DOI QR코드

DOI QR Code

소아 수면호흡장애의 진단과 상악확장술의 치료효과

Diagnosis and Effect of Maxillary Expansion in Pediatric Sleep-Disordered Breathing

  • 김도영 (별가람소아치과) ;
  • 백경희 (전북대학교 치의학전문대학원 소아치과학교실 및 구강생체과학연구소) ;
  • 이대우 (전북대학교 치의학전문대학원 소아치과학교실 및 구강생체과학연구소) ;
  • 김재곤 (전북대학교 치의학전문대학원 소아치과학교실 및 구강생체과학연구소) ;
  • 양연미 (전북대학교 치의학전문대학원 소아치과학교실 및 구강생체과학연구소)
  • Kim, Doyoung (Byeolgalam Dental Clinic) ;
  • Baek, Kyounghee (Department of Pediatric Dentistry and Institute of Oral Bioscience, School of Dentistry, Chonbuk National University) ;
  • Lee, Daewoo (Department of Pediatric Dentistry and Institute of Oral Bioscience, School of Dentistry, Chonbuk National University) ;
  • Kim, Jaegon (Department of Pediatric Dentistry and Institute of Oral Bioscience, School of Dentistry, Chonbuk National University) ;
  • Yang, Yeonmi (Department of Pediatric Dentistry and Institute of Oral Bioscience, School of Dentistry, Chonbuk National University)
  • 투고 : 2019.07.23
  • 심사 : 2019.08.21
  • 발행 : 2019.11.30

초록

이 연구의 목적은 수면호흡장애 증상을 보이며 협착된 상악궁을 가진 7 - 9세 어린이에서 상악 확장술(semi-rapid maxillary expansion, SRME)을 이용한 상악 측방확장 치료 전후 수면호흡장애 증상의 변화와 개선을 소아수면설문지, 간이수면검사 및 측방두부규격 방사선사진을 통해 기도부위의 변화를 비교, 분석하고자 하는 것이다. 대상자는 총 15명으로 AHI 1 이상이며 좁은 상악궁을 가진 어린이였다. 모든 대상자는 SRME가 적용되기 전 소아수면설문지, 측방두부규격 방사선사진 및 간이수면검사를 시행하였다(T0). SRME가 적용되었고, 평균 확장 2개월 후 유지단계 3개월을 시행하였다. 치료 종료 후 소아수면설문지, 측방두부규격 방사선사진 및 휴대용 간이수면검사를 시행하였다(T1). 총 PSQ scale은 확장 전(T0) 평균 0.45에서 확장 후(T1) 평균 0.18로 통계적으로 유의하게 감소하였다(p = 0.001). 특히 코골이, 호흡문제, 집중력 저하 영역에서 유의한 감소를 보였다(p = 0.001). 아데노이드 비대율은 확장 전(T0) 평균 0.63에서 확장 후(T1) 평균 0.51로 유의하게 감소하였다(p = 0.003). 상기도 폭경 중 구개인두 폭경만이 치료 후(T1) 통계적으로 유의한 증가를 보였다(p = 0.035). 설골 위치는 치료 전후에 통계학적으로 유의한 차이를 보이지 않았다. 휴대용 간이수면검사 결과 AHI와 ODI는 치료 후(T1) 통계적으로 유의한 감소를 보였고, 최저 산소포화도는 유의한 증가를 보였다. 따라서, 수면호흡장애 증상은 치료 후 전반적으로 개선되었음을 알 수 있다.

The aim of this study was to analyze the changes and improvements in symptoms of sleep-disordered breathing (SDB) using semi-rapid maxillary expansion (SRME) in children with narrow maxilla and SDB symptoms. Subjects were 15 patients with sleep disorder (apnea-hypopnea index, AHI ≥ 1) and narrow maxillary arch between 7 and 9 years of age. Before the SRME was applied, all subjects underwent pediatric sleep questionnaires (PSQ), lateral cephalometry, and portable sleep monitoring before expansion (T0). All subjects were treated with SRME for 2 months, followed by maintenance for the next 3 months. All subjects had undergone PSQ, lateral cephalometry, and portable sleep monitoring after expansion (T1). Adenoidal-nasopharyngeal ratio (ANR), upper airway width and hyoid bone position were measured by lateral cephalometry. The data before and after SRME were statistically analyzed with frequency analysis and Wilcoxon signed rank test. As reported by PSQ, the total PSQ scale was declined significantly from 0.45 (T0) to 0.18 (T1) (p = 0.001). Particularly, snoring, breathing, and inattention hyperactivity were significantly improved (p = 0.001). ANR significantly decreased from 0.63 (T0) to 0.51 (T1) (p = 0.003). After maxillary expansion, only palatopharyngeal airway width was significantly increased (p = 0.035). There was no statistically significant difference in position of hyoid bone after expansion (p = 0.333). From analysis of portable sleep monitoring, changes in sleep characteristics showed a statistically significant decrease in AHI and ODI, and the lowest oxygen desaturation was significantly increased after SRME (p = 0.001, 0.004, 0.023). In conclusion, early diagnosis with questionnaires and portable sleep monitoring is important. Treatment using SRME will improve breathing of children with SDB.

