2015 HSC Section 1 Book of Articles

Management of sleep apnea in the cleft population Muntz

Conflicts of interest The author has no conflict of interest in this area.

these children may be managed with CPAP in the acute setting and with time the sleep improves. Some may require chronic assistance with CPAP. Alteration of the obstructing flapmay be an effective alternative [16]. Flexible endoscopic evaluation of the velophar- ynx is done during speech. This will allow the assess- ment of the palatal and lateral wall function to see if there is an obvious area that the obstructive flap(s) can be altered. As an example, if there was good velar motion and the sphincter pharyngoplasty had lateral velopharyngeal obstruction that was unneeded for speech, the flaps can be altered to open the lateral aspects of the velopharyngeal port increasing the airway. These alterations need to be done precisely with attention to reduce scaring by closing the mucosa. There have been many reports of the takedown of a pharyngeal flap for the improvement of the airway with no deterioration of the speech [17]. CONCLUSION It is imperative that we screen children with clefts for sleep disordered breathing. Though often the history may be significant enough for intervention, most of the children in this category will have abnormal sleep studies. Understanding the severity may assist in defining the need for intervention. Intervention for sleep disordered breathing and obstructive sleep apnea may vary depending on the anatomical findings. Though tonsillectomy and partial adenoidectomy may be the initial approach, there is a high likelihood that this alone will not solve the problem. Midface advancement, mandibular distraction, flap alteration and CPAP must all be considered in the care of these patients. Coordination of care between cleft surgeons, otolar- yngologists, sleep medicine and pediatrics is necess- ary to optimize the treatment and decrease the risk for cognitive disruption.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 544). 1. Bonuck KA, Chervin RD, Cole TJ, et al. Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study. Sleep 2011; 34:875–884. 2. Muntz H, Wilson M, Park A, et al. Sleep disordered breathing and obstructive sleep apnea in the cleft population. Laryngoscope 2008; 118:348–353. 3. MacLean JE, Fitzsimons D, Hayward P, et al. The identification of children with cleft palate and sleep disordered breathing using a referral system. Pediatr Pulmonol 2008; 43:245–250. 4. Robison JG, Otteson TD. Increased prevalence of obstructive sleep apnea in patients with cleft palate. Arch Otolaryngol Head Neck Surg 2011; 137:269– 274. 5. Scott AR, Moldan MM, Tibesar RJ, et al. A theoretical cause of nasal obstruction in patients with repaired cleft palate. Am J Rhinol Allergy 2011; 25:58–60. 6. && Scott AR, Tibesar RJ, Sidman JD. Pierre Robin sequence: evaluation, manage- ment, indications for surgery, and pitfalls. Otolaryngol Clin North Am 2012; 45:695–710. Interesting insights into the surgical management of children with Robin Sequence. 7. && Parhizkar N, Saltzman B, Grote K, et al. Nasopharyngeal airway for manage- ment of airway obstruction in infants with micrognathia. Cleft Palate Craniofac J 2011; 48:478–482. This is a most interesting article as it suggests the successful management of children with Robin Sequence with a nasopharyngeal airway. 8. Sedaghat AR, Anderson IC, McGinley BM, et al. Characterization of obstructive sleep apnea before and after tongue–lip adhesion in children with micrognathia. Cleft Palate Craniofac J 2012; 49:21–26. 9. Abramowicz S, Bacic JD, Mulliken JB, Rogers GF. Validation of the GILLS score for tongue–lip adhesion in Robin Sequence patients. J Craniofac Surg 2012; 23:382–386. 10. Shapiro RS. Partial adenoidectomy. Laryngoscope 1982; 92:135–139. 11. Smatt Y, Ferri J. Retrospective study of 18 patients treated by maxilloman- dibular advancement with adjunctive procedures for obstructive sleep apnea syndrome. J Craniofac Surg 2005; 16:770–777. 12. Ronchi P, Novelli G, Colombo L, et al. Effectiveness of maxillo-mandibular advancement in obstructive sleep apnea patients with and without skeletal anomalies. Int J Oral Maxillofac Surg 2010; 39:541–547. 13. Elwood ET, Burstein FD, Graham L, et al. Midface distraction to alleviate upper airway obstruction in achondroplastic dwarfs. Cleft Palate Craniofac J 2003; 40:100–103. 14. Mehendale F, Lane R, Laverty A, et al. Effect of palate re-repairs and Hynes pharyngoplasties on paediatric airways. An analysis of pre and post operative cardio-respiratory sleep studies. Cleft Palate Craniofac J 2012. [Epub ahead of print] 15. Pen˜a M, Choi S, Boyajian M, Zalzal G. Perioperative airway complications following pharyngeal flap palatoplasty. Ann Otol Rhinol Laryngol 2000; 109:808–811. 16. Barot LR, Cohen MA, LaRossa D. Surgical indications and techniques for posterior pharyngeal flap revision. Ann Plast Surg 1986; 16:527–531. 17. Agarwal T, Sloan GM, Zajac D, et al. Speech benefits of posterior pharyngeal flap are preserved after surgical flap division for obstructive sleep apnea: experience with division of 12 flaps. J Craniofac Surg 2003; 14:630–636.

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