Hear a Patient Power interview with Dr. Kristina Rosbe, a pediatric head and neck surgeon, who explains how enlarged adenoids and tonsils can cause sleeping and breathing disorders.
Enlarged adenoids and tonsils can cause sleeping and even breathing disorders in children. Coming up, Dr. Kristina Rosbe from UCSF Benioff Children's Hospital will discuss these problems and the latest treatments. It's all next on Patient Power.
Hello and welcome to Patient Power. I'm Andrew Schorr. This program is sponsored by UCSF Medical Center and UCSF Benioff Children's Hospital. I'm going to think back to when I was a kid and there were so many people, so many kids, who had their tonsils and adenoids out. Then it stopped happening so much. I was one who as a teenager, had it because I had recurrent sore throats, but there are other kids who didn't have their tonsils out and still have their tonsils as adults. Now, we're realizing that some children need their tonsils and adenoids looked at because they may play a role in sleep problems.
Up to 10 percent of children will have some type of sleep issue, whether it's just snoring or something more severe such as sleep apnea.
Of those kids, do we have a sense of how many may really need to have a doctor look at their tonsils and adenoids?
Well, I would say a large percentage. Whether the tonsils and adenoids are actually causing true sleep apnea is probably somewhere in the range of 1 to 3 percent of all children.
When we look at those kids, what would be signs, what would a parent see first of all to say maybe there's some sleep problem going on? Is it just that your kid snores at night, night after night, or wakes up a lot? What would be things you'd look for?
Well, certainly that's part of it. Often, parents remark that their children seem to be much louder sleepers. Often, they're very restless. They seem to either move about the bed or wake up more times than other siblings or friends. And they also don't seem well rested. They either have to be woken up in the morning, they don't wake up on their own, or when they are awake, they seem tired. Sometimes this is related to fatigue, although some children when they're tired, they're actually hyperactive, so it can carry over and cause some daytime behaviors that can be associated with the lack of good quality sleep.
So they could be cranky.
Now, some of the things you talked about, nowadays we say, well, gee, maybe it's ADHD (attention deficit hyperactive disorder), but are you saying that if we look more closely, it could be their tonsils and adenoids?
Absolutely. In fact, there are a fair number of studies now linking and showing a correlation between sleep apnea or sleep disorder breathing in children and a more likely diagnosis of ADHD. In one study, they compared getting tonsils and adenoids out in children who had a diagnosis of ADHD compared to going on medication, traditional medication for ADHD. The children who had their tonsils and adenoids out did better in terms of their daytime behavior.
So there does seem to be a link. It makes sense. If you think about yourself, if you don't get a good night's sleep, it's often hard to concentrate the next day.
What about bed wetting?
That's another association that has been demonstrated time and time again. One of the thoughts is that there are important hormones secreted at night. Generally, you have to be in deep sleep or REM sleep for them to be secreted. If children are never really quite getting into that good, deep sleep, then these hormones that help regulate bed wetting and even growth are disregulated and can have some effects.
Now, don't pediatricians pick up on this? Your kid goes in for an exam or you have these issues, bed wetting or cranky behavior, fatigue, and they look at their tonsils and say that's it?
I think there's more and more focus. The American Academy of Pediatrics came out with a guideline saying that all children should be screened for snoring, but I think there's still some confusion about what to do if you do find snoring in a child and how significantly you have to intervene, when you need to refer and those types of things. So we're still figuring those things out.
If a child's tonsils and adenoids could be the problem, what happens next? How do you determine what's going on?
Asking a lot of questions to parents about how much sleep does your child actually get, do they fall asleep when they're in the car, are they napping more than other kids seem to be napping at their age, what's their daytime behavior like? Also, are they quite loud at night, are they mouth-breathing, are they moving around in the bed, kicking off their blankets? Those sorts of things.
There are some tests we can do. Certainly, we do a physical examination and if there are large tonsils and adenoids, that tends to support the diagnosis. Sometimes it's helpful if parents videotape their child for a little while while they're sleeping. It's most helpful if they're in deep sleep. That's usually several hours after they've gone to bed. Now, we have all these fancy devices, even things like portable phones, that you can get a good video on. That's often helpful and we ask parents to do that.