키워드

참고문헌

  1. Marcus CL : Sleep-disordered breathing in children. Am J Respir Crit Care Med , 164:16-30, 2001. https://doi.org/10.1164/ajrccm.164.1.2008171
  2. Lumeng JC, Chervin RD : Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc , 5:242-252, 2008. https://doi.org/10.1513/pats.200708-135MG
  3. Oh JI, Lee SH : Obstructive sleep apnea syndrome in children. Hanyang Med Rev , 33:246-252, 2013. https://doi.org/10.7599/hmr.2013.33.4.246
  4. Marcus CL, Brooks LJ, Spruyt K, et al.: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics , 130:714-755, 2012.
  5. Berry RB, Gamaldo CE, Marcus CL, et al.: AASM scoring manual version 2.2 updates: new chapters for scoring infant sleep staging and home sleep apnea testing. J Clin Sleep Med , 11:1253-1254, 2015. https://doi.org/10.5664/jcsm.5176
  6. Schechter MS : Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics , 109:69, 2002. https://doi.org/10.1542/peds.109.4.e69
  7. Spruyt K, Gozal D : Development of pediatric sleep questionnaires as diagnostic or epidemiological tools: a brief review of dos and don'ts. Sleep Med Rev , 15:7-17, 2011. https://doi.org/10.1016/j.smrv.2010.06.003
  8. Spruyt K, Gozal D : Pediatric sleep questionnaires as diagnostic or epidemiological tools: a review of currently available instruments. Sleep Med Rev , 15:19-32, 2011. https://doi.org/10.1016/j.smrv.2010.07.005
  9. Chervin RD, Hedger K, Dillon JE, Pituch KJ : Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med , 1:21-32, 2000. https://doi.org/10.1016/S1389-9457(99)00009-X
  10. Hamada M, Iida M : Home monitoring using portable polygraphy for perioperative assessment of pediatric obstructive sleep apnea syndrome. Tokai J Exp Clin Med , 37:66-70, 2012.
  11. Villa M, Rizzoli A, Miano S, Malagola C : Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath , 15:179-184, 2011. https://doi.org/10.1007/s11325-011-0505-1
  12. Pirelli P, Saponara M, Guilleminault C : Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep , 27:761-766, 2004. https://doi.org/10.1093/sleep/27.4.761
  13. Pirelli P, Saponara M, Guilleminault C : Rapid maxillary expansion (RME) for pediatric obstructive sleep apnea: a 12-year follow-up. Sleep Med, 16:933-935, 2015. https://doi.org/10.1016/j.sleep.2015.04.012
  14. Fujioka M, Young LW, Girdany BR : Radiographic evaluation of adenoidal size in children: adenoidal-nasopharyngeal ratio. AJR Am J Roentgenol, 133:401-404, 1979. https://doi.org/10.2214/ajr.133.3.401
  15. Marcus CL : Sleep-disordered breathing in children. Am J Respir Crit Care Med , 164:16-30, 2001. https://doi.org/10.1164/ajrccm.164.1.2008171
  16. Jeans WD, Fernando DC, Maw AR, Leighton BC : A longitudinal study of the growth of the nasopharynx and its contents in normal children. Br J Radiol , 54:117-121, 1981. https://doi.org/10.1259/0007-1285-54-638-117
  17. Brunetti L, Rana S, Armenio L, et al.: Prevalence of obstructive sleep apnea syndrome in a cohort of 1,207 children of southern Italy. Chest , 120:1930-1935, 2001. https://doi.org/10.1378/chest.120.6.1930
  18. Linder-Aronson S : Adenoids. Their effect on mode of breathing and nasal air flow and their relationship to characteristics of the facial skeleton and the dentition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids. Acta Otolaryngol Suppl , 265:1-132, 1970.
  19. Johns MW : A new method for measuring daytime sleepiness: the epworth sleepiness scale. Sleep , 14:540-545, 1991. https://doi.org/10.1093/sleep/14.6.540
  20. Schechter MS : Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics , 109:69, 2002. https://doi.org/10.1542/peds.109.4.e69
  21. Tan HL, Gozal D, Kheirandish-Gozal L : Overnight polysomnography versus respiratory polygraphy in the diagnosis of pediatric obstructive sleep apnea. Sleep , 37:255-260, 2014. https://doi.org/10.5665/sleep.3392
  22. Kaditis AG, Alonso Alvarez ML, Verhulst S, et al. : Obstructive sleep disordered breathing in 2 to 18 year old. Eur Respir J , 47:69-94, 2016. https://doi.org/10.1183/13993003.00385-2015
