Kiran Nandalike

Upper airway structure and body fat composition in obese children with obstructive sleep apnea syndrome.

RATIONALE Mechanisms leading to obstructive sleep apnea syndrome (OSAS) in obese children are not well understood. OBJECTIVES The aim of the study was to determine anatomical risk factors associated with OSAS in obese children as compared with obese control subjects without OSAS. METHODS Magnetic resonance imaging was used to determine the size of upper airway structure, and body fat composition. Paired analysis was used to compare between groups. Mixed effects regression models and conditional multiple logistic regression models were used to determine whether body mass index (BMI) Z-score was an effect modifier of each anatomic characteristic as it relates to OSAS. MEASUREMENTS AND MAIN RESULTS We studied 22 obese subjects with OSAS (12.5 ± 2.8 yr; BMI Z-score, 2.4 ± 0.4) and 22 obese control subjects (12.3 ± 2.9 yr; BMI Z-score, 2.3 ± 0.3). As compared with control subjects, subjects with OSAS had a smaller oropharynx (P < 0.05) and larger adenoid (P < 0.01), tonsils (P < 0.05), and retropharyngeal nodes (P < 0.05). The size of lymphoid tissues correlated with severity of OSAS whereas BMI Z-score did not have a modifier effect on these tissues. Subjects with OSAS demonstrated increased size of parapharyngeal fat pads (P < 0.05) and abdominal visceral fat (P < 0.05). The size of these tissues did not correlate with severity of OSAS and BMI Z-score did not have a modifier effect on these tissues. CONCLUSIONS Upper airway lymphoid hypertrophy is significant in obese children with OSAS. The lack of correlation of lymphoid tissue size with obesity suggests that this hypertrophy is caused by other mechanisms. Although the parapharyngeal fat pads and abdominal visceral fat are larger in obese children with OSAS we could not find a direct association with severity of OSAS or with obesity.

Severe Asthma With Fungal Sensitization in a Child: Response to Itraconazole Therapy

People with severe asthma with fungal sensitization may represent an underdiagnosed subset of patients with refractory disease. It is important to know that such patients may benefit from adjunct treatment with antifungal agents. We describe here the case of a child with refractory asthma, persistent airway obstruction, a serum immunoglobulin E level of >20000 IU/mL, and severe eosinophilic airway infiltration. Although he did not meet diagnostic criteria for allergic bronchopulmonary aspergillosis, he demonstrated evidence of sensitization to several fungi and responded dramatically to the addition of itraconazole therapy. We also discuss emerging hypotheses regarding fungal-induced asthma.

Adenotonsillectomy in Obese Children with Obstructive Sleep Apnea Syndrome: Magnetic Resonance Imaging Findings and Considerations

OBJECTIVE The reasons why adenotonsillectomy (AT) is less effective treating obese children with obstructive sleep apnea syndrome (OSAS) are not understood. Thus, the aim of the study was to evaluate how anatomical factors contributing to airway obstruction are affected by AT in these children. METHODS Twenty-seven obese children with OSAS (age 13.0 ± 2.3 y, body mass index Z-score 2.5 ± 0.3) underwent polysomnography and magnetic resonance imaging of the head during wakefulness before and after AT. Volumetric analysis of the upper airway and surrounding tissues was performed using commercial software (AMIRA®). RESULTS Patients were followed for 6.1 ± 3.6 mo after AT. AT improved mean obstructive apnea-hypopnea index (AHI) from 23.7 ± 21.4 to 5.6 ± 8.7 (P < 0.001). Resolution of OSAS was noted in 44% (12 of 27), but only in 22% (4 of 18) of those with severe OSAS (AHI > 10). AT increased the volume of the nasopharynx and oropharynx (2.9 ± 1.3 versus 4.4 ± 0.9 cm(3), P < 0.001, and 3.2 ± 1.2 versus 4.3 ± 2.0 cm(3), P < 0.01, respectively), reduced tonsils (11.3 ± 4.3 versus 1.3 ± 1.4 cm(3), P < 0.001), but had no effect on the adenoid, lingual tonsil, or retropharyngeal nodes. A small significant increase in the volume of the soft palate and tongue was also noted (7.3 ± 2.5 versus 8.0 ± 1.9 cm(3), P = 0.02, and 88.2 ± 18.3 versus 89.3 ± 24.4 cm(3), P = 0.005, respectively). CONCLUSIONS This is the first report to quantify volumetric changes in the upper airway in obese children with OSAS after adenotonsillectomy showing significant residual adenoid tissue and an increase in the volume of the tongue and soft palate. These findings could explain the low success rate of AT reported in obese children with OSAS and are important considerations for clinicians treating these children.

