Modified Expansion Sphincter Pharyngoplasty for Treatment of Children with Obstructive Sleep Apnea

Research

Original Investigation Modified Expansion Sphincter Pharyngoplasty for Treatment of Children With Obstructive Sleep Apnea

Seckin O. Ulualp, MD

IMPORTANCE Lateral pharyngeal wall collapse has been implicated in the pathogenesis of obstructive sleep apnea (OSA). Modified expansion sphincter pharyngoplasty (ESP) is a simple procedure and can be considered in the surgical management of children with severe OSA.

OBJECTIVE To describe a modified ESP addressing lateral pharyngeal muscle wall collapse in the treatment of children with OSA.

DESIGN, SETTING, AND PARTICIPANTS Retrospective review of the medical records of children with OSA and lateral pharyngeal muscle wall collapse who underwent modified ESP and children who had tonsillectomy and adenoidectomy (TA) for OSA between 2008 and 2013 at a tertiary care children’s hospital.

INTERVENTIONS Modified ESP.

MAIN OUTCOMES AND MEASURES The primary outcome measure was the rate of cure, which was defined as an apnea-hypopnea index (AHI) lower than 1. Other outcomes were differences in preoperative and postoperative AHI, minimum saturation of peripheral oxygen, and percentage of total sleep study time with oxygen saturation less than 90%.

RESULTS Twenty-five children who had modified ESP and 25 AHI-matched children who had TA for severe OSA were identified. The postoperative AHI was lower than the preoperative AHI in both groups. Preoperative AHI was similar between modified ESP and TA groups. The Author Affiliations: Department of Otolaryngology–Head and Neck mean (SD) postoperative AHI of the modified ESP group (2.4 [3.9]) was lower than that of the Surgery, University of Texas TA group (6.2 [6.0]) (P < .001). Cure rates for the modified ESP group (AHI <1, 64%; AHI <2, Southwestern Medical Center, Dallas; 72%; and AHI <5, 80%) were greater than those for the TA group (AHI <1, 8%; AHI <2, 44%; Division of Pediatric Otolaryngology, and AHI <5, 60%). Children’s Medical Center, Dallas, Texas. Corresponding Author: Seckin O. CONCLUSIONS AND RELEVANCE Modified ESP provided objective clinical improvement of OSA Ulualp, MD, Department of in children with severe OSA and lateral pharyngeal wall collapse and might serve as an Otolaryngology–Head and Neck effective alternative to TA for treatment of OSA. Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX JAMA Otolaryngol Head Neck Surg. 2014;140(9):817-822. doi:10.1001/jamaoto.2014.1329 75390-9035 Published online July 31, 2014. ([email protected]) .

bstructive sleep apnea (OSA) occurs due to fixed and/or partial glossectomy, and genioglossus advancement have been dynamic upper airway obstruction caused by ana- used with varying results to cure OSA. Addition of new surgi- O tomical factors and abnormal upper airway motor cal techniques to the surgeon’s armamentarium potentially im- tone.1 Upper airway obstruction may be caused by collapse of proves the management of OSA in children. single or multiple structures such as the soft palate, uvula, pala- Lateral pharyngeal wall collapse has been documented in tine tonsils, lateral pharyngeal walls, base of the tongue, and adults and children with OSA.2,7,8 Lateral pharyngoplasty and epiglottis.2 Tonsillectomy and adenoidectomy (TA) is com- expansion sphincter pharyngoplasty (ESP) have been used to monly used as an initial procedure to treat OSA; however, TA address lateral pharyngeal wall collapse in adults with OSA.9-12 may not be curative in 21% to 75% of the children with OSA.3-6 The ESP procedure involves a combination of tonsillectomy, In children with Down syndrome or neurological impair- expansion pharyngoplasty, rotation of the palatopharyngeus ment, pillar closure, uvulopalatopharyngoplasty, lingual ton- muscle, a partial uvulectomy, and closure of the anterior and sillectomy, modified pharyngoplasty, lateral pharyngoplasty, posterior tonsillar pillars.10 Treatment with ESP prevents lat-

