Sleep Apnea and Airway Obstruction
Sleep Apnea and compromised airways can occur due to a variety of abnormal conditions. The cause of a compromised airway can be determined by careful examination, radiographic studies and endoscopy. Additionally, a sleep study is often utilized to determine the severity of the airway problem.
Common causes of sleep apnea and compromised airways include:
- Choanal stenosis
- Enlarged tonsils and adenoids
- Enlarged tongue and small chin
- Underdeveloped upper jaw (maxilla)
- Underdeveloped lower jaw (mandible)
- Collapse of the larynx or trachea
Many of the craniofacial syndromes we see and treat have obstructive sleep apnea which may be caused by a blockage of the airway. In Apert and Crouzon Syndrome, upper airway obstruction can be caused by mid-face deficiency, mandibular deficiency, or both. In Pierre Robin Syndrome, Treacher Collins Syndrome, and Nager’s Syndrome often there is a profound retromicrognathia, with a small recessed mandible, causing airway obstruction.
Sleep apnea is a common disorder with significant adverse health consequences. Those with untreated sleep apnea stop breathing repeatedly throughout sleep which can lead to high blood pressure, cardiovascular disease, memory problems, weight gain and headaches. Due to the lack of awareness among the public and healthcare professionals, many remain undiagnosed. The most common etiology of airway obstruction in children is enlarged tonsils and adenoid hypertrophy. A determination must be made between central and obstructive sleep apnea. Both can be commonly found in craniofacial patients and may have detrimental effects on brain function. However, treatment plans are different depending on the root source. In obstructive cases, often the midface or mandible can be moved forward to enlarge the airway opening and remove or prevent a tracheostomy. In central apnea sometimes the cause is increased intracranial pressure from a chiari malformation which requires neurosurgical intervention.
Evaluation and Treatment
The most common rationale for the indication of surgery is the need to alleviate the symptoms of excessive daytime sleepiness and minimize or eliminate the associated cardiovascular and metabolic complications associated with sleep disordered breathing. To determine the severity of sleep apnea, a presurgical evaluation must be completed with the following studies:
- Overnight sleep study
- Comprehensive head and neck physical exam
- 3D CT scan
- Direct nasopharyngeal endoscopy
Some treatment techniques used to correct obstructive sleep apnea include tracheostomy, nasal reconstruction, turbinectomy, midface or jaw distraction, hyoid suspension and orthognathic surgery. Our goal in treating patients with obstructive sleep apnea is to prevent a tracheostomy.
In children with obstructive sleep apnea and micrognathia (as in Pierre Robin Syndrome and Treacher Collins Syndrome) surgical treatment of the airway can be an emergency. Our goal is first to provide a stable airway and this may require a tracheostomy in some cases. However, in many cases a tracheostomy may be omitted if the mandible can be moved forward. Distraction osteogenesis of the mandible is a surgical technique that involves the use of internally or externally placed devices that allow the team to slowly advance the bone without the need of bone grafting. This takes a period of time, often 2 weeks, and can be done at home after the distraction device is placed. This is followed by a one month period of bone healing prior to the removal of the devices. Many cases have successfully been performed relieving the obstruction and returning the patient to a normal airway.