Pediatric Sleep Apnea

Anh Q. Truong, MD

Bellevue ENT

1231 116th Avenue NE, Suite 915

Bellevue, WA 98004

Phone: (425) 454 - 3938

What are the tonsils and adenoid?

The palatine tonsils are a pair of lymphoid tissue in the back of throat that can be visualized through the mouth. The adenoid is a mass of lymphoid tissue located deep behind the nose. The adenoid can only be visualized with special a endoscopic equipment. The tonsils and adenoid have immune cells covered by mucosa with invaginations that are called crypts.

What are the functions of tonsils?

The tonsils and adenoid are a small part of the lymphatic system which helps fight infections. Other major immune and lymphatic organs include lymph nodes, the thymus, and the spleen. The tonsils and adenoid typically regress as you get older. In most adults, the adenoid and tonsils are typically much smaller.

What is sleep disordered breathing (SDB) and pediatric obstructive sleep apnea (OSA)?

Sleep-disordered breathing is a general term describing a spectrum of sleep disturbances, ranging from snoring to obstructive sleep apnea. Snoring can occur in 10% of the pediatric population while obstructive sleep apnea is seen in about 4% of the pediatric population. Sleep disturbances may lead to both fatigue and behavioral changes.

Obstructive sleep apnea occurs when a child has a partial or complete blockage of the airway during sleep, resulting in disrupted sleep, decreased oxygen level, decreased heart rate and increased blood pressure.

How do sleep disordered breathing and obstructive sleep apnea typically present?

Signs of sleep-disordered breathing and sleep apnea include loud snoring, breath holding while sleeping, waking up coughing and gasping for air, snorting and frequent awakening throughout the night. While not always present, the finding of enlarged tonsils and nasal congestion are common.

More importantly, children with SDB and OSA may have difficulty waking up and getting started in the morning, fatigue and sleepiness throughout the day and in school, trouble concentrating, inattentiveness, irritability, hyperactivity, and bedwetting. Other systemic symptoms include hypertension, slow growth and development and weight gain.

How is obstructive sleep apnea diagnosed and classified?

Pediatric sleep-disordered breathing and obstructive sleep apnea can usually be diagnosed by the history and physical exam alone. In cases which the history is equivocal or in patients with other concurrent syndrome/significant co-morbidities, a sleep study (polysomnography) can be obtained to further characterize sleep apnea. Sleep studies can occasionally be inaccurate in children. As a result, the parent’s history the clinical picture remains a critical feature of the diagnosis.

When a sleep study is obtained, multiple different variables are considered. The apnea-hypopnea index (AHI) is often reported. The AHI is the average number of significant respiratory event that occurs per hour. An AHI of 1-5 is considered mild OSA, 6-10 is mild to moderate, 11-20 is moderate, and greater than 20 is considered severe. Because apnea is rare in children, anything AHI greater than 1 is considered abnormal.

Why is it important to treat sleep apnea in the pediatric population?

There have been multiple studies which correlate obstructive sleep apnea with behavioral changes and cognitive impairment. While the studies are well established, public awareness of pediatric sleep apnea is still poor. Obstructive sleep apnea can cause a constellation of symptoms including difficulty waking up and getting started in the morning, fatigue and sleepiness throughout the day and in school, trouble concentrating, inattentiveness, irritability, hyperactivity, and bedwetting. Other systemic symptoms include hypertension, weight gain, and slow growth and development.

How is obstructive sleep apnea treated?

A tonsillectomy and adenoidectomy are typically the first line of treatment for pediatric obstruct sleep apnea. It will eliminate OSA symptoms in most patients. In patients with craniofacial abnormalities, obesity or neurological disorders, additional treatment such as positive airway pressure therapy (PAP) or craniofacial surgery may be needed.

When is a tonsillectomy and adenoidectomy (T&A) surgery indicated?

It is usually indicated in patients who have signs and symptoms of obstructive sleep apnea. Other indications include recurrent and chronic tonsillitis and abnormal enlargement of the tonsil. Relative indications for a tonsillectomy include trouble swallowing, voice change and chronic tonsil stones (tonsilliths).

Please click here to learn more about tonsillectomy and adenoidectomy and post-operative care for a T&A.

References:

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