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eral pharyngeal collapse and reduces apnea episodes in adults cautery (Figure 1A).13 The anterior fascicules of the palatopha- with OSA.10-12 Outcomes of ESP have not been studied in chil- ryngeus muscle were transected horizontally at the junction dren with OSA. The aim of the present study is to describe a of upper third and mid-third portions using a protected needle- modified ESP technique and compare outcomes of modified tip bovie (Figure 1B). Superficial fibers of the upper third por- ESP to those of TA in children with OSA. tion of the palatopharyngeus muscle were isolated, and deep fibers left with the muscle’s posterior surface attached to the pharyngeal constrictor muscles. Methods A blunt palate tunneling extending superolaterally from the arching fibers of the palatoglossus muscle into soft palate This study was approved by the University of Texas South- was created using a curved hemostatic forceps (Figure 1C). The western Medical Center institutional human research review isolated portion of palatopharyngeus muscle was pulled su- board, and informed consent was waived. peroanterolaterally into the palate tunnel while the lateral pharyngeal wall tension was observed. Then the isolated portion Evaluation of Study Participants of palatopharyngeus muscle was attached to the arching muscle The medical records were retrospectively reviewed for pa- fibers of soft palate with a single mattress stitch using Vicryl tients who underwent modified ESP and control subjects who 4-0 suture (Ethicon Inc) and a round-bodied needle (Figure 1D). had TA from September 2008 to September 2013. All patients The same steps were repeated on the opposite side (Figure 1E). in both the ESP and TA groups were younger than 21 years and In the modified ESP technique, increased distance is cre- underwent both preoperative and postoperative polysomnog- ated between, and tension within, the lateral pharyngeal walls. raphy for OSA assessment. The TA group included children In the present study, the modifications to previously de- whose apnea-hypopnea index (AHI) was matched to the chil- scribed ESP techniques included (1) transection of the palato- dren in the ESP group so as obtain similar levels of OSA sever- pharyngeal muscle at the upper third portion instead of the in- ity in both groups. No patients were excluded for craniofacial ferior end10,11; (2) transection of the superficial fibers of the anomalies, developmental delay, psychiatric illness, immu- palatopharyngeal muscle instead of full-thickness transec- nodeficiency, possible neoplasia, possible posttransplant lym- tion of the palatopharyngeal muscle11,12; (3) blunt palate tun- phoproliferative disorder, or other chronic conditions. All neling without mucosal incision10; (4) preservation of the uvula participants were identified using an electronic medical rec- instead of partial uvulectomy10; (5) no apposition of the en- ord system documenting surgical procedures performed by the tire anterior and posterior pillars10; and (6) lack of palate inci- author. sion for second intermediate suturing of flap.11 All participants underwent all-night, attended polysom- A microdebrider was used to remove the adenoid, and suc- nography by computerized polygraph performed in the dedi- tion electrocautery was used for hemostatic control of the ad- cated pediatric sleep laboratory at a tertiary care children’s hos- enoid bed. The tonsillar fossae and adenoid bed were exam- pital; sleep measurements were based on the criteria of the ined after oropharyngeal and gastric suctioning and before 2007 American Academy of Sleep Medicine guidelines. Poly- reversal of anesthesia. somnograms were scored by pediatric sleep medicine special- Postoperatively, overnight monitoring consisted of con- ists, and the AHI was calculated as the sum of obstructive ap- tinuous measurement of pulse oximetry, blood pressure, and neas and hypopneas per hour. Central apnea, central hypopnea, pulse rate. Analgesia was achieved by alternating between ac- and mixed apnea were not included in the AHI. The severity etaminophen and ibuprofen. For the next 2 weeks, adequate of OSA was categorized according to AHI as mild (AHI, 1-5); oral fluid intake for proper hydration and a soft blended diet moderate (AHI, 5-10); or severe (AHI >10).6 In the modified ESP were recommended. Parents were instructed to return to the group, drug-induced sleep endoscopy (DISE) was performed hospital for evaluation if they saw any volume of oropharyn- during induction of anesthesia by using the previously de- geal bleeding or epistaxis during the postoperative period. scribed protocol.2 Data Collection and Statistical Analysis ESP Indications and Techniques Data pertaining to age, sex, medical history, surgical history, Indications for modified ESP included severe OSA and lateral comorbid conditions, body mass index (BMI), tonsil size,14 ad- pharyngeal wall collapse documented by DISE. At the time of enoid size,2 and findings of polysomnography were obtained surgery planning during the clinic visit, caregivers were of- from the charts. Centers for Disease Control and Prevention fered the option of modified ESP, in addition to TA, if the DISE growth standards were used to determine BMI percentiles. Chil- findings indicated lateral pharyngeal wall collapse. dren with a BMI greater than the 95th percentile were consid- The detailed description of modified ESP is as follows. Af- ered obese. The primary outcome measure of the study was ter the patient was placed in a supine position on the operat- the rate of cure, defined as an AHI lower than 1. Additionally, ing table; general anesthesia was induced, during which DISE the rates of cure were assessed for the following criteria used was performed. All patients received 1 intravenous dose of in previous studies: AHI lower than 2,5,15 AHI lower than 5,5,16,17 dexamethasone, 0.5 mg/kg. 50% reduction in AHI and AHI lower than 15,10 and 50% re- The patient was then placed in the Rose position. The pala- duction in AHI and AHI lower than 20.10 The secondary out- tine tonsils were exposed using a Crowe–Davis mouth retrac- come measures included percentage AHI reduction, improve- tor. A bilateral tonsillectomy was performed using bipolar ment in minimum saturation of peripheral oxygen level

