Symptoms Diagnosis and Treatment
Snoring and Obstructive Sleep apnea Syndrome in children is getting more common in India. More to do with affluence and resulting obesity makes the issue worse. Few decades ago I rarely used to see children with sleep apnea. Those days tonsillitis was the common cause for Tonsillectomy. Now the scenario has changed in countries like India.
Obstructive sleep apnea (OSA) is a condition in which there are brief stoppages in breathing during sleep.
Although your child may not be aware he or she is waking up, these interruptions in sleep can lead to lack of oxygen to brain and other vital organs in the body.
Tonsils: Between the age of two and five, the tonsils become large in size and may be large enough to touch each other. It is normal for a young child to have large tonsils, and if they appear normal and are not causing any problem the size of the tonsils alone is generally not a concern. The tonsils are lymphoid tissue, that is, one of the things that the body uses to fight infections. But they only represent a small portion of the body’s defense systems; lymphoid tissue is present all along the lining of the nose and throat.
Adenoids: The “adenoid” is the name given to a third lump of lymphoid tissue that sits between the tonsils, above the palate (the roof of the mouth), in the back of the nose. This tissue cannot be seen without special instruments or X-rays or CT scan, since it is hidden from view by the palate. It is located in an area called the nasopharynx, and if it is large enough, it can block air from flowing through the nose.
Just as with tonsils, it is normal for a young child have large adenoids, and the simple fact that the adenoid pad is large is not a reason for surgery. Babies are born without visible tonsils and adenoids. The adenoids begin to grow in the first year of life, peak in size between age one and five, then slowly get smaller as a child grows. While the occasional teenager may still have adenoids big enough to cause blockage of the nose, this is rare and the adenoids typically shrink away before adolescence.
Tonsils and adenoids cause snoring and sleep apnea
The path that air takes from the nose through the throat down into the lungs is called the airway. The tonsils and adenoids form a ring of tissue in the back of the throat. If the tonsils and adenoids are large, they narrow the airway and reduce the flow of air into and out of the lungs.
Even if the tonsils and adenoids are very large, they generally do not cause significant breathing difficulties while a child is awake. They may cause lesser symptoms such as a continuous stuffy nose, “nasal” speech, drooling or a habit of keeping the mouth open, but these alone are rarely reasons for surgery.
During sleep, however, the muscles of the throat relax. Air flowing through the narrowed space results in a drop in air pressure. The combination of relaxed muscles and low pressure causes collapse of the throat and the child will be temporarily unable to breathe (apnea). After a few seconds of struggling, the child is partially aroused from sleep by the apnea (although he or she will not completely wake up), the muscle tone returns, and the throat opens- often with a gasp. A child may go through many of these cycles in an hour, resulting in a disturbance of the normal sleep patterns. This condition is known as Obstructive Sleep Apnea (OSA).
Causes of Snoring and Sleep Apnea in Children
The most common cause of sleep apnea in children is enlarged tonsils and adenoids that block the airway and breathing during sleep. During the daytime, muscles in the head and neck more easily keep the airway passages open. During sleep, muscle tone decreases, allowing tissue to come closer together and these large tonsils and adenoids tend to block the airway for periods of time. Other tissues in the nose, neck and the tongue also contribute.
Other causes of OSA include:
and obesity and retrognathia (small jaw)
and narrow facial bone structure
and low muscle tone (hypotonia as in neuromuscular diseases)
and high muscle tone (as in cerebral palsy)
and Sleep apnea also occurs more commonly in children with Down syndrome.
and Other children who may be at greater risk for developing OSA include those with nasal allergies, asthma, reflux, and frequent upper airway infections.
What are the signs and symptoms of obstructive sleep apnea?
and loud snoring, or mouth breathing during sleep
and brief pauses in breathing during sleep or difficulty breathing during sleep
and restless sleep ( lots of tossing and turning)
and sweating heavily during sleep
and bed wetting
and sleeping in odd positions
and excessive daytime sleepiness (child falls asleep in school)
and poor academic performance
and irritable mood, aggressiveness, other behavioral problems
and morning headaches
How is obstructive sleep apnea diagnosed?
and Sleep history a report of your child\’s nightly sleeping pattern.
and Upper airway evaluation by instrument evaluation and/or by X-rays or CT scan.
and Sleep study also called a polysomnogram. This test is usually conducted in a specialized sleep room with an adult caretaker nearby. It can be done at home too (Home Sleep Study). It measures your child\’s brain activity, heart rate, amount of air flow through the mouth and nose, oxygen and carbon dioxide content in the blood, muscle activity, chest and abdominal wall movement and sleep interruptions.
Treatment for obstructive sleep apnea:
The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway blockage in children, the treatment is surgery and removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy). Your child’s ENT Surgeon will discuss the treatment options, risks, and benefits with you. This surgery requires general anesthesia. Depending on the health of the child, surgery may be performed on an outpatient basis.
During the surgery, your child will be anesthetized in the operating room. The surgeon will remove your child’s tonsils and adenoids through the mouth. There will be no cut on the skin.
In most cases, after the surgery, your child will go to a recovery room where he/she can be monitored closely. After the child is fully awake and doing well, the recovery room nurse will bring the child back to the day surgery area.
At this point, if everything is going well, you and your child will be able to go home. If your child is going to stay the night in the hospital, the child will be brought from the recovery room to his/her room. Usually, the parents are in the room to meet the child.Bleeding is a complication of this surgery and should be addressed immediately by the surgeon. If the bleeding is severe, the child may return to the operating room.
If the cause of the disorder is obesity, less invasive treatments may be appropriate, including weight loss and wearing a special mask while sleeping to keep the airway open. This mask delivers continuous positive airway pressure (CPAP). The device itself is often clumsy, and it may be difficult to convince a child to wear such a mask.
Continuous positive airway pressure (CPAP) — CPAP involves wearing a mask over the nose during sleep. The mask is attached to a small portable machine that blows air through the nasal passages and into the airway. The air pressure generated by the machine keeps your child\’s airway open and allows him or her to breathe normally during sleep.
