Obstructive sleep apnea hypoventilation syndrome in children is very common clinically, among which adenoids and tonsillar hypertrophy are the most common causes. I would like to extract the relevant guidelines published in the Chinese Journal of Otolaryngology Head and Neck Surgery for the reference of patients, to learn and deepen the understanding of the disease.
I. Definition
Obstructive sleep apnea hypopnea syndrom (OSAHS) is a series of pathophysiological changes caused by frequent partial or total upper airway obstruction during sleep, which disturbs the normal ventilation and sleep structure of children.
II. Etiology
The common causes of OSAHS in children include increased upper airway resistance causing compliance changes and factors affecting neuromodulation.
1. Nasal: chronic rhinitis (infectious, allergic), sinusitis, nasal polyps, nasal masses, nasal septal deviation, and posterior nostril atresia are common.
2, nasopharynx and oropharynx: the most common causes are adenoid hypertrophy, tonsillar hypertrophy, other causes of right tongue hypertrophy, fat accumulation due to obesity, pharyngeal and nasopharyngeal masses, post-surgical obstruction of cleft palate and palatopharyngeal flap, etc.
3.Larynx and trachea: congenital laryngeal cartilage softening, laryngeal webbing, laryngeal cyst, laryngotracheal neoplasm and tracheal stenosis, etc.
4, craniofacial anomalies: the development of the middle part of the face (Down’s syndrome, Grouzon syndrome, cartilage development, etc.); mandibular development, such as Pierre-robin syndrome, mandibular facial dysplasia, shy-Drager syndrome, etc. Others, such as mucopolysaccharide storage disease type II and IH (Hunter syndrome and Hurler syndrome), and metabolic diseases (such as osteosclerosis) are associated with abnormalities of craniofacial structures.
5. Factors affecting neuromodulation: generalized hypotonia (Down syndrome, neuromuscular diseases), application of sedative drugs, etc.
III. Clinical manifestations and complications of OSAHS in children
Sleep snoring, open-mouth breathing, breath-holding, repeated awakening, enuresis, excessive sweating, hyperactivity, etc. Occasionally, daytime sleepiness may occur. Long-term open-mouth breathing can lead to obvious deformities of maxillofacial development and the formation of “adenoid face”. In severe cases, cognitive defects, memory loss, learning difficulties, abnormal behavior, growth retardation, hypertension, pulmonary hypertension, right heart failure and other cardiovascular diseases can occur.
IV. Diagnosis and differential diagnosis
1, Diagnosis.
Obstructive sleep apnea (OSA) is the cessation of oral and nasal airflow during sleep, but chest and abdominal breathing are still present.
Hypopnea (hypopnea) is defined as a 50% reduction in peak oral and nasal airflow signals with a decrease in oxygen saturation of 0.03 or more and/or arousal.
The duration of the respiratory event was defined as greater than or equal to 2 respiratory cycles.
Polysomnogruphy (PSG) monitoring: an obstructive apnea index OAI greater than or equal to 1 per night during sleep or an AHI (sleep apnea hypoventilation index) greater than 5 was considered abnormal. A minimum arterial oxygen saturation (LAaO2) of less than 0.92 is defined as hypoxemia. Meeting the above two items can diagnose OSAHS.
2. Diagnostic methods.
Nocturnal PSG examination is the current standard method for diagnosing sleep breathing disorders and can be performed in children of any age. For children without PSG examination, medical history, physical examination, nasopharyngeal X-ray, nasopharyngeal endoscopy, snoring sound recording, video recording, pulse oximetry and other means can be used to assist in the diagnosis. Lateral nasopharyngeal radiography or CT can help to determine the site of airway obstruction, and nasopharyngeal endoscopy can dynamically observe the narrowing of upper airway.
The purpose of performing PSG examination is to.
① to distinguish simple snoring from OSAHS.
② to determine the diagnosis of OSAHS.
③ evaluate the severity of OSAHS.
④to evaluate the effect of surgery.
⑤ to distinguish central apnea and alveolar hypoventilation.
⑥assess sleep architecture and non-breathing related sleep disorders (e.g., nocturnal seizures, etc.).
The classification of OSHAS disease level in children is shown in Table I
Table 1 Basis for determining the degree of OSHAS in children
Degree of illness AHI or OAI (times/h) LSaO2
Mild 5-10 or 1-5 0.85-0.94
Moderate -20 or -10 0.75-0.84
Severe >20 or >10 <0.75
Note: AHI is apnea hypoventilation index; OAI is obstructive apnea index; LSaO2 is the minimum oxygen saturation.
3. Differential diagnosis.
It should be distinguished from simple snoring, central sleep apnea hypoventilation syndrome, episodic sleeping sickness, laryngospasm, epilepsy, etc.
V. Treatment
Treatment principles: early diagnosis and treatment, release of upper airway obstruction factors, prevention and treatment of complications.
(A) Surgical treatment
1. Adenoidectomy and tonsillectomy.
Adenoidectomy and tonsillectomy are feasible for children with OSAHS caused by enlarged tonsils and adenoids. When both tonsils and adenoids are enlarged, adenoids alone or tonsillectomy alone has limited efficacy. Most obese children can be treated effectively with adenoidectomy and tonsillectomy. In infants and children with severe OSAHS hypertrophy of the tonsils and adenoids, conservative treatment is not effective and surgical excision should also be performed.
Children younger than 3 years of age with severe OSAHS, pulmonary heart disease, malnutrition, morbid obesity, neuromuscular tumors, and craniofacial developmental abnormalities are at high risk for postoperative complications. In this regard, detailed evaluation must be performed before surgery, and close monitoring should be performed after surgery.
Other surgical treatments include craniofacial orthognathic surgery (for children with some craniofacial developmental anomalies), uvulopalatopharyngoplasty, inferior turbinate reduction, tracheotomy and other treatments that may affect the growth and development of children and their quality of life, and should be treated with great caution.
(B) Non-surgical treatment
1.Continuous positive airway pressure (CPAP): For children with contraindications to surgery, large adenoid tonsils, OSAHS after adenoid tonsillectomy, and children who choose non-surgical treatment, CPAP treatment can be chosen. The pressure titration of CPAP must be done in the sleep laboratory and needs to be adjusted periodically.
Oral appliances: For children with mild to moderate OSAHS who can be operated on or who cannot tolerate CPAP treatment.
3. Other treatment methods.
① Treatment of nasal diseases: rhinitis, allergic rhinitis and sinusitis should be treated in a systematic and standardized manner.
(②Children with obesity should lose weight.