Master Handout Milwaukeelr PDF

Tonsillectomy
y
Review
Cecille Sulman, MD
© Children’s Specialty Group. All rights reserved.
Disclosures
I have no relevant financial

relationships to disclose.
disclose

Objectives
j
• Discuss tonsillectomy guidelines
• Discuss patient assessment for tonsillectomy
• Review
e e perioperative
pe ope a e course
cou se
• Summarize tonsillectomy outcomes

Tonsillectomy
y
Tonsillectomy is the third most common surgery (after circumcision and ear tubes)
performed on children in the United States, with over 530,000 annual procedures (1 in 7
ambulatory surgeries under age 15 years).
years)
In nonobese and otherwise healthy children younger than 8 years, the prevalence of
obstructive sleep apnea (OSA) is estimated to be 1-3%.
Habitual snoring is common during childhood and affects approximately 10% of

children aged 2-8 years.
Obesity confers 4-fold

4 fold to 5-fold
5 fold added risk for sleep-disordered
sleep disordered breathing.
breathing
Obstructive sleep apnea occurs more commonly among black and Hispanic
individuals than among white adults and children. In patients younger than 18 years,
blacks are 33.5
5 times more likely to develop obstructive sleep apnea than whites
whites.
Guilleminault. Otolaryngol Head Neck Surg. 2007 Feb. 136(2):169-75

Tonsillectomy Guidelines

AAO-HNS 2011 Tonsillectomy Guidelines
Strong Recommendations
• Strong recommendation
St d ti for
f a single,
i l iintraoperative
t ti d dose off
intravenous dexamethasone to children undergoing tonsillectomy.
• Strong recommendation against routinely administering or prescribing
perioperative
p p antibiotics to children undergoing
g g tonsillectomy.y
• Adherence: Cohort of 16,310 pts at 19 hospitals by 61 surgeons. The

majority of hospitals and surgeons administered perioperative
dexamethasone before and after the guidelines were published.
published
While the rate of antibiotic administration statistically decreased in
2012 compared to 2007-2011, only 2 of 17 surgeons who prescribed
perioperative antibiotics appeared to have changed their practice.
P di Otolaryngology
Padia. Ot l l -- Head
H d and
dNNeck
kSSurgery S
September
t b 2014 151
151: P103

Recommendations
Watchful waiting for recurrent throat infection if there have
been fewer than 7 episodes in the past year or fewer than
5 episodes per year in the past 2 years or fewer than 3
episodes per year in the past 3 years.
Assessing the child with recurrent throat infection who does

not meet criteria in statement 2 for modifying factors that
may nonetheless favor tonsillectomy, which may include
but are not limited to multiple antibiotic
allergy/intolerance periodic fever
allergy/intolerance, fever, aphthous stomatitis,
stomatitis
pharyngitis and adenitis, or history of peritonsillar abscess.
Recommendations
Asking caregivers of children with sleep
sleep-disordered
disordered breathing
and tonsil hypertrophy about comorbid conditions that might
improve after tonsillectomy, including growth retardation, poor
school performance, enuresis, and behavioral problems.
Counseling caregivers about tonsillectomy as a means to

improve health in children with abnormal polysomnography who
also have
ha e tonsil h
hypertrophy
pertroph and sleep
sleep-disordered
disordered breathing.
breathing
Counseling caregivers that sleep-disordered breathing may

persist or recur after tonsillectomy and may require further
management.
Recommendations
Advocating
i f pain
for i management after
f tonsillectomy
i and
educating caregivers about the importance of managing
and reassessing pain.
Clinicians who p
perform tonsillectomy
y should determine their
rate of primary and secondary post-tonsillectomy
hemorrhage at least annually.

Screening for Sleep Disorders in Pediatric
Primary Care: Are We There Yet?
• Aim. determine if AAP guidelines are adhered to in pediatric primary care.
• St d design.
Study d i I all,
In ll 1032 electronic
l t i charts
h t off children
hild 4 to
t 17 years old
ld presenting
ti
for well-child visits to 17 pediatricians between January 1 and December 31, 2010,
were manually reviewed. Abstracted data included demographic variables and
documentation of snoring as well as other sleep-related complaints.
• Results The mean age was 8.5
Results. 8 5 ± 3.9
3 9 years (mean ± standard deviation),
deviation) 49.9%
49 9% were
male, and 79.7% were Hispanic; 24.4% (n = 252) were screened for snoring. Of the
children screened for sleep-related issues, 34.1% (n = 86) snored, but the majority of
them (61.6%, n = 53) received no further evaluation. In the present sample, 0.5% (n
= 5) had a diagnosis of OSA.
• Conclusions. The low prevalence of OSA may be explained by the relatively low
frequency of sleep-related problem screening by pediatricians and thus the
inordinately low adherence to the AAP guidelines. Modification and transition to
electronic medical records as well as expanded efforts to educate health care
providers and caregivers may improve detection and timely treatment of children
at risk for SDB.
Erichsen Clin Pediatr Dec 2012 51:1125

Why
y does OSA matter?
• Pulmonary hypertension
• Cor pulmonale
• Failure to thrive
• Growth retardation
• Behavioral disturbances
• Poor school performance
• Enuresis

Patient assessment

History
y
Snoring Mouth breathing
A
Apneas R tl
Restless sleeping
l i
Enuresis Difficult to wake
G
Gaspingi B h i
Behavioral l abnormalities
b liti
Choking Dysphagia
Allergies Learning disabilities
Tonsillitis Nightmares/night terrors
Speech Sleep habits
Halitosis © Children’s Specialty Group. All rights reserved.
Examination
• Overall appearance, weight
• Stertor and/or stridor
• Mouth-breathing, drooling
• Hyponasal speech
• Craniofacial deformities
• Hypotonia, neuromuscular disorders

