Advertisement

Pediatric Radiology

, Volume 48, Issue 9, pp 1223–1233 | Cite as

Magnetic resonance imaging of obstructive sleep apnea in children

  • Robert J. Fleck
  • Sally R. Shott
  • Mohamed Mahmoud
  • Stacey L. Ishman
  • Raouf S. Amin
  • Lane F. Donnelly
Pediatric Body MRI

Abstract

Sleep-disordered breathing has a spectrum of severity that spans from snoring and partial airway collapse with increased upper airway resistance, to complete upper airway obstruction with obstructive sleep apnea during sleeping. While snoring occurs in up to 20% of children, obstructive sleep apnea affects approximately 1–5% of children. The obstruction that occurs in obstructive sleep apnea is the result of the airway collapsing during sleep, which causes arousal and impairs restful sleep. Adenotonsillectomy is the first-line treatment of obstructive sleep apnea and is usually effective in otherwise healthy nonsyndromic children. However, there are subgroups in which this surgery is less effective. These subgroups include children with obesity, severe obstructive sleep apnea preoperatively, Down syndrome, craniofacial anomalies and polycystic ovarian disease. Continuous positive airway pressure (CPAP) is the first-line therapy for persistent obstructive sleep apnea despite previous adenotonsillectomy, but it is often poorly tolerated by children. When CPAP is not tolerated or preferred by the family, surgical options beyond adenotonsillectomy are discussed with the parent and child. Dynamic MRI of the airway provides a means to identify and localize the site or sites of obstruction for these children. In this review the authors address clinical indications for imaging, ideal team members to involve in an effective multidisciplinary program, basic anesthesia requirements, MRI protocol techniques and interpretation of the findings on MRI that help guide surgery.

Keywords

Adenoids Children Laryngomalacia Lingual tonsils Macroglossia Magnetic resonance imaging Obstructive sleep apnea Surgery 

Notes

Acknowledgments

This paper was supported by National Institutes of Health (NIH) grant RO1HL105206-01. The authors have indicated no financial conflicts of interest.

The project described was supported by the National Center for Advancing Translational Sciences of the NIH, under award number 5UL1TR001425-03. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Compliance with ethical standards

Conflicts of interest

None

Supplementary material

247_2018_4180_MOESM1_ESM.docx (1.1 mb)
ESM 1 Supplemental word document Cine upper airway MRI technologist protocol (DOCX 1170 kb)
247_2018_4180_MOESM2_ESM.mp4 (2.9 mb)
Cine 1 MRI in a 15-year-old girl with Down syndrome and persistent obstructive sleep apnea after lingual tonsillectomy, with an apnea hypopnea index of 5.1 events per hour. Midline cine gradient echo sequence available as a movie online shows soft-tissue movement at base of tongue causing intermittent obstruction at the level of the epiglottis. Corresponds to Fig. 2d. (MP4 2,968 kb)
247_2018_4180_MOESM3_ESM.mp4 (1.7 mb)
Cine 2 MRI in a 9-year-old boy with Down syndrome and severe obstructive sleep apnea, with apnea hypopnea index of 142 events per hour. Midline sagittal cine gradient recalled echo (GRE) image shows the airway open with enlarged, recurrent adenoids and then the airway collapsed and closed at multiple levels. If viewed only in sagittal plane this motion could be mistaken for glossoptosis, but cine 3 shows the true nature of the collapse is circumferential. Corresponds to Fig. 5a and b. This child underwent a midline posterior glossectomy, genioglossus advancement and revision adenoidectomy with postoperative apnea hypopnea index of 3.4. (MP4 1,705 kb)
247_2018_4180_MOESM4_ESM.mp4 (1.2 mb)
Cine 3 MRI in a 9-year-old boy with Down syndrome and severe obstructive sleep apnea, with apnea hypopnea index of 142 events per hour. Axial retroglossal cine gradient recalled echo (GRE) image of the airway balloons open and then completely collapses in this boy, demonstrating the concentric collapse seen in hypopharyngeal collapse. Corresponds to Fig. 5c and d. This boy underwent a midline posterior glossectomy, genioglossus advancement and revision adenoidectomy with postoperative apnea hypopnea index of 3.4. (MP4 1,243 kb)
247_2018_4180_MOESM5_ESM.mp4 (909 kb)
Cine 4 MRI in a 15-year-old boy with obesity, obstructive sleep apnea and headaches with poor compliance to CPAP. Axial gradient recalled echo cine of the retroglossal airway shows a wide patency during peak expiration. The tongue collapses posteriorly and obstructs the airway. This is probably occurring during a period of cessation of airflow during transition to inspiration because of the rapid motion indicated by the blurring of the tongue edge. A small central airway opening exists while the posterior tongue is in contact with the posterior pharynx for three frames (about 1 s) during inspiration and then on expiration the airway “pops” open again. Corresponds to Fig. 6a to c. The boy and family improved compliance to CPAP and the headaches resolved. CPAP continuous positive airway pressure (MP4 908 kb)

