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Obstructive Sleep Apnea in Pediatric Patients: Evaluation with Cine MR Sleep Studies¹

¹ From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH, 45229-3039. Received February 16, 2004; revision requested April 21; final revision received July 19; accepted August 4. Address correspondence to the author (e-mail: Lane.Donnelly{at}cchmc.org).

View larger version (137K): [in a new window]   Figure 1a. Sagittal midline T1-weighted SE MR images (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) illustrate terminology and definitions for anatomy of the supraglottic airway. (a) Anatomy in a 14-year-old boy with cerebral palsy. Nasopharynx (light green) is defined as the aerated space bordered by soft palate anteriorly, adenoids posteriorly, and nasal turbinates anteriorly and superiorly. The inferior border is defined by the inferior tip of the uvula. Oropharynx (gray) is defined as the aerated space bordered by hard palate superiorly, tongue inferiorly, and soft palate posteriorly. Hypopharynx (dark green) is defined as the aerated spaced bordered by posterior aspect of tongue anteriorly, posterior pharyngeal wall posteriorly, and inferior aspect of soft palate anteriorly. The inferior border is defined by the inferior extent (or base) of the tongue. (b) More typical configuration encountered during normal sleep in a 9-year-old boy. The mouth is closed and the oral cavity (small arrowheads) is collapsed. The hypopharynx (arrows) and nasopharynx (large arrowhead) are patent.

View larger version (177K): [in a new window]   Figure 1b. Sagittal midline T1-weighted SE MR images (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) illustrate terminology and definitions for anatomy of the supraglottic airway. (a) Anatomy in a 14-year-old boy with cerebral palsy. Nasopharynx (light green) is defined as the aerated space bordered by soft palate anteriorly, adenoids posteriorly, and nasal turbinates anteriorly and superiorly. The inferior border is defined by the inferior tip of the uvula. Oropharynx (gray) is defined as the aerated space bordered by hard palate superiorly, tongue inferiorly, and soft palate posteriorly. Hypopharynx (dark green) is defined as the aerated spaced bordered by posterior aspect of tongue anteriorly, posterior pharyngeal wall posteriorly, and inferior aspect of soft palate anteriorly. The inferior border is defined by the inferior extent (or base) of the tongue. (b) More typical configuration encountered during normal sleep in a 9-year-old boy. The mouth is closed and the oral cavity (small arrowheads) is collapsed. The hypopharynx (arrows) and nasopharynx (large arrowhead) are patent.

View larger version (145K): [in a new window]   Figure 2a. Optimal level to perform transverse cine MR imaging at level of the middle portion of the tongue is shown in a 14-year-old boy with cerebral palsy. (a) Sagittal midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows appropriate level (line) for transverse cine images to be obtained. (b) Transverse gradient-echo cine MR image (8200/3600, 80° flip angle, 12-mm section thickness, 128 images obtained) obtained at level corresponding to the line in a. Arrows = hypopharynx, T = floor of mouth.

View larger version (128K): [in a new window]   Figure 2b. Optimal level to perform transverse cine MR imaging at level of the middle portion of the tongue is shown in a 14-year-old boy with cerebral palsy. (a) Sagittal midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows appropriate level (line) for transverse cine images to be obtained. (b) Transverse gradient-echo cine MR image (8200/3600, 80° flip angle, 12-mm section thickness, 128 images obtained) obtained at level corresponding to the line in a. Arrows = hypopharynx, T = floor of mouth.

View larger version (133K): [in a new window]   Figure 3a. Artifacts associated with dental braces interfere with area of interest on sagittal midline T1-weighted SE MR images (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) in a 15-year-old boy. (a) With dental braces in place, marked artifact (arrows) obscures depiction of portions of area of interest. (b) After removal of dental braces, glossoptosis is seen. Posterior aspect of tongue (arrow) abuts posterior pharyngeal wall.

View larger version (138K): [in a new window]   Figure 3b. Artifacts associated with dental braces interfere with area of interest on sagittal midline T1-weighted SE MR images (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) in a 15-year-old boy. (a) With dental braces in place, marked artifact (arrows) obscures depiction of portions of area of interest. (b) After removal of dental braces, glossoptosis is seen. Posterior aspect of tongue (arrow) abuts posterior pharyngeal wall.

