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.
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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.
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Electronic supplementary material
Supplemental word document Cine upper airway MRI technologist protocol (DOCX 1170 kb)
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)
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)
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)
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)
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Fleck, R.J., Shott, S.R., Mahmoud, M. et al. Magnetic resonance imaging of obstructive sleep apnea in children. Pediatr Radiol 48, 1223–1233 (2018). https://doi.org/10.1007/s00247-018-4180-2
- Lingual tonsils
- Magnetic resonance imaging
- Obstructive sleep apnea