Obstructive Sleep Disordered Breathing

1. THE SNORING CHILD:
Dr Kristy Fraser-Kirk
ENT Surgeon // Otologist // Auditory Implant Surgeon
Sunshine Coast University Hospital
Evolve ENT
Paediatric Obstructive SDB and the
Difficult Dance of Diagnosing Mild Disease

2. PAEDIATRIC
OBSTRUCIVE SDB
Episodic, prolonged upper airway obstruction during
sleep which continue despite increased respiratory effort
May result in:
- Complete: apnoea with airway obstruction
- Partial: hypopnoea (≥30% airflow reduction / ≥3% sats
reduction +/- arousal
- In essence, cessation of airflow at the nose and/or
mouth resulting in disrupted sleep

3. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?

4. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?
- Hospital snoring versus ‘Domestic’ snoring

5. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?
- Hospital snoring versus ‘Domestic’ snoring
- In the hospital setting:
- ‘Waiting List’ snorers with severe/neglected disease
- Complex children with medical comorbidities
- Obese or hypotonic children
- Children with craniofacial dysmorphism
- Post-adenotonsillectomy treatment failures
- Supplemental oxygen, respiratory support (CPAP)

6. PAEDIATRIC
OBSTRUCIVE SDB
In the hospital setting:
- Advanced investigation and treatments
- Polysomnography
- Supplemental oxygen
- Respiratory support (CPAP)
- Airway evaluation +/- airway surgery
Consider ‘Family Therapy’:
- In home nursing support, NDIS, resilience therapy
- Hospital admission for parental respite
- ‘Deterioration’ management plan for intercurrent
illnesses

7. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?

8. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?
- In the domestic setting, exhausted parents and
disruptive, ‘hyper’ kids who food refuse and under-
perform at school predominate

9. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?
- In the domestic setting, exhausted parents and
disruptive, ‘hyper’ kids who food refuse and under-
perform at school predominate
- When compared with ‘hospital snorers’, these children
may appear ‘subclinical’ or ‘mild’ – however, impacts
of obstructive SDB on a child’s night-time, daytime,
dietary performance can be significant

10. PAEDIATRIC
OBSTRUCIVE SDB
- Who needs sleep anyway?
- Clinical improvement in all parameters can be
achieved with careful assessment, conservative ‘in-
home and lifestyle’ measures, medical and surgical
therapy
- The dramatic post-treatment improvement of patient
(and families’) functional performance is one of the
surprising delights of new ENT consultancy.

11. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
- Differentiating between ‘snuffly normal’ and mild
obstructive SDB

12. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
- Ask the right questions
- Night-time wellbeing
- Daytime wellbeing
- Dietary behaviours
- Historical factors:
- Family history of atopy
- Personal history of atopy
- Eczema, dietary intolerances
- Personal history of recurrent AOM or URTI
- Birth order and family childcare history

13. ASK THE RIGHT QUESTIONS
- Night-time wellbeing
- Snoring and apnoeas: Low hanging fruit!

14. ASK THE RIGHT QUESTIONS
- Night-time wellbeing
- Snoring and apnoeas: Low hanging fruit!
‘Can you hear your child breathing?’
‘Noisy breathing… Darth Vader?’
‘How close is their room to yours? Door open or shut?
‘How long has it been since you’ve slept with them?
‘All the time or only when unwell?

15. ASK THE RIGHT QUESTIONS
- Night-time wellbeing
- Snoring and apnoeas: Low hanging fruit!
‘Can you hear your child breathing?’
‘Noisy breathing… Darth Vader?’
‘How close is their room to yours? Door open or shut?’
‘How long has it been since you’ve slept with them?’
‘All the time or only when unwell?’
Mouthbreathing is not normal: Helpful to conceptualise
the mouth as an ‘emergency snorkel’ used only during
periods of nasal restriction

16. ASK THE RIGHT QUESTIONS
- Hypermotor Activation
- ‘The trapped terrain between sleep and
wakefulness’
- Hypermotor activation:
- The trap between sleep and wakefulness
- Head hyper-extension, ‘Thrashy sweaty sleepers’

17. ASK THE RIGHT QUESTIONS
- Hypermotor Activation
- ‘The trapped terrain between sleep and
wakefulness’
- Hypermotor activation:
- The trap between sleep and wakefulness
- Head hyper-extension, ‘Thrashy sweaty sleepers’
- Sleep-walking, sleep talking, night terrors

18. ASK THE RIGHT QUESTIONS
- Hypermotor Activation
- ‘The trapped terrain between sleep and
wakefulness’
- Hypermotor activation:
- The trap between sleep and wakefulness
- Head hyper-extension, ‘Thrashy sweaty sleepers’
- Sleep-walking, sleep talking, night terrors
- ‘Age inappropriate’ enuresis (caution: Age 7)
- Bruxism: Caution – soft correlation, may not resolve

19. ASK THE RIGHT QUESTIONS
Parental Impact
- How long does the child remain in bed?
- Where is the child sleeping?
- Number of ‘trips back to bed’ / co-sleeping?
- Has child’s sleep behaviour changed over time?
- Did they ever sleep through?
- Sibling sleep behaviour?
- Sleep clinic / medications?
- How long do they remain in bed?