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Figure 1. The Main Steps of the Modified Expansion Sphincter Pharyngoplasty (ESP)

A B C

D E

After completion of a tonsillectomy (A), a horizontal incision is made to divide muscle is attached to the arching fibers of the soft palate. Comparative views the anterior fascicules of the palatopharyngeus muscle (B), and the superficial before modified ESP (A) and after modified ESP (E) show the created tension in fibers of the palatopharyngeus muscle are isolated. C, A blunt palate tunneling lateral pharyngeal walls and the increased distance between the lateral extending superolaterally from the arching fibers of the palatoglossus muscle pharyngeal walls. into soft palate is created. D, Then the isolated portion of palatopharyngeus

(min SpO2), and reduction in percentage of total sleep time with and 18 patients (72%) were obese. Most children had grade III oxygen level less than 90%. hypertrophy of the adenoids and grade II and grade III hyper- Statistical comparisons between groups were performed trophy of the tonsils (Table 1). All patients had severe OSA be- using a 1-way analysis of variance or a Kruskal-Wallis 1-way fore the surgery. After the surgery, 16 patients had no OSA; 4 analysis of variance, and within-group analyses were per- had mild OSA; 3 had moderate OSA; and 2 had severe OSA. In formed by a paired t test or a Wilcoxon signed rank test, as ap- children with persistent OSA, DISE revealed base-of-the- propriate. The χ2 test was used to test the cure rate between tongue obstruction with lingual tonsil hypertrophy in 1 pa- treatment groups. Statistical significance was set at P < .05. Data tient (postoperative AHI, 13.6), complete concentric velum ob- are presented as mean (SD). struction in 1 (AHI, 12.7), partial concentric velum obstruction in 1 (AHI, 2.2), partial anterior-posterior velum obstruction in 2 (AHIs, 6.0 and 9.5), and no other sites in 4 (AHIs, 1.3, 1.6, 2.3, Results and 5.4). Postoperative reduction in AHI ranged from 66% to 100% (mean [SD] reduction, 95% [9.2%]). Postoperative AHI Twenty-five patients, aged 2 to 17 years (median age, 8 years), (median, 0.8; range, 0-13.6) was lower than preoperative AHI underwent modified ESP with no complications on the day of (median, 52.0; range, 20.0-154.2) (P < .001) (Table 2). Postop-

the surgery (Table 1). One patient had bleeding 3 days after the erative min SpO2 was greater than preoperative min SpO2 surgery. There was no dysphagia or voice change at the post- (P < .001) (Table 2). Postoperative percentage of total sleep time operative follow-up visit. Comorbid conditions included with oxygen level less than 90% was less than preoperative per- asthma in 6 patients, type 1 diabetes mellitus in 2, and aller- centage of total sleep time with oxygen level less than 90% gic rhinitis in 2. The BMI ranged from 13.3 to 48.7 (median, 32), (P < .001).

