OBSTRUCTIVE SLEEP DISORDERS IN BREATHING IN CHILDHOOD

Adenotonsillar Hypertrophy

A. Kaditis, MD

Pediatric Pulmonology Unit, Sleep Disorders Laboratory

First Department of Pediatrics

University of Athens School of Medicine

and Aghia Sophia Children’s Hospital

Athens, Greece

Obstructive Sleep-Disordered Breathing (SDB)

Spectrum of abnormal respiratory patterns during sleep characterized by snoring and increased respiratory effort

Primary snoring Upper airway resistance syndrome Obstructive hypoventilation Obstructive sleep apnea (OSA)

Adenotonsillar Hypertrophy

Pathophysiology of Obstructive SDB

A Mechanical Model for Obstructive Sleep-Disordered Breathing (SDB)

Upper Airway Resistance

Arens et al. Changes in Upper Airway Size during Tidal Breathing in Children with OSAS. AJRCCM 2005;171:1298

Healthy OSA

Inspiration

Expiration

Symptoms of Obstructive SDB directly associated with intermittent upper airway obstruction

Snoring

Reported apneas during sleep

Difficulty breathing during sleep

Mouth breathing

Restless sleep

Frequent arousals

Conditions affecting Upper Airway Resistance and/or Pharyngeal Collapsibility

Adenotonsillar hypertrophy, allergic rhinitis, nasal septum deviation, nasal polyps

Obesity

Craniofacial abnormalities

Neuromuscular disorders

Upper Airway Dysfunction and Adenotonsillar Hypertrophy

Adenotonsillar Hypertrophy

Pathogenesis of Adenotonsillar Tissue

Hypertrophy

Risk factors Dependent variable: tonsillar hypertrophy

OR (95% CI)

pvalue

Age 0.97 (0.90-1.04)

0.321

Gender 1.03 (0.64-1.65)

0.906

Obesity 0.69 (0.38-1.25)

0.219

PassiveSmoking

0.96 (0.60-1.53)

0.851

History of wheezing 2.23(1.37-3.63)

0.001

Kaditis et al. Associations of Tonsillar Hypertrophy and Snoring with History of Wheezing in Childhood. Pediatr Pulmonol 2010;45:275

Dayyat et al. Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive

sleep apnea. Chest 2009;135:1142

Goldbart et al. Leukotriene Modifier Therapy for Mild SDB. AJRCCM 2005; 172: 364

OSA Recurrent tonsillitis

Kaditis et al. CysLT-Rs in Tonsillar Tissue of Children with OSA. Chest 2008;134:324-31

OSA Recurrent tonsillitis

Adenotonsillar Hypertrophy

Does Adenotonsillectomy Cure OSA?

Brietzke et al. The Effectiveness of AT in the Treatment of Pediatric OSA. Otolaryngol Head Neck Surg 2006;134:979

Garetz et al. Behavior,

Cognition and Quality of Life after AT for

Pediatric SDB: Summary of the

Literature. Otolaryngol Head Neck

Surg 2008;138:s19-26

Pediatrics 2006;117:e61-6

Nasal budesonide + po montelukast vs. Placebo

for 12 weeks in children with residual SDB pAT

Bhattarjee et al. AT outcomes in Treatment of OSA in Children. AJRCCM 2010; 182:676-683

Amin et al. Growth Velocity Predicts Recurrence of SDB 1 Year After AT. AJRCCM 2008;177:654-9

70 children (mean age: ≈ 10 y.o.)

Guilleminault et al. AT and OSA in Children: A Prospective Study. Otolaryngol Head Neck Surg 2007;136:169-75

Villa et al. Randomized controlled study of an oral jaw-positioning device for treatment of OSA in children with malocclusion. AJRCCM 2002;165:123-7

Before After

Conclusions

Adenotonsillar hypertrophy is a major risk factor for obstructive sleep-disordered breathing in childhood

Cysteinyl leukotrienes promote adenotonsillar hypertrophy

Residual sleep-disordered breathing post AT may be the result of co-existing nasal inflammation, obesity or craniofacial abnormalities.