Overview
Definition:
Sleep-disordered breathing (SDB) in children encompasses a spectrum of conditions characterized by abnormal respiratory patterns during sleep
The most common form is obstructive sleep apnea (OSA), a condition where the upper airway becomes partially or completely blocked during sleep, leading to intermittent hypoxemia and hypercapnia
Adenotonsillar hypertrophy is a leading cause of pediatric OSA.
Epidemiology:
The prevalence of SDB in children varies widely depending on age and diagnostic criteria, ranging from 1% to over 5%
Obstructive sleep apnea is estimated to affect 1-4% of children, with a higher incidence in obese children and those with craniofacial abnormalities
Adenotonsillar hypertrophy is present in a significant proportion of children with SDB.
Clinical Significance:
Undiagnosed and untreated SDB, particularly OSA, can have significant long-term consequences for children, including impaired neurocognitive development, behavioral problems, cardiovascular complications (hypertension, arrhythmias), and metabolic disturbances
Early diagnosis and appropriate management, including adenotonsillectomy in select cases, are crucial for improving quality of life and preventing serious health issues.
Clinical Presentation
Symptoms:
Loud snoring
Witnessed apneas or pauses in breathing during sleep
Restless sleep or frequent awakenings
Daytime sleepiness or fatigue
Morning headaches
Behavioral changes including hyperactivity or inattention
Poor school performance
Nocturnal enuresis (bedwetting)
Poor growth or failure to thrive.
Signs:
Obesity
Oropharyngeal findings: enlarged tonsils (Friedman classification Grade 3-4), enlarged adenoids, narrow dental arch, retrognathia, macroglossia
Nasal obstruction
Mouth breathing
Paradoxical chest wall movements during sleep
Poor school performance
Behavioral issues.
Diagnostic Criteria:
Diagnostic criteria for pediatric OSA typically involve a combination of clinical history, physical examination, and polysomnography (PSG)
A respiratory disturbance index (RDI) or apnea-hypopnea index (AHI) of >= 5 events per hour in the presence of symptoms, or >= 1 event per hour in asymptomatic children, is generally considered diagnostic
Other SDB diagnoses are based on specific polysomnographic findings.
Diagnostic Approach
History Taking:
Detailed history from parents/caregivers is paramount
Inquire about snoring characteristics (loudness, regularity), witnessed apneas, breathing pauses, restless sleep, daytime behavior, school performance, and presence of comorbidities like obesity, asthma, or craniofacial anomalies
Ask about any history of tonsillitis or frequent upper respiratory infections.
Physical Examination:
Comprehensive head and neck examination focusing on airway patency
Assess tonsillar size (tonsillar grading scale), adenoid size (indirect or fiberoptic visualization if possible), nasal airway, dentition, palate shape, and mandibular position
Evaluate for signs of obesity, cardiopulmonary status, and neurological development
Measure height and weight to calculate BMI.
Investigations:
Polysomnography (PSG) is the gold standard for diagnosing SDB and OSA
It measures airflow, respiratory effort, oxygen saturation, heart rate, electroencephalogram (EEG), electrooculogram (EOG), and electromyogram (EMG) during sleep
Overnight pulse oximetry can be a screening tool but is not diagnostic for OSA
Lateral neck X-ray or CT scan may be used to assess adenotonsillar size and airway dimensions, but is not a substitute for PSG.
Differential Diagnosis:
Other causes of upper airway obstruction, such as laryngomalacia, tracheomalacia, vocal cord paralysis, and choanal atresia
Central sleep apnea
Narcolepsy or other primary sleep disorders
Behavioral issues mimicking SDB symptoms
Asthma or other pulmonary conditions causing nocturnal cough or dyspnea.
Management
Initial Management:
Weight loss is a cornerstone for obese children with SDB
Positioning (avoiding supine sleeping), nasal saline sprays, and allergen avoidance may be considered for mild cases
CPAP or BiPAP therapy is indicated for moderate to severe OSA or when surgery is not feasible or has failed.