Sleep and cardiometabolic function in obese adolescent girls with polycystic ovary syndrome.

OBJECTIVE To compare the polysomnography findings and cardiometabolic function among adolescent girls with polycystic ovary syndrome (PCOS) and matched female and male controls. METHOD Retrospective chart review of electronic medical records of 28 girls with PCOS (age: 16.8±1.9 years, body mass index (BMI) Z-score 2.4±0.4), 28 control females (age: 17.1±1.8, BMI Z-score 2.4±0.3) and 28 control males (age: 16.6±1.6, BMI Z-score 2.5±0.5) in a tertiary care centre. RESULTS The prevalence of obstructive sleep apnoea (OSA) was higher in girls with PCOS compared to control females (16/28 (57%) vs. 4/28(14.3%), p<0.01); however, it was comparable to that of the control males (16/28(57%) vs. 21/28(75%), p=0.4). Girls with PCOS had a significantly higher prevalence of insulin resistance compared to control females and control males (20/28 (71.4%) vs. 9/22 (41.0%) (p=0.04) vs. 8/23 (34.8%) (p=0.01). Among girls with PCOS, those with OSA had significantly higher proportions of metabolic syndrome (MetS) (9/16 (56.3%) vs. 1/12 (8.3%) p=0.03), higher insulin resistance (14/16 (87.5%) vs. 6/12 (50%), p=0.04), elevated daytime systolic blood pressure (128.4±12.8 vs. 115.6±11.4, p<0.01), lower high-density lipoprotein (HDL) (38.6±8.7 vs. 49±10.9, p=0.01) and elevated triglycerides (TG) (149.7±87.7 vs. 93.3±25.8, p=0.03) compared to those without OSA. CONCLUSIONS We report a higher prevalence of OSA and metabolic dysfunction in a selected group of obese girls with PCOS referred with sleep-related complaints compared to BMI-matched control girls without PCOS. We also report higher prevalence of cardiometabolic dysfunction in girls with PCOS and OSA compared to girls with PCOS without OSA.

Screening for Sleep-Disordered Breathing and Excessive Daytime Sleepiness in Adolescent Girls with Polycystic Ovarian Syndrome

OBJECTIVE To determine the prevalence and clinical and metabolic correlates of sleep-disordered breathing (SDB) and excessive daytime sleepiness (EDS) in adolescent girls with polycystic ovarian syndrome (PCOS). STUDY DESIGN Standardized questionnaires were administered to participants with PCOS and age-, sex-, ethnicity-, and body mass index (BMI) z score-matched controls. Medical records were reviewed for anthropometric and metabolic data. RESULTS We studied 103 participants with PCOS (16.9 ± 1.5 years) and 90 controls (16.8 ± 1.7 years). Compared with controls, girls with PCOS had a higher prevalence of SDB (45.6% vs 27.8%; P = .01) and EDS (54.4% vs 35.6%; P < .01). Within PCOS, those with SDB had higher BMI z score (2.1 ± 0.5 vs 1.7 ± 0.6; P < .01), higher homeostatic model assessment index (5.1 ± 2.3 vs 4.1 ± 3.5; P < .01), and higher prevalence of the metabolic syndrome (MetS) (42.6% vs 16.1%; P = .003) compared with those without SDB. Similarly, participants with PCOS and EDS had a higher BMI z score (2.0 ± 0.6 vs 1.7 ± 0.6; P = .03), higher homeostatic model assessment index (5.1 ± 2.9 vs 3.8 ± 3.1; P = .01), and higher rate of MetS (39.3% vs. 14.9%; P < .01) compared with those without EDS. MetS was independently associated with SDB (OR, 3.2; 95% CI, 1.0-10.1) and EDS (OR, 4.5; 95% CI, 1.2-16). CONCLUSIONS SDB and EDS are highly prevalent in adolescent girls with PCOS compared with matched controls. The MetS is independently associated with SDB and EDS in this group.