20. ASK THE RIGHT QUESTIONS
Reliability of Parental Account:
Does attending parent actually do the ‘night work’?
How close is the child’s room?
Door open or closed?

21. ASK THE RIGHT QUESTIONS
Reliability of Parental Account:
Is parental ‘observer’ actually observing?
Inattentive or absent: shift work
‘Deep sleeper’: obtunded, alcohol, sedatives, OSA
‘Light sleeper’: earplugs or white-noise, sedatives
‘Masking’: Spouse snoring, traffic, CPAP, white noise
Particularly relevant in children over 5: Don’t require
closer supervision developmentally
“Even good parents ignore their older kids at night.”

22. ASK THE RIGHT QUESTIONS
Daytime wellbeing
- Energy and Fatigue
- Behaviour and Emotional Regulation
- Attention, engagement and distractibility
- Restrictive dietary behaviours and growth

23. ASK THE RIGHT QUESTIONS
Energy and Fatigue
- How are your child’s energy levels?
- Have they changed over time?
- Relative to their siblings?
- Older children: self report

24. ASK THE RIGHT QUESTIONS
Energy and Fatigue
- How are your child’s energy levels?
- Have they changed over time?
- Relative to their siblings?
- Older children: self report
‘Low energy’ phenotype less common
- Age-inappropriate ‘day sleep’
- Sleeps on short car trips, at/after school
- Sleep requirement increasing
- Difficult to wake, long sleep-in
- Screen for poor sleep hygiene: bedtime, screens

25. ASK THE RIGHT QUESTIONS
Energy and Fatigue

26. ASK THE RIGHT QUESTIONS
Energy and Fatigue
Attention, Engagement and Distractibility

27. ASK THE RIGHT QUESTIONS
Energy and Fatigue
Attention, Engagement and Distractibility
‘High energy’ phenotype with distractibility more
common than low energy / fatigue in young children

28. ASK THE RIGHT QUESTIONS
Energy and Fatigue
Attention, Engagement and Distractibility
‘High energy’ phenotype with distractibility more
common than low energy / fatigue in young children
- ‘Hyperactive’ children
- Difficulties engaging / persisting with tasks
- Classroom impact
- Tutoring?
- Academic decline?
- Learning support?
- Change over time?

29. ASK THE RIGHT QUESTIONS
Energy and Fatigue
Attention, Engagement and Distractibility
‘High energy’ phenotype with distractibility more
common than low energy / fatigue in young children
- ‘Hyperactive’ children
- Difficulties engaging / persisting with tasks
- Classroom impact
- Tutoring?
- Academic decline?
- Learning support?
- Change over time?
Consider developmental stage, ‘age in class’, and
gender differences during ‘classroom’ assessment

30. ASK THE RIGHT QUESTIONS
Behaviour and emotional regulation

31. ASK THE RIGHT QUESTIONS
Behaviour and emotional regulation
Behaviour: ‘Ratty’ or ‘combative’
Emotional regulation: ‘Mood swings & melt-downs’
Carer collateral: Teachers, carers, parents,
paediatricians, psychologists
HOWEVER: Caution not to pathologise normal.

32. ASK THE RIGHT QUESTIONS
Behaviour and emotional regulation
Behaviour: ‘Ratty’ or ‘combative’
Emotional regulation: ‘Mood swings & melt-downs’
Carer collateral: Teachers, carers, parents,
paediatricians, psychologists
Personality: Placid, sensitive or highly strung
- Has ‘personality’ changed over time?
Consider developmental stage
Don’t ‘pathologize normal’

33. ASK THE RIGHT QUESTIONS
Behaviour and emotional regulation
Behaviour: ‘Ratty’ or ‘combative’
Emotional regulation: ‘Mood swings & melt-downs’
Carer collateral: Teachers, carers, parents,
paediatricians, psychologists
Personality: Placid, sensitive or highly strung
- Has ‘personality’ changed over time?
Consider developmental stage
Don’t ‘pathologize normal’
Austism Spectrum Disorder:
ASD diagnosis, Ix or referrals pending?
Significant overlap in early diagnostic phase.