Nasal examination
• Anterior rhinoscopy
– Deviated septum
p
– Septal dislocation
– Rhinitis
– Turbinate hypertrophy
• Flexible endoscopy
– Choanal atresia/stenosis, pyriform aperture stenosis
– Masses – polyps, dermoid, glioma, teratoma, fibrous histiocytoma,
encephalocele nasolacrimal duct cyst
encephalocele,
– Foreign bodies

Nasopharynx
p y
• Adenoid hypertrophy
• Lymphoma, PTLD
• Acquired stenosis
– Pharyngeal flap
– s/p T&A
• Papillomatosis
• Juvenile nasopharyngeal fibromatosis

Adenoid hypertrophy
yp p y

Mouth and oropharynx
p y
• Tonsil hypertrophy
• Elongated and/or thickened palate and uvula
• Lymphoma
• Lingual cyst
• Lingual tonsillar hypertrophy
• Macroglossia
• Micrognathia
• Papillomatosis
• Vascular malformation

T
Tonsil
il hypertrophy
h t h
Tonsil size is relative to oropharynx

Mallampati
p

Hypopharynx
yp p y
• E
Enlarged
l d base
b off ttongue
• Decreased diameter of the
hypopharynx with obesity,
Down syndrome
• Lingual tonsil hypertrophy
• Masses - lingual thyroid

Larynx/trachea
y /
• Vocal cord paralysis
• Laryngomalacia
• Tracheal atresia
• Intrinsic tracheal lesions
• Laryngeal and tracheal webs
• Laryngeal cysts

At risk patients
p
• Craniosynostosis
– Apert's
pe s sy syndrome
do e
– Crouzon's disease
– Pfeiffer's syndrome
• Micrognathia
g - obstructed at the hypopharyngeal
yp p y g level
– Treacher Collins syndrome
– Pierre Robin syndrome
– Goldenhar's syndrome
y
• Down syndrome - narrow upper airway combined with
macroglossia and hypotonic musculature predisposes them to
OSA.

Nasopharyngoscopy
p y g py
• No radiation exposure.
• Useful to evaluate the obstruction at the
retropalatal and retroglossal levels.
• Easily
E il reproducible
d ibl pre- and d postoperatively.
t ti l
• May be performed sitting or supine.
• May be performed with the patient awake or
sleeping.

Disadvantages of
nasopharyngoscopy
• It can produce some discomfort when introducing
the nasopharyngoscope into the nose.
• It gives
i an approximate
i t idea
id off th
the pharynx.
h
• The evaluation depends on the experience of the
e aminer
examiner.

Sleep
p endoscopy
py
No apnea Adenotonsillar hypertrophy

Sleep
p endoscopy
py
No apnea Circumferential collapse

From: A New Scoring System for Upper
Airway Pediatric Sleep Endoscopy
JAMA Otolaryngol Head Neck Surg.
2014;140(7):595-602.
doi:10.1001/jamaoto.2014.612
Figure Legend: Representative Images:Each of the 4 ordinal scores at each of the 5 upper-airway sites are shown.
Copyright © 2015 American Medical

Association. All rights reserved.
Sleep
p tape
p
• A sleep tape has a sensitivity of 88%, specificity of
52% positive
52%, iti predictive
di ti valuel off 63%
• H
Home video
id tape
t recording
di off th
the child’s
hild’ night-time
i ht ti
screening method for OSA with a sensitivity of 94%,
and a specificity of 68% in predicting a positive
study

Overnight
g oximetry
y
• Advantages: relatively simple to perform, widely available,
and has a p
positive p
predictive value of g
greater than 90%.
• Disadvantages:
– In a study of a cohort of 349 children referred for assessment of
snoring to a tertiary sleep laboratory, screening oximetry had a
negative
ti predictive
di ti valuel off only
l 47% when
h compared d with
ith
polysomnography. Therefore, negative findings can not be used
to confidently exclude OSAS.
– Different types
yp of oximeters may y have varying
y gp performance
characteristics, especially with regard to averaging times and
movement artefact. Thus, the presence and severity of
desaturation episodes may vary according to the specific type of
equipment used in the study.

Polysomnogram
y g
• Gold Standard
• PSG has been most useful to confirm the diagnosis of
OSA and document its severity in the following situations:
– Children < 2 years
– High risk patients for which surgery is contraindicated
– Craniofacial anomalies, morbid obesity, cerebral palsy
– When there is a discrepancy between history and physical
exam
– Children who are symptomatic after T&A
– CPAP titration
– Laryngomalacia
L l i with ith significant
i ifi t sleep
l symptoms
t

Medical approaches
pp
• Antibiotics during acute infection
• Nasal steroids
• Systemic steroids for acute obstruction
• Supplemental oxygen
• Nasopharyngeal intubation (trumpet)
• CPAP/BiPAP
• Weight loss

Peri-operative management

Surgical
g approaches
pp to treat OSA
• Adenotonsillectomy
• Uvulopalatopharyngoplasty (UPPP)
• Craniofacial distraction
• Hyoid suspension
• Tongue procedures
• Septoplasty/turbinate reduction
• Tracheotomy

T & A Techniques
q
• The first report of tonsillectomy was performed in
I di 3
India 3,000
000 years ago
• C
Celsus
l i 30 AD described
in d ib d scraping
i th
the ttonsils
il and
d
tearing them out or picking them up with a hook
and excising them with a scalpel