  23. Alonso-Alvarez ML, Teran-Santos J, Gozal D, et al.: Reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children. Chest , 147:1020-1028, 2015. https://doi.org/10.1378/chest.14-1959
  24. Villa MP, Malagola C, Ronchetti R, et al.: Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med , 8:128-134, 2007. https://doi.org/10.1016/j.sleep.2006.06.009
  25. Certal V, Camacho M, Costa-Pereira A, et al.: Unattended sleep studies in pediatric OSA: a systematic review and meta-analysis. Laryngoscope , 125:255-262, 2015. https://doi.org/10.1002/lary.24662
  26. Vale F, Albergaria M, Malo L, et al.: Efficacy of rapid maxillary expansion in the treatment of obstructive sleep apnea syndrome: a systematic review with meta-analysis. J Evid Based Dent Pract , 17:159-168, 2017. https://doi.org/10.1016/j.jebdp.2017.02.001
  27. Monini S, Malagola C, Barbara M, et al.: Rapid maxillary expansion for the treatment of nasal obstruction in children younger than 12 years. Arch Otolaryngol Head Neck Surg , 135:22-27, 2009. https://doi.org/10.1001/archoto.2008.521
  28. Won TB : Contemporary methods of upper airway evaluation in obstructive sleep apnea patients. Korean J Otorhinolaryngol- Head Neck Surg , 56:7-13, 2013. https://doi.org/10.3342/kjorl-hns.2013.56.1.7
  29. Faber CE, Grymer L : Available techniques for objective assessment of upper airway narrowing in snoring and sleep apnea. Sleep Breath , 7:77-86, 2003. https://doi.org/10.1007/s11325-003-0077-9
  30. Major MP, Flores-Mir C, Major PW : Assessment of lateral cephalometric diagnosis of adenoid hypertrophy and posterior upper airway obstruction: a systematic review. Am J Orthod Dentofacial Orthop , 130:700-708, 2006. https://doi.org/10.1016/j.ajodo.2005.05.050
  31. Donner MW, Bosma JF, Robertson DL : Anatomy and physiology of the pharynx. Gastrointest Radiol , 10:196-212, 1985.
  32. Katyal V, Pamula Y, Sampson WJ, et al.: Craniofacial and upper airway morphology in pediatric sleep-disordered breathing and changes in quality of life with rapid maxillary expansion. Am J Orthod Dentofacial Orthop , 144:860-871, 2013. https://doi.org/10.1016/j.ajodo.2013.08.015
  33. Pirila-Parkkinen K, Lopponen H, Pirttiniemi P, et al.: Validity of upper airway assessment in children: a clinical, cephalometric, and MRI study. Angle Orthod , 81:433-439, 2011. https://doi.org/10.2319/063010-362.1
  34. Pracharktam N, Hans MG, Strohl KP, Redline S : Upright and supine cephalometric evaluation of obstructive sleep apnea syndrome and snoring subjects. Angle Orthod , 64:63-73, 1994.
  35. Bibby RE : The hyoid bone position in mouth breathers and tongue-thrusters. Am J Orthod , 85:431-433, 1984. https://doi.org/10.1016/0002-9416(84)90164-7
  36. Guilleminault C, Riley R, Powell N : Obstructive sleep apnea and abnormal cephalometric measurements. Implications for treatment. Chest , 86:793-794, 1984. https://doi.org/10.1378/chest.86.5.793
  37. Attanasio R : Dental management of sleep disorders, Wiley-Blackwell, 2010.
  38. Gungor AY, Turkkahraman H, Yilmaz HH, Yariktas M : Cephalometric comparison of obstructive sleep apnea patients and healthy controls. Eur J Dent, 7:48-54, 2013. https://doi.org/10.1055/s-0039-1698995
  39. Battagel JM, Johal A, Kotecha B : A cephalometric comparison of subjects with snoring and obstructive sleep apnoea. Eur J Orthod , 22:353-365, 2000. https://doi.org/10.1093/ejo/22.4.353
  40. Endo S, Mataki S, Kurosaki N : Cephalometric evaluation of craniofacial and upper airway structures in Japanese patients with obstructive sleep apnea. J Med Dent Sci , 50:109-120, 2003.
  41. Phoenix A, Valiathan M, Hans M, et al.: Changes in hyoid bone position following rapid maxillary expansion in adolescents. Angle Orthod , 81:632-638, 2011. https://doi.org/10.2319/060710-313.1
  42. Verin E, Tardif C, Pasquis P, et al.: Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients. Respir Physiol , 129:335-343, 2002. https://doi.org/10.1016/S0034-5687(01)00324-3