34. ASK THE RIGHT QUESTIONS
Restrictive Dietary Behaviour and Growth
Food aversions related to choking/gagging events
- Progressive narrowing of palate
- Exclusion of offending food groups
- ‘My child used to be a good eater, but is so fussy now -
everything has to be soft’
Poor co-ordination of eating and breathing:
- Eating is effortful, breathless and difficult
- ‘Mealtimes take forever – he just wants to go and play’

35. ASK THE RIGHT QUESTIONS
Restrictive Dietary Behaviour and Growth
Blunted olfaction and taste: Poorer smell and taste
- Poor smell and taste: eating is unrewarding
- ‘We argue about him chewing with his mouth open’
- ‘She’s just not interested in food like other kids are’
- ‘She won’t eat anything that’s not soft or chopped fine’
- ‘She’s tinier than her siblings were at the same age’

36. ASK THE RIGHT QUESTIONS
Restrictive Dietary Behaviour and Growth
Blunted olfaction and taste: Poorer smell and taste
- Poor smell and taste: eating is unrewarding
- ‘We argue about him chewing with his mouth open’
- ‘She’s just not interested in food like other kids are’
- ‘She won’t eat anything that’s not soft or chopped fine’
- ‘She’s tinier than her siblings were at the same age’
Paediatric autonomy, power and family dynamics
- Children will exert control over their personal autonomy
and family wherever they can
- ‘My child is so stubborn – eating is a power struggle’
- ‘We clash around family mealtimes – they’re a battle
ground’

37. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
- Risk stratify: Family and early history
- Educate the parents: ‘How to Watch your child’
- Exhaust non-invasive therapies
- Optimise the environment
- Obtain objective evidence
- Low threshold to operate
- Review your own diagnostic accuracy

38. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
- Soft dysmorphism
- (Any hereditary component?)
- Disordered behaviour: Tearing the room apart
- Underweight: ‘skinny, pale and tired’
- Venous pooling
- Mouth breathing, drooling, Hyponasal
- ‘Rim of rhinorrheoa’
- Drooling
- Atopy: Allergic salute, pale turbinates, eczema

39. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
- Mirror Examination
‘Dragon’s Breath’ test
Demonstrate: Misting?
Occlude one nostril
Immediate air-hunger/mouthbreathing?
- Tonsils: Grade (width), comment on AP projection
- Palate: Velopharyngeal Insufficiency risk
- Bifid uvula, zona pellucida
- Habitus: Overweight, thick cervical girth
- Consider scope if will change management

40. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
- Educate the parents: ‘How to Watch your child’
- Exhaust non-invasive therapies
- Optimise the environment
- Obtain objective evidence
- Low threshold to operate
- Review your own diagnostic accuracy

41. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Risk stratify: Family and early history

42. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Risk stratify: Family and early history
- Is this an ‘ENT family’?
- “Did either of you have tonsil, adenoid or ear
problems as kids?
- Use lay terminology

43. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Risk stratify: Family and early history
- Is this an ‘ENT family’?
- “Did either of you have tonsil, adenoid or ear
problems as kids?
- Use lay terms
- Is this an ‘atopy family’?
- Ask about hayfever, asthma, eczema, dermatitis,
food allergies and drug allergies
- “Are you an itchy, scratchy, sneezy, allergic kind
of family?”

44. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Risk stratify: Family and early history
- Is this an ‘ENT family’?
- “Did either of you have tonsil, adenoid or ear
problems as kids?
- Use lay terms
- Is this an ‘atopy family’?
- Ask about hayfever, asthma, eczema, dermatitis,
food allergies and drug allergies
- “Are you an itchy, scratchy, sneezy allergic kind
of family?”
- Recurrent infant URTI as risk factor
- Did they/sibling attend daycare early?
- Were they sick a lot as a baby?

45. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
Educate the parents: ‘How to Watch your Child’
- Exhaust non-invasive therapies
- Optimise the environment
- Obtain objective evidence
- Low threshold to operate
- Review your own diagnostic accuracy

46. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Educate the parents: ‘How to Watch Your Child’

47. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Educate the parents: ‘How to Watch Your Child’
- Six week review period
- Parents as ‘diagnostic partners’
- Written information: Night / Day / Dietary signs
- Aids parental understanding
- Enhances parental ‘buy in’ for children who
progress to surgery
- Enhances parental reassurance in subclinical
cases

48. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
Educate the parents: ‘How to Watch your child’
Exhaust non-invasive therapies
- Optimise the environment
- Obtain objective evidence
- Low threshold to operate
- Review your own diagnostic accuracy

49. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Exhaust non-invasive therapies

50. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Exhaust non-invasive therapies
- Dairy exclusion: trial 2/52
- Nasal saline and HDM bedroom measures in all
- Low threshold for INCS to assess all for subclinical
rhinitis, esp if PMx / FHx AR / atopy
- Compliance:
- Counsel technique
- Saline primer 1/52
- Single / Dual agent: cost, convenience, taste
- ‘Child administered’, weekend breaks
- Oral non-sedating anti-histamine if poor / no
compliance +/- prominent non-nasal
symptoms

51. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
Educate the parents: ‘How to Watch your child’
Exhaust non-invasive therapies
Optimise the environment
- Obtain objective evidence
- Low threshold to operate
- Review your own diagnostic accuracy

52. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Optimise the environment

53. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Optimise the environment
- Diagnostic and therapeutic benefits
- HDM measures
- Pets and soft toys: exclusion high yield
- Consider baby monitor / iPhone sleep app monitoring

54. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
Educate the parents: ‘How to Watch your child’
Exhaust non-invasive therapies
Optimise the environment
Obtain objective evidence

55. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Obtain objective evidence

56. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Obtain objective evidence
- Diarise recurrent illness / allergic episodes
- ‘Forced observation’
- Parental sleep video/audio
- iPhone alarm, 9pm
- 5 recordings over 6 weeks
- Chase collateral: Teachers, clinicians, allied health

57. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
Educate the parents: ‘How to Watch your child’
Exhaust non-invasive therapies
Optimise the environment
Obtain objective evidence
- Low threshold to operate
- Review your own diagnostic accuracy

58. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Low threshold to operate

59. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Low threshold to operate
- Stand-alone symptoms not sufficient for surgery
- ‘Tonsils are not a disease’
- Inadequate symptoms to diagnose:
- Reassure and discharge
- Borderline symptoms: 6/12 ’surveillance pause’
- Watchful waiting with no or ‘low-impact’ treatment
- Interval craniofacial growth / seasonal variations

60. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Low threshold to operate
- Stand-alone symptoms not sufficient for surgery
- ‘Tonsils are not a disease’
- Inadequate symptoms to diagnose:
- Reassure and discharge
- Borderline symptoms: 6/12 ’surveillance pause’
- Watchful waiting with no or ‘low-impact’ treatment
- Interval craniofacial growth / seasonal variations
- Consider origin of referral
- Dentists: tendency to over-call
- GPs: tendency to under-call
- Feedback of outcome and rationale
improves diagnostic accuracy among
referrers

61. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Low threshold to operate
- While tonsils are not a disease, however, detecting
mild disease requires a ‘forest amidst the trees’ lens
- Nuanced history and careful clinical examination
- ‘Educated’ parental observation
- Therapeutic trial medical / conservative measures
- Careful approach often identifies surgically
correctible mild-moderate obstructive SDB
missed by ‘hospital grade’ diagnostic approach
designed to identify moderate-severe disease
- Surgery can deliver dramatic gains in carefully
selected mild-moderate cases (esp. daytime,
behavioural, diet

62. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Ask the right questions
Examine the patient carefully
Risk stratify: Family and early history
Educate the parents: ‘How to Watch your child’
Exhaust non-invasive therapies
Optimise the environment
Obtain objective evidence
Low threshold to operate
Review your own diagnostic accuracy

63. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Review your own diagnostic accuracy

64. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Review your own diagnostic accuracy
- “Hammer / Nail” effect
- Clinical assessment is nuanced and complex
- Children ‘grow out of ENT disease’… Treat or not?
- Patient factors: age, craniofacial growth, ‘allergic
march’
- Seasonal and environmental factors
- Immunological factors: lymphoid
hyperplasia/regression
- Correlation imperfect between clinic diagnosis and
operative findings: even in experienced hands

65. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Review your own diagnostic accuracy
- Adopting a ‘low operative threshold’ requires
rigorous and ongoing introspection of diagnostic
accuracy and outcomes
- Parental and surgeon post-operative impressions
biased: Cost, suffering, service, altruism, (ego?)

66. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Review your own diagnostic accuracy
”Internal audit” marries in-clinic diagnosis with operative
findings to examine and improve diagnostic accuracy
Define secretory Vs obstructive features in AR
- Improve accuracy of patient selection for
CITS/RFRITS
- Improve prognostic accuracy re: ongoing need for
INCS post-operatively

67. THE DIFFICULT DANCE OF
DIAGNOSING MILD DISEASE
Review your own diagnostic accuracy
”Internal audit” marries in-clinic diagnosis with operative
findings to examine and improve diagnostic accuracy
Define secretory Vs obstructive features in AR
- Improve accuracy of patient selection for
CITS/RFRITS
- Improve prognostic accuracy re: ongoing need for
INCS post-operatively
Professional integrity and community trust mandates
scrupulous self regulation and record keeping