T & A Techniques –
Cold knife dissection
• Commonly used
• Scalpel, dissection and
snare
• Benefits: Reduced
postoperative pain and
bleeding rate
• Drawbacks: Intra-
operative bleeding
T & A Techniques –
Electrocautery
• Commonly used
• Cautery dissection
• Benefits: Short
operative time and
reduced blood loss
• Drawbacks: More
painful and increased
bleeding incidence
over cold technique

Adenoidectomy
y techniques
q
• Cold knife (currette)

• Cautery
• Microdebrider
• Coblation
• Plasma

Post-operative
p T&A expectations
p
• Recovery time 1-2 weeks
• Louder breathing first several days - week
• Throat pain and ear pain
• Halitosis, scabbing
• Irritation with certain foods
• Change in voice
• Transient velopharyngeal insufficiency

Postoperative
p complications
p
• Respiratory distress
– < 3 yo
– Edema
– OSA – RDI > 40
40, Pox < 70
– Neuromuscular disorder
– Obesity
– Craniofacial disorders

Postoperative
p complications
p
• Bleeding
– < 24 hours surgical technique
– > 24 delayed, 7-10 days post-op
– National average ~ 3%
Waltier DC Anesthesiology 2003;98(6):1497-1502

Postoperative
p complications
p
• Dehydration • Post-obstructive pulmonary
– Most common edema
complication • Subluxation of the atlanto-
• Velopharyngeal axial joint
insufficiency
y – Down
Down’ss syndrome
– 1/1500 - 3000 • Mortality
• Nasopharyngeal – 1/16,000 – 35,000
stenosis
• Complex patients
• Grisel’s – – Cerebral palsy, chronic lung
retropharyngeal disease, sickle cell disease,
infection central hypoventilation
Randall DA Otolaryngol HNS 1998;118:61-68
1998;118:61 68
syndromes, genetic/metabolic/
or storage diseases
Deutsch ES Ped Clin N Amer 1996;43(6):1319-1338

Post-operative
Post operative appearance

Tonsillectomy outcomes

Risk factors for recurrence of OSA
• Gain velocity in BMI
• Obesity
• African American
• 40 children followed 6 wks, 6 mos and 1 year post
T&A
Amin AJRCCM 2008

Adenotonsillectomy
y outcomes
• In 60-100% PSG OSA resolves after T&A
Clinical Practice Guidelines: Management Pediatric OSA Pediatrics 2004;109(4):704-712
Friedman Otolaryngology -- Head and Neck Surgery June 2009 140: 800
• Academic performance
– Cohort of 297 first graders with poor academic performance
there was a 6- to 9-fold increase in the prevalence of OSAS
– T&A in the children who had OSAS resulted in a significant
improvement in their academic performance in the following
year
– There was no improvement in those with OSAS whose parents
declined treatment
G
Gozal
l D.
D PPediatrics
di t i 1998;
1998 102
102: 616
616-620
620

Quality of life after tonsillectomy in
children with recurrent tonsillitis
• Objective To describe changes in disease-specific and global quality of life (QOL)
for children with recurrent or chronic tonsillitis at 6 months and 1 year after
tonsillectomy using two validated instruments,
instruments the Tonsil and Adenoid Health Status
Instrument (TAHSI) and the Child Health Questionaire-PF28 (CHQ-PF28).
• Study Design and Setting A multicenter, prospective observational outcomes study.
• Results Ninety-two children, mean age (SD) 10.6 (3.4) years, enrolled with follow-up
available for 58 children at 6 months and 38 children at 1 year. The children
showed significant improvements in all subscales of the TAHSI including airway and
breathing,
g infection, health care utilization, cost of care, eating
g and swallowing
g (all
(
P < 0.001), and behavior (P = 0.01). Significant improvements were also found on
several subscales of the CHQ-PF28, such as general health perceptions, physical
functioning, parental impact, and family activities (all P < 0.001).
• Conclusion/Significance
C l i /Si ifi Thi uncontrolled
This t ll d study
t d provides
id prospective ti evidence
id off
improved disease-specific and global QOL in children after tonsillectomy.
Goldstein Otolaryngology -- Head and Neck Surgery January 2008 138: S9

What does value mean with
respect to tonsillectomy?
Education (patient, nursing)
Phone app
Phone app
Youtube® videos
Stepping stones
Diet – uniform practice
Pain – optimize control
Pain – optimize control
Value = Quality + Experience Criteria – referral, admission
Cost Physician behavior ‐ instilling trust
OR ‐ transparency for
t f
cost/physician; improve
efficiencies; cost containment for
supplies
Office visits phone call follow up
Office visits ‐ phone call follow up
to reduce resource utilization
Decreased ED/readmissions

Conclusions
• Tonsillectomy is a common surgery with
significant morbidity that results in improved
breathing, academic performance and quality
of life.
• Tonsillectomy guidelines provide direction.
• Recurrence of sleep apnea/failed treatment

may occur.
occur

Thank you
y

Contact Information
Cecille Sulman
Sulman, MD
(414) 266-6467
Physician Consultation and Referral: (800) 266-0366

Sleep Disorders in Children
Hari Bandla, MD
Disclosures

disclose

Objectives
j
• Review sleep physiology and age
dependent sleep requirements
i
• Discuss sleep
ppproblems in early
y child
hood and adolescence
• Review obstructive sleep apnea, a
common sleep disorder in children
• Introduce the Sleep Program at CHW
Sleep Physiology
• Active and complex process
• Highly Regulated
• Involves different neuronal groups
• Multiple functions
• Memory consolidation, energy conservation,
lid i i
• brain restoration, protective behavioral
adaptation
• immune function regulation
• Essential
• Composed of two fundamentally different states:
Composed of two fundamentally different states:
• REM sleep & NREM sleep Rosenzweig, Breedlove & Leimna
Biologica Psychology, Sinauer Associates, 2002
Insufficient Sleep Fragmented Sleep
(Sleep Deprivation) (Sleep Disruption)
Sleep Dysfunction in Children
Primary Disorders
of Excessive Daytime
Sleepiness

Sleep Deprivation in children
• Infants get 12.7 hours vs recommended 14-15 hours.

