Adenoid facies is typical changes in the face of young children because of enlarged adenoids.
Chronic mouth breathing because of enlarged adenoids during the age of active facial skeleton growth results in facial structural changes.
The features of adenoid facies include elongated face, pinched nostrils, open mouth, high arched palate, shortened upper lip, and vacant expression.
Jaws and teeth are affected and disfigured ; usually teeth of the upper jaw are irregular and crowded and there is malocclusion of upper and lower jaws.
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Snoring is noise produced during inspiration, when one is asleep, due to partial obstruction of the upper airway. It is due to the vibration of the soft palate, uvula, base of tongue and other soft tissues in the throat when one inhales. As much as 30% of the adult population or 60% of men over 40 years of age snore.
Snoring child may sound funny; but sometimes it’s a sign of a serious medical problem that should be treated. It is important to know if snoring is just normal or child has obstructive sleep apnea.
Children who snore or struggle to breathe while sleeping may suffer from Obstructive Sleep Apnea Syndrome (OSA). OSA is common in children more so in the age of 2-6 yrs when tonsils and adenoids are relatively larger.
Sleep problems and sleep apnea in children usually go unnoticed by parents. It may be the cause of poor school performance, learning disabilities, bed wetting, hyperactivity and even heart failure. Persistent open mouth, open mouth while sleeping, hypo nasal speech, nocturnal snoring, and abnormal sleep positions may be considered habitual or may escape the parents notice as patients may not be aware of significance of these symptoms.
Some common medical terminologies and definitions
Apnea means “without breath” in Greek. Sleep Apnea is described as cessation of breathing (For 10 seconds or longer) while asleep.
Hypopnea is 10 second event where breathing is continuous but ventilation is reduced by 50%.
Sleep apnea syndrome is when 30 or more episodes of apnea occur during a 7 hour sleep period.
Sum of Apnea and Hypopnea in per hour is Apnea –Hypopnea Index (AHI) and OSAS is AHI more than 5. Obstructive Sleep Apnea Syndrome by definition is excessive day time sleepiness with irregular breathing at night.
Severity of OSA is measured in terms of the number of pause of breathing per hour at night during sleep.
AHI 5-14 is mild, 15- 30 is moderate and more than 30 is severe. OSA has physical, mental and social impact on the child
Types of apnea
Obstructive Sleep Apnea – OSA is repeated episodes of airway blockage during sleep, and usually associated with snoring and reduction in blood oxygen level.
Central Sleep Apnea – Airway is not blocked but breathing centers in brain are suppressed and fail to give signals to respiratory muscles to breathe.
Mechanism of Obstructive sleep apnea
The stoppages in breathing are usually caused by the upper airway being partially or completely collapsed during sleep. During sleep upper pharyngeal airway muscles tone decrease leading to narrowing. Increase respiratory effort causes arousal from deep sleep. This circle continues several times.
Upper airway collapse may occur at various levels – palate, base of tongue, hypo pharynx. Nasal block exacerbates it.
Causes/ Risk factors of obstructive sleep apnea in children may be physical or dysfunctional
- Nasal congestion
- Blocked nose (b/c cold or sinusitis/deviated nasal septum/nasal polyp)
- Allergic rhinitis
- Enlarged adenoids
- Enlarged tonsils
- Large tongue
- Elongated Uvula
- Thick neck as in obese child
- Down syndrome
- Children with abnormal face
- Cerebral palsy or neuromuscular disorder
- Asthmatic children
- Smoking (active and passive)
- Family history of Sleep apnea
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Features/symptoms/consequences of sleep apnea
Dominant symptoms of OSAS are excessive daytime sleepiness, impaired concentration and snoring.
Child with sleep apnea will actually stop breathing for short amounts of time many times a night. After apnea event child may wake up to resume normal breathing and again goes to sleep thus sleep may be disturbed or poor quality and child may have excessive day time sleepiness (though it is more common in adults as sleep arousal threshold is higher in children).
Child may not get enough oxygen because of apneas which in long-term puts strain on heart and lungs and may cause heart attacks, heart failure, high blood pressure, strokes and sudden death while sleeping.
During the night:
- Loud snoring (Cardinal symptom)
- Apnea (stop breathing)
- Gasping for air
- Choking sensation
- Restless sleep / tossing & turning in bed
- Disturbed sleep/Frequent arousal
- Sleeping in unusual positions (sitting position and hyper extended neck)
- Waking up with a loud snore/ nightmare
- Nocturia (frequent urine passing)
- Enuresis (bed wetting)
During the day:
- Un refreshing sleep/ difficulty getting up in the morning
- Morning headache
- Dry mouth / throat
- Daytime sleepiness, tiredness
- Poor concentration
- Poor memory
- Poor school performance
- Mood changes
- Paradoxical hyper activities (ADHD)
Diagnosis of Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) must be differentiated from simple snoring. which is usually not accompanied by reduced levels of oxygen , increased co2 levels, or sleep disruption.