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Table 1. Patient Characteristics and Grades of Tonsils and Adenoids Table 2. Comparison of The 3 Major Study Parameters in the Modified in the Study Populationa ESP and TA Groupsa

Characteristic Modified ESP TA P Value Parameter Modified ESP TA P Value Age, mean (SD), y 9.0 (4.3) 5.0 (3.4) .002 AHI Sex Preoperative 60.5 (38.5) 59.8 (33.6) <.001 [20.0-154.2] [20.7-142] Male 14 (56) 15 (60) NR Postoperative 2.0 (3.9) 6.2 (6.0) <.001 Female 11 (44) 10 (40) [0-13.6] [0.9-20.2]

BMI, mean (SD) 29.0 (9.5) 23.0 (10.0) .02 Min SpO2 Obese 18 (72) 11 (44) <.001 Preoperative 79.8 (9.5) 74.6 (9.0) .003 Tonsil grade Postoperative 92.6 (4.2) 88.2 (5.3) .01

I01(4)%TST at SpO2 < 90% II 12 (48) 3 (12) Preoperative 9.9 (17.8) 13.8 (22.6) .10 <.05 III 12 (48) 14 (56) Postoperative 0.3 (0.9) 0.7 (2.1) .40 IV 1 (4) 7 (28) Abbreviations: AHI, apnea hypopnea index; ESP, expansion sphincter

Adenoid grade pharyngoplasty; min SpO2, minimum saturation of peripheral oxygen; I 4 (16) 3 (12) TA, tonsillectomy and adenoidectomy; %TST, percentage of total sleep time. a II 4 (16) 4 (16) Unless otherwise indicated, data are presented as mean (SD) [range] <.05 or mean (SD). III 13 (52) 10 (40) IV 4 (16) 8 (32)

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided Figure 2. Comparison of the Cure Rates of Modified Expansion by height in meters squared); ESP, expansion sphincter pharyngoplasty; NR, not Sphincter Pharyngoplasty (ESP) and Tonsillectomy and Adenoidectomy reported; TA, tonsillectomy and adenoidectomy. (TA) Groups a Unless otherwise specified, data are number (percentage) of participants. a 100 Modified ESP

Twenty-five patients, aged 2 to 16 years (median age, 5 TA a 80 years), had TA with no complications on the day of TA. There a

was no bleeding, dysphagia, or voice change at the follow-up a

visit. Comorbid conditions included asthma in 5 patients, sei- 60 zure disorder in 2, allergic rhinitis in 2, Down syndrome in 1, and sickle cell disease in 1. The BMI ranged from 14.4 to 54 (me-

