CCA posts a monthly blog series called, "Ask the Doctor." You can submit your questions to Annie Reeves (firstname.lastname@example.org) and we will ask Dr. Earl Gage of Kids' Plastic Surgery in St. Louis to answer them. Thanks Dr. Gage for helping spread information and resources for our cranio families! Today's question is about two options for addressing obstructive sleep apnea.
Ask the Doctor
Question: My son is 15 and has developed sleep apnea with oxygen saturations dropping to 88% while sleeping. Would you recommend a take-down of his pharyngeal flap or skipping to jaw advancement surgery? My concern is that taking down the flap will take us back to square one with speech issues. Is this something you see often? What would you recommend?
Answer: Obstructive sleep apnea (OSA) can occur as a result of pharyngeal flap surgery. OSA is most likely to occur in the weeks to months immediately after surgery and occurs in as many as 30-40% of patients. Some studies suggest that this incidence decreases with time as the swelling from surgery subsides and as the scars soften and relax.
When sleep apnea is demonstrated after pharyngeal flap surgery, there are a variety of things to consider in creating a treatment plan. I assume that your son has had a sleep study to document the type and severity of his apnea. It is important to clarify whether his apnea is obstructive (caused by a mechanical blockage) or central (caused by the brain not sending the signal to breathe). Obstructive apnea may be improved by surgical management that relieves the mechanical obstruction. Central apnea may or may not be improved by surgery, depending on the reason for the central apnea.
Any child or adolescent with sleep apnea should also have his or her tonsils assessed. If the tonsils are still present and are enlarged, tonsillectomy may be effective in treating the apnea. This is actually a very common first step in addressing obstructive sleep apnea in a child.
If obstructive apnea cannot be improved by simple tonsillectomy, then you will need to have a more nuanced discussion with your team. In general, if your child will tolerate it, a CPAP mask at night might be the best option. This would allow you to improve the quality of sleep and decrease the obstructive episodes without compromising speech.
If your child will not tolerate CPAP, then surgical management of the flap may be needed. In some cases, the lateral ports may be enlarged to allow air to pass more easily and hopefully decrease obstruction. Sometimes, the flap may need to be taken down completely.
You are correct that taking down the flap will likely compromise speech. However, when other interventions fail to improve the obstruction, this is sometimes the best option. Good sleep and good oxygenation at night are important for brain growth and development and good performance in school and in your son’s future professional life.
As for jaw advancement, this is hard to answer without seeing your child. If the lower jaw is small or sits too far back, bringing it forward may help. If the midface is underdeveloped or sits too far back, then midface advancement may help alleviate the obstruction. If your child has a normal midface and lower jaw and the teeth meet the way that they should already, I am not sure that jaw advancement will be beneficial. When required, jaw surgery should ideally be delayed until your son is done with his facial growth, typically at 17-18 years of age. This helps ensure a stable long-term result. However, there are instances where your team may recommend earlier surgery. The risks and benefits of earlier surgery need to be carefully weighed and discussed.
Best of luck as you discuss these options with your team!