Obstructive sleep apnea (OSA) occurs when there are episodes of upper airway obstruction during sleep. OSA occurs in 2-5% of children. Just as untreated OSA can increase health problems in adults, untreated OSA in children can lead to cardiovascular complications, impaired growth, learning, and behavioral problems.
History taking is so important in these cases. As patients are coming in for a surgical consult, I want to know if the child is also experiencing other clinical symptoms of daytime sleepiness, behavioral issues, enuresis (bedwetting at night).
After a thorough history is taken, I would then evaluate the child’s tonsils.
Just because someone’s tonsils are enlarged, it does not mean that you have to remove them. However, if you see obvious 4+ tonsils on exam and the story is fitting, the tonsils may play a role in the obstruction.
History? Check. Physical exam? Check. Where do we go from here?
The next ideal diagnostic tool would be to get a sleep study/polysomnogram (PSG).
Now, how much value is there for a sleep study? It certainly is helpful to get subjective data, however, it’s not always feasible. In which case, you may have to use your best clinical judgment. PSGs are performed in a sleep lab overnight. PSG’s record muscle movement, heart rate/ECG as well as pulse oximetry.
PSG interpretation: OSA is defined as have an apnea hypopnea index (AHI) > 1 or hypoventilation (CO2 >50 mmHg for >25% total sleep time)
AHI: the number of apneas (pauses) plus hypopneas/hour of sleep
- The decision to treat depends on a variety of factors such as the child’s age, symptoms, comorbidities and PSG results.
- If a PSG reads as mild (AHI 1-4.9) OSA, we typically recommend corticosteroids or anti-inflammatory therapy such as Flonase and Singular in conjunction with watchful waiting.
- If no improvement after their follow up visit (up to 6 months), we would then recommend surgery.
- Moderate (AHI 5-9.9) to severe (AHI >10) OSA would warrant surgery (adenotonsillectomy).
- C/C: Patient will present to the office for a complaint of “persistent snoring.” As part of my screening, I’ll also ask parents, “Have you witnessed your child gasping or stop breathing in their sleep?”
- Physical exam: tonsillar hypertrophy, look for other underlying signs such as allergies
- Assessment/Plan: Consider ordering a PSG/sleep study, if not feasible, trial of medications (Flonase, Montelukast), watchful waiting, or consideration of adenotonsillectomy (T&A)
To read more about tonsillectomies, you can check out my previous post here!
P.s. Happy Leap Day!