A 6-year-old boy is brought to the office by his mother due to noisy breathing. Approximately 6 months ago, his older brother asked to be moved to a different room because the patient's noisy breathing was keeping him up at night; his mother reports that it sounds like he gasps for air while sleeping. During the day, the patient breathes through his mouth and eats and drinks without gagging or choking. He is able to keep up with his peers during outdoor play. The patient takes no medications and is up to date with vaccinations. He lives with his mother, father, older brother, and the family cat. No one in the household smokes. Height is at the 40th percentile and weight is at the 25th percentile. Which of the following is the most likely diagnosis in this patient?

Question

A 6-year-old boy is brought to the office by his mother due to noisy breathing.  Approximately 6 months ago, his older brother asked to be moved to a different room because the patient's noisy breathing was keeping him up at night; his mother reports that it sounds like he gasps for air while sleeping.  During the day, the patient breathes through his mouth and eats and drinks without gagging or choking.  He is able to keep up with his peers during outdoor play.  The patient takes no medications and is up to date with vaccinations.  He lives with his mother, father, older brother, and the family cat.  No one in the household smokes.  Height is at the 40th percentile and weight is at the 25th percentile.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d2ac_31f9_bc81_9df770ff72b9_MD0003_00 This child with loud snoring (eg, noisy breathing at night) and gasping for air during sleep likely has obstructive sleep apnea (OSA). As in adults, pediatric OSA is a sleep disorder in which there is episodic upper airway obstruction, resulting in difficulty breathing and disrupted sleep. This often manifests as restless sleep, loud snoring, periods of apnea, and gasping for air. In addition, night symptoms in children may also include enuresis and parasomnias. In contrast to adults, children with OSA may not demonstrate daytime sleepiness. Daytime symptoms in children may manifest as inattention, learning difficulties, and behavioral problems. In adults, OSA is often associated with obesity. Management includes weight loss and continuous positive airway pressure. In contrast, OSA in young children is often due to adenotonsillar hypertrophy and may, in fact, result in failure to thrive (eg, low percentile for weight). This patient's open-mouth breathing during the day suggests significant nasal airway obstruction by adenoid hypertrophy. First-line management for pediatric OSA is tonsillectomy and adenoidectomy. Both pediatric and adult OSA can result in significant cardiovascular complications (eg, hypertension, structural heart changes). (Choice A) Allergic rhinitis can present with open-mouth breathing due to nasal obstruction. However, patients also typically have a runny nose, sneezing, and itchy eyes. (Choice B) Asthma can present with noisy breathing, and attacks commonly occur at night. However, if asthma attacks were severe enough to be audible, the patient would wake up fully. In addition, the patient would likely have difficulty breathing during vigorous daytime play. (Choice C) Although bilateral choanal atresia (ie, congenital blockage of the nasal cavity) presents with noisy breathing, it occurs in neonates. Unilateral choanal atresia becomes symptomatic in childhood but presents with chronic nasal discharge rather than difficulty breathing. choanal atresia (Choice D) Laryngomalacia is characterized by floppy supraglottic structures that collapse during inspiration due to laryngeal hypotonia (possibly from delayed maturation). It causes inspiratory stridor that worsens in the supine position. However, it presents in infancy and typically resolves by age 18 months. (Choice F) Vascular rings are congenital malformations of the great vessels that encircle and compress the trachea and/or esophagus. Respiratory symptoms classically include biphasic stridor that improves with neck extension. Symptoms would be worse with activity rather than during sleep. Educational objective: Nighttime snoring and gasping for air is suspicious for obstructive sleep apnea, which is commonly caused by adenotonsillar hypertrophy in children. References: Managing the child with persistent sleep apnea. (http://www.ncbi.nlm.nih.gov/pubmed/31301824) Pediatric obstructive sleep apnea. (http://www.ncbi.nlm.nih.gov/pubmed/27810015)

A 6-Year-Old Boy Is Brought to the Office by His