Other causes of excessive day time sleep are to be ruled out like Chaotic sleep schedules, Sleep deprivation, fragmented sleep., restless leg syndrome, narcolepsy, hypothyroididm, drugs-sedatives, previous encephalitis, previous head injury, stimulants-caffeine, amphetamines, b blockers
Thorough medical history, including sleep history like total sleep time, bedtime routine & sleeping environment; and any behavioral problem are to be asked very thoroughly.
Asking the parents to video record the child during sleep is often useful.
Height and weight, Neck Circumference, Blood Pressure should be recorded.
Nose and Throat examination are to be done thoroughly.
Video Flexible Nasal Endoscopy and Laryngoscopy are helpful to identify and quantify the site of the obstruction accurately.
X-Ray Nasopharynx –for adenoid and tonsil enlargement
X-Ray chest-to see heart size
Sleep observation, oxygen saturation and ECG in most children may be sufficient to document the need for adenoids and tonsil removal.
Overnight Sleep study (polysomnogram)-
It is detailed examination during sleep to record the sleep stages, heart rate, oxygen and carbon dioxide levels, eye movement, chest wall movement, and the flow of air through the nose.
Child is attached to machines that check EEG (Encephalogram –measure brain waves), EMG (Electromyogram-leg movement ) EOG (Electroocculogram-measure eye movement) ECG/EKG (electrocardiogram- measure heart rate and rhythm); chest and abdominal movement (measure breathing movements); and monitoring of oxygen and carbon dioxide levels in the blood.
None of the devices is painful still it may be a little frightening for a young child.
A sleep technologist monitors the recordings during sleep and after wards report is analyzed by sleep physician.
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- Regular exercise
- Weight loss
- Avoid heavy diner
- Healthy high fiber diet
- Develop regular sleeping patterns
- Tilting the top of a bed upward a few inches,
- Sleeping on the side
- Avoid alcohol/smoking
- Avoid allergy triggers (stuffed animals, pets, and feather/down pillows from the bedroom.
Nasal Continuous Positive Airway Pressure (CPAP)
CPAP (Continuous Positive Airway Pressure by a nasal mask throughout the night) is the most effective and frequently used treatment for OSA.
Compliance is a major problem but family should be motivated as major surgeries can be avoided. Sleep study should be repeated every 6-12 months with upper airway growth with age.
Oral Appliances (OA)
Mouthpieces worn at night works by repositioning the tongue or mandible forward
Nasopharyngeal airway – It may be the only treatment required for some children. Like Adequate airway is developed by the age of about 3 months in Pierre Robin syndrome.
Major complication of OSAS are reversible before the end stage heart and lung disease therefore surgery should be done for obstructive lesions of upper airway as soon as possible.
Tonsillectomy and Adenoidectomy (TAR / T&A) cures most children and it should be the initial treatment in children with other factors also.
In patients with craniofacial anomalies specific surgery can be done.
UPPP is done in selected cases.
Sleep apnea can have serious significant complications yet vast majority remain undiagnosed and untreated because of lack of awareness by the parents and health care providers.
All children with ADHD, behavioral problems and poor academic performances should be assessed for sleep apnea by ENT specialist or pulmonologists and upper airway should be evaluated by ENT specialists for every sleep apnea child.
Tonsillectomy and adenoidectomy results in dramatic resolution of symptoms of OSAS.
As otolaryngologists, we are frequently asked to evaluate the upper airway, especially by the dentists in children undergoing orthodontic treatment or by pulmonologist in children undergoing evaluation for sleep disorders. While assessing the upper airway parents are asked few questions.
- Does your child keep his mouth open, especially while asleep?
- Does your child snore at night?
- Does he have repeated colds and coughs?
Under normal condition, breathing takes place by the nose. Mouth breathing or snoring should not be overlooked and proper evaluation is to be done. Mouth breathing syndrome may cause abnormal positioning of teeth, and facial deformity. It May progress to sleep disorder and poor school performance and in some cases lead to adverse effects on heart and lungs.
Mouth breathing and snoring due to adenoid is common in children, but since the signs and symptoms of adenoids are so ubiquitous, often the general physician or pediatrician may fail to think about adenoids.
Nose block may be of three types–
a. Organic—some mechanical obstruction –enlarged adenoids, tonsils, deviated nasal septum, allergic rhinitis, nasal foreign bodies, enlarged nasal turbinates, Nasal polyps etc.
