The physical examination includes assessment of body mass index, blood pressure, and central muscle tone. Examine the nose for septal deviation; nasal polyps; and size, shape, and patency of the nares. Examine the midface for retrusion/hypoplasia and the mouth for evidence of crossbite, overjet, overbite, or underbite. Note the size of the tonsils and the Mallampati classification (Figure), the symmetry of the soft palate, and any evidence of inflammation of the soft palate and uvula. Check the mandible for retrognathia, and measure the neck circumference. Note whether acanthosis nigricans is evident, and assess for scoliosis. Identify any signs of right-sided heart failure.
Although lateral neck films are sometimes used to assess for adenoidal hypertrophy, remember that a lateral neck film that is obtained in an awake child in the upright position may underrepresent dynamic changes that occur in the upper airway while the child is in supine REM sleep.23 Also keep in mind that in contrast to the tonsils, adenoids can grow back after removal. Consider the possibility of adenoidal regrowth when treating a child with symptoms of OSA who has had his or her adenoids removed; a second adenoidectomy, with or without tonsillectomy, may be sufficient to treat the OSA.
The current gold standard for determining whether a child has OSA is attended polysomnography (PSG). In PSG, defined physiological parameters (electroencephalogram, ECG, electromyogram, eye movements, pulse oximetry, end-tidal carbon dioxide levels, air flow, respiratory effort) are monitored while the child sleeps in a controlled environment under the supervision of a sleep technologist.24
Figure – The Mallampati classification is a rough estimate of the size of the tongue relative to the size of the oral cavity.
Whether every child with symptoms of sleep disordered breathing needs to undergo a diagnostic PSG before initiation of treatment (adenotonsillectomy in most cases) is still an open question.25-27 PSG is very useful in determining the severity of OSA and in guiding perioperative care. However, distinctions between abnormal and normal results are still not well defined. In fact, one study found that the behavior of children referred for adenotonsillectomy because of clinical symptoms of OSA improved irrespective of the findings on PSG19; these results suggest that relying solely on PSG to decide whether to proceed to adenotonsillectomy in otherwise healthy children who snore and who have enlarged adenoids and tonsils may lead to undertreatment of OSA. Because of the lack of clear PSG criteria for the diagnosis of OSA, many clinicians rely on the clinical history and physical examination. A recent survey revealed that fewer than 10% of pediatric otolaryngologists ordered PSG for children with suspected OSA before proceeding to adenotonsillectomy, and over 60% stated that they would perform adenotonsillectomy in a child with clinical symptoms of OSA regardless of the findings on PSG.28
TREATMENT OF OSA IN CHILDREN
Pharmacotherapy and positional therapy for mild OSA. In children with mild OSA, both nasal corticosteroids and montelukast(Drug information on montelukast) have been shown to reduce symptoms and the degree of obstruction, although they are not considered to be as effective as adenotonsillectomy.29,30 Elimination of other secondary causes of soft tissue inflammation (such as exposure to environmental tobacco smoke) and treatment of allergies and gastroesophageal reflux disease can also significantly reduce the degree of obstruction. Positional treatments can be effective as well. For example, if obstruction is seen only while the child is in the supine position, a wedge—or a T-shirt with a tennis ball sewn into the pocket and worn backwards—can be used to keep the child out of that position. Similarly, in some children, especially those with central hypotonia and a restrictive lung disease, sleeping with the head of the bed elevated is often the only intervention required to control obstruction.