• Toddlers get 11.7
11 7 hours,
hours vs recommended 12-14
12 14 hours
• Preschoolers get 10.4 hours, vs recommended 11-13
hours.
hours
• School-aged children (1st through 5th grades) get
9.5 hours vs recommended 10-11 hours.
2004 Children and Sleep

Sleep Dysfunction in Children:
C
Conceptual Framework
t lF k

Behavioral Insomnia of Childhood
Sleep-onset Association Type

• Child begins
g to associate sleep
p
onset with circumstances that are
problematic and demanding of the
caregiver
• Child unable to fall asleep without

these associations either at initial
sleep onset or during nocturnal
awakenings

Behavioral Insomnia of Childhood
Limit setting Type
Limit-setting
• Parents unable to set
consistent bedtime
rules leading to prolonged
bedtime struggles, bedtime
refusal behavior;; protests,
p ,
requests, excuses
• results in: prolonged sleep
onset latency; night wakening
usually not problematic; most
common in 2-6 yyear olds

Extinction
• A behavior that is not reinforced is reduced or eliminated
overtime
o e e (operant
(ope a theory)
eo y)
• Used for bed time difficulties and night awakenings
• Child put to bed at a designated time and systematically ignore
the child’s
child s responses until a set time following morning
• Effective in 3-5 days and maintained over time
• Decreased compliance due to parental stress letting the child
cry out
‘cry out’.

Graduated extinction
• Extinction combined with parental checks
• Incremental graduated extinction is the most commonly
used method
• Ability to check the child improves parental compliance
• Fading parental involvement as the child transitions from
awake to sleep
• Four areas targeted for fading include
– amount of physical contact
– Proximity of the parent to child
– Duration of check in
– Duration of intervals between check-ins

Phase 1: Gradual Fading
• Stand next to crib rubbing child’s back – 3 nights
• Stand next to crib
crib, no physical contact – 3 nights
• Sit in chair next to crib – 3 nights
• Sit in chair in the middle of the room – 3 nights
• Sit in chair by the door – 3 nights
• Sit on other side of the door – 3 nights
g
Phase 2:Scheduled Checks

• Open door, look in, very limited interaction, under 1 min – Every 5 min, until child asleep, 2 nights
• Open door, look in, very limited interaction, under 1 min – Every 10 minutes, until child asleep, 2 nights
• Open door
door, look in,
in very limited interaction
interaction, under 1 min – Every 45 minutes,
minutes until child asleep,
asleep 2 nights

Bedtime Pass
• A bedtime pass can help parents set limits and can be
extremely helpful with children who make multiple
requests after lights out.
• Parents provide children with one or two “bedtime
passes”,, which can be as simple as an index card that
passes
has been decorated.
• The child must turn in a card for each request made.
• No more passes means no more requests.
requests
• Provide a reward for any pass that the child still has in
the morning.

Scheduled awakenings
g
• Provide the child a brief awakening and transition back to sleep
preventing
p e e g a level
e e of
o arousal
a ousa that
a ca
can result
esu in full
u awakening
a a e g
• Monitoring of child’s sleep patterns and time of night awakenings
at baseline
• Parents briefly awaken the child 15 minutes before a typical night
awakenings for 10 days
• Awakenings faded out over time
• Has been reported to be successful in the treatment of NREM
parasomnias

Adolescent Sleep
A Time of Transition

Social pressures Delayed sleep phase
Sleep Genetic
School start times
School start times Time predisposition
Hormonal influence,
Substance abuse
Substance abuse
obesity

Trying
y g to Get Enough
g Sleep
p
Late bedtime
Afternoon Afternoon
napping napping
i
Problem with
Adolescent Problem with
d ti
daytime
alertness
Vicious daytime
alertness
Cycle
Sleep restricted Sleep restricted
during school during school
week week
Difficulty
Graphic courtesy of Helene Emsellem, MD, George
initiating sleep
initiating sleep
Washington University.

Consequences
q of Sleep
p Deprivation
p
• Impaired cognitive, social and behavioral
performance.
• Poor school performance and lower grades
• Tardiness and absence from school
• Difficulty remaining alert,
alert less ability to
concentrate.
• Irritability and impaired mood.
• I
Increases iin substance
bt abuse.
b
• Drowsy driving, injury and possibly, death

Adolescent Sleep Disorders - Prevalence
• Insomnia – 2 - 40%
• Daytime sleepiness – 20 - 35%
– Sleep attacks
– Restlessness, hyperactivity
yp y
– Irritability
– Impulsivity
• Attention
Att ti deficits
d fi it
– Poor attention span
– Staring spells (microsleep episodes)
– Failure to finish tasks, decreased motivation
– Poor school performance

Advocacy
y Issue: School Start Times
High school and middle school start times tend to be early ‐ interrupting
adolescents’ sleep patterns ‐
adolescents sleep patterns ‐ and making it difficult to wake up and be alert.
and making it difficult to wake up and be alert
• Symptoms
y p are worst in the morning.
g
• Students are often living with the
consequences of sleep deprivation
throughout the day.
• Many
a y schools
sc oo s across
ac oss the e country
cou y are
ae
establishing later start times to get in
sync with a teen’s sleep schedule
• Several studies cite the positive
outcomes of “sleep
sleep-friendly
friendly” school
start time policies

