Stacey Quo

Critical role of myofascial reeducation in pediatric sleep-disordered breathing

BACKGROUND Limited studies suggest that pubertal development may lead to a recurrence of sleep-disordered breathing (SDB) despite previous curative surgery. Our study evaluates the impact of myofunctional reeducation in children with SDB referred for adenotonsillectomy, orthodontia, and myofunctional treatment in three different geographic areas. METHODS A retrospective investigation of children with polysomnographic analysis following adenotonsillectomy were referred for orthodontic treatment and were considered for myofunctional therapy. Clinical information was obtained during pediatric and orthodontic follow-up. Polysomnography (PSG) at the time of diagnosis, following adenotonsillectomy, and at long-term follow-up, were compared. The PSG obtained at long-term follow-up was scored by a single-blinded investigator. RESULTS Complete charts providing the necessary medical information for long-term follow-up were limited. A subgroup of 24 subjects (14 boys) with normal PSG following adenotonsillectomy and orthodontia were referred for myofunctional therapy, with only 11 subjects receiving treatment. Follow-up evaluation was performed between the 22nd and 50th month after termination of myofunctional reeducation or orthodontic treatment if reeducation was not received. Thirteen out of 24 subjects who did not receive myofunctional reeducation developed recurrence of symptoms with a mean apnea-hypopnea index (AHI)=5.3±1.5 and mean minimum oxygen saturation=91±1.8%. All 11 subjects who completed myofunctional reeducation for 24 months revealed healthy results. CONCLUSION Despite experimental and orthodontic data supporting the connection between orofacial muscle activity and oropharyngeal development as well as the demonstration of abnormal muscle contraction of upper airway muscles during sleep in patients with SDB, myofunctional therapy rarely is considered in the treatment of pediatric SDB. Absence of myofascial treatment is associated with a recurrence of SDB.

Teenage sleep-disordered breathing: Recurrence of syndrome

OBJECTIVES The study aims to better understand the reappearance of sleep apnoea in adolescents considered cured of obstructive sleep apnoea (OSA) following adenotonsillectomy and orthodontic treatment. STUDY DESIGN The study employs a retrospective analysis of 29 adolescents (nine girls and 20 boys) with OSA previously treated with adenotonsillectomy and orthodontia at a mean age of 7.5years. During follow-up at 11 and 14years of age, patients were clinically evaluated, filled the Pediatric Sleep Questionnaire (PSQ) and had systematic cephalometric X-rays performed by orthodontists. Polysomnographic (PSG) data were compared at the time of OSA diagnosis, following surgical and orthodontic treatment and during pubertal follow-up evaluation. RESULTS Following the diagnosis of OSA and treatment with adenotonsillectomy and rapid maxillary expansion (Apnea-Hypopnea Index (AHI) 0.4±0.4), children were re-evaluated at a mean age of 11years. During follow-up at 14years, all children had normal body mass indices (BMIs). Teenagers were subdivided into two groups based on complaints: Nine asymptomatic subjects (seven girls and two boys) and 20 subjects with decline in school performance, presence of fatigue, indicators of sleep-phase delays and, less frequently, specific symptoms of daytime sleepiness and snoring. Presence of mouth breathing, abnormal AHI and RDI and significant reduction of posterior airway space (PAS) was demonstrated during repeat polysomnography and cephalometry. Compared to cephalometry obtained at a mean of 11years of age, there was a significant reduction of PAS of 2.3±0.4mm at a mean age of 14years. CONCLUSION Previously suggested recurrence of OSA during teenage years has again been demonstrated in this small group of subjects. Prospective investigations are needed to establish frequency of risk, especially in non-orthodontically treated children.

Chapter 143 – Oropharyngeal Growth and Skeletal Malformations

• Sleep-disordered breathing (SDB) is marked by varying degrees of collapsibility of the pharyngeal airway. The hard tissue boundaries of the airway dictate the size and therefore the responsiveness of the muscles that form this part of the upper airway. Thus, the airway is shaped not only by the performance of the pharyngeal muscles to stimulation but also by the surrounding skeletal framework. • The upper and lower jaws are key components of the craniofacial skeleton and the determinants of the anterior wall of the upper airway. The morphology of the jaws can be negatively altered by dysfunction of the upper airway during growth and development. In turn, the altered morphology of the jaws can be positively influenced by orthodontic treatment. • The association between altered dentofacial morphology and SDB has been well documented in children, adults, and patients with craniofacial syndromes. Whether this disease of childhood has the same origins as adult obstructive sleep apnea but more subtle manifestations has not been determined. The length and volume of the airway increase until the age of 20 years, at which time there is a variable period of stability, followed by a slow decrease in airway size after the fifth decade of life. The possibility of addressing the early forms of this disease with the notions of intervention and prevention can change the landscape of care. • Correction of specific skeletal anatomic deficiencies can improve or eliminate SDB symptoms in both children and adults. It is possible that the clinician may adapt or modify the growth expression, although the extent of this impact is uncertain. These strategies seek to alter an abnormal facial growth pattern wherein SDB worsens over time. Future research should focus on determining in which individuals dentofacial morphology makes a significant contribution to the pathogenesis of SDB. This may bring clinicians one step closer to targeting specific treatments that more effectively treat the disorder. Chapter Highlights

It Is Just Attention-Deficit Hyperactivity Disorder…or Is It?

CASE Carly is a 5-year-old girl who presents for an interdisciplinary evaluation due to behaviors at school and home suggestive of attention-deficit hyperactivity disorder (ADHD). Parent report of preschool teacher concerns was consistent with ADHD. Psychological testing showed verbal, visual-spatial, and fluid reasoning IQ scores in the average range; processing speed and working memory were below average. Carlys behavior improved when her mother left the room, and she was attentive during testing with a psychologist. Tests of executive function (EF) skills showed mixed results. Working memory was in the borderline range, although scores for response inhibition and verbal fluency were average. Parent ratings of ADHD symptoms and EF difficulties were elevated.Carlys parents recently separated; she now lives with her mother and sees her father on weekends. Multiple caregivers with inconsistent approaches to discipline assist with child care while her mother works at night as a medical assistant. Family history is positive for ADHD and learning problems in her father. Medical history is unremarkable. Review of systems is significant for nightly mouth breathing and snoring, but no night waking, bruxism, or daytime sleepiness. She has enlarged tonsils and a high-arched palate on physical examination.At a follow-up visit, parent rating scales are consistent with ADHD-combined type; teacher rating scales support ADHD hyperactive-impulsive type. Snoring has persisted. A sleep study indicated obstructive sleep apnea. After adenotonsillectomy, Carly had significant improvement in ADHD symptoms. She developed recurrence of behavior problems 1 year after the surgery.