Snoring & Sleep Apnea

Sleep-disordered breathing (SBD) is used to describe snoring and obstructive sleep apnea (OSA) syndrome. Snoring and OSA are common medical conditions that affect 15-50% of adult population worldwide. These conditions affect children too. 

Snoring, due to the vibration of tissues in the throat, can be a symptom of partial airway obstruction. The partial obstruction can lead to complete airway obstruction (OSA). With upper airway obstruction, the oxygen supply to the brain, heart and vital organs is transiently reduced. This results in other medical complications, such as heart disease and stroke, over a long period of time. 

Snoring is sometimes accompanied with mouth breathing. Prolonged mouth breathing may result in an open bite as the child’s jaw grow and develop over time.

Studies have shown that OSA presents a huge economic burden to society. Individuals with untreated OSA are associated with poor work performances, occupational injuries and are involved in road traffic accidents more often. 

In children, OSA is manifested in poorer academic and extracurricular performances.

SYMPTOMS OF OSA

A child with OSA may have the following complaints:

  1. Snoring
  2. Excessive daytime sleepiness despite a good 8–9-hour sleep period
  3. Choking or gasping episodes during sleep 
  4. Hyperactivity in the daytime
  5. Poor academic performance
  6. Morning headaches

RISK FACTORS FOR OSA IN CHILDREN

Anatomic abnormality

Snoring and OSA can occur due to anatomic abnormality in a child’s upper airway leading to narrowing and obstruction. 

A child may have

  1. Large inferior turbinates in the nose due to untreated allergic rhinitis
  2. Nasal polyps within the nose
  3. Large adenoids at the back of the nose
  4. Large tonsils causing oral airway obstruction

In a small group of special kids, the airway narrowing may be due to underlying genetic conditions such as Pierre Robin Sequence or Treacher Collins Syndrome resulting in narrowing of the jaw and facial skeleton. 

Weight

Weight gain in children can contribute to snoring and OSA. Excessive fat accumulation around the upper airway can result in narrowing and obstruction. 

DIAGNOSIS AND EVALUATION

A child who snores persistently should be reviewed by an ENT surgeon. At the ENT office, we will perform a comprehensive examination which includes a nasoendoscopy to assess the upper airway. 

A sleep study or polysomnography may be recommended for further evaluation of the child’s sleep dynamics. 

TREATMENT

Medical treatment

Our first approach to our pediatric patients is always to manage the condition with medications before we consider surgical means. 

Most snoring children have underlying untreated or poorly treated allergic rhinitis. We endeavor to create a treatment plan which would maximize the child’s clinical response to allergic rhinitis – this may involve certain household measures, intranasal steroids, oral antihistamines and other medications.

Surgical treatment for upper airway obstruction

By and large, upper airway obstruction in children is usually related to hypertrophy of the tonsils and adenoids. In this case, surgery to remove the adenoids and tonsils will result in resolution of the symptoms, and better sleep outcomes for the child. (Please link to Tonsils and Adenoids)

Other more complex surgeries include tracheostomy, palate surgery, tongue base surgery and remodeling of the facial skeleton. These surgical methods are rarely employed in children.

Figure 1. Large tonsils causing airway obstruction in a child

Other Measures

Weight loss measures may be recommended if the child is likely to benefit. 

Continuous Positive Airway Pressure (CPAP)

As the name implies, the application of CPAP to the narrow upper airway (similar to blowing air continuously into a bouncy castle!) allows it to maintain its shape – essential for oxygen transfer. This is done via a face mask and special machine at the child’s bedside. This treatment plan is administered by a pediatric sleep physician in consultation with an ENT surgeon.

Figure 2. A child using a CPAP machine for sleep apnea

SUMMARY

A child with significant snoring at night may require a comprehensive evaluation by a pediatric ENT surgeon, and a pediatric respiratory physician. A full treatment plan can only be crafted after such a careful evaluation.

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