For children with cognitive impairments who develop obesity and sleep apnea, the treatment options are not good. Adenotonsillectomy sometimes improves symptoms, but if it does not, then home continuous positive airway pressure (CPAP) is the only option. However, CPAP requires the patient’s understanding and cooperation. If the patient does not have the cognitive capacity to understand the need for CPAP, difficult ethical questions arise. We present a case in which decisions had to be made for such a patient, with commentary by 2 experts in pediatric pulmonary medicine. Dennis Rosen is an Instructor in Medicine at the Harvard Medical School and Associate Medial Director of the Sleep Laboratory at Children's Hospital Boston. Ben Wilfond is a pediatric pulmonologist and Director of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital.
J.R., a 17-year-old girl with profound cognitive impairment secondary to hypoxic encephalopathy in infancy, was referred to the...
Comments
Tongue Base Surgery for Obstructive Sleep Apnea
I want to commend the authors on an excellent paper presenting a very complicated situation, namely the treatment of obstructive sleep apnea in a patient with profound cognitive impairment.
In the scenario presented, this patient has previously undergone an adenotonsillectomy for the treatment of obstructive sleep apnea. After a short period of improvement following the surgery, her symptoms resurged, with an apnea - hypopnea index (AHI) of 26 and lowest oxygen saturation of 63%. The article focuses on treatment recommendations in a child whose behavioral issues make utilizing continuous positive airway pressure (CPAP) quite difficult.
I believe a key omission in the treatment options presented is that of tongue base surgery. In the pediatric population, adenotonsillectomy is an excellent first line surgery for obstructive sleep apnea / sleep disordered breathing. However, when such an intervention fails, as it did in this case presentation, further surgical options are available.
Studies have shown that in the pediatric population with obstructive sleep apnea, the addition of tongue base surgery can result in an improvement in OSA.1,2 Surgical procedures consisting of tongue base suspension, lingual tonsil reduction, and radiofrequency ablation of the tongue base have been shown to improve the AHI in this patient population, when adenotonsillectomy alone has not resulted in improvement. Furthermore, such procedures can be performed without significant patient morbidity.
Patient selection is paramount to determine which patients will respond best to tongue base surgery and in office laryngoscopy and even drug induced sleep endoscopy can be performed to assess for retrolingual obstruction.3
Such surgical options fall short of the definitive cure promised by a tracheostomy, however for families with children non compliant with CPAP for behavioral reasons, the addition of tongue base surgical procedures provides another level of promise in treating those individuals not responsive to adenotonsillectomy.
References
1. Hartzell LD, Guillory RM, Munson PD, et al. Tongue base suspension in children with cerebral palsy and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2013 Apr;77(4):534-537.
2. Wootten CT, Shott SR. Evolving therapies to treat retroglossal and base of tongue obstruction in pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2010 Oct;136(10):983-987.
3. Fishman G, Zemel M, Derowe A, et al. Fiber optic sleep endoscopy in children with persistent obstructive sleep apnea: Inter-observer correlation and comparison with awake endoscopy. Int J Pediatr Otorhinolaryngol. 2013 Feb 21.
Conflict of Interest:
None declared