dian BMI, 20.3). Eleven patients were obese. Most children in Cure Rate, % 40 TA group had grade III hypertrophy of the tonsils and grade II and grade III hypertrophy of the adenoids (Table 1). All 20 patients had severe OSA. Postoperatively, OSA was resolved in 2 patients, mild in 13, moderate in 2, and severe in 8. Post- 0 operative reduction in AHI ranged from 53.6% to 99.2% <1<2 <5 Reduced by Reduced by (mean [SD] reduction 87.4% [13.8%]). Postoperative AHI 50% and <15 50% and <20 (range, 0.9-20.2; median, .2) was lower than the preopera- AHI Criteria tive AHI (range, 20.7-142.0; median, 49.2) (P < .001). Postop- The cure rates, as defined by 4 of the 5 illustrated apnea-hypopnea index (AHI) erative min SpO2 was higher than preoperative min SpO2 criteria, were significantly greater in the modified ESP group than in the TA (P < .001) (Table 2). Postoperative percentage of the total group. The cure rates as defined by 50% reduction in AHI and AHI lower than sleep time with oxygen saturation less than 90% was less 20 were similar between the modified ESP and TA groups. a than preoperative total sleep time with oxygen saturation P < .05 for comparison. less than 90% (P < .001) (Table 2). As a group, patients who underwent modified ESP were older than TA patients (P = .002) (Table 1). The BMI in the modi- 96.9%) (P < .001). Preoperative and postoperative percent- fied ESP group was greater than that in the TA group (P =.02) ages of the total sleep time with oxygen saturation less than (Table 1). Grades of tonsil hypertrophy and adenoid hypertro- 90% were similar between modified ESP and TA groups phy in the modified ESP group were lower than those in TA (Table 2). group (P < .05). The preoperative AHI in the modified ESP group In the modified ESP group, cure rates (AHI <1, 64%; AHI was similar to that in the TA group (P = .90) (Table 2). The post- <2, 72%; and AHI <5, 80%) and 50% reduction in AHI and AHI operative AHI of the modified ESP group was lower than that lower than 15 (100%) were greater than those in the TA group of the TA group (P < .001). The postoperative reduction in AHI (AHI <1, 8%; AHI <2, 44%; and AHI <5, 60%, and 50% reduc- in the modified ESP group (median, 98.1%; 25th percentile- tion and AHI <15, 92%) (P < .05) (Figure 2). Cure rate for the cri- 75th percentile, 96.7%-99.7%) was more than that in the TA teria 50% reduction in AHI and AHI lower than 20 were simi- group (median, 93.1%; 25th percentile-75th percentile, 80.4%- lar between the modified ESP and TA groups.