Medical Management:
Weight management programs, including dietary modifications and increased physical activity
Medications are generally not first-line for SDB itself but may be used to manage comorbidities like asthma or ADHD
Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy is the primary non-surgical treatment for moderate to severe OSA.
Surgical Management:
Adenotonsillectomy is the surgical treatment of choice for pediatric OSA secondary to adenotonsillar hypertrophy
Indications for adenotonsillectomy in SDB include: moderate to severe OSA (AHI >= 5 with symptoms, or >= 10 in asymptomatic children) confirmed by PSG, tonsillar enlargement that is clearly obstructive, and failure or intolerance to CPAP therapy
Other indications for tonsillectomy include recurrent tonsillitis (e.g., >7 episodes in the past year, >5 episodes per year for 2 years, or >3 episodes per year for 3 years).
Supportive Care:
Close monitoring of respiratory status and oxygen saturation, especially post-operatively
Education for parents regarding CPAP use, humidification, and mask fitting if applicable
Nutritional counseling for weight management
Behavioral therapy for associated behavioral issues
Sleep hygiene education.
Complications
Early Complications:
Bleeding (hemorrhage) from the surgical site, typically occurring within the first 24 hours or 7-10 days post-operatively
Pain and discomfort
Dehydration
Anesthesia-related complications
Infection
Airway obstruction (rare but serious).
Late Complications:
Residual or recurrent SDB if adenotonsillar tissue regrows or if other airway issues persist
Velopharyngeal insufficiency (VPI) leading to nasal regurgitation or speech changes (rare after adenoidectomy)
Scarring or synechiae formation
Chronic pain
Failure to achieve optimal neurocognitive or behavioral outcomes if SDB was prolonged.
Prevention Strategies:
Meticulous surgical technique to minimize bleeding
Adequate hydration and pain control post-operatively
Parental education on signs of bleeding and when to seek immediate medical attention
Careful patient selection for adenotonsillectomy to ensure appropriate indications
Trial of conservative management for mild SDB
Early intervention with CPAP if indicated.
Prognosis
Factors Affecting Prognosis:
Severity of SDB, presence of comorbidities (obesity, craniofacial anomalies), adherence to treatment (CPAP or post-operative care), and timing of intervention
Obesity is a significant factor impacting long-term outcomes.
Outcomes:
Adenotonsillectomy is highly effective in resolving SDB in most children with moderate to severe OSA due to adenotonsillar hypertrophy, with cure rates of up to 80%
Significant improvement in snoring, breathing, daytime behavior, and neurocognitive function is expected
CPAP therapy is effective in managing OSA but requires long-term adherence.
Follow Up:
Post-adenotonsillectomy, a follow-up PSG is recommended within 3-6 months to confirm resolution of OSA, especially in severe cases or in the presence of residual risk factors
Children with SDB should have regular monitoring for growth, development, and behavior
For those on CPAP, regular device checks and follow-up with a sleep specialist are essential.
Key Points
Exam Focus:
Understand the spectrum of SDB, with OSA being the most common
Recognize the strong association between adenotonsillar hypertrophy and pediatric OSA
Master the indications for adenotonsillectomy based on PSG findings and clinical presentation
Differentiate surgical from medical management of SDB
Know the complications of adenotonsillectomy and their management.
Clinical Pearls:
Always consider SDB in children with snoring and daytime behavior issues, especially if obese
Do not rely solely on visual inspection of tonsils
PSG is crucial for diagnosis and management decisions
Post-operative bleeding after adenotonsillectomy is a critical concern
educate parents well
A multidisciplinary approach involving otolaryngology, pulmonology, and sleep medicine is often beneficial.
Common Mistakes:
Attributing snoring solely to "habit" without further investigation
Delaying PSG in children with suspected OSA
Performing adenotonsillectomy without objective evidence of significant airway obstruction or PSG confirmation of OSA
Underestimating the impact of obesity on SDB severity and treatment outcomes
Inadequate post-operative care and parental education after adenotonsillectomy.