CHIT1 Mutations: Genetic Risk Factor for Severe Asthma With Fungal Sensitization?

Fungi can exacerbate symptoms in patients with asthma. To our knowledge, genetic risk factors for fungal-associated asthma have not been described. We present here the cases of 6 children who carried the diagnosis of severe asthma with fungal sensitization, 3 of whom were treated with and responded clinically to itraconazole therapy. All 6 patients were heterozygous for a 24-base pair duplication in the CHIT1 gene, which has been associated with decreased levels of circulating chitotriosidase and susceptibility to fungal infection.

Deep cervical lymph node hypertrophy: A new paradigm in the understanding of pediatric obstructive sleep apnea

To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy.

Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea

IMPORTANCE Limited information exists regarding clinical outcomes of children undergoing extracapsular tonsillectomy and adenoidectomy (ETA) or intracapsular tonsillectomy and adenoidectomy (ITA) for treatment of obstructive sleep apnea syndrome (OSAS). OBJECTIVES To quantify polysomnography (PSG) and clinical outcomes of ETA and ITA in children with OSAS and to assess the contribution of comorbid conditions of asthma and obesity. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using medical records at a tertiary pediatrics inner-city hospital. Medical records from 89 children who underwent ETA or ITA between October 1, 2008, and December 31, 2013, were analyzed. The dates of our analysis were January 6, 2014, to April 11, 2014. Inclusion criteria required no evidence of craniofacial or neurological disorders, confirmation of OSAS by PSG within the 2 years before surgery, and a second PSG within the 2 years after surgery. INTERVENTIONS Each child underwent ETA or ITA after being evaluated by a pediatric otolaryngologist and obtaining written parental informed consent. MAIN OUTCOMES AND MEASURES Main primary outcomes were derived from PSG. Secondary outcomes included treatment failure, defined as residual OSAS with an obstructive apnea-hypopnea index of at least 5 events per hour. Comparisons were made between and within groups. Logistic regression was used to identify factors associated with treatment failure. RESULTS Fifty-two children underwent ETA, and 37 children underwent ITA. Children in the ETA group were older (7.5 vs 5.2 years, P = .001) and more obese (60% [31 of 52] vs 30% [11 of 37], P = .004). However, both groups had similar severity of OSAS, with median preoperative obstructive apnea-hypopnea indexes of 17.0 in the ETA group and 24.1 in the ITA group (P = .21), and similar prevalences of asthma (38% [20 of 52] vs 38% [14 of 37]). After surgery, significant improvement was noted on PSG in both groups, with no differences in any clinical outcomes. There was no association between procedure type, age, or body mass index z score and treatment failure. However, in a subset of patients with asthma and obesity, ITA was associated with residual OSAS (odds ratio, 16.5; 95% CI, 1.1-250.2; P = .04). CONCLUSIONS AND RELEVANCE Both ETA and ITA are effective modalities to treat OSAS, with comparable surgical outcomes on short-term follow-up. However, when comorbid diagnoses of both asthma and obesity exist, OSAS is likely to be refractory to treatment with ITA compared with ETA.

Anterior nasal resistance in obese children with obstructive sleep apnea syndrome

To evaluate nasal resistance in obese children with and without obstructive sleep apnea syndrome (OSAS), study the correlation between nasal resistance and severity of OSAS using the apnea‐hypopnea index (AHI), and examine the association of gender and body mass index (BMI) with this measurement.

Obstructive sleep apnea due to extrathoracic tracheomalacia.

We report obstructive sleep apnea in a 3-year-old boy with tracheomalacia secondary to tracheotomy that resolved after placement of a metallic stent in the region of tracheomalacia. The tracheal location of obstruction during sleep in this case contrasts with the usual location in the pharynx or, less often, the larynx. This case also demonstrates the utility of polysomnography in managing decannulation of tracheostomies.