Pediatric Obstructive Sleep Apnea: Many Causes, Many Treatment Options

Traditional surgical options included resection of a wedge at the base of the tongue. The problem with this surgery is it hurts a lot and recovery is protracted, Dr. Shott said.

Radiofrequency (RF) ablation reduction to the base of the tongue is another option for treating glossoptosis and macroglossia. In adults, initial studies showed RF reduction resulted in a 55% reduction in the RDI.

Dr. Shott’s experience, however, has shown that RF reduction is usually not enough. I more commonly use this in addition to other procedures on the base of the tongue, she said.

With the midline osteotomy genioglossus advancement the intent is to take a segment of the midline mandible with attached genioglossus muscle, and pull it forward.

The problem is that in children it’s limited in that they have to have their secondary dentition in. I don’t feel it gives enough pull to the base of the tongue, particularly in children who have a lot of hypotonia, she said.

An alternative version of the technique is the Repose genioglossus advancement. A permanent suture is anchored at the genial tubercle with a 3-mm titanium screw. The suture is passed in a triangular fashion through the base of the tongue and posterior to the circumvallate papillae, and a small titanium screw is attached. It is done via a submental incision and initial results have been good.

A newer procedure is the submucosal minimally invasive lingual excision (SMILE). Through a midline dorsum incision on the dorsum, 2 cm from the tongue tip, submucosal removal of tomgue muscle is done using the Coblater II Surgery system.

The surgery is done medial to the lingual arteries, which can be identified with ultrasound, which lowers the risk of hypoglossal nerve injury. The procedure is apparently associated with less postoperative pain. However, its use has been reported on only four patients.

Lingual Tonsillectomy

Dr. Koltai discussed some of the challenges with the rarely performed lingual tonsillectomy.

Lingual tonsil hypertrophy (LTH) is not very common. On the other hand, airway obstruction secondary to lingual tonsil hypertrophy is well recognized, he said.

It usually presents as sleep-disordered breathing and in Down syndrome. To do lingual tonsillectomy, children need to undergo nasotracheal intubation.

Especially challenging cases are post-T&A cases with no obvious lateral lingual tonsil hypertrophy, or cases with no previous T&A and no anatomical cause.