Autism and Sleep
p Problems
• It has been estimated that between 44% and
83% of children with autism have sleep
problems (Patzold et al, 1998; Richdale & Prior, 1995;
Wiggs & Stores, 1996)
• Si
Significant
ifi t sleep
l onsett and
d maintenance
i t
problems (Malow, 2005)
• Also irregular sleep
sleep-wake
wake patterns,
patterns early waking
and poor sleep routines (Hoshino et al, 1984;
Clements et al, 1986; Quine, 1991; Schreck & Mulick,
2000; Honomichl et al
al, 2002)

ADHD and Sleep
• Common neurobehavioral disorder of childhood
• Affects 3%
3%-5%
5% of school-aged
g children
• Persistent pattern of inattention and/or hyperactive-
impulsive behaviors
• Clinically
Cli i ll significant
i ifi t iimpairment
i t iin academic,
d i social
i l
or occupational functioning
• Inattentive/hyperactive
Inattentive/hyperactive-impulsive/combined
impulsive/combined types
• Sleep problems are reported in up to 50 % of
children with ADHD

Melatonin and Autism
• Several studies have demonstrated
significantly lower nocturnal melatonin in
subjects
j with autism compared
p with controls
– Nocturnal serum melatonin 25% decreased in
autistic subjects (Nir, 1995)
– None of 14 subjects
j with autism showed a
physiological
h i l i l iincrease iin nocturnal
t l serum
melatonin (Kulman, 2000)
• Growing evidence that melatonin is effective
in treating sleep-onset
sleep onset insomnia and possibly
middle/terminal insomnia
Nir et al, J Autism Dev Disord 25, 1995
Kulman et al, Neuroendocrinol Lett 20, 2000
Melatonin and ADHD
• Small (N=9), double-blind, randomized placebo cross-
over study of high dose melatonin (6 mg) to treat sleep
sleep-
onset insomnia in children (6-13 y/o) with ADHD
– Parental reports of significantly shorter sleep onset latency
with melatonin treatment comparedp with pplacebo
• Open label trial (N=27) of melatonin 3 mg for sleep-onset
insomnia in children with ADHD on methylphenidate
– Subjects fell asleep significantly sooner immediately after
starting melatonin (median of 135 minutes sooner, range of
15 to 240 minutes)
Weiss et al, October 2003 Tjon Pian Gi et al, Eur J Pediatr (2003) 62:554‐555

Obstructive Sleep
p Apnea
p
Disorder of breathing
d i
during
sleep characterized by
p
• Partial or complete
obstruction of upper
airway during sleep
– Associated with O2
desaturations and
hypercarbia
– Sleep fragmentation

Obstructive Sleep Apnea in Children
Epidemiology
• Habitual snoring in 10% of
preschool children
p
• OSA in 1-3 % of preschool
children
• Peak Prevalence between 2-5
yr of age
• Equal prevalence in boys and
girls
• Higher prevalence in Hispanic
and Afro-american children
• Adenotonsillar hypertrophy is
the commonest cause
Laurikainen 1987, Brooks 1998, Guilleminault 1990

Obesity and OSA
• Prevalence
P l doubled
d bl d among children
hild
6–11 years and tripled among 12–17-
years
• 15% of OSA children are obese in 90s
vs 50% in the last few years
• Estimated prevalence range from 29
% to 39%
• For every increment of raise in mean
BMI for age and gender, prevalence
of OSA
o OS increases
c eases by 12%
%
• Presence of obesity modifies end
organ susceptibility to OSA
• + ve correlation between BMI, apnea
i d
index, SSpO2
O2 nadir
di andd sleepiness
l i on
MSLT
Ogden JAMA 2002; Redline S AJRRC 1999 NANOS study- Alonso-Alvarez ML et al, Sleep 2014 May 1;37(5):943-9
OSA in Children - symptoms
y p
Nocturnal Diurnal
• Loud snoring • Neurocognitive Dysfunction

• Observed apneic pauses – hyperactivity
• Snorting / gasping / choking – inattention
• Restless sleep
• Diaphoresis – poor school performance
• Paradoxical chest wall – EDS (teen agers)
movement – behavior problems
• Abnormal sleeping position • Morning headache
• Secondary enuresis
• Noisy breathing

ADHD symptoms
y p in OSA

Polysomnographic study is
the Gold standard for the
diagnosis of Sleep Disordered
Breathing in Children

Adenotonsillectomy
y
• Treatment of choice for
Pediatric OSA in
children > 2 yrs of age
• First line of treatment
even in obese children
• Success rate 82%
• Higher recurrence
rate(47%-75)
• Higher recurrence in
children with
– Obesity
– Cranio facial
malformations
– Syndromic children
– RDI> 19
Suen 1995; Michael Schechter

2002
Rapid
p Maxillaryy Expansion
p
• Acquired Maxillary
constriction secondary to
chronic
h i mouth th breathing
b thi
• High arched hard palate
and midpalatal groove
• Rapid maxillary expander to
deliver a lateral force to
upper posterior molars
• Opens the mid palatal
suture and widens the nasal
cavity
• Expansion is continued for 3-
4 months followed by
consolidation for 2-3 months
with subsequent removal

Continuous Positive Pressure Airway
Therapy
• Most common non-surgical treatment
• Indications:
• 1.When tonsillectomy y is delayed,
y , contraindicated or unsuccessful
• 2. Persistent OSA following tonsillectomy
• PAP is not approved by the Food and Drug Administration for children
younger than 7 years of age or weighing less than 40 pounds
• Variety
V i t off iinterface
t f options
ti
Pixie Nasal mask(2-7yrs) Mini Me Nasal mask Mirage Kidsta Nasal mask

