2015 HSC Section 1 Book of Articles

72 / 280

CURRENT
OPINION 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:
Curr Opin Otolaryngol Head Neck Surg 2012, 20:518–521
DOI:10.1097/MOO.0b013e3283585685
Reprinted by permission of Curr Opin Otolaryngol Head Neck Surg. 2012; 20(6):518-521.
50