View larger version (150K): [in a new window]   Figure 4a. MR imaging findings related to placement of nasal trumpet to establish patent airway. (a) Sagittal off-midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows nasal trumpet (arrows) bypassing enlarged adenoids and glossoptosis in a 15-year old patient. Nasal trumpet passes inferior to level of the tongue. (b–e) Sagittal gradient-echo cine images (80° flip angle, 8200/3600, 12-mm section thickness, 128 images acquired) in 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy show changes in dynamic motion of the airway. (b, c) Images obtained at two points during respiratory cycle with nasal trumpet (not visible) show difference in diameter of hypopharynx (arrows) to be minimal. (d, e) Images obtained at two points during respiratory cycle without nasal trumpet in place show marked differences in diameter of hypopharynx (arrows), with intermittent collapse.

View larger version (135K): [in a new window]   Figure 4b. MR imaging findings related to placement of nasal trumpet to establish patent airway. (a) Sagittal off-midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows nasal trumpet (arrows) bypassing enlarged adenoids and glossoptosis in a 15-year old patient. Nasal trumpet passes inferior to level of the tongue. (b–e) Sagittal gradient-echo cine images (80° flip angle, 8200/3600, 12-mm section thickness, 128 images acquired) in 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy show changes in dynamic motion of the airway. (b, c) Images obtained at two points during respiratory cycle with nasal trumpet (not visible) show difference in diameter of hypopharynx (arrows) to be minimal. (d, e) Images obtained at two points during respiratory cycle without nasal trumpet in place show marked differences in diameter of hypopharynx (arrows), with intermittent collapse.

View larger version (130K): [in a new window]   Figure 4c. MR imaging findings related to placement of nasal trumpet to establish patent airway. (a) Sagittal off-midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows nasal trumpet (arrows) bypassing enlarged adenoids and glossoptosis in a 15-year old patient. Nasal trumpet passes inferior to level of the tongue. (b–e) Sagittal gradient-echo cine images (80° flip angle, 8200/3600, 12-mm section thickness, 128 images acquired) in 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy show changes in dynamic motion of the airway. (b, c) Images obtained at two points during respiratory cycle with nasal trumpet (not visible) show difference in diameter of hypopharynx (arrows) to be minimal. (d, e) Images obtained at two points during respiratory cycle without nasal trumpet in place show marked differences in diameter of hypopharynx (arrows), with intermittent collapse.

View larger version (155K): [in a new window]   Figure 4d. MR imaging findings related to placement of nasal trumpet to establish patent airway. (a) Sagittal off-midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows nasal trumpet (arrows) bypassing enlarged adenoids and glossoptosis in a 15-year old patient. Nasal trumpet passes inferior to level of the tongue. (b–e) Sagittal gradient-echo cine images (80° flip angle, 8200/3600, 12-mm section thickness, 128 images acquired) in 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy show changes in dynamic motion of the airway. (b, c) Images obtained at two points during respiratory cycle with nasal trumpet (not visible) show difference in diameter of hypopharynx (arrows) to be minimal. (d, e) Images obtained at two points during respiratory cycle without nasal trumpet in place show marked differences in diameter of hypopharynx (arrows), with intermittent collapse.

View larger version (147K): [in a new window]   Figure 4e. MR imaging findings related to placement of nasal trumpet to establish patent airway. (a) Sagittal off-midline T1-weighted SE image (400/minimal, 22-cm field of view, 4-mm section thickness with 1-mm gap, 256 x 192 matrix, two signals acquired) shows nasal trumpet (arrows) bypassing enlarged adenoids and glossoptosis in a 15-year old patient. Nasal trumpet passes inferior to level of the tongue. (b–e) Sagittal gradient-echo cine images (80° flip angle, 8200/3600, 12-mm section thickness, 128 images acquired) in 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy show changes in dynamic motion of the airway. (b, c) Images obtained at two points during respiratory cycle with nasal trumpet (not visible) show difference in diameter of hypopharynx (arrows) to be minimal. (d, e) Images obtained at two points during respiratory cycle without nasal trumpet in place show marked differences in diameter of hypopharynx (arrows), with intermittent collapse.