(>7yrs)
Clinical Practice Guidelines
• All children should be screened for
snoring.
g
– Snoring, labored breathing, snorting and
gasping
– Daytime sleepiness
– Changes in behavior
– Abnormal ENT exam (adenotonsillar
hypertrophy, mouthbreathing, micro-
/retrognathia, large tongue, long soft palate,
abnormal cranial nerve function)
• Complex, high-risk children should be
referred to a specialist.
specialist
• Patients with cardiorespiratory failure
cannot await elective evaluation.
» AAP, Pediatrics
i i 2002; 109:704-712

Clinical Practice Guidelines (2)
• Thorough
g diagnostic
g evaluation should
be performed.
– History
y and p
physical
y exam are ppoor at discriminating
g
between primary snoring and OSA
– Polysomnography is the diagnostic test of choice
– Other diagnostic studies
st dies (audio/videotaping,
(a dio/ ideotaping
overnight oximetry studies, daytime nap
studies) have limitations

Clinical Practice Guidelines (3)
• Adenotonsillectomy is first line of treatment for most

children
children.
– CPAP is an option for those who are not
candidates for surgery or do not respond to surgery
g loss,
– Treatment for select cases includes weight
management of allergies, craniofacial surgery, tracheotomy
• High-risk patients should be monitored inpatient post-

operatively.
operatively
– Associated complex medical condition
– Children <3 years old
– Children with “severe” OSA by polysomnography
-McColley et al, Arch Otolaryngol Head Neck Surg 1992; 118:940-943
• Patients
P ti t should
h ld be
b reevaluated
l t d postoperatively
t ti l to
t
determine whether additional treatment is required.
American Academy of Pediatrics Task
Force on Sudden Infant Death Syndrome
• Infants should sleep
p in a crib or bassinet
conforming with standards of Consumer
Product Safety Commission.
• Infants may be brought to bed for

nursing or comforting but should not
bed share for sleep.
sleep
• The crib or bassinet should be placed in

parents’ room close to their bed.
bed

American Academy y of Pediatrics
Guidelines for health supervision for children with Down
syndrome, Pediatrics, August 2011
• Discuss with parents symptoms of Obstructive Sleep
Apnea at each health maintenance visits during
infancy, early childhood, late childhood and
adolescence
• Referral to Pediatric Sleep Laboratory for a sleep study
for all children with Down syndrome by 4 years of age
• Refer to a physician with expertise in pediatric sleep of
any child with signs and symptoms of OSA or abnormal
sleep study results
• Discuss obesity as a risk factor for OSA

Sleep History:
“ Bears”
 Bedtime
dti
 Excessive daytime sleepiness
 Awakenings: night wakings
y morning
early g wakingg
 Regularity and duration of sleep
 Snoring
Children’s Hospital of Wisconsin Sleep Center
Louella Amos MD
Louella Amos, MD H i B dl MD
Hari Bandla, MD
Lynn D’Andrea, MD Nan Norins, MD
Megan Grekowicz, MSN

Pediatric Sleep Laboratory
• State-of-the art facilities
• 8-bed laboratory y
– Milwaukee Campus
– New Berlin
• Remote testingg
• 5 nights per week
• Testing can include:
– Overnight sleep studies
– Esophageal pH monitoring
– Multiple Sleep Latency Tests
– CPAP/BiPAP titrations
– Seizure monitoring
– Actigraphy

Contact Information
Hari Bandla,
Bandla MD
(414) 266-6730
Physician Consultation and Referral: (800) 266-0366

Otitis Media
G id li
Guidelines Update
U d t 2016
Michael McCormick, MD
©
© Children’s
Children’s Specialty
Specialty Group.
Group. All
All rights
rights reserved.
reserved.
Disclosures

disclose

Objectives
j
• Review
e e relevant
ee a a anatomy
ao ya and
d the
e ea
ear e
examination
a a o
• Review risk factors for otitis media.
• Differentiate AOM vs OME.
• Discuss new clinical practice guidelines on otitis media

with
ith effusion.
ff i

Otologic
g Exam
• Clinical education is key
b t often
but ft difficult
diffi lt
– Tough skill to master
• IInspectt pinna
i
• Pull up & out to examine
• External auditory canal
– Cartilaginous canal
contains hair follicles

Otologic
g Exam
• 360° exam is critical
• Identify all landmarks
• Umbo
• Pars Flaccida
• Annulus
• Cone of Light

Otologic
g Exam
• Pneumatic otoscopy
– Insufflation of air into external
auditory canal with a good seal to
determine mobility of tympanic
membrane
– Gold standard for diagnosing
g g
middle ear effusions
• Tympanometry
– Excellent teaching tool
– Helps confirm unclear cases
– Skilled practitioner can perform in
office in situations without
audiology availability

Otitis Media
• Very common
– Most common reason for an ill child to see an MD
in the US
– Most common reason for
f childhood hearing loss
• Very expensive
– Approximately $6 billion/year in U.S.
• Veryy significant
g complications
p

Risk factors
• Lack of breast–feeding: Breast–feeding for at least three months
pp
appears to lower the risk of otitis media.
• Male gender
• Age: Children younger than 10 years, and especially between the
ages
g of six months and two yyears, are most commonly y affected.
• Use of pacifiers and bottle–feeding
• Day care attendance
• Exposure to tobacco smoke and air pollution
• Hereditary factors
• Fall and winter months

Acute Otitis Media
• Rapid onset of signs and symptoms of middle ear
inflammation (most often with ear pain) in a bulging
eardrum
• 2013 AAP CPG on AOM Recommendations
1. Diagnose AOM in children with moderate to severe bulging of
the TM or new onset of otorrhea not due to acute otitis externa
2 Diagnose AOM in children who present with mild bulging of the
2.
TM and recent (<48 hours) onset of ear pain or intense
erythema of TM
3 Do NOT diagnose AOM in children without middle ear effusion
3.