References

  1. 1.
    Donnelly LF (2005) Obstructive sleep apnea in pediatric patients: evaluation with cine MR sleep studies. Radiology 236:768–778CrossRefPubMedGoogle Scholar
  2. 2.
    Marcus C, Brooks L, Ward S et al (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130:E714–E755CrossRefPubMedGoogle Scholar
  3. 3.
    Berry R, Brooks R, Gamaldo C et al (2017) AASM scoring manual updates for 2017 (version 2.4). J Clin Sleep Med 13:665–666CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Berry RB, Brooks R, Gamaldo DE et al (2017) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Version 2.4. American Academy of Sleep Medicine, DarienGoogle Scholar
  5. 5.
    Berry R, Budhiraja R, Gottlieb D et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med 8:597–619PubMedPubMedCentralGoogle Scholar
  6. 6.
    Bhattacharjee R, Kheirandish-Gozal L, Spruyt K et al (2010) Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children a multicenter retrospective study. Am J Respir Crit Care Med 182:676–683CrossRefPubMedGoogle Scholar
  7. 7.
    Shott SR, Donnelly LF (2004) Cine magnetic resonance imaging: evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with down syndrome. Laryngoscope 114:1724–1729CrossRefPubMedGoogle Scholar
  8. 8.
    Mahmoud M, Gunter J, Donnelly LF et al (2009) A comparison of dexmedetomidine with propofol for magnetic resonance imaging sleep studies in children. Anesth Analg 109:745–753CrossRefPubMedGoogle Scholar
  9. 9.
    Arens R, McDonough J, Corbin A et al (2003) Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 167:65–70CrossRefPubMedGoogle Scholar
  10. 10.
    Chatterjee D, Friedman N, Shott S et al (2014) Anesthetic dilemmas for dynamic evaluation of the pediatric upper airway. Semin Cardiothorac Vasc Anesth 18:371–378CrossRefPubMedGoogle Scholar
  11. 11.
    Donnelly LF, Strife JL, Myer CM (2001) Is sedation safe during dynamic sleep fluoroscopy of children with obstructive sleep apnea? AJR Am J Roentgenol 177:1031–1034CrossRefPubMedGoogle Scholar
  12. 12.
    Mahmoud M, Gunter J, Sadhasivam S (2009) Cine MRI airway studies in children with sleep apnea: optimal images and anesthetic challenges. Pediatr Radiol 39:1034–1037CrossRefPubMedGoogle Scholar
  13. 13.
    Fleck RJ, Amin RS, Shott SR et al (2014) MRI sleep studies: use of positive airway pressure support in patients with severe obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 78:1163–1166CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Mahmoud M, Radhakrishman R, Gunter J et al (2010) Effect of increasing depth of dexmedetomidine anesthesia on upper airway morphology in children. Paediatr Anaesth 20:506–515CrossRefPubMedGoogle Scholar
  15. 15.
    Luscri N, Tobias J (2006) Monitored anesthesia care with a combination of ketamine and dexmedetomidine during magnetic resonance imaging in three children with trisomy 21 and obstructive sleep apnea. Pediatr Anesth 16:782–786CrossRefGoogle Scholar
  16. 16.
    Kandil A, Subramanyam R, Hossain M et al (2016) Comparison of the combination of dexmedetomidine and ketamine to propofol or propofol/sevoflurane for drug-induced sleep endoscopy in children. Pediatr Anesth 26:742–751CrossRefGoogle Scholar
  17. 17.
    Fleck RJ, Mahmoud M, McConnell K et al (2013) An adverse effect of positive airway pressure on the upper airway documented with magnetic resonance imaging. JAMA Otolaryngol Head Neck Surg 139:636–638CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Donnelly LF, Surdulescu V, Chini BA et al (2003) Upper airway motion depicted at cine MR imaging performed during sleep: comparison between young patients with and those without obstructive sleep apnea. Radiology 227:239–245CrossRefPubMedGoogle Scholar