Beyond that, there's something called a sleep study where a child comes into the hospital overnight and the parent can sleep with them. They have monitors monitoring their oxygen level, their blood pressure, their heart rate and other things to see what's happening during the snoring and if they are pausing or gasping for breath, which is one of the more classic symptoms of true sleep apnea.
Would you move directly to a sleep study or would there be X-rays to show the adenoids or tonsils?
A physical exam can be quite helpful. The tonsils are readily apparent when you look in the mouth. The adenoids aren't always easy to see but generally correlate with the tonsils. If a child has big tonsils, we don't always need to demonstrate that the adenoids are big as well. Most of the time, we go by the clinical history and the exam. We don't necessarily jump to the sleep study right away because there aren't a lot of other things that cause these symptoms.
I'm pretty clear on what tonsils are. I know they can be those big things that are at the back of your throat, and my understanding is they help prevent infection from spreading in the body. What are adenoids? Where are they?
They're both the same tissues. You're correct. They're part of your immune system, and they help you fight viruses and bacteria and things that come through your mouth and nose. The adenoids are in the back of your nose. If you stuck your finger all the way back there, they're on the roof of your mouth. They're the same tissue as the tonsils. They're just slightly higher up in the back of the nose.
What happens in a child when they cause a problem?
We don't completely understand the etiology of big tonsils and adenoids. We think there's probably a genetic component because siblings tend to have big tonsils and adenoids. It does seem to run in families. But there's some data to support that children who are exposed to bad viruses — one is RSV, a virus that if a young infant gets can cause a pretty bad pneumonia — are more likely later on to have bigger tonsils and adenoids.
Another theory is that children, who are exposed to a lot of viruses at a young age, have hyperstimulated immune systems and the tonsils and adenoids become larger.
So a child is having troubling getting breath. Is this a dangerous thing as it continues?
It can be. Generally, the permanent effects would take months or years to develop. What's happening with these small pauses or gasps during sleep is the oxygen level in the body is going down. Even though it's very brief, if it goes on for long periods of time, it can cause some changes in the circulation, something called pulmonary hypertension, and ultimately in the heart, and even some changes in the brain and thought and cognition and things of that nature.
So you don't want to wait. You mentioned a sleep study. What is that like for a child and how can it be done in a way that's not anxiety producing?
It's certainly not a perfect test. It is the best test we have at this point. It's probably more successful in slightly older children. The average age of a child diagnosed with sleep apnea is probably somewhere between 3 and 5. Younger children are probably going to have a harder time. Part of it is they're sleeping in a place they're not familiar with. It's not their own bedroom. They have all these stickers on them.
What they try to do is simulate sleep. There is a technician who is there to put the monitors back on if they get pulled off during sleep. Hopefully, at least a certain amount of sleep eventually occurs even in the hospital setting so that the monitors can pick up what's happening. But for children who are younger or who may have some developmental delay, often the tests are not as successful as they could be.
For the children who have a successful sleep study, they have these little electrodes put on. I understand the electrodes may be put on after they fall asleep. Mom or dad, or both, can be there, right?
Then, they sleep and you monitor their breathing. You have monitors going on. From that, you can tell if there is a sleep problem. You also have the physical exam saying whether these blockages are the bad guys.
Correct. Unlike adult sleep apnea, which is a much more complicated animal and can be multifactorial, the majority of pediatric sleep apnea is due to large tonsils and adenoids.
If you determine it is that, what happens next?
If it's mild, and there are specific criteria, the sleep studies get graded. We can put the results into mild, moderate or severe categories. If a child has mild sleep apnea sometimes we can either observe or treat with medication. The natural history of the adenoid and tonsil tissue is that it will start to involute or shrink as children get older. Sometimes, if you give it a little bit of time, things will improve on their own.
There are some studies showing that nasal steroids can also help shrink the adenoids. Sometimes we put children on those for several months to see if that gives us enough time until the child grows and the tissue stays the same so proportionately it's not blocking the airway as much.
Then beyond that, the mainstay of treatment is removal of tonsils and adenoids. In adults, sometimes a machine called CPAP or Continue Positive Airway Pressure, is used, but this is generally not well tolerated in children. It's a mask that air blows through that people have to wear at night, so we usually don't use that in children unless for some reason they really can't undergo surgery.
