Changes in sleep apnea after supraglottoplasty in infants with laryngomalacia

Presented at the 2010 AAO-HNSF Annual Academy Meeting Scientific Session in Boston, MA
https://doi.org/10.1016/j.ijporl.2011.06.021Get rights and content

Abstract

Objective

To determine the clinical and polysomnography outcomes in infants with laryngomalacia undergoing supraglottoplasty.

Methods

Infants (<1 year old) who underwent polysomnography pre- and post-supraglottoplasty at our tertiary referral center between 2003 and 2009 were reviewed retrospectively. Outcome measures included changes in stridor, sleep disordered breathing, swallowing, and polysomnography parameters before and after surgery. Pre- and postoperative distributions were compared using a Wilcoxon signed-rank test.

Results

20 children met inclusion criteria. Statistically significant improvements were found in pre- to postoperative median values for apnea-hypopnea index (AHI) (median change: −6.4 points, p = 0.02) and obstructive apnea index (median change: −2.9 points, p = 0.01) values. Obstructive AHI, O2 saturation nadir, and percentage of sleep spent with <90% O2 saturation improved, although not significantly. Postoperative AHI scores correlated with improvements in stridor in 80% of patients. Stratification showed similar improvements in AHI after supraglottoplasty regardless of reflux treatment, secondary airway lesions, age at supraglottoplasty, or time lag between supraglottoplasty and postoperative polysomnography. Secondary airway lesions are the only potential confounders shown to have significantly better improvements in O2 nadir. While the sleep study improved in patients with AHI >5, infants with AHI <5 had worse polysomnography parameter values postoperatively. Five patients had dysphagia that resolved within one month postoperatively; otherwise, supraglottoplasty resulted in no complications.

Conclusion

Supraglottoplasty may be an effective and safe option to improve moderate to severe obstructive sleep apnea in infants with laryngomalacia. In addition, polysomnography may be useful in infants with laryngomalacia to identify obstructive sleep apnea and/or to objectively measure outcomes after supraglottoplasty. This pilot study warrants a larger, prospective, and controlled study to validate these findings.

Introduction

Although often overlooked, the most common cause of laryngeal obstruction in infants, laryngomalacia (LM), has been shown to be a source of significant obstructive sleep apnea (OSA) [1], [2], [3]. While the true incidence of OSA in infants with LM is unknown, it has been reported in up to 100% of patients undergoing supraglottoplasty (SGP) for severe LM [1], [2]. Patients with less severe LM have also been shown to suffer from significant OSA and benefit from SGP [3]. Polysomnography (PSG) is considered to be the “gold standard” in diagnosing OSA and a useful objective outcome measure after SGP in these patients [1], [2], [3]. Definitive guidelines regarding the role of PSG in evaluating patients with LM, however, have not yet been established. Likewise, the use of SGP to treat OSA in the setting of LM is not well understood. In this study, we present our experience using pre and postoperative polysomnorgaphic parameters to evaluate the affect a SGP has on OSA in infants (<1 year old) with severe LM.

Section snippets

Methods

With institutional review board approval, a retrospective chart review of infants with LM treated at our institution between 2003 and 2009 was performed. Inclusion criteria included patients less than one year of age who underwent PSG pre- and post-SGP. Two subgroups were analyzed according to their surgical indication. The first group had “severe” LM and presented with failure to thrive or signs of severe respiratory distress, such as cyanotic spells, severe retractions, or prolonged apneas

Results

20 patients with a median follow up of 9.5 months (range of 1–24 months) were reviewed. See Table 1 for patient characteristics and Table 2 for pre- and postoperative PSG findings. Subjects ranged in age at the time of surgery from 2 weeks to 10 months with a median age of 3.9 months. Stridor improved or resolved in all patients after SGP. No cases of supraglottic stenosis occurred from SGP. Five patients had self-limiting dysphagia that resolved within one month after SGP. There was no

Discussion

Surgical indications for infants with LM are not always straight forward. Only about 5–10% of patients will have a clear reason to operate, such as failure to thrive or severe apnea causing cyanosis or life-threatening levels of hypoxia [9], [10]. A good portion of patients have more moderate symptoms [3], such as stridor and sleep disordered breathing with associated retractions and/or intermittent problems with feeding. Indications for surgery in this group can be more ambiguous, and PSG may

Conclusion

In this study, PSG parameters improved in infants with LM and moderate to severe OSA after SGP. Infants with mild OSA (AHI <5) but severe LM did not show PSG improvement after SGP. Confounding factors such as reflux therapy and age did not seem to influence PSG outcomes after SGP, but larger controlled studies are needed to validate this finding. Reported improvements in SDB and stridor correlated with improved PSG parameters in 85% and 80% of patients, respectively. There were no reports of

Acknowledgements

Dr. Kris Sekar, pediatric neonatologist, for assistance on information and advice regarding sleep study parameters.

References (18)

There are more references available in the full text version of this article.

Cited by (37)

  • Optimal laser usage improves surgical efficiency in pediatric supraglottoplasty

    2023, International Journal of Pediatric Otorhinolaryngology
    Citation Excerpt :

    Both CO2 laser and cold steel instrumentation are effective for performing SGP. However, prior comparative studies have utilized the CO2 laser in Superpulse or continuous mode and combined data from different surgeons, which can affect outcomes due to variations in technique, skill level and comfort [5,8–14]. The objective of the present study was to compare the flexible fiber CO2 laser in Ultrapulse mode versus cold steel in pediatric SGP.

  • A novel sleep oximetry scoring tool for pediatric laryngomalacia

    2022, International Journal of Pediatric Otorhinolaryngology
  • Evaluation and Management of the Pediatric Airway

    2021, Cummings Pediatric Otolaryngology
View all citing articles on Scopus
View full text