Sleep & Snoring Conditions

Sleep & Snoring conditions treated by Dr Jae Park

What is paediatric sleep disordered breathing?

Paediatric sleep disordered breathing (SDB) is a general term for breathing difficulties during sleep. SDB can range from frequent loud snoring to obstructive sleep apnoea (OSA), a condition where part, or all, of the airway is blocked repeatedly during sleep.

When a child’s breathing is disrupted during sleep, the body thinks the child is choking. The heart rate increases, blood pressure rises, the brain is aroused, and sleep is disrupted. Oxygen levels in the blood can also drop. Approximately 10 percent of children snore regularly, and about two to four percent of children experience OSA. Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.

What Are the Symptoms of Pediatric SDB?

Potential symptoms and consequences of untreated paediatric SDB may include:

§  Snoring—The most obvious symptom of SDB is loud snoring that is present on most nights. The snoring can be interrupted by complete blockage of breathing, with gasping and snorting noises associated with waking up from sleep. Loud snoring can also become a significant social problem if a child shares a room with siblings, or at sleepovers and summer camp.

§  Irritability—A child with SDB may become irritable, sleepy during the day, or have difficulty concentrating in school. He or she may also display busy or hyperactive behavior.

§  Bedwetting—SDB can cause increased urine production at night, which may lead to bedwetting (also called enuresis).

§  Learning difficulties—Children with SDB may become moody and disruptive, or not pay attention, both at home and at school. SDB can also be a contributing factor to attention deficit disorders in some children.

§  Slow growth—Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.

§  Cardiovascular difficulties—OSA can be associated with an increased risk of high blood pressure, or other heart and lung problems.

§  Obesity—SDB may cause the body to have increased resistance to insulin, and daytime fatigue can lead to decreased physical activity. These factors can contribute to obesity.

What Causes Pediatric SDB?

A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue, or neuromuscular deficits such as cerebral palsy, have a higher risk of developing SDB.

How is Sleep Apnoea Diagnosed?

Sometimes doctors will make a diagnosis of SDB based on history and physical examination. In other cases, like children suspected of having severe OSA due to craniofacial syndromes, morbid obesity, neuromuscular disorders, or for children less than three-years-old, additional testing such as a sleep test may be recommended.

The sleep study, or polysomnography (PSG), is an objective test for SDB. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.

What Are the Treatment Options?

Enlarged tonsils and adenoids are a common cause for SDB. Surgical removal of the tonsils and adenoids, called tonsillectomy and adenoidectomy (T&A), is generally considered the first line treatment for paediatric SDB if the symptoms are significant, and the tonsils and adenoids are enlarged. Many children with OSA show both short- and long-term improvement in their sleep and behaviour after T&A.

Not every child with snoring needs to undergo T&A. If the SDB symptoms are mild or intermittent, academic performance and behaviour is not an issue, the tonsils are small, or the child is near puberty (because tonsils and adenoids often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated surgically only if symptoms worsen.

What is Obstructive Sleep Apnoea (OSA)?

Nearly half of adults snore, and over 25 percent are habitual snorers. Problem snoring and sleeping disorders are more frequent in males and people who are overweight, and usually worsen with age.

Snoring is bothersome to others, but it can also be a sign of a more serious condition known as obstructive sleep apnoea (OSA), which is present in three percent of the general population. OSA is characterized by multiple pauses in breathing greater than 10 seconds at a time due to upper airway narrowing or collapse. This lowers the amount of oxygen in the blood and causes the heart to work harder. Because the snorer does not get a good rest, they may be sleepy during the day, which decreases their performance. Untreated OSA can contribute to high blood pressure, stroke, heart disease, workplace or motor vehicle accidents, and more.

What Are the Symptoms of OSA?

Symptoms associated with OSA can include:

• Loud snoring

• Pauses in breathing during sleep

• Waking up gasping or choking

• Waking up with a dry mouth or sore throat

• Daytime sleepiness or fatigue

• Frequent nighttime urination

• Morning headache

• Irritability, mood changes, depression, difficulty concentrating

• High blood pressure, heart disease, stroke, or other cardiac issues

What Causes OSA?

The noisy sounds of snoring occur when there is a partial obstruction to the flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures strike each other and vibrate during breathing. Apnoea occurs when the obstruction of air flow is more severe, leading to reduced, compromised, or completely blocked air flow while trying to breathe.

In children, snoring may be a sign of problems with the tonsils and adenoids. In adults, the site of obstruction may not be as simple to identify. Obstruction in an adult may be due to a combination of factors in different areas, making it more challenging to identify and treat.

What Other Factors Contribute to Snoring and Sleep Apnoea?

Poor muscle tone in the tongue and throat—When muscles are too relaxed, the tongue falls backward into the airway, or the throat muscles draw in from the sides into the airway. Alcohol or drugs that cause sleepiness may worsen muscle relaxation and obstruction.

Excessive bulkiness of throat tissue—Children with large tonsils and adenoids often snore. Overweight people may have excess soft tissue in the neck that can lead to airway narrowing. Those with very large tongues are especially susceptible to snoring and OSA. Cysts or tumours are rare causes of airway narrowing.

Long soft palate and/or uvula—A long palate narrows the opening from the nose into the throat. The excessive length of the soft palate and/or uvula acts as a noisy flutter valve during relaxed breathing.

Obstructed nasal airways—A stuffy nose requires extra effort to pull air through it. This creates an exaggerated vacuum in the throat that pulls together the floppy tissues of the throat. Sometimes, snoring only occurs during allergy season or with a cold or sinus infection. Deformities of the nose or nasal septum, such as a deviated septum (a deformity of the wall that separates one nostril from the other) can also cause snoring and OSA.

What are the treatment options?

Heavy snorers—people who snore constantly in any position or who negatively impact a bed partner’s sleep—should seek medical advice to ensure that sleep apnoea is not a problem. An examination can reveal if the snoring is caused by nasal allergy, infection, nasal obstruction, or enlargement of tonsils and adenoids. A sleep study in a laboratory or at home may be necessary to determine if snoring is due to OSA.

OSA is most often treated with a device that opens the airway with a small amount of positive pressure. This pressure is delivered by an appliance through either the nose and/or mouth that is worn during sleep. This treatment is called continuous positive airway pressure, or CPAP, and it is currently the initial treatment of choice for patients with OSA. The challenge of treating OSA is that obstruction can occur at multiple levels of the airway. CPAP stabilizes pressure at all parts of the upper airway and can be very effective, but some wearers cannot tolerate CPAP and must seek other options.

A custom-fit oral appliance, which repositions the lower jaw forward, may also be considered for certain patients with snoring/OSA. In some patients, significant weight loss can also improve snoring and OSA.

There are numerous surgical treatments for snoring/OSA, including:

• Uvulopalatopharyngoplasty (UPPP) is a plastic surgery of the throat involving tissue repositioning, or removal of excess soft tissue, to open the airway. In addition, the remaining tissue stiffens as it heals, helping to minimize tissue vibration. A tonsillectomy can also help enlarge the airway.

• Thermal ablation procedures reduce tissue bulk in the nasal turbinates (structures on the side wall of the inside of the nose), tongue base, and/or soft palate. These procedures are used for both snoring and OSA, and several treatments may be required.

• The soft palate may be stiffened by inserting stiffening rods into the soft palate, or by injecting an irritating substance that causes stiffness in the injected area near the uvula.

• “Hypoglossal nerve stimulator” technology implants a tongue pacemaker, which stiffens and projects the tongue forward during sleep. Other procedures may be used to surgically target tongue muscles or the boney configuration of the midface.