What is Snoring and Sleep Apnea?
Snoring is the sound produced by vibration of the uvula and soft palate while the child is sleeping. The opening and closing of the air passage causes a vibration of the tissues in the throat. The loudness is affected by how much air is passing through and how fast the throat tissue is vibrating. Loud and regular nightly snoring is often abnormal in otherwise healthy children. Sometimes it is a sign of a respiratory infection, a stuffy nose or allergy; other times it may be a symptom of obstructive sleep apnea.
Obstructive sleep apnea (OSA) is a disorder in which a person stops breathing during the night, perhaps hundreds of times. These stoppages of breathing are called apneas. The word apnea means absence of breath. An obstructive apnea episode is defined as the absence of airflow for at least 10 seconds. Sleep apnea is usually accompanied by snoring, disturbed sleep, and daytime sleepiness. Obstructive sleep apnea (OSA) occurs when tissues in the upper throat collapse at different times during sleep, thereby blocking the passage of air.
Young children’s tonsils and adenoid are quite large in comparison to the throat, peaking at five to seven years of age. Swollen tonsils and adenoid can block the airway, making it difficult to breathe and could signify apnea.
About Tonsil and Adenoid
The tonsils are located in the back of the mouth on each side. The adenoids are in the back of the nose. The tonsils can be seen by looking in the mouth, but the adenoids usually cannot be seen on routine exam. Evaluating the adenoids usually requires passing an endoscope through the nose, using a mirror in the back of the mouth or obtaining an x-ray or CT scan.
Why Tonsil Adenoid in Children?
Tonsils and adenoids are lymphoid tissue and part of the immune system, but their role is limited. Removing tonsils and adenoids does not weaken the immune system. Instead, their removal may actually reduce the frequency of illnesses in some children.
Problems of Enlarged Adenoid and Tonsil
Children with obstructive sleep may experience excessive daytime sleepiness including fatigue and may fall asleep at inappropriate times. In actuality, the more common daytime consequence of children’s poor sleep quality is irritability and poor concentration, not tiredness. They tend to be cranky. They can have difficulty concentrating resulting in poor school performance. Admittedly, to determine whether poor behavior and school performance is more due to sleep issues or other factors is difficult.
Children with enlarged tonsils and adenoids may be slow eaters and refuse certain foods due to the difficulty in chewing and breathing at the same time. They may have difficulty swallowing and occasional choking. In addition, they may have a poor appetite due to diminished senses of smell and taste resulting from poor airflow through the nose.
Delayed growth can be caused by the eating problems associated with enlarged tonsils and adenoids. Delayed growth can also result from disrupted sleep because growth hormone is predominantly produced during deep sleep. In addition to these growth issues, severe obstructive sleep apnea can, on rare occasions, lead to heart and lung problems.
Other Signs and Symptoms
• obstructed breathing during sleep (i.e. sleep apnea)
• Poor disposition and irritable behavior
• Poor appetite
• delayed growth, poor performance in school
• Constant nasal obstruction and congestion
• Poor alignment of teeth and abnormal facial development
• Mouth breathing throughout the night
• Restless and fitful sleep that result in moving all around in the bed
• sleeping in unusual positions including tilting the head back or sleeping propped up
• choking episodes, periods of not breathing or apparent struggling to breathe
• waking up or sweating during the night for unknown reasons
• Age-inappropriate bed wetting
Nasal Symptoms in Children
Enlarged adenoids, allergies, sinus infections and colds can all cause nasal obstruction. Determining which one is the cause of the obstruction can be difficult. In general, enlarged adenoids cause constant nasal obstruction without significant discharge. In contrast, nasal obstruction from allergies may fluctuate based on different seasons, locations and activities. Allergies often cause other symptoms in addition to nasal obstruction including clear discharge and itchy nose and eyes. Nasal obstruction from sinus infections and colds occurs when the child is sick and is associated with infected secretions.
Any dental problems?