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dren. Resolution of OSA was documented in 66% of children Discussion after TA in a meta-analysis.18 Persistent OSA after TA indi- cates additional obstruction at other sites of the upper air- Collapse of the lateral pharyngeal wall contributes to the patho- way. In these cases, DISE and cine magnetic resonance imaging genesis of OSA by increasing airway resistance and causing par- have been used to identify single and multiple sites of airway tial or complete obstruction of the airway.2,10 To date, no gold obstruction in children with OSA.2,19,20 DISE has revealed that standard surgical procedure has been identified to address lat- the oropharynx/lateral wall area is the most common site of eral pharyngeal wall collapse. Lateral pharyngoplasty and ESP obstruction in children with single-site airway obstruction.2 have been suggested as effective surgical procedures to treat The velum and oropharynx/lateral wall are the most com- lateral pharyngeal wall collapse in adults with OSA.9-12 In the mon sites of obstruction in OSA children with multiple-site air- present study, modified ESP was evaluated as an effective sur- way obstruction.2 gical treatment option for lateral pharyngeal wall collapse in In the present study, modified ESP was used to address lat- children with OSA. eral pharyngeal wall collapse in addition to obstruction caused Lateral pharyngoplasty consists of dissection of the supe- by palatine tonsils and adenoids in children with OSA. Lat- rior pharyngeal constrictor muscle in the tonsillar fossa, su- eral pharyngeal wall collapse was documented in all children turing the muscle flap to the palatoglossus muscle, and pala- who underwent modified ESP. DISE also revealed obstruc- topharyngeal Z-plasty to prevent retropalatal collapse.9 tions at other sites in 5 patients who had persistent OSA (AHI Complications of lateral pharyngoplasty include dysphagia, >1) after modified ESP. The presence of additional obstruc- oronasal reflux of liquids, and wound dehiscence. The ESP tion sites may be responsible for the residual OSA; however, procedure creates lateral wall tension and removes the bulk in 4 of the 9 children with persistent OSA, DISE did not reveal of lateral pharyngeal wall by isolating and rotating the pala- other obstruction sites. topharyngeus muscle superoanterolaterally. Partial or com- In the present study, the modified ESP patients were plete uvulectomy is also performed in ESP.10 Dysphagia or older and had greater BMI than the TA patients. Given that voice change has not been reported after ESP. Lateral pha- previous studies have reported obesity, older age, and ryngoplasty and ESP provide better improvement in AHI severe sleep apnea as risk factors for persistent OSA after than uvulopalatopharyngoplasty.9-11 Lateral pharyngoplasty TA, the modified ESP group was expected to have poorer and ESP have not been used to treat lateral pharyngeal wall outcomes than the TA group in the present study. However, collapse in children with OSA. In the present study, modi- the modified ESP group showed a higher cure rate, greater fied ESP was used as a conservative technique to address postoperative reduction in AHI, and lower postoperative lateral pharyngeal wall collapse in children with OSA. The AHI than the TA group. Similar to previous studies, cure modifications made to the ESP procedure addressed con- rates for modified ESP and TA varied depending on the AHI cerns over possible dysphagia and oronasal reflux of liquids criteria used. In previous studies, cure rates of TA ranged associated with lateral pharyngoplasty as well as concerns from 27% to 59% for AHI lower than 1,3,17,18 28% to 82% for over potential hypernasality and velopharyngeal dysfunc- AHI lower than 2,5,15 and 21% to 84% for AHI lower than tion due to excision of soft palate and uvula tissue per- 5.5,16,17 In the present study, cure rates after TA were lower formed as part of unmodified ESP. than in previous studies. Differences in AHI criteria to The modified ESP techniques were formulated based on define cure and patient characteristics such as BMI, age, those used in previously described ESP procedures.10-12 The obesity, and presence of comorbidities may account for the original ESP involves transecting the palatopharyngeus muscle interstudy differences in cure rates of TA. to decrease the bulk of the lateral pharyngeal wall while cre- The limitations of the present study include its retrospec- ating lateral pharyngeal wall tension and partial or complete tive nature, precluding comparison of modified ESP out- excision of the uvula.10 Transecting a long segment of the pala- comes with TA outcomes in age-matched, BMI-matched, tonsil- topharyngeus muscle to debulk the lateral pharyngeal wall po- and-adenoid-size matched children with lateral pharyngeal tentially impairs swallowing function in children because the wall collapse and varying severity of OSA. In the present study, palatopharyngeus muscle narrows the pharynx, lowers the soft differences in BMI, age, and size of tonsils and adenoids placed palate, narrows the velopharyngeal orifice, and elevates the the modified ESP group at a higher risk of residual OSA after larynx. Therefore, in the modified ESP procedure, a short seg- surgery compared with the TA group. Lateral pharyngeal wall ment of the palatopharyngeus muscle is transected, and no collapse was documented in the modified ESP group; how- uvulectomy is performed in an effort to reduce the risks of dys- ever, presence of lateral pharyngeal wall collapse could not be phagia and oronasal reflux. The modified ESP procedure pro- assessed in the TA group because DISE was not performed in vides lateral pharyngeal wall tension, expands the pharynx by children who underwent TA. Nonetheless, the modified ESP widening the interpalatopharyngeus muscle distance, and re- group had better cure rates and improvement in AHI the TA duces the bulk of the palatopharyngeus muscle. Complica- group. tions such as dysphagia, oronasal reflux, wound dehiscence, In the present study, the modified ESP group included and voice change did not occur in this group of children after children with OSA whose AHI was higher than 20. The modified ESP. outcomes of modified ESP in children with OSA and lateral Tonsillectomy and adenoidectomy is commonly used as pharyngeal collapse and AHI lower than 20 merit further the first-line surgical procedure for treatment of OSA in chil- investigation.

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vides objective clinical improvement as determined by reduc-

Conclusions tion in AHI, min SpO2, and percentage of total sleep time with oxygen saturation less than 90% in children with severe OSA Modified ESP is a simple procedure to address lateral pharyn- and lateral pharyngeal wall collapse. Modified ESP was more geal wall collapse in children with severe OSA and carries mini- effective than TA for achieving better cure rates and improve- mal risk of potential complications such as dysphagia, voice ment in the majority of children with severe OSA and lateral change, and velopharyngeal dysfunction. Modified ESP pro- pharyngeal wall collapse.