  19. 19.
    Chen W, Gillett E, Khoo M et al (2017) Real-time multislice MRI during continuous positive airway pressure reveals upper airway response to pressure change. J Magn Reson Imaging 46:1400–1408CrossRefPubMedGoogle Scholar
  20. 20.
    Donnelly LF, Strife JL, Myer CM (2000) Glossoptosis (posterior displacement of the tongue) during sleep: a frequent cause of sleep apnea in pediatric patients referred for dynamic sleep fluoroscopy. AJR Am J Roentgenol 175:1557–1560CrossRefPubMedGoogle Scholar
  21. 21.
    Schwab RJ, Gefter WB, Hoffman EA et al (1993) Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis 148:1385–1400CrossRefPubMedGoogle Scholar
  22. 22.
    Bates A, Schuh A, Amine-Eddine G et al (2018) Assessing the relationship between movement and airflow in the upper airway using computational fluid dynamics with motion determined from magnetic resonance imaging. Clin Biomech.  https://doi.org/10.1016/j.clinbiomech.2017.10.011
  23. 23.
    Guimaraes CV, Donnelly LF, Shott SR et al (2008) Relative rather than absolute macroglossia in patients with down syndrome: implications for treatment of obstructive sleep apnea. Pediatr Radiol 38:1062–1067CrossRefPubMedGoogle Scholar
  24. 24.
    Donnelly LF, Shott SR, LaRose CR et al (2004) Causes of persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy in children with down syndrome as depicted on static and dynamic cine MRI. AJR Am J Roentgenol 183:175–181CrossRefPubMedGoogle Scholar
  25. 25.
    Guimaraes CV, Kalra M, Donnelly LF et al (2008) The frequency of lingual tonsil enlargement in obese children. AJR Am J Roentgenol 190:973–975CrossRefPubMedGoogle Scholar
  26. 26.
    Fricke BL, Donnelly LF, Shott SR et al (2006) Comparison of lingual tonsil size as depicted on MR imaging between children with obstructive sleep apnea despite previous tonsillectomy and adenoidectomy and normal controls. Pediatr Radiol 36:518–523CrossRefPubMedGoogle Scholar
  27. 27.
    Kang K, Koltai P, Lee C et al (2017) Lingual tonsillectomy for treatment of pediatric obstructive sleep apnea: a meta-analysis. JAMA Otolaryngol Head Neck Surg 143:561–568CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kim C, Jackson N, Chawla S et al (2011) Quantification of tongue fat by novel MRI techniques and its relationship to BMI. Am J Respir Crit Care Med 183:A3678Google Scholar
  29. 29.
    Kim A, Keenan B, Jackson N et al (2014) Metabolic activity of the tongue in obstructive sleep apnea: a novel application of FDG positron emission tomography imaging. Am J Respir Crit Care Med 189:1416–1425CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Radiology, Cincinnati Children’s Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiUSA
  2. 2.Center for Pulmonary Imaging ResearchCincinnati Children’s HospitalCincinnatiUSA
  3. 3.Imaging Research CenterCincinnati Children’s HospitalCincinnatiUSA
  4. 4.Division of Pediatric Otolaryngology–Head and Neck SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  5. 5.Department of Otolaryngology–Head and Neck SurgeryUniversity of Cincinnati School of MedicineCincinnatiUSA
  6. 6.Department of Anesthesia, Cincinnati Children’s Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiUSA
  7. 7.Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiUSA
  8. 8.Department of RadiologyStanford UniversityStanfordUSA
  9. 9.Quality and SafetyLucile Packard Children’s HospitalStanfordUSA

Personalised recommendations