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Permalink Reply by RockRpsgt on April 29, 2009 at 12:57am

Snoring does not always constitute a breathing problem. Yes it is a sign that there might be a problem. Is the child getting good sleep? Does he/she wake up alot due to the snoring? Is there a cessation in breathing? Is the child hyper or sleepy doing the day? Is the child ADD/ADHD? My own daughter just went through the procedure in December. She still has a light snore. She has no other sleep problems so I am not to worried about it. I will remind you that because my daughter has already had a sleep related breathing problem the %s are high that she will continue to have them as an adult. I will have her sleep evaluated every 5-7 years

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Permalink Reply by Steven Y. Park, MD on April 29, 2009 at 10:52am

This is a difficult issue. It sounds like this 5 year old has persistent sleep apnea despite a tonsillectomy. Most children who undergo tonsillectomy do very well, but there's still a significant percentage that either don't do well or have only partial improvement. Since most children who undergo tonsillectomy do not undergo pre and post-surgery sleep studies, we'll never know the true numbers. Limited studies have shown in the past that the rate of failure is around 10-30%. Remember that in children, an AHI of 1 is considered abnormal.

We know that removing the tonsils alone is not definitively treating the problem, but in most cases it does help significantly. Typically, jaw narrowing aggravates tonsil enlargement. So even if your tonsils are removed, you still have various degrees of oral cavity narrowing, and in some children will manifest with persistent sleep-breathing problems. Many of these kids will be diagnosed with ADHD. It's important to note that you don't have to snore to have a sleep-breathing problem. The more symptoms the child has, the more likely you may consider further treatment options.

If you have a child with persistent OSA despite tonsillectomy, what do you do? CPAP is obviously not a very good option, and dental devices are definitely not an option. We don't do major tongue base procedure in children. But here are two options to consider:

A recent Stanford study showed the benefits of rapid palatal expansion (RPE), in addition to tonsillectomy. They split a group of children into two groups, where one group underwent adenotonsillectomy and the other underwent RPE. Both groups improved significantly, based on objective testing measures. Then both groups were crossed over to the other treatment option. What they found was that having both treatments resulted in added improvements, where the combination of both options worked much better than either performed individually. So an evaluation by an orthodontist would be one possibility, to see if RPE is even an option. This has to be done before age 8-10. I'm working on getting a pediatric orthodontist to talk about this in one of my upcoming expert interviews.

This is more theoretical, but surgeons are performing minimally invasive debulking procedures for children with large tongues using the Coblator, especially in syndromic children such as Down's. It's also being applied more and more frequently in adults with obstructive sleep apnea. I've also had some limited experience with my patients and I think it's promising, but we need more studies to figure out who to offer it to, how much to remove, and lots of other logistical and practical answers.

All this brings up an important question: Just because we know we have a problem, does it need to be fixed? It seems like almost everyone may have some degree of dental crowding and a sleep-breathing problem. Some people have major anatomic narrowing but are relatively asymptomatic, whereas others have mild narrowing and are very symptomatic. But overall, the more narrow the airway, the more symptomatic you'll be. You have to start conservatively first, but with regard to further medical intervention, ultimately, the decision should be made on an individual case by case basis.

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Permalink Reply by Sandra Limbach on May 4, 2009 at 3:32pm

First sorry for the delay in responding.. I was out of town. Two, I have two kids w/ OSA. Tonsills did not do it. Needed CPAP for both children. I don't know where you live, but pedatric specialists are the way to go. If your in Northern Ca. I have connections for you.

Next... I am going to probably reiterate some of Dr. Parks recommendations. My trials started with the dentist and then the orthodontist and then the sleep center. The orthodontist spotted it right away but wanted confirmation from a study. Next was cpap and palate expansion. My son even had to do the mandibular extension at 9 . Both my children will need this. Then more expansion. My son does not sleep w/ cpap but my daughter does untill she is developed enough for surgery.

Last I am going to pleed the case that without proper intervention, a child with significant OSA, does not grow and develop properly.

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Permalink Reply by Sandra Limbach on May 4, 2009 at 3:37pm

Dr. Park.

Try Dr. Stacy Quo. Palo Alto Ca. Her office is Mid Peninsula orthodontics (650) 328-1600. She has been on the leading edge of orthodontic treatment for kids,including mine,. She volunteers at the Stanford clinic and is teaching at UCSF.

Steven Y. Park, MD said:

This is a difficult issue. It sounds like this 5 year old has persistent sleep apnea despite a tonsillectomy. Most children who undergo tonsillectomy do very well, but there's still a significant percentage that either don't do well or have only partial improvement. Since most children who undergo tonsillectomy do not undergo pre and post-surgery sleep studies, we'll never know the true numbers. Limited studies have shown in the past that the rate of failure is around 10-30%. Remember that in children, an AHI of 1 is considered abnormal.

We know that removing the tonsils alone is not definitively treating the problem, but in most cases it does help significantly. Typically, jaw narrowing aggravates tonsil enlargement. So even if your tonsils are removed, you still have various degrees of oral cavity narrowing, and in some children will manifest with persistent sleep-breathing problems. Many of these kids will be diagnosed with ADHD. It's important to note that you don't have to snore to have a sleep-breathing problem. The more symptoms the child has, the more likely you may consider further treatment options.

If you have a child with persistent OSA despite tonsillectomy, what do you do? CPAP is obviously not a very good option, and dental devices are definitely not an option. We don't do major tongue base procedure in children. But here are two options to consider:

A recent Stanford study showed the benefits of rapid palatal expansion (RPE), in addition to tonsillectomy. They split a group of children into two groups, where one group underwent adenotonsillectomy and the other underwent RPE. Both groups improved significantly, based on objective testing measures. Then both groups were crossed over to the other treatment option. What they found was that having both treatments resulted in added improvements, where the combination of both options worked much better than either performed individually. So an evaluation by an orthodontist would be one possibility, to see if RPE is even an option. This has to be done before age 8-10. I'm working on getting a pediatric orthodontist to talk about this in one of my upcoming expert interviews.

This is more theoretical, but surgeons are performing minimally invasive debulking procedures for children with large tongues using the Coblator, especially in syndromic children such as Down's. It's also being applied more and more frequently in adults with obstructive sleep apnea. I've also had some limited experience with my patients and I think it's promising, but we need more studies to figure out who to offer it to, how much to remove, and lots of other logistical and practical answers.

All this brings up an important question: Just because we know we have a problem, does it need to be fixed? It seems like almost everyone may have some degree of dental crowding and a sleep-breathing problem. Some people have major anatomic narrowing but are relatively asymptomatic, whereas others have mild narrowing and are very symptomatic. But overall, the more narrow the airway, the more symptomatic you'll be. You have to start conservatively first, but with regard to further medical intervention, ultimately, the decision should be made on an individual case by case basis.

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Permalink Reply by Steven Y. Park, MD on May 5, 2009 at 10:32pm

Sandra,

Thanks for the information.

Steve

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Permalink Reply by Nancy on May 6, 2009 at 5:24am

you haven't mentioned the adenoids. are those already gone too? sometimes these are more trouble than the tonsils.
I work in a pediatric sleep facitlity. It is not unheard of to try CPAP even on young patients although this would usually be a last resort. Also is she having the sleep study performed in an accredited pediatric facility? sometimes adult facitlites have difficulty reading pediatric EEG's

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Permalink Reply by RockRpsgt on May 6, 2009 at 7:44am

we do not do pediatric studies. In the last lab I worked at we sometimes had trouble with the few children we got.

The surgery seemed to work for my daughter so far. She does have a slight snore every now and then. I have done 2 sleep studies on her. So far so good.

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