Adenoids and Tonsils
Tonsils and adenoids are clumps of lymphoid tissue, the tonsils are located on both sides of the back of the throat (Oropharynx) and adenoids are located higher in the passage that connects the back of the nose to the throat (Nasopharynx).
The tonsils are visible through the mouth, but the adenoids are not directly visible. A small mirror or a nasal endoscope is used to see the adenoids.
Role of the Adenoids/Tonsils:
Tonsils and adenoids trap bacteria and viruses entering through the throat and nose and produce antibodies to help the body fight infections. But they are not considered to be very important as our body has other means of preventing infection and fighting off bacteria and viruses.
Children are born with adenoids which are quite small and usually the adenoids shrink after about 5 years of age, and it practically disappear by the teenage years.
Some children (and adults) are prone to develop infections of the tonsils and adenoids. These infections can be caused by different kinds of bacteria other than streptococcus( the one most people know about).
Symptoms of enlarged tonsils and adenoids
Adenoids enlarge because of repeated allergy or infection. Children with enlarged tonsils or adenoids may have a sore throat and discomfort or pain during swallowing.
Enlarged or hypertrophied adenoids can block a child’s nasal passages and result in–
- Nasal block and Difficulty breathing through the nose
- Breathing through the mouth / child will keep mouth open specially during sleep
- Noisy breathing
- Snoring while sleeping
- Stops breathing for a few seconds while sleeping (called sleep apnea)
- Hyponasal voice/ as if nostrils are pinched
- Chronic ear infections, ear pain and hearing loss because of Eustachian tubes block
- Change in face (adenoid facies ) of young children
Diagnosing tonsillitis and the enlarged Adenoids—
Most common cause of nasal obstruction in children is enlarged adenoids but nasal allergy may be contributing factor which should also be ruled out and managed.
Proper history and clinical examination are very important.
Number of episodes of sore throat during the past 1 to 3 years is more important than the size of the tonsils alone. Very large tonsils may be normal and chronically infected tonsils may be normal-sized.
Redness of the tonsils, enlargement of lymph nodes in the neck, and the effect of the tonsils on breathing is also assessed.
Parents may neglect open mouth of the child while sleeping, considering it normal or habitual but actually it may be an indication of sleep apnea.
Sometimes Parents may report that child has restless sleep indicated by moving around in bed or the child stops breathing frequently during sleep.
History of Dry mouth may be found on probing. The child may be hyperactive and have poor performance in school and may be falsely labeled as ADHD (attention deficit hyperactive disorder).
Patient may have a high arched palate and overcrowding of teeth, change in the face called adenoid facies.
Investigations to diagnose Tonsillitis and Adenoids
The tonsils are visible through the mouth, but the adenoids are not directly visible.
To view Adenoids post nasal mirror or nasopharyngoscopy (Rigid or fibreoptic) is usually required. Nasenendoscopy is reliable in assessing the size of the adenoids.
X-Ray of soft tissue of nasopharynx / Occasional CT scan is done.
Observation or Video recording of a child while sleeping may be helpful.
Polysomnography (Sleep Study) may be advised to see oxygen levels in the blood.
Why to remove the Tonsils and adenoids?
Tonsil surgery is less common now. The tonsils are normally large during childhood and begin to shrink in size after the age of 7-8 years.
Children who benefit from Tonsil surgery include those with the following:-
- Obstructive sleep apnea
- Extreme discomfort when talking and breathing
- Lack of weight gain: Children may not eat sufficiently because of pain
- Multiple throat or ear infections (Seven or more infections in 1 year, five or more infections a year over 2 years, or three or more a year over 3 years)
- Chronic or recurrent tonsillitis associated with the streptococcal sore throat not responding to beta-lactamase-resistant antibiotics
- Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy
The only treatment for enlarged obstructing adenoids is to surgically remove them. Antibiotics and other medications do not help.
Though adenoids usually shrink in the second decade of life, however, blockage and sleep apnea may affect growth and development and cause permanent changes in facial or dental development. Decision to remove adenoids is usually taken before it occurs.
Adenoidectomy is recommended for the following:
- Recurring nasal congestion and sinus infections
- Blockage of back of nose :- Enlarged adenoids may cause “mouth breathing”, snoring, or sleep apnea (stop breathing for brief periods during sleep). Because of the blockage of upper airway, oxygen levels in the blood may be low, and children may wake up frequently and feel sleepy during the day. Rarely, obstructive sleep apnea can cause serious effects on lung and heart.
- Chronic ear infections and hearing loss: -Adenoids block eustachian tubes (tube connecting back space of nose to the middle ear) resulting in fluid accumulation in the middle ear.
