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Clinical Symptoms/ Signs has been associated with specific clinical problems
and findings. Snoring is the most common symptom
Abnormal narrowing in the airway from nose, reported by parents of children with OSAS. Snoring is
nasopharynx, oropharynx, to hypopharynx causes very sensitive (most children with OSAS snore) but not
abnormal air exchange during sleep, which in turn leads very specific for OSAS (all snorers do not necessarily
to clinical symptoms. The accompanying symptoms have OSAS).7 The American Academy of Pediatrics
can change with age. Table 1 indicates the parental recommends systematic screening of children for a
complaints concerning children seen at sleep clinics history of snoring. A positive history of snoring should
over time.12,23-30 Abnormal breathing during sleep then lead to further evaluation to rule out or confirm
Table 1. Complaints reported by parents regarding their children1,17-23
Age group and age
Infants, 3-12 mo Toddlers, 1-3 y Preschool-aged children School-aged children
Disturbed nocturnal sleep Noisy breathing or snoring Regular, heavy snoring Regular, heavy snoring
with repetitive crying Agitated sleep or disrupted Mouth breathing Agitated sleep
Poorly established day/ nocturnal sleep Drooling during sleep Abnormal sleeping positions
night cycle Crying spells or sleep terrors Agitated sleep Insomnia
Noisy breathing or snoring Grouchy and/or aggressive Nocturnal awakenings Delayed sleep phase
Nocturnal sweating daytime behavior Confusional arousals syndrome
Poor sucking Daytime fatigue Sleepwalking Confusional arousal
Absence of normal growth Nocturnal sweating Sleep terrors Sleepwalking
pattern or failure to thrive Mouth breathing Nocturnal sweating Sleep talking
Observation of apneic Poor eating or failure to Abnormal sleeping Persistence of bed-wetting
events thrive positions Nocturnal sweating
Report of apparently (?) Repetitive URI Persistence of bed-wetting Hard to wake up in the
life-threatening event Witnessed apneic episodes Abnormal daytime behavior morning
Presence of repetitrive Aggressiveness Mouth breathing
earaches or URI Hyperactivity Drooling
Inattention Morning headache
Daytime fatigue Daytime fatigue
Hard to wake up in the Daytime sleepiness with
morning regular napping
Morning headache Abnormal daytime behaviors
Increased need for napping Pattern of attention-deficit/
compared with peers hyperactivity disorder
Poor eating Aggressiveness
Growth problems Abnormal shyness,
Frequent URI withdrawn and depressive
presentation
Learning difficulties
Abnormal growth patterns
Delayed puberty
Repetitive URI
Dental problems appreciated
by dentist
Crossbite
Malocclusion (class II or III)
Small jaw with overcrowding
of teeth
OSAS:obstructive sleep apnea syndrome; URI, upper respiratory tract infection
13
Mu SC, et al.
Table 2. Comparison of the symptoms and some other features of OSAS in adults and children31
Snoring Often continuous, snorting Loud, alternating with pauses
Predominant respiratory pattern Mixture of obstructive, mixed and Obstructive apneas predominate
central apneas and hypoventilation
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Adenoidectomy-tonsillectomy in OSAS children
Cor pulmonale due to chronic upper airway obstruction The most accurate and comprehensive method of
in children has been well reported.40, 41 Children with diagnosing OSAS is nocturnal polysomnography
apparent OSAS suffering from congestive heart-failure (PSG).47 The diagnostic criteria are usually based
and even pulmonary edema, which resolved after on a certain apnea/hyperpnoea index (AHI), but de-
treatment, have been described.40 saturation, hypercapnic episodes, and arousals may be
Behavioral disorders, which have been reported included in the criteria, then often called the respiratory
in OSAS children, may have negative long-term disturbance index (RDI), either as their own parameters
consequences for the children if they last for a longer or in association with apnea or hyperpnoea.48
period. 42, 43 Consequently, most pediatric sleep specialists
Learning problems may occur at school age. regard an apnea index (AI) of more than 1 or an apnea
Aggression, inattention and hyperactivity have been hypopnea index (AHI) of 1.5 as abnormal and most
found to improve after adeno-tonsillectomy in children recommend treatment of any child with an AI greater
with mild sleep disturbance, according to a parent than 5. Regular PSG parameters such as AI, AHI, RDI
questionnaire. Surgery also had a positive effect on and the nadir of oxygen saturation (SpO2) are helpful
vigilance, reflection and impulsivity.38 to evaluate the severity of OSAS. (Table 3)49
According to the consensus statement, PSG is
indicated as a diagnostic tool in a variety of situations,
Diagnosis most importantly: 1) for evaluating the child with
Many physicians have to base their diagnosis of disturbed sleep patterns, excessive daytime sleepiness,
OSAS on the clinical symptoms and signs of the cor pulmonale, failure to thrive, or polycythemia
children. Brouilette et al derived a symptom score unexplained by other factors or conditions, especially
which, according to their research, classified correctly if the child also snores; 2) in the child who has
all controls and 22 out of 23 OSAS patients.44 Observed clinically significant airway obstruction during sleep
apneas, constant snoring and difficulty in breathing as observed by medical personnel, or documented by
during sleep were found to be fairly predictive of audiovideo recording; 3) Since children with OSAS are
OSAS. Mahboubi et al stated that the radiologically at a higher risk of postoperative complications,50 PSG
assessed adenoidal size would not give much is recommended if the surgeon is uncertain whether the
information about the degree of airway obstruction, clinical observation of obstructed breathing is sufficient
whereas Fernbach et al found hardly any OSAS- to warrant surgery.
