Malady Wise

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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