Curtis’ mother has been a patient in my office for over 15 years. At 32, she began having myofascial pain issues. She was recounting her pain and sleep issues to my hygienist when I entered the room.
At the end of my examination, I sent her home with a cardiopulmonary coupling (CPC) unit to assist in determining the amount of sympathetic and parasympathetic sleep during a normal night. ( See the Spear Online course “Airway Screening Tools: Cardiopulmonary Coupling” for more details)
Before I left the room, I asked her, “Do your husband and son mouth breathe, snore or hold their breath during sleep?”
It is a very simple question to cover a range of sleep breathing issues and promote further discussion. In this case, her son did have some issues. I told her to use the CPC on him for two nights while she had it checked out from the office. This is the way I came to know 6-year-old Curtis.
Curtis’ mom described him as an active child. His medical history indicated that he had recently been diagnosed with attention deficit hyperactivity disorder (ADHD). His parents were not convinced that he needed medication.
His eyes had “allergic shiners” under them. Many mouth breathing patients present with this due to the venous pooling that occurs when the patient is not breathing appropriately through their nose. His mother confirmed that he is a mouth breather both day and night. As with most parents, she blames it on nasal congestion from allergies. His pediatrician has sent him twice for allergy testing. Both times, the results were negative.
He is at the low end of the growth curve. His parents are far above normal for their height. Curtis gags during the examination and has difficulty eating, especially foods with certain textures. His tonsils are 4+ size, indicating that they touch.
His dental examination revealed a bilateral crossbite and anterior underbite. He has an infantile swallowing pattern of pushing his tongue back and forth during swallowing rather than pushing liquids up and back.
Finally, he lisps when we talk. I explained to his mother that Curtis is displaying many signs that are indicative of a compromised airway. At the time, my protocol for children was to immediately enlist the assistance of a pediatric sleep physician and get a polysomnographic (PSG) examination. I had been taught that a PSG was the “gold standard” for evaluating sleep-disordered breathing in adults and children.
In this case, the results of the sleep study killed my hopes of getting Curtis resolved. His AHI was 0, RDI 0.3, and O2 sat <90% 0. Even though he had