012.02.028 10 . Fishman G, Zemel M, DeRowe A, Sadot E, Sivan Y, Koltai PJ. Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: inter-observer correlation and comparison with awake endoscopy. Int J Pediatr Otorhinolaryngol . 2013;77(5):752-755. doi: 10.1016/j.ijporl.2013.02.002 11 . Marcus CL. Pathophysiology of childhood obstructive sleep apnea: current concepts. Respir Physiol . 2000;119(2-3):143-154. doi: 10.1016/S0034 -5687(99)00109-7 12 . Hsu WC, Kang KT, Weng WC, Lee PL. Impacts of body weight after surgery for obstructive sleep apnea in children. Int J Obes (Lond) . 2013;37(4): 527-531. doi: 10.1038/ijo.2012.194 13 . Nandalike K, Shifteh K, Sin S, et al. Adenotonsillectomy in obese children with obstructive sleep apnea syndrome: magnetic resonance imaging findings and considerations. Sleep . 2013;36(6):841-847. doi: 10.5665/sleep.2708 14 . Schechter MS; Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea

ARTICLE INFORMATION Accepted for Publication: June 18, 2018. Published Online: September 13, 2018. doi: 10.1001/jamaoto.2018.1809

syndrome. Pediatrics . 2002;109(4):e69. doi: 10.1542/peds.109.4.e69

15 . Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med . 2010;182(5):676-683. doi: 10.1164/rccm.200912 -1930OC 16 . Tauman R, Gozal D. Obesity and obstructive sleep apnea in children. Paediatr Respir Rev . 2006;7 (4):247-259. doi: 10.1016/j.prrv.2006.08.003 17 . Kang KT, Chou CH, Weng WC, Lee PL, Hsu WC. Associations between adenotonsillar hypertrophy, age, and obesity in children with obstructive sleep apnea. PLoS One . 2013;8(10):e78666. doi: 10.1371 /journal.pone.0078666 18 . Schwab RJ, Gupta KB, Gefter WB, Metzger LJ, Hoffman EA, Pack AI. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing: significance of the lateral pharyngeal walls. Am J Respir Crit Care Med . 1995;152(5, pt 1):1673-1689. doi: 10.1164/ajrccm.152.5 .7582313 19 . Brodsky L, Moore L, Stanievich JF. A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol . 1987;13(2):149-156. doi: 10.1016 /0165-5876(87)90091-7 20 . Friedman M, Hamilton C, Samuelson CG, Lundgren ME, Pott T. Diagnostic value of the Friedman tongue position and Mallampati classification for obstructive sleep apnea: a meta-analysis. Otolaryngol Head Neck Surg . 2013; 148(4):540-547. doi: 10.1177/0194599812473413 21 . FujiokaM, Young LW, Girdany BR. Radiographic evaluation of adenoidal size in children: adenoidal- nasopharyngeal ratio. AJR Am J Roentgenol . 1979;133 (3):401-404. doi: 10.2214/ajr.133.3.401 22 . Major MP, Flores-Mir C, Major PW. Assessment of lateral cephalometric diagnosis of adenoid hypertrophy and posterior upper airway obstruction: a systematic review. Am J Orthod Dentofacial Orthop . 2006;130(6):700-708. doi: 10.1016/j.ajodo.2005.05.050 23 . Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus C, Vaughn B. The AASMManual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications . Darien, IL: American Academy of Sleep Medicine; 2012. 24 . Jones DH. Observations and results in adenoid and tonsil surgery. Laryngoscope . 1930;40:667-674. doi: 10.1288/00005537-193009000-00010

Author Contributions: Dr Hsu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Lin, Chen, Hsiao, Lee, Hsu. Acquisition, analysis, or interpretation of data: Lin, Chen, Kang, Hsu. Drafting of the manuscript: Lin, Hsu. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Hsu. Obtained funding: Hsu. Administrative, technical, or material support: Lin, Chen, Lee, Hsu. Study supervision: Kang, Hsiao, Hsu. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: This study received grant support from the National Taiwan University Hospital (NTUH 106-S3560) and the Ministry of Science and Technology of the Republic of China (Taiwan); (MOST 106-2511-S-002 -021). No additional external funding was received for this study. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: The authors thank the Therapeutics and the staff from the Center of Sleep Disorders, National Taiwan University Hospital, for their technical support. They received no additional compensation for their contributions. REFERENCES 1 . Downey R III, Rowley JA, Wickramasinghe H. Obstructive Sleep Apnea. Updated January 27, 2017. https://emedicine.medscape.com/article /295807-overview . Accessed February 18, 2017. 2 . Powell S, Kubba H, O’Brien C, Tremlett M. Paediatric obstructive sleep apnoea. ClinOtolaryngol . 2010;35(5):418-423. doi: 10.1111/j.1749-4486.2010 .02168.x staff from the Ultrasound Division of the Department of Integrated Diagnostics &

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