ARTICLE INFORMATION obstructive sleep apnea in children: a multicenter 14. Brodsky L, Moore L, Stanievich JF. A Submitted for Publication: October 28, 2013; final retrospective study. Am J Respir Crit Care Med. comparison of tonsillar size and oropharyngeal revision received, February 12, 2014; accepted, 2010;182(5):676-683. dimensions in children with obstructive March 9, 2014. 7. Remmers JE, deGroot WJ, Sauerland EK, Anch adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol. 1987;13(2):149-156. Published Online: July 31, 2014. AM. Pathogenesis of upper airway occlusion during doi:10.1001/jamaoto.2014.1329. sleep. J Appl Physiol Respir Environ Exerc Physiol. 15. Mitchell RB, Kelly J. Outcome of 1978;44(6):931-938. adenotonsillectomy for obstructive sleep apnea in Conflict of Interest Disclosures: None reported. 8. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, obese and normal-weight children. Otolaryngol Previous Presentation: This article was presented Pack AI. Dynamic upper airway imaging during Head Neck Surg. 2007;137(1):43-48. at the Triological Society Combined Sections awake respiration in normal subjects and patients 16. Friedman M, Samuelson CG, Hamilton C, et al. Meeting; January 10-12, 2014; Miami Beach, Florida. with sleep disordered breathing. Am Rev Respir Dis. Modified adenotonsillectomy to improve cure rates 1993;148(5):1385-1400. for pediatric obstructive sleep apnea: a randomized REFERENCES 9. Cahali MB. Lateral pharyngoplasty: a new controlled trial. Otolaryngol Head Neck Surg.2012; 1. Ulualp SO. Snoring and obstructive sleep apnea. treatment for obstructive sleep apnea hypopnea 147(1):132-138. Med Clin North Am. 2010;94(5):1047-1055. syndrome. Laryngoscope. 2003;113:1961-1968. 17. Nath A, Emani J, Suskind DL, Baroody FM. 2. Ulualp SO, Szmuk P. Drug-induced sleep 10. Pang KP, Woodson BT. Expansion sphincter Predictors of persistent sleep apnea after surgery in endoscopy for upper airway evaluation in children pharyngoplasty: a new technique for the treatment children younger than 3 years. JAMA Otolaryngol with obstructive sleep apnea. Laryngoscope.2013; of obstructive sleep apnea. Otolaryngol Head Neck Head Neck Surg. 2013;139(10):1002-1008. 123(1):292-297. Surg. 2007;137(1):110-114. 18. Friedman M, Wilson M, Lin HC, Chang HW. 3. Tauman R, Gulliver TE, Krishna J, et al. 11. Sorrenti G, Piccin O. Functional expansion Updated systematic review of tonsillectomy and Persistence of obstructive sleep apnea syndrome in pharyngoplasty in the treatment of obstructive adenoidectomy for treatment of pediatric children after adenotonsillectomy. J Pediatr. 2006; sleep apnea. Laryngoscope. 2013;123(11):2905-2908. obstructive sleep apnea/hypopnea syndrome. 149(6):803-808. Otolaryngol Head Neck Surg. 2009;140(6):800-808. 12. Vicini C, Montevecchi F, Pang K, et al. Combined 4. O’Brien LM, Sitha S, Baur LA, Waters KA. Obesity transoral robotic tongue base surgery and palate 19. Shott SR, Donnelly LF. Cine magnetic resonance increases the risk for persisting obstructive sleep surgery in obstructive sleep apnea-hypopnea imaging: evaluation of persistent airway apnea after treatment in children. Int J Pediatr syndrome: expansion sphincter pharyngoplasty obstruction after tonsil and adenoidectomy in Otorhinolaryngol. 2006;70(9):1555-1560. versus uvulopalatopharyngoplasty. Head Neck. children with Down syndrome. Laryngoscope. 5. Mitchell RB. Adenotonsillectomy for obstructive 2014;36(1):77-83. 2004;114(10):1724-1729. sleep apnea in children: outcome evaluated by pre- 13. Ulualp SO. Rate of post-tonsillectomy 20. Truong MT, Woo VG, Koltai PJ. Sleep and postoperative polysomnography. Laryngoscope. hemorrhage after elective bipolar endoscopy as a diagnostic tool in pediatric 2007;117(10):1844-1854. microcauterization of nonbleeding vessels. Eur Arch obstructive sleep apnea. Int J Pediatr 6. Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Otorhinolaryngol. 2012;269(4):1269-1275. Otorhinolaryngol. 2012;76(5):722-727. et al. Adenotonsillectomy outcomes in treatment of

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