Airway Development and Prevention of Obstructive Sleep Apnea in Children

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A Case Report, part 1

by Juan-Carlos Quintero, DMD, MS
Obstructive sleep apnea (OSA) is a debilitating disease resulting in greater loss of life expectancy (LLE) and diminished quality of life (QOL) affecting anywhere from 3% to 7% of the US population. 1The prevalence of OSA is higher in some subpopulations such as obese adults. 2Comorbidities include cardiovascular disease, renal disease, diabetes, depression, and motor vehicle accidents, among others.
1The number of patients being diagnosed with OSA is increasing at an alarming rate of 15% per year. The estimated annual costs of obstructive sleep apnea and its related comorbidities is to be between $65 billion and $165 billion a year, according to a 2010 report published by the Harvard Medical School. Treatment modalities include weight loss, positional therapy, nasal decongestion, oral appliances, CPAP, soft tissue surgery – uvulopalatopharyngoplasty (UPPP), orthognathic surgery in the form of maxillo-mandibular advancement (MMA) or mandibular advancement (MA), and tracheotomy. But perhaps the most effective and least invasive modality is prevention in children through airway development. 7, 8, 9,1 0, 11, 12, 13 Part 1 of this article will explore the rationale and potential of preventing OSA in children at risk for OSA through proven methods of airway development and evolving diagnostic aids.
Breathing is a function of craniofacial anatomy and the resultant airflow resistance caused by the collapse of the structures surrounding the upper airway (Figure 1), such as the tongue. The larger the size of the pharyngeal airway, or more specifically, the larger the minimum cross sectional area (MCA) of the airway, the less collapse or obstruction that occurs during sleep when voluntary muscles such as the tongue become flaccid. Recent studies have correlated dentofacial morphology with airway volume, and reduced airway dimensions have logically been correlated with risk factors for OSA. 4, 5, 6 Furthermore, recent advances in imaging technology have made ultra-low-dose cone beam computed tomography (CBCT) such as the i-CAT FLX from Imaging Sciences International (Hatfield, Pa.) and everyday imaging of the airways possible with dose exposure less than a panorex and as low as 8 µSv 14, 15 (Figures 2 and 3). The applications and implications of this technology in the screening and prevention of OSA in the pediatric population are enormous. It is now possible to screen children with small airways who either have OSA, are at risk for OSA, or are at risk for developing OSA later in life, and treat accordingly.

Discussion

Orthognathic surgery in the form of maxillomandibular advancement has been shown to be the definitive treatment for patients suffering from obstructive sleep apnea. Several studies have demonstrated a 100% success rate of OSA treatment through MMA, when compared to CPAP or oral appliances, using AHI scores through polysomnograms as the measuring tool. 16, 17, 18This is because Grauer, et al., and others have reported that pharyngeal airspace dimensions are a function of jaw position. 4,5,6It would seem only reasonable to equally expect enlargement of the pharyngeal airspace in children concurrent with the forward growth of the craniofacial complex. Just as the airway is enlarged in non-growing patients when the face is surgically positioned forward through MMA, so can the airway be enlarged through proper inter-professional collaboration when facial-growth-friendly orthodontics are applied in children.
Part 2 of Dr. Quintero’s article will illustrate treatment of a case of a young patient with a narrow pharyngeal airway. Follow Dr. Quintero’s blog on airway development onwww.airwaydevelopment.com


References

  1. Chiong,T.L.(2009). Sleepmedicineessentials.Hoboken,N.J.:Wiley-Blackwell.
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  3. ThePriceofFatigue. SleepMedicine. HarvardMedicalSchool. The Harvard Medical Division of Sleep Medicine. December2010.
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  9. Villa MP, Rizzoli A, Miano S, Malagola C. May 2011; Epub 2001 March 25. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome:36 months of follow-up. SleepBreath.15(2):179-84.
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  13. Miano S, Rizzoli A, Evangelisti M, Bruni O, Ferri R, Pagani J, Villa MP. April 2009; Epub 2008 August 26. NREM sleep in stability changes following rapid maxillary expansion in children with obstructive apnea sleep syndrome. Sleep Med. 10(4):471-8
  14. John B. Ludlow and Cameron Walker Assessment of phantomdosimetry and image quality of i-CAT FLX cone-beam computed tomography Am J Orthod Dentofacial Orthop 2013;144:802-17
  15. Quintero, JC. New Study May Change the Face of Orthodonitcs. Orthodontic Practice US. January/February 2014 – Volume5, N01. Page41-43
  16. Prinsell JR. Maxillom and ibular advancement surgery in a site – specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest. 1999 Dec;116(6):1519-29.
  17. Riley RW,  Powell NBGuilleminault C, Stanford University Medical Center, CA. Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction. J OralMaxillofacSurg. 1993 Jul;51(7):742-7;discussion748-9.
  18. White PD, Wooten V, Lachner J, Guyette RF: Maxillom and ibular advancement surgery in 23 pts with OSA syndrome. JOralMaxillofacSurg 47:1256,1989

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