1221 Worsening Central Sleep Apnea After Adenotonsillectomy

Abstract

Introduction: Central sleep apnea following initiation of positive airway pressure (PAP) device for obstructive sleep apnea (OSA) is frequently seen. Rapid decline in carbon dioxide level after initiation of PAP therapy is considered to result in central apnea. Multiple studies have reported improved central sleep apnea after adenotonsillectomy. Few studies reported worsening central apnea after surgical interventions for OSA and nasal obstruction in adults. We report a case of central sleep apnea and obstructive hypoventilation where central sleep apnea worsened after adenotonsillectomy. Report of Case: A 10 year old, overweight girl without past medical history presented to clinic complaining of loud snoring, witnessed apnea, daytime sleepiness and tonsillar hypertrophy. Physical exam revealed Mallampati 3, 4+ tonsils bilaterally, over bite, normal hard palate, height 148 cm, weight 77.3kg with BMI at 96.6 percentile. Polysomnography (PSG) showed predominantly central apnea and obstructive hypoventilation with apnea hypopnea index (AHI) 10.9/ hour, nadir oxygen saturation 92.6% and ETCO2>50 mmHg for 37% of total sleep time. Magnetic Resonance Imaging of brain without contrast did not show any intracranial abnormalities. She received adenotonsillectomy for grade 4+ bilateral tonsils and 50% obstruction of adenoid pad. After 2 months of surgery, she complained of persistent sleep symptoms. Repeat PSG showed primary central sleep apnea with AHI 44.4/hour with nadir oxygen of 85.9%. Hypoventilation was resolved. Another PSG after 8 months of surgery showed persistent central sleep apnea with AHI 37.7/hour with nadir oxygen saturation of 86.7%. She will be evaluated for nocturnal oxygen supplementation. Conclusion: Although studies reported improved central sleep apnea after adenotonsillectomy in pediatric patients, we experienced worsening central sleep apnea which persisted after 8 months of surgery. Future studies are needed to understand the pathophysiology of worsening central sleep apnea after surgical correction of upper airway obstruction.