The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc. Utility of Brain MRI in Children With Sleep-Disordered Breathing Sarah Selvadurai, BSc; Suhail Al-Saleh, MBBS, FRCPC, MSc; Reshma Amin, MD, FRCPC, MSc; Allison Zweerink, NP-Peds; James Drake, MBBCH, FRCSC, MSc; Evan J. Propst, MD, MSc, FRCSC; Indra Narang, MBBCH, MD Objectives/Hypothesis: To investigate the utility of a brain magnetic resonance imaging (MRI) in children with sleep- disordered breathing (SDB), classified as isolated obstructive sleep apnea (OSA) in the absence of adenotonsillar hypertrophy, persistent OSA following adenotonsillectomy, isolated central sleep apnea (CSA) of unclear etiology, OSA with coexisting CSA of unclear etiology, or unexplained nocturnal hypoventilation (NH). Study Design: Retrospective chart review of polysomnography (PSG) and brain MRI data. Methods: Children with PSG evidence of SDB, as described above, and who subsequently had their first brain MRI, were included. PSG, MRI data, and subsequent interventions were recorded. Results: A total of 59 of 6,087 (1%) children met inclusion criteria. Of those, 28 of 59 (47%) were nonsyndromic chil- dren and 31 of 59 (53%) were syndromic children with an underlying medical disorder. Abnormal brain MRI findings were observed in 19 of 59 (32%) children, where eight of 19 (42%) were nonsyndromic and 11 of 19 (58%) were syndromic. Abnormal brain MRI findings were most common in syndromic children with combined OSA and CSA without adenotonsillar hypertrophy. Isolated OSA was also a common PSG finding associated with an abnormal brain MRI. Of the nonsyndromic chil- dren with an abnormal brain MRI, the most common abnormal brain MRI finding was Chiari malformation (CM), observed in 88% of the group. A brainstem tumor was identified in one nonsyndromic child. Interventions following brain MRI included neurosurgery, chemotherapy, and noninvasive positive pressure ventilation (NiPPV). Conclusion: A brain MRI is an important diagnostic tool in syndromic and nonsyndromic children, especially in children with either isolated OSA or combined OSA and CSA without a clear etiology. Key Words: Pediatric, magnetic resonance imaging, sleep-disordered breathing, persistent, sleep apnea, obstructive, central. Level of Evidence: 4. Laryngoscope, 00:000–000, 2016 INTRODUCTION Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing (SDB) in children, with central sleep apnea (CSA) and nocturnal hypoventi- lation (NH) syndrome being diagnosed much less fre- quently. Obstructive sleep apnea affects 1% to 4% of otherwise healthy children and is characterized by pro- longed partial or complete airway obstruction that may disrupt normal ventilation during sleep and predispose to sleep fragmentation. 1,2 In healthy, nonobese children, the most common etiologic factor for OSA is adenotonsil- lar hypertrophy; as such, an adenotonsillectomy (AT) is curative in > 70% of patients. 3 However, those children with persistent OSA following AT are usually treated with noninvasive positive pressure ventilation (NiPPV) such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (Bi-level PAP). 1,2,4 Cen- tral sleep apnea is characterized by a lack of drive to breathe during sleep, which results in compromised gas exchange. 5,6 Inadequate ventilation may result in NH. CSA and NH can be treated with NiPPV and/or oxygen therapy. 7–9 In more severe cases, invasive ventilation via a tracheotomy may be the treatment of choice. In children, a polysomnography (PSG) diagnosis of OSA in the absence of adenotonsillar hypertrophy or per- sistent significant OSA following AT poses a diagnostic and management dilemma for clinicians. Although tonsil size did not correlate with OSA severity in one study with 70 healthy children, a larger proportion of patients with large tonsils (Brodsky grade 31/41) had complete resolu- tion of OSA following AT compared with those who had smaller tonsils (Brodsky grade 21). 10 Similarly, a system- atic review of 20 articles comparing subjective tonsil size to polysomnography (PSG) severity revealed only a weak correlation, if any. 11 In syndromic children—children with underlying medical disorders—persistent OSA following AT may be due to lingual tonsil hypertrophy and/or rela- tive macroglossia in Down syndrome, Beckwith- Wiedemann syndrome, or velocardiofacial syndrome. 12 However, not all of these patients are cured of their OSA From the Division of Respiratory Medicine (S.S., S.A-S. R.A., A.Z., I.N.); the Division of Neurosurgery (J.D.); the Department of Otolaryngol- ogy–Head & Neck Surgery (E.J.P .), Hospital for Sick Children; and the University of Toronto (S.S., S.A-S., R.A., J.D., E.J.P ., I.N.), Toronto, Ontario, Canada. Editor’s Note: This Manuscript was accepted for publication March 25, 2016. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Dr. Indra Narang, Division of Respiratory Medicine, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada. E-mail: indra.narang@sickkids.ca DOI: 10.1002/lary.26042 Laryngoscope 00: Month 2016 Selvadurai et al.: Brain MRI for SleepDisordered Breathing 1