Understanding the Anatomic Basis for Obstructive Sleep Apnea Syndrome in Adolescents: How to Proceed?

摘要

I read with great interest the recent article by Schwab and colleagues regarding the anatomic basis for obstructive sleep apnea in adolescents (1). Their research shows that increased size of the pharyngeal lymphoid tissue is the predominant anatomic risk factor for obstructive sleep apnea syndrome (OSAS) in obese adolescents. The authors state that adenotonsillectomy should be considered as the initial treatment for OSAS in obese adolescents, according to their findings. Although preliminary imaging research from our group largely agrees with the present findings (2), I have several comments regarding this recommendation. I think it is extremely important to consider, diagnose, and treat obstructive sleep apnea not as a standalone entity but, rather, as an important and interacting part in several major comorbidities such as insulin resistance, dyslipidemia, hypertension, psychological comorbidities, and so on. I believe it is of utmost importance to treat every aspect of pediatric obesity, and therefore, every obese child or adolescent should be managed in a multidisciplinary clinic in which the pediatric pulmonologist or sleep specialist should play an essential role. The emphasis should always be put on lifestyle interventions, including weight management therapy. Additional treatment modalities can be indicated, but I recommend that we individualize treatment for pediatric subjects with complex OSAS. Although prospective trials are lacking, we have an array of diagnostic techniques that we can use to pinpoint the most likely anatomical cause of OSAS in a specific child. Examples include various classical imaging techniques (lateral neck X-ray, cephalometry, computed tomography, or magnetic resonance imaging scan), possibly complemented with more advanced modalities (cine magnetic resonance imaging, computational fluid dynamics) (3), drug-induced sleep endoscopy (4), and so on. The question that is left unanswered by the present article is whether the present findings could predict the effect of treatment. For instance, what was the variability in pharyngeal lymphoid tissue in the obese adolescents with OSAS?