II. Epidemiology

  1. Prevalence in Children
    1. Obstructive Sleep Apnea: 1-5%
    2. Snoring: 3-12%
      1. Isolated loud snoring without apnea in up to 27% of children
  2. Onset: Ages 2-8 years old
  3. Gender predominance
    1. Before Puberty: Males and females equally affected
    2. After Puberty: Males are more often affected

III. Types

  1. Obstructive Sleep Apnea (OSA)
  2. Upper Airway Resistance Syndrome (UARS)
    1. Disordered breathing despite normal Polysomnogram

IV. Risk Factors

  1. Black ethnicity
  2. Obesity
  3. Pectus Excavatum
  4. Tobacco Smoke Exposure
  5. Pediatric Neuromuscular Disorder
  6. Craniofacial abnormalities
    1. Craniosynostosis (e.g. Apert's Syndrome)
    2. Micrognathia (e.g. Pierre Robin Syndrome)
    3. Retrognathia
    4. Midfacial hypoplasia
    5. Trisomy 21 (Down Syndrome)
    6. Macroglossia
    7. Choanal Atresia

V. Causes

  1. Large Tonsils, adenoids (Adenotonsillar Hypertrophy)
  2. Nasoseptal obstruction
  3. Allergic Rhinitis

VI. Symptoms

  1. Altered observed sleep-related breathing patterns
    1. Snoring
    2. Mouth breathing
    3. Frequent Nocturnal awakenings
    4. Witnessed apneas, Choking or paradoxical breathing
  2. Behavior changes
    1. Daytime Sleepiness (less common, but seen in obese children)
    2. Nocturnal Enuresis
    3. Decreased attention
    4. Unusual behavior
    5. Poor academic performance
  3. Atypical sleep position
    1. Hyperextended neck
    2. Seated with mouth open
  4. Associated symptoms
    1. Morning Headache
    2. Night Sweats

VII. Signs

  1. Assess growth
    1. Obtain height and weight and plot for Growth Velocity
    2. Assess for Failure to Thrive
    3. Calculate Body Mass Index for Pediatric Obesity
  2. Adenotonsillar Hypertrophy
    1. See Tonsillar Hypertrophy Grading Scale
    2. See Mallampati Score
    3. Tonsillar grading does not correlate with Obstructive Sleep Apnea severity
  3. Craniofacial abnormalities
    1. Adenoid Facies (long face syndrome)
      1. Long face with open mouth
      2. Seen in children with adenoid hypertrophy
    2. High Arched Palate
    3. Macroglossia
    4. Micrognathia
    5. Midfacial hypoplasia
      1. Underdeveloped upper Mandible, Maxilla and orbits
      2. Results in bug-eyed appearance, under-bite
  4. Nasal obstruction
    1. Choanal Atresia or septal deviation in infants
    2. Turbinate swelling or Nasal Polyps in children
  5. Chest abnormalities (e.g. Pectus Excavatum)
  6. Neurologic Exam

VIII. Imaging

  1. Lateral neck XRay (consider)

IX. Associated Conditions

X. Complications

  1. Failure to Thrive
  2. Pulmonary Hypertension
  3. Systemic Hypertension
  4. Attention Deficit Disorder-like behavior (or other worsening school performance)

XI. Diagnosis

  1. Adenotonsillar Hypertrophy with OSA symptoms
    1. See Tonsillar Hypertrophy Grading Scale
    2. No further studies needed to indicate Tonsillectomy
  2. Polysomonogram
    1. Indications (required in most cases of suspected pediatric OSA)
      1. Craniofacial abnormalities
      2. Comorbid conditions
      3. Unclear diagnosis
    2. Precautions
      1. Polysomnogram may be normal despite UARS (above)
      2. Home Sleep Apnea testing and abbreviated Polysomnograms are not recommended in children
    3. Criteria for Obstructive Sleep Apnea Diagnosis
      1. Pediatric criteria differs from that for adults
      2. Apnea-Hypopnea Index >1.5 events per hour of sleep
      3. Minimum Oxygen Saturation <92%

XII. Management

  1. Adenotonsillar Hypertrophy
    1. Adenotonsillectomy is treatment of choice in almost all cases of pediatric Obstructive Sleep Apnea
    2. Efficacy: Resolution of Obstructive Sleep Apnea after Adenotonsillectomy
      1. Non-Obese: 70%
      2. Obese: 30%
    3. Indications for hospital observation overnight stay after Adenotonsillectomy (risk of post-op respiratory compromise)
      1. Age <3 years
      2. Pediatric Neuromuscular Disorders
      3. Chromosomal Abnormalities
      4. Loud snoring with apnea prior to surgery
    4. Post-operative management
      1. Repeat Polysomnogram in 6-8 weeks after Adenotonsillectomy to evaluate for Sleep Apnea resolution
      2. Consider sleep medicine referral for high risk cases or those who fail resolution after Adenotonsillectomy
    5. References
      1. Marcus (2012) Pediatrics 130(3): e714-55 [PubMed]
      2. Tarasiuk (2004) Pediatrics 113:351-6 [PubMed]
  2. Management if Tonsillectomy not effective or contraindicated
    1. Manage Obesity in Children
    2. Continuous positive airway pressure (CPAP)
      1. See CPAP for Obstructive Sleep Apnea
      2. Recheck mask fitting every 6 months
    3. Treat concurrent Allergic Rhinitis
      1. Nasal Corticosteroids
      2. Consider Montelukast (Singulair)
    4. Treat recurrent Tonsillitis
      1. Consider course of antibiotics
    5. Rapid Maxillary expansion
      1. Orthodontic device to widen the upper jaw
    6. Uvulopalatopharyngoplasty (UPPP) Indications
      1. No longer recommended due to low efficacy in adults
      2. Oropharyngeal soft tissue obstruction
        1. See Mallampati Score
      3. Severe OSA without Adenotonsillar Hypertrophy
      4. Trisomy 21
  3. Indications for sleep medicine referral: higher risk conditions
    1. Cardiorespiratory failure
    2. Craniofacial abnormalities or congenital defects
    3. Attention Deficit Disorder
  4. Management of severe OSA refractory to above measures
    1. Tracheotomy

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