View larger version (172K): [in a new window]   Figure 5a. Recurrent and enlarged adenoids in a 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy. (a) Sagittal midline fast SE IR MR image (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) shows recurrent and enlarged adenoids (A), which encroach on the nasopharynx. (b, c) Transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images) obtained at level of base of the tongue. (b) At one point during respiratory cycle, airway (*) is patent. (c) At another point during respiratory cycle, airway shows cylindric collapse (arrows) with anterior, posterior, and lateral walls of hypopharynx having moved centrally.

View larger version (137K): [in a new window]   Figure 5b. Recurrent and enlarged adenoids in a 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy. (a) Sagittal midline fast SE IR MR image (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) shows recurrent and enlarged adenoids (A), which encroach on the nasopharynx. (b, c) Transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images) obtained at level of base of the tongue. (b) At one point during respiratory cycle, airway (*) is patent. (c) At another point during respiratory cycle, airway shows cylindric collapse (arrows) with anterior, posterior, and lateral walls of hypopharynx having moved centrally.

View larger version (136K): [in a new window]   Figure 5c. Recurrent and enlarged adenoids in a 9-year-old girl with obstructive sleep apnea despite previous adenoidectomy. (a) Sagittal midline fast SE IR MR image (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) shows recurrent and enlarged adenoids (A), which encroach on the nasopharynx. (b, c) Transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images) obtained at level of base of the tongue. (b) At one point during respiratory cycle, airway (*) is patent. (c) At another point during respiratory cycle, airway shows cylindric collapse (arrows) with anterior, posterior, and lateral walls of hypopharynx having moved centrally.

View larger version (166K): [in a new window]   Figure 6. Postoperative MR appearance of recurrent enlarged adenoid tonsils in 10-year-old boy with Down syndrome. Transverse fast SE IR image (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) shows enlarged adenoids (A), which measured 20 mm in anterior-posterior diameter. Note central wedgelike defect (arrow) in adenoids, which is related to previous adenoidectomy.

View larger version (124K): [in a new window]   Figure 7a. Fast SE IR MR images (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) of enlarged palatine tonsils in a 2-year-old boy with history of micrognathia and recurrent obstructive sleep apnea after mandibular extraction procedure. (a) Transverse image shows enlarged palatine tonsils (P) as well-defined high-signal-intensity structures in palatine fossa. (b) Sagittal image obtained through palatine fossa shows superior-to-inferior extent of enlarged palatine tonsil (P), as well as adenoids (A).

View larger version (161K): [in a new window]   Figure 7b. Fast SE IR MR images (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) of enlarged palatine tonsils in a 2-year-old boy with history of micrognathia and recurrent obstructive sleep apnea after mandibular extraction procedure. (a) Transverse image shows enlarged palatine tonsils (P) as well-defined high-signal-intensity structures in palatine fossa. (b) Sagittal image obtained through palatine fossa shows superior-to-inferior extent of enlarged palatine tonsil (P), as well as adenoids (A).

View larger version (158K): [in a new window]   Figure 8a. Enlarged lingual tonsils in a 13-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) Sagittal and (b) transverse fast SE IR MR images (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) show enlarged lingual tonsil (arrows) filling and obstructing the hypopharynx.

View larger version (139K): [in a new window]   Figure 8b. Enlarged lingual tonsils in a 13-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) Sagittal and (b) transverse fast SE IR MR images (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) show enlarged lingual tonsil (arrows) filling and obstructing the hypopharynx.

View larger version (175K): [in a new window]   Figure 9. Glossoptosis in 7-year-old boy with persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. Sagittal fast SE IR MR image (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) shows tongue positioned posteriorly, such that the posterior aspect of the tongue (arrow) abuts the posterior wall of the hypopharynx, leading to occlusion and displacement of the soft palate posteriorly (arrowheads). There is recurrence of the adenoids (A).

View larger version (165K): [in a new window]   Figure 10a. Sagittal gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images) show glossoptosis in 8-year-old boy with persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) At one point during the respiratory cycle, the hypopharynx is patent, with the posterior aspect of the tongue (arrow) separated from the posterior wall of the hypopharynx. (b) At anther point during the respiratory cycle, the posterior aspect of the tongue has moved posteriorly, collapsing the hypopharynx (arrows) and displacing the soft palate posteriorly (arrowhead).