children to have an adenoidal-nasopharyngeal ratio Videofluoroscopy can provide an information
greater than two standard deviations above the mean additional to lateral radiographs and PSG in children
value of normal controls.45,46 But airway obstruction is with minor adeno-tonsillar enlargement or with
a dynamic phenomenon, and lateral neck radiography predisposing factors.46 Virtual endoscopy has proved to
does not provide sufficient information on which to effectively show fixed lesions in the upper airways, but
base a decision to perform adeno-tonsillectomy to it is not sensitive enough to detect dynamic movements
relieve airway obstruction during sleep in children . leading to obstruction.51 Flexible fiberoscopy has been
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Mu SC, et al.
shown to identify reliably the site of obstruction in Treatment of OSAS has been shown to improve
children with anomalous upper airways with obstructive dentofacial deformities. Maxillofacial surgery is rare
symptoms even when awake.52 Sleep nasoendoscopy in children, and obviously applied only in OSAS
combined with rigid laryngo-bronchoscopy has cases with upper airway anomalies, where adeno-
been suggested to be valuable in detecting the site of tonsillectomy is either insufficient or contraindicated.
obstruction in children with residual symptoms after The long-term outcome linked the recurrence of
adeno-tonsillectomy.53 Magnetic resonance imaging of abnormal breathing during sleep to the absence of
the upper airways may reveal structural abnormalities dealing with a narrow maxilla and/or mandible at the
in children with OSAS.54 time of the initial surgery and the later occurrence of
tongue/mucosal enlargement at the time of puberty,
when 90% of oro-facial adult growth had already
Management of and Concise occurred. Adeno-tonsillectomy has been performed
Indications for Adenotonsillectomy in association with orthodontic treatment.61 Rapid and
The American Academy of Otolaryngology-Head slow maxillary distractions are performed between 5
and Neck Surgery points to a study showing the benefit and 11 years of age. Distraction results in widening of
of tonsil removal for kids who have had three or more the palate and the nose; thus, this procedure remedies
tonsil infections in a year. However, tonsillectomy and/ nasal occlusion related to a deviated septum, for which
or adenoidectomy is recommended if the tonsils are little can be done before 14 to 16 years of age.
so large they obstruct breathing or swallowing, or if However, many children, especially the obese, those
the child is diagnosed with obstructive sleep apnea, a with underlying medical conditions such as Down
condition where children briefly stop breathing during syndrome or craniofacial anomalies, and those with
sleep and wake up frequently throughout the night. more severe OSAS, require further treatment after
The predominant cause of adenoidectomy and this surgery.59,62-64 Continuous positive airway pressure
tonsillectomy is recurrent infections,55 but there has been (CPAP) delivered via a nasal interface is the most
a dramatic increase in OSAS as a significant indication common non-surgical therapy for pediatric OSAS,
for surgery.56 Tonsillectomy is reluctantly performed especially in cases of congenital malformations,
on children under three years of age, and sleep apnea when in the past, tracheotomy usually had to be
seems to be the leading cause for operation in this age performed if adeno-tonsillectomy failed to relieve
group.57 From the clinical perspective, cephalometrics a serious obstruction. Hence, one of the challenges
is a noninvasive and inexpensive method, and is an that pediatric sleep specialists face is finding new
objective technique for evaluation of children with treatments for OSAS, especially as the prevalence of
OSAS and for further treatment planning.58 Even if the OSAS is expected to increase along with the current
tonsils and/or adenoids are 6 not seemingly enlarged, obesity epidemic.65,66 The current review will focus
adeno-tonsillectomy will provide more airway space. on newer treatment modalities for OSAS, including
Different anomalies or concomitant diseases anti-inflammation, dental treatments, high-flow nasal
may predispose to OSAS, and in such cases adeno- cannula, and weight loss. A double-blind, placebo-
tonsillectomy is not always a curative treatment, controlled study, montelukast effectively reduced
even though the adenoid is enlarged and a supposed polysomnographic findings, symptoms, and the size of
site of obstruction.13 Adeno-tonsillectomy improves the adenoidal tissue in children with non-severe OSAS.
respiratory abnormalities in children with OSAS, The findings support the potential of a leukotriene
but complete normalization occurs in only 25% of modifier as a novel, safe, noninvasive alternative for
patients.59 CO2 laser tonsillotomy in combination with children with mild to moderate OSAS.67
adenoidectomy is highly effective in the treatment Also, the authors have proposed an easy-to-follow
of pediatric OSAS and should be preferred over flowchart (Figure 1) regarding the diagnosis and
tonsillectomy because of less postoperative pain and a management of pediatric OSAS for pediatricians.68,69
lower risk of postoperative bleeding.60
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Adenoidectomy-tonsillectomy in OSAS children
Symptoms/signs
Observation of apnea
Arousal
Habitual snoring Other causes of sleep
Mouth breathing disorders
Daytime fatigue No
Learning difficulties
Abnormal growth
Delayed puberty
Repetitive URI
Yes
No
Positive result
17
Mu SC, et al.
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Adenoidectomy-tonsillectomy in OSAS children
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