Anomalies in the anatomy of the upper airway leading to different degrees of airway stenosis
(1) Nasal and nasopharyngeal stenosis: including chronic rhinitis (infectious, allergic), deviated nasal septum, enlarged turbinates, nasal polyps, posterior nostril atresia and nasal masses, adenoid hypertrophy, etc. Among them, adenoid hypertrophy is the most common obstructive cause in pediatric patients.
②Stenosis of the oropharynx: common ones such as tonsillar hypertrophy, soft palate hypertrophy, pharyngeal lateral wall hypertrophy, tongue root hypertrophy, tongue root recession, etc. can cause stenosis in this area.
③Larynx: congenital softening of laryngeal cartilage, laryngeal webbing, tracheal atresia, etc., but they are less common.
④ Congenital diseases and developmental malformations: such as micromaxillary malformations, cranio-facial malformations, tongue root cysts or ectopic thyroid, nasopharyngeal atresia, chondrodysplastic dwarfism, mucopolysaccharidosis, and cervical spine malformations can cause obstructive sleep apnea.
Upper airway dilator muscle and tone abnormalities
The main manifestations are abnormal tone of the chin and tongue muscles, pharyngeal wall muscles and soft palate muscles. Others such as generalized hypotonia (Down’s syndrome, neuromuscular diseases)
Obesity, sedative medication, alcohol consumption, etc. In addition, genetic factors can increase the chance of OSAHS in children.
Clinical manifestations
1. Nighttime snoring, open-mouth inhalation, breath-holding, repeated awakening during sleep, limb tossing, etc.
2, bedwetting, night sweating, abnormal sleeping posture; often love to sleep on their backs, serious can appear on their backs pouting head looking forward to sleep.
3, daytime manifestations of inattention, hyperactivity; memory loss, academic performance decline; behavior change, cognitive impairment, etc..
4. Long-term attacks may include signs of growth retardation, hypertension, heart enlargement, right heart failure and pulmonary heart disease.
5. Some children may also have recurrent whistling infections and other manifestations.
Main hazards
1, leading to slow growth of children – snoring causes a decrease in sleep quality, which inevitably reduces the release of growth hormone and affects the growth and development of children.
2, leading to children’s intellectual development backward – snoring will make children in sleep serious lack of oxygen, directly leading to insufficient oxygen supply for brain development, will affect the child’s intellectual level.
3. Long-term open-mouth whistling affects children’s facial appearance – When children snore, due to nasopharyngeal obstruction, open-mouth whistling, upper and lower teeth bite together abnormally, over time, the upper teeth may appear convex, lips upturned, face elongated, eyes dull, that is, the so-called “adenoid face.
4, causing exudative otitis media Adenoid hyperplasia can cause recurrent exudative otitis media if it blocks the pharyngeal orifice of the nasopharyngeal side wall, resulting in symptoms such as stuffy ears, tinnitus, and hearing loss.
Auxiliary tests
1.Polygraphic sleep monitoring (PSG): It is considered the gold standard for diagnosing OSAHS. ≥1 OAI (obstructive sleep apnea index) or ≥5 AHI (sleep apnea hypoventilation index) during each night of sleep is considered abnormal, and a minimum oxygen saturation (SO2) of less than 92% is defined as hypoxemia. the basis for determining the degree of OSAHS condition is shown in the table below.
2, Electronic (fiber) nasopharyngoscopy is now commonly used to examine the plane of upper airway stenosis. The nasal cavity is constricted and surface anesthesia is applied before the examination, and then the obstruction is examined from the nasal cavity through the nasopharynx, oropharynx and laryngopharynx in sequence. It is best to examine in the supine position, which is also closer to the sleeping position.
3.Lateral nasopharyngeal X-ray or CT can help to determine the site of airway obstruction.
4.Chest X-ray and electrocardiogram can help to exclude right ventricular hypertrophy and cardiopulmonary disorders.
5.The application of sleep video and pulse oximeter can also help to understand the state of sleep.
Diagnosis and differential diagnosis
Based on the history of snoring and recurrent inhalation pauses, physical examination, lateral nasopharyngeal X-ray, electronic or fiberoptic nasopharyngoscopy, snoring recording, application of video, pulse oximetry, multi-channel sleep monitoring (PSG) and other auxiliary examinations, it is not difficult to diagnose. It should be differentiated from episodic sleep disorder, epilepsy, chronic obstructive pulmonary disease, nocturnal sleep disorder, insomnia syndrome and other diseases.
Treatment
The etiology of children is different from that of adults, so the treatment varies greatly and a reasonable treatment plan must be made taking into account the specific situation of the child. There are two types of treatment: surgical and non-surgical.
Adenoidectomy and tonsillectomy
Adenotonsillectomy is the most common first-line treatment for OSAHS in children, with an efficiency of 85-90%. When both tonsils and adenoids are enlarged, adenoidectomy or tonsillectomy alone is not sufficient and the outcome is not satisfactory.
Some studies have shown that in children with adenoids and tonsils that are otherwise healthy (e.g., simple snoring), 75% to 100% of the children’s PSG improves after adenoidectomy and tonsillectomy, along with the disappearance of the corresponding symptoms.
The long-term results after surgery in obese children are less satisfactory, but most obese children can be effectively treated by adenoidectomy. More attention is currently being paid to reducing wound bleeding and alleviating pain. In addition to traditional tonsil dissection some people apply plasma radiofrequency ablation for removal, which can significantly reduce pain.
Other surgical treatments
These include uvulopalatopharyngoplasty, craniofacial orthognathic surgery, inferior turbinate decompression, and tracheotomy in severe cases. However, treatment such as uvulopalatopharyngoplasty and tracheotomy may affect the growth and quality of life of children and should be done with great caution.
Non-surgical treatment
1.Continuous positive airway pressure ventilation (CPAP)
CPAP is an optional treatment for patients with contraindications to surgical procedures, small adenoid tonsils, OSAHS still present after adenoid tonsillectomy, and those who choose non-surgical treatment. pressure titration of CPAP must be done in the sleep laboratory and needs to be adjusted periodically.
2.Other treatment methods
(1) Treatment of rhinitis, children with inferior turbinate hypertrophy can be treated with inferior turbinate reduction in conjunction with general anesthesia surgery. The treatment of rhinitis, allergic rhinitis and sinusitis should be treated systematically and regularly before and after surgery.
(2) Obese patients should control their weight.
(3) Oral orthodontic appliances (maxillofacial deformities can be corrected by orthodontics).
7.Postoperative follow-up
All patients should be followed up after treatment. In particular, patients with persistent signs and symptoms after initial treatment, children with severe OSAHS or obese patients need objective re-evaluation to decide whether other treatment measures are needed. A re-evaluation 6-8 weeks after surgery is recommended. Some children with poor surgical outcome will require further non-invasive positive pressure ventilation after re-evaluation.
8.Disease prevention
1.Nutrition should be kept balanced to prevent obesity due to overnutrition.
2.When the symptoms of snoring appear and last for more than 2 months, you should consult a doctor promptly.
3. Pay attention to strengthening body resistance, reducing the occurrence of various acute and chronic infectious diseases of the whistle, and avoiding the obstruction of the upper whistle caused by inflammation.