Acute Otitis Media
• Changes from 2004 CPG:
–D
Definition
fi iti off AOM iis no llonger b
based
d on 3 classic
l i
criteria:
• Acute onset of symptoms
• Middle ear effusion
• Signs of middle ear
inflammation
– More stringent otoscopic criteria proposed

Diagnosis
g of AOM
• Clinical history is a poor predictor
– Huge overlap with viral URI
• Huge problem!
– Impacts treatment: If and When
– Negative
Negati e impact on research into this topic
• No standard objective measure to diagnose each
patient (relies on practitioner’s
practitioner s skills and experience)

Bacterial Otitis Media
• “Big Three”
– Streptococcus
St t pneumoniae
i
– Haemophilus influenzae
– Moraxella catarrhalis
• Also:
– Group A Streptococcus
– St h l
Staphylococcus aureus
– Gram negatives
– Anaerobes

Viral Otitis Media
• Sole causative agent in
30% of cases
• “Mixed” Infections
– Significant precursor to
bacterial infections
– RSV identified in 53% of
MEE by PCR
(Okamoto, J Infect Dis,
1993))

Viral Otitis Media
• Increased interest due to potential for
vaccines
• Most common:
– RSV
– Influenza
– Parainfluenza
– Adenovirus
– Rhinovirus

Otitis Media with Effusion
• Presence of middle ear fluid
without signs or symptoms of
acute ear infection
• “Occupational hazard of
childhood”
– More than 90% of children
have it before school age
g
– 4 episodes per year
• ~$4 billion annual healthcare
costs in US
Rosenfeld R et al. “Clinical Practice Guideline: Otitis Media with Effusion (Update).” Otolaryngol Head Neck Surg. 2016; 154: S1‐S41.
Rosenfeld R. A Parent’s Guide to Ear Tubes. Hamilton, Canada: BC Deceker Inc. 2005.
Tos M. “Epidemiology and natural history of secretory otitis.” Am J Otol. 1984; 5: 459‐62.
• Common during g URI
• Common after AOM
• >50% children
hild under
d 12 monthsth
• y school age
By g ((5-6yo),
y ), about 1 in 8
children screened will have OME

Casselbrant ML and Mandel EM. “Epidemiology” In: Rosenfeld RM, Bluestone CD, eds. Evidence‐Based Otitis Media, 2nd. Ed. Hamilton, Canada: BC Decker Inc; 2003: 147‐162.

• ~75% resolve within 3 months
• 30-40% of children have repeated
episodes
• 5-10% last more than 1 year

CPG: Otitis Media with Effusion
• Purpose
p
Identify quality improvement opportunities in
managing OME and to create explicit and
actionable recommendations to implement
these opportunities in clinical practice

CPG: Otitis Media with Effusion
• Specific goals
1. Improve diagnostic accuracy
2. Identifyy children who are most susceptible
p to
developmental sequelae from OME
3. Educate clinicians and p patients regarding
g g
the favorable history of most OME and the
lack of clinical benefits for medical therapy

Diagnosis
g
– Clinicians should
document presence of
middle ear effusion
with pneumatic
otoscopy when
di
diagnosing
i OME iin a
child (Strong
Recommendation))

Diagnosis
g
– Clinicians should
perform pneumatic
otoscopy
t t assess for
to f
OME in a child with
otalgia hearing loss
otalgia, loss,
or both (Strong
Recommendation))

Diagnosis
g
• Tympanometry
– Obtain in a child with
suspected OME for
whom
h di
diagnosisi iis
uncertain after pneumatic
otoscopy (Strong
Recommendation)

OME and Failed Newborn
Hearing Screen
• Clinicians should document counseling of
parents of infants with OME who fail a
newborn
b h
hearing
i screen regarding
di ththe
importance of follow-up to ensure that
hearing is normal when OME resolves

OME and Failed NBHS
• Important cause of transient hearing loss in
newborns
– Boudewyns et al, 2011 - Up to 55% of failed
screenings have OME
• 23% of these spontaneously resolve
• Hearing normalized after tympanostomy tube
placement in remainder of patients
– Boone et al, 2005 – up to 11% have remaining
SNHL after OME resolved
Boudewyns A et al. “Otitis media with effusion: an underestimated cause of hearing loss in infants.” Otol Neurotol. 2011; 32: 799‐804.
Boone RT et al. “Failed newborn hearing screens as presentation for otitis media with effusion in the newborn popuilation.” Int J Pedaitr Otorhinolaryngol. 2005; 69: 393‐7.
Identifying
y g At-Risk Children

Identifying
y g At-Risk Children
• Clinicians should
determine if a child
with OME is at
increased risk for
speech, language, or
learning problems

Evaluating
g At-Risk Children
• Clinicians should evaluate at-risk children
for OME at the time of diagnosis of an at-
risk condition and at 12 and 18 months of
age (if diagnosed in infancy)
• Consider referral to otolaryngologist when

OME diagnosed in these populations
Screening
g Healthy
y Children
• Clinicians should not routinely screen for
OME in children who are not at risk and do
not have symptoms suggestive of OME
– Hearing difficulties
– Balance problems
– Poor school performance
– Behavioral problems
– Ear discomfort