View larger version (166K): [in a new window]   Figure 10b. Sagittal gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images) show glossoptosis in 8-year-old boy with persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) At one point during the respiratory cycle, the hypopharynx is patent, with the posterior aspect of the tongue (arrow) separated from the posterior wall of the hypopharynx. (b) At anther point during the respiratory cycle, the posterior aspect of the tongue has moved posteriorly, collapsing the hypopharynx (arrows) and displacing the soft palate posteriorly (arrowhead).

View larger version (128K): [in a new window]   Figure 11a. Comparison between hypopharyngeal collapse and glossoptosis with regard to hypopharyngeal wall motion patterns on transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images). (a, b) Hypopharyngeal collapse in 8-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (b) Image obtained at same level as a but at another point during respiratory cycle shows cylindric collapse (arrows) of airway, with anterior, posterior, and lateral walls of hypopharynx moving centrally. (c, d) Glossoptosis in 13-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (c) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (d) Image obtained at same level as c but at another point during respiratory cycle shows airway collapse (arrows), which is related to posterior motion of the tongue rather than cylindric collapse of the airway.

View larger version (135K): [in a new window]   Figure 11b. Comparison between hypopharyngeal collapse and glossoptosis with regard to hypopharyngeal wall motion patterns on transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images). (a, b) Hypopharyngeal collapse in 8-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (b) Image obtained at same level as a but at another point during respiratory cycle shows cylindric collapse (arrows) of airway, with anterior, posterior, and lateral walls of hypopharynx moving centrally. (c, d) Glossoptosis in 13-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (c) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (d) Image obtained at same level as c but at another point during respiratory cycle shows airway collapse (arrows), which is related to posterior motion of the tongue rather than cylindric collapse of the airway.

View larger version (160K): [in a new window]   Figure 11c. Comparison between hypopharyngeal collapse and glossoptosis with regard to hypopharyngeal wall motion patterns on transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images). (a, b) Hypopharyngeal collapse in 8-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (b) Image obtained at same level as a but at another point during respiratory cycle shows cylindric collapse (arrows) of airway, with anterior, posterior, and lateral walls of hypopharynx moving centrally. (c, d) Glossoptosis in 13-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (c) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (d) Image obtained at same level as c but at another point during respiratory cycle shows airway collapse (arrows), which is related to posterior motion of the tongue rather than cylindric collapse of the airway.

View larger version (162K): [in a new window]   Figure 11d. Comparison between hypopharyngeal collapse and glossoptosis with regard to hypopharyngeal wall motion patterns on transverse gradient-echo cine MR images (8200/3600, 80° flip angle, 12-mm section thickness, 128 images). (a, b) Hypopharyngeal collapse in 8-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (a) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (b) Image obtained at same level as a but at another point during respiratory cycle shows cylindric collapse (arrows) of airway, with anterior, posterior, and lateral walls of hypopharynx moving centrally. (c, d) Glossoptosis in 13-year-old boy with Down syndrome and persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy. (c) Image obtained at level of the base of the tongue at one point during respiratory cycle shows airway (*) to be patent. (d) Image obtained at same level as c but at another point during respiratory cycle shows airway collapse (arrows), which is related to posterior motion of the tongue rather than cylindric collapse of the airway.

View larger version (171K): [in a new window]   Figure 12. MR findings of edematous soft palate in a 5-year-old girl with obstructive sleep apnea. Midline sagittal fast SE IR image (5000/34, echo train length of 12, 22-cm field of view, 6-mm section thickness with 2-mm gap, 256 x 192 matrix, two signals acquired) shows high signal intensity within soft palate (arrows), consistent with edema. Note high signal intensity of soft palate compared with that of tongue musculature (T).

View larger version (64K): [in a new window]   Figure 13. Differences in dynamic motion of hypopharynx in 2-year-old boy with inability to tolerate tracheotomy tube decannulation. Volume segmentation of transverse cine MR data depicted on graph of hypopharyngeal airway volume versus time. Note markedly increased changes in volume when tracheotomy tube is capped (gray line) compared with when tube is not capped (black line).