- lack of weight gain: -Children may not eat sufficiently because of pain or because breathing takes constant physical effort
Surgery to Remove Adenoid and Tonsils
Usually surgery is under general-anaesthesia and child will not be allowed to eat or drink minimum 6 hours before surgery start time, and the patient doesn’t feel any pain during surgery.
Tonsils and the adenoids are removed through open mouth —no need to cut through skin.
Adenoids– traditional curettage method, endoscopic shaver, electrocautery or suction coagulator
Tonsil -Cold blunt dissection method, Bipolar Diathermy, LASER or Radio frequency
Complications of tonsils and adenods surgery:
Anesthetic risk -serious anesthetic complications can occur, but are very unusual. Bleeding is rare.
The Tonsillar and adenoid bed usually becomes superficially infected, and can cause 7-10 days of bad breath, but serious infections are very rare.
Adenoids should be removed with careful consideration and examination to avoid effects on speech and/or swallowing. To be avoided in achild with sub mucous cleft palate.
Bleeding is a potential complication of tonsillectomy and before embarking on surgery family history of any abnormal bleeding should be excluded and patient’s coagulation profile is to be examined.
What to expect after Tonsils /adenoid surgery -read next blog post
- Tonsillectomy and adenoidectomy are usually done on an outpatient basis. These operations should be done at least 3 weeks after any infection has cleared to avoid risk of complications.
- Removing the adenoids can help reduce snoring, but may not completely cure it because several other reasons may be responsible for snoring.
- Tonsillectomy and adenoidectomy do not appear to decrease the frequency or severity of colds or cough.
- Voice may sound different for a short while after the operation because of swelling in the area. However, this usually comes to normal within 1 or 2 weeks.
- Removing the tonsils or adenoids does not cause any problems with the immune system.
White patches on the tonsils are mistaken for an infection. Most often this is of no medical significance. Furthermore, large tonsils do not necessarily mean the child needs to have them removed. The most common reasons to consider removal of the adenoids and tonsils are recurrent infections and obstructive sleep apnea (OSA). Adenoidectomy has tremendous benefits for child’s health and is essential to safeguard child’s breathing and hearing.
Sleeping child with mouth open– By Daniel Dwase (http://www.child-development-guide.com) [GFDL (www.gnu.org/copyleft/fdl.html) or CC-BY-3.0 (www.creativecommons.org/licenses/by/3.0)], via Wikimedia Commons from Wikimedia Commons
Tonsillectomy (Surgery to remove of Tonsils) tends to be more painful in adults than children. However, pain perception and tolerance is different for everyone.
Adenoidectomy is removal of adenoids. Read more about tonsils/adenoids in my old post
What to expect after Tonsil /Adenoid Surgery?
- Normally tonsillectomy takes half an hour to 45 min on an average, adenoid removal by traditional methods will take 30 minutes.
- When the patient wakes up, he may be slow and clumsy for initial few hours.
- He will be kept with head low and lying to one side post-operatively.
- Patient is usually discharged in 4-6 hours, child less than 2 years of age and child with obstructive sleep apnea is admitted in hospital for 1 day.
- Child/adult may have mild soreness of throat for 7-10 days, mild earache (referred ear pain) for one week, blood mixed mucus for one week and mouth breathing for 10-14 days . These are normal after tonsils /adenoids surgery and settles with time.
- Child may have mild fever for a few days and nausea or vomiting.
Key of post operative management is— “Good hydration” and “effective pain management”.
Pain after tonsils and adenoids surgery: – Pain reception varies from person to person, Adenoidectomy typically is much less painful than a tonsillectomy. Acetaminophen is usually given for pain relief. You can put Ice-packs around the neck to reduce the pain. Diet after tonsil surgery: – Ice cream is an ideal first meal after surgery because it is soft and offers comfort for sore throat.
- lots of cold water.
- For first 24 hour patient can have cold yogurt, jelly, and pudding.
- For one week soft, bland diet (should not be very hot) like mashed potatoes, oatmeal, soups.
- Avoid acidic, spicy and rough food.
- Lot of chewing-gums helps.
Medicine: – Antibiotics are often prescribed for 5-7 days to improve healing, along with analgesics. Bad breath:–Oral-hygiene is very important after surgery so the patient has to do gargles every time he eats something. Fluid intake should be encouraged. Mouth breathing /snoring: Due to post operative swelling in the throat patient may have mild snoring/mouth breathing for 10-14 days after surgery. School, Work and physical activity: – After 7 to 10 days child can start to go to school and adult can start working. Heavy physical work is to be avoided for 14 days after surgery.
When to call/visit doctor?
If significant bleeding, high fever or signs of dehydration are present consult your ENT surgeon.
Before Tonsil/Adenoid Surgery, have thorough discussion with your ENT surgeon on what to expect of surgery.