Sleep Disordered Breathing

Summary of Lecture Dr. Niall Jefferson (ENT) via HMRI ENT update 2023

Anatomy

• The relationship of adenoids to ET opening is important

• Most of the nose has ciliated mechanisms, cilia more in response to air, signals sent to the brain indicating that we have breathed

• Cilia don’t move as freely is obstruction and increased sense of a blocked nose

• Sense of smell is also important

Physiology

• Nasal cycle - normal variation that inferior turbinates get bigger and smaller and switch sides

• If deviated nasal septum or baseline swelling due to allergies, you will be more aware of this normal nasal cycle

• Nitric Oxide (NO) acts as a vasodilator, regulates blood flow, and exhibits antimicrobial properties

• Helps maintain normal airway tone and supports immune response

• Nasal breathing promotes efficient gas exachange by slowing down the airflow, allowing better oxygen uptake and CO2 elimination

• Aids as a filter to remove particle, allergens and pathogens

• Contributes to humidifcations

Paediatric Sleep Disordered Breathing

• Medium and long term complications if not fixed early

• Common condition characterized by breathing difficulties during sleep, including snoring, mouth breathing, and obstructive sleep apnoea.

• Prevalence 2 to 10% of children experienced SDB with OSA affecting 1 to 5% of children

• Severe symptoms are grossly undertreated

Why do we treat Paeds SDB?

• Impaired sleep quality

  • Fragmented and poor-quality sleep, day time sleepiness, irritability, decreased attention span

• Behavioural

  • Hyperactivity, inattentiveness, aggression, emotional disturbances

• Cognitive

  • Decreased academic performance, memory problems, impaired executive functioning

• OSA

  • Risk of early CV disease

    • AMI, Stroke

  • Diabetes

• Risk of accidents

• Lower growth, stunted height and weight, if SDB is treated then often massive growth spurt afterwards

Facial development

• Chronic mouth breathing can lead to

  • Open bite

  • Increased overjet

  • Narrow upper dental arch

• Can affect development of facial muscles leading to long face

• Causes the tongue to rest in a lower position

• Can lead to dental extractions due to dental crowding

History

• Snoring

  • Wakes dry mouth, drink bottle next to bed, drinks through night

  • Exhausted

  • Hot overnight

  • Restless in bed

• Mouth breathing

• Daytime sleepiness

  • Behaviour changes early afternoon

  • Goes to bed earlier sometimes, but is sometimes resistant to sleeping

• Nasal congestion

Exam

• Nasal passages anteriorly

• Tonsils

• Facial structures

• Ear exam

  • Middle ear effusion common

• Hearing can be okay in a quiet room like doctor's surgery but very obviously worse in loud classroom

Investigations

• Nasal endoscopy

• Sleep study

  • Useful but hard to get

  • Would be great to get 30 days of testing

• Imaging

  • Limited role

  • Age 2 to 5 can sometimes get a lateral airway film +/- AP for adenoids size, sinusitis

• Allergy testing

  • Useful if clear severe robust reactions

  • Also useful if suspicion of allergic rhinitis but a partial response to treatment

• Nasal provocation tests

Enlarged Adenoids

• Normal structure

• Lymphoid tissue in the back of the nasal cavity

• Grows from 12 to 18 months until about 3, then growth spurts 4-6

• Maximum size age 3 to 7

• Disappear by adolescence

• Effaces eustachian tube

Allergic rhinitis

• Chronic inflammatory condition caused by allergic reaction to pollen, dust, pet dander, mould

• Nasal congestion, itching, sneezing, nasal discharge

• Local reaction

• Inflammatory mediators and histamine

• Inferior turbinate hypertrophy

• Affects

  • Sleep dsitrubance

  • Impaired cognitive function

  • Quality of life

    • Discomfort

    • Hard to exercise and mouth breath in exercising

    • Loss of smell

• Consider in dysphagia / textural issues

Management of allergic rhinitis

• Saline

  • Very effective, underused

  • Needs to be irrigation

  • Normal saline

  • Shows kids how to do it

  • Mechanisms washes inflammatory particles out of nose and secretions

  • Very effective

• INCS

  • Effective

  • 20-30% are fixed with INCS at ENT level with SDB

  • Most kids most of the time with nasal obstruction

    • Avamys preferred, better tolerated, anecdotally better, some evidence superior

    • Evening with brushing teeth, leave next to toothbrush

    • Tape spray to toothbrush

    • Daily

    • Effect will be noticed within days

    • Get kid to do their own spray

    • Kids where it helps, the kid will ask for it

  • Allergic base

    • Saline has the greatest role here

    • Start with FESS

    • Rialtris, less foul taste compared to Dymista

Deviated Nasal Septum

• Most congenital

• Cartilage and grows

• Rare to operate in kids

• Females 15-16, males 16-18

• Can used INCS

Hollistic

• Paeds ENT

• Immunologist

• PAeds Resp

• PAeds Dent

• SP

• Paediatrician

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