Patient Education
• Educate families of children with OME
regarding natural history, need for follow-
up and possible sequelae
up,

Patient Education
• Verbal and written
education

Watchful Waiting
g
• Manage child with OME who is
NOT att risk
i k with
ith watchful
t hf l waiting
iti
for 3 months from the date of
onset (if known) or date of
diagnosis (Strong
Recommendation))

Watchful Waiting
g
• Goal: Avoid unnecessary referral
and surgery
• 75-90% of effusions after AOM
resolved at 3 months
• >50% newly diagnosed OME
resolved at 3 months
• Little potential harm in
observation in child who is not at
risk

Hearing
g Testing
g
• Clinicians should obtain
age appropriate
age-appropriate
hearing test if OME
persists for 3 months or
if OME is present in an
at-risk child
– Significant hearing loss
present in at least 50%
of kids with chronic OME

Speech
p and Language
g g
• Clinicians should counsel families of
children with bilateral OME and
documented hearing loss about potential
impact on speech and language
development

Speech
p and Language
g g

Speech
p and Language
g g
• Keys:
– Preschool kids: ask if there are concerns about child’s
child s
communication development
– Ask basic questions about speech and language skills and
compare
p to typical
yp age-appropriate
g pp p development
p ((www.asha.org)
g)
– Use parent questionnaire or more formal screening test to
assess development
– If p
provider and/or p
parent not completely
p y satisfied with speech
p
and language development in child with OME, refer to
Otolaryngology
• SLP referral may be appropriate if hearing confirmed normal first

Management
g Options
p
1. Nothing
g ((observation))
2. Medical management
3 Surgical
3. S i l managementt

Surveillance of COME
• Evaluate child with COME at 3- to 6-month
intervals until effusion is no longer present,
significant hearing loss is identified
identified, or
structural abnormalities of the TM or
middle ear are suspected

• Risk factors with reduced likelihood of
spontaneous resolution
– Onset of OME in summer or fall season
– Hearing loss >30dB in better hearing ear
– History
Hi t off prior
i ttympanostomy
t tubes
t b
– Not having a prior adenoidectomy

• Management
considerations
– Autoinflation of eustachian
tube
• Low cost, low adverse events
• Inconvenient,
I i t compliance
li
– Optimize listening OtoVent® http://www.gluear.co.uk/
environment

• Optimize
p listening
g environment

Medical Management
g
• 3 Strong Recommendations Against:
1 Steroids – no significant benefit with either systemic
1.
or topical nasal steroids
2. Antibiotics
• Small benefit in resolution of effusion ONLY, not hearing
levels or need for future surgery
• Offset by
y adverse events and bacterial resistance
3. Antihistamines/decongestants – no benefit, more
adverse events
• Includes montelukast

Surgery
g y
• Two Recommendations:
• Child <4 years old • Child 4 years or older

– Tympanostomy tubes – Tympanostomy tubes
– Adenoidectomy not – Adenoidectomy
recommended unless – Both
distinct indication
(nasal obstruction,
chronic adenoiditis)

Surgery
g y
• Tympanostomy tubes
– OME >3 months AND
documented hearing difficulties
(Recommendation)
– OME >3 months AND symptoms
likely attributable to OME
(Option)
– RAOM with ith effusion
ff i att titime off
assessment (Recommendation)
– OME in at-risk children (Option)

Rosenfeld R et al. “Clinical Practice Guideline: tympanostomy tubes in children.” Otolaryngol Head Neck Surg. 2013; 149(1): S1‐S35.

Surgery
g y
• Adenoidectomy
– No longer recommended for
second tympanostomy tubes in
children <4
– Children >4
• Fewer days with OME over next
12 months
• Lower failure rates
• Lower rate of future surgery

Surgery
g y
• Shared
Decision
Making
Model

Outcome Assessment
• When managing
g g child with OME,
document resolution of OME, improved
hearing and/or improved QOL
hearing,
– OM-6 – valid and disease-specific survey
completed at baseline and again at least 1
month later

Summary
y
• OME is a very common diagnosis that is often asymptomatic but can
negatively impact hearing and speech and language development
• Observation of OME is appropriate in non-at-risk children
• At-risk children with OME should be considered for referral to
Otolaryngology
• Obtain hearing testing in children with OME if symptoms of hearing difficulty
or if effusion persists for 3 months
• No evidence of benefit for steroids, antibiotics, antihistamines, or
g
decongestants
• If surgery is needed, tympanostomy tubes are recommended for children
under 4 years old
• If surgery is needed in child 4 years or older, tympanostomy tubes alone,
adenoidectomy alone
alone, or both may be considered

Contact Information
Mi h l E
Michael E. M
McCormick,
C i k MD
(414) 266-6479
chw.org/ent
Physician Referral and Consultation: (800) 266-0366

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Tonsillectomy

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• Discuss patient assessment for tonsillectomy

• Summarize tonsillectomy outcomes

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Habitual snoring is common during childhood and affects approximately 10% of

Obesity confers 4-fold

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• Adherence: Cohort of 16,310 pts at 19 hospitals by 61 surgeons. The

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Assessing the child with recurrent throat infection who does

Counseling caregivers about tonsillectomy as a means to

Counseling caregivers that sleep-disordered breathing may

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Tonsil size is relative to oropharynx

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No apnea Adenotonsillar hypertrophy

No apnea Circumferential collapse

Copyright © 2015 American Medical

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• Cold knife (currette)

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• Study Design and Setting A multicenter, prospective observational outcomes study.

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• Tonsillectomy guidelines provide direction.

• Recurrence of sleep apnea/failed treatment

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Physician Consultation and Referral: (800) 266-0366

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I have no relevant financial

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