A 4-year-old boy is brought to the office due to snoring. For the past 5 months, his mother has heard loud snoring at night, with pauses in his breathing followed by gasping for air. Medical history is significant for 2 episodes of otitis media that resolved with antibiotic therapy. The patient is up to date with vaccinations. He attends day care 5 days a week. His father smokes outside the home. The family has a cat. Height is at the 40th percentile and weight is at the 15th percentile. On physical examination, the patient appears well. The tympanic membranes are clear with no middle ear effusion. The nose is clear with no rhinorrhea. Oral examination shows good dentition and tonsillar hypertrophy. The lungs are clear to auscultation and heart sounds are normal. Which of the following is the best next step in management?

Question

A 4-year-old boy is brought to the office due to snoring.  For the past 5 months, his mother has heard loud snoring at night, with pauses in his breathing followed by gasping for air.  Medical history is significant for 2 episodes of otitis media that resolved with antibiotic therapy.  The patient is up to date with vaccinations.  He attends day care 5 days a week.  His father smokes outside the home.  The family has a cat.  Height is at the 40th percentile and weight is at the 15th percentile.  On physical examination, the patient appears well.  The tympanic membranes are clear with no middle ear effusion.  The nose is clear with no rhinorrhea.  Oral examination shows good dentition and tonsillar hypertrophy.  The lungs are clear to auscultation and heart sounds are normal.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c083_db9f_8f63_f3ed5877461a_MD0005_00 This child with loud snoring, pauses in breathing, and gasping for breath during sleep likely has obstructive sleep apnea (OSA). As in adults, OSA in children is a sleep disorder in which episodic upper airway obstruction results in difficulty breathing and disrupted sleep. This often manifests as restless sleep, loud snoring, periods of apnea, and gasping for breath at night. Other symptoms in children may include enuresis and parasomnias. In adults, OSA is often associated with obesity, so weight loss is usually recommended. In contrast, young children with OSA are often underweight, and severe cases may result in failure to thrive. In these patients, adenotonsillar hypertrophy contributes to a significant narrowing of the upper airway, resulting in intermittent obstruction. Therefore, first-line management for pediatric OSA is tonsillectomy and adenoidectomy. (Choice A) Recurrent infections early in life may contribute to adenotonsillar hypertrophy, but this patient has no symptoms of a bacterial infection that would require antibiotics. Although antibiotics sometimes temporarily decrease tonsil size, they would not result in permanent improvement in the airway caliber. (Choices B and C) Changing sleep position and continuous positive airway pressure may be recommended as therapy for OSA in adults. In young children, adenotonsillectomy is often curative, obviating the need for an intervention unlikely to be successful due to significant difficulty with adherence. (Choice D) Some children with OSA may benefit from avoiding environmental allergens (eg, cat) or irritants (eg, tobacco smoke), but it is unlikely that this alone would resolve OSA symptoms. Therefore, this is recommended as adjuvant, rather than initial, therapy. Educational objective: In contrast to the treatment for obstructive sleep apnea (OSA) in adults, first-line therapy for OSA in children is tonsillectomy and adenoidectomy. References: Clinical practice guideline: Tonsillectomy in children (update). (http://www.ncbi.nlm.nih.gov/pubmed/30798778) Detection of common respiratory viruses in tonsillar tissue of children with obstructive sleep apnea. (http://www.ncbi.nlm.nih.gov/pubmed/24574078)

A 4-Year-Old Boy Is Brought to the Office Due to Snoring