Okay. Tell us about the surgery. How do you do it? How long does it take? How long does it take to recover from, and are there different ways of doing it?
It is one of the most common surgeries done in the United States. I think last time I checked it's something like over 400,000 are done per year. It's generally an outpatient procedure in children who are 3 years or older and who don't have other medical issues. We take out both the adenoids and the tonsils through the mouth. A child does have to be put under general anesthesia for the procedure. So they have a breathing tube in their mouth.
Then, there are a variety of techniques in terms of instruments that can be used. Traditionally, it was a knife that was used or a snare. Now, we have an instrument, called a "bovie," which cauterizes as it cuts. One of the complications of tonsillectomy, because it's a vascular area and there are a lot of blood vessels, is that bleeding can occur. So, one of the advantages of the cautery is that it stops the bleeding as it cuts.
There are other techniques using technology such as radiofrequency. Some folks have used the laser, something called a microdebrider, so a variety of different technologies have been used. I think it is surgeon preference that determines the instrument used by a particular surgeon.
I remember when I had the snare approach many, many years ago, and it took a while to recover. And you always would say, well, the kid needs to eat ice cream and all that. Talk about recovery, complications, and just what the expectations are. Any special diet? What have you seen in the children you've helped?
I've tried all these different technologies because the bottom line is getting your tonsils out is just no fun. It hurts and it's going to hurt for a while. I generally counsel children and their families that it can be up to two weeks before they're really feeling back to themselves. Generally, they want to prepare to be out of school for at least a week and not doing any kind of physical activity for a full two weeks. You also have to be on a soft diet for a full two weeks as well.
You have a raw surface back there in your throat after the tonsils are taken out, and that takes a while to heal. There are little scabs that form, like when you skin your knee, but they're in your throat, and the usual time for them to fall off is about a week later. That's when sometimes children may cough up a little blood.
One of the more common complications of the surgery is bleeding, what's called secondary bleeding. That happens greater than 24 hours after the surgery. Most of the time, if a child does cough up one of the scabs, it stops bleeding. It's just an isolated event. But in rare cases, it continues to bleed and we recommend that families come in so they can be evaluated. In rare cases, children may have to go back to the operating room to get something cauterized.
As far as the sleep problem, which is where we started, when does that resolve itself or is that immediate?
Well, it varies. Often parents notice an immediate difference but it can take several weeks until all the tissue has healed and the swelling has gone down before the final result is apparent. Over 90 to 95 percent of children will stop snoring after the surgery.
So for parents listening who are trying to say is this my kid and if it is, how quickly do I need to sort of go to a specialist such as you, maybe there will be a sleep study. I mean, in the scheme of things what would you recommend as far as a pace of getting to the bottom of it so your kid can go on with a happy healthy life?
I think the most important things are is your child snoring, are they having pauses, do they seem like they're very restless and then do they seem cranky or not well rested during the day. If any of those things are happening, then I would recommend that a parent request an evaluation with a pediatric otolaryngologist. It doesn't have to be the next day, but probably within a few weeks. Generally within a few weeks or months if the diagnosis is made, you want to have the intervention.
Hopefully, within a week or two of recovery, you have a happy kid who is sleeping well, doing well in school, not cranky, not bed-wetting and you go on. You probably have other challenges, but at least not that one, right?
One last thing just out of curiosity. If the child has the tonsils and adenoids out, does that make it less likely they'll have a sleep problem as an adult or is that a whole other issue?
That's a good question. I don't think we know the answer to that.
Well, certainly we want the best for our kids. If I hear my kids snoring, I'll get the camera or smart phone, as you said, and bring it to the doctor and say what's going on. Dr. Kristina Rosbe, director of Pediatric Otolaryngology . . . so glad I can pronounce that . . . at UCSF Benioff Children's Hospital, thank you for helping us understand sleep problems in children and when tonsils and adenoids may be part of the problem. Thanks for being with us, doctor.
Recorded February 2011
Reviewed by health care specialists at UCSF Benioff Children's Hospital.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
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