Their enlargement leads to chronic mouth-breathing which may result in abnormal facial development, misalignment of the teeth, and tooth discoloration. Admittedly, not all children with enlarged tonsils and adenoids develop a poor bite requiring orthodontic work. Orthodontists have differing opinions on the need for tonsil and adenoid removal to prevent or assist with dental braces.
How to diagnosis obstructive sleep apnea?
A sleep study can be performed in the hospital or a sleep lab or at home which records numerous aspects of sleep including breathing pattern, oxygen level, heart rhythm and brain waves. By measuring these parameters, the presence and severity of obstructive sleep apnea can be determined. A formal sleep study is a reasonable consideration if uncertainty exists regarding the degree of a child’s obstructive sleep problems. On the other hand, if a parent describes a sleeping pattern consistent with significant obstruction, most physicians will proceed directly with tonsillectomy and adenoidectomy based solely on parental observations without a sleep study.
Treatment-Tonsil Adenoid Removal
Both tonsils and adenoids are removed through the mouth without any external incisions. The instruments used to remove the tonsils and adenoids vary between surgeons because none has been proven to be consistently safer, less painful and more cost-effective than another. Bleeding is usually minimal and easily controlled with electrocautery, not sutures. The time in the operating room is typically less than one hour.
A parent is allowed to go back to the recovery room once the child is becoming more alert. The child is initially upset and disoriented but soon settles down. He/she remains at the surgical facility for at least a few hours after surgery to ensure that there are no problems with pain, nausea, bleeding or breathing. If a child is having any such difficulties, or if the child is under three years old, then he/she may be admitted to a hospital overnight for observation.
Benefits of Surgery
Tonsillectomy and adenoidectomy has an excellent chance of eliminating obstructive sleep problems. If a child has fatigue, irritability, or concentration problems due to poor sleep quality, then these problems can also be improved. A child may eat better and gain weight after tonsillectomy and adenoidectomy. In addition, the surgery often allows a child to breathe better through the nose which potentially can help with normal facial and dental development. Although removal of tonsils and adenoids has multiple potential benefits, these benefits cannot be guaranteed in every case.
Any risks of tonsillectomy and adenoidectomy?
The main risk associated with tonsillectomy is bleeding. Scabs form where the tonsils are removed. These scabs fall off after approximately one week and can lead to bleeding. Stopping the bleeding may require going back to the operating room. Even in the cases of post op bleeding, needing a transfusion or choking on the blood is extremely rare. Other uncommon risks of tonsillectomy include teeth injury, taste disturbance, and cautery burns.
The main risk associated with adenoidectomy is a change in voice quality. Adenoidectomy opens more space behind the nose which allows more air into the nose while talking, possibly resulting in a high-pitched, squeaky voice. While a temporary nasal voice is common, a permanent voice problem is rare.
Dehydration can occur during recovery due to poor pain control. The duration and severity of pain varies among children. In general, the pain lasts approximately one week and can be controlled with medications. On rare occasions, the discomfort prevents adequate fluid intake, requiring a return to the hospital for intravenous (IV) fluids. Dehydration requiring intravenous fluids can also result from persisting nausea and/or vomiting.
Any alternatives to Surgery?
Antibiotics are unlikely to permanently reduce the size of tonsils and adenoids. Medical treatment of any associated allergies or chronic sinus infections may improve nasal breathing and sleep quality, but probably will not affect the size of the tonsils and adenoids.
Watchful waiting may be a reasonable alternative. Tonsils and adenoids typically get smaller as the child gets older. They usually are at maximum size around six years of age and have substantially reduced in size by around 12 years. The issue usually is not whether the child will outgrow the problem. Instead, the issue is the impact on the child’s quality of life while waiting for conditions to improve. The other concern is any long-term consequences on the heart, lung, or facial development.
My advice to parents whose child is habitually snoring
If you suspect your child may have symptoms of snoring and sleep apnea, talk to your doctor who may refer you to a ENT specialist and get an overnight sleep study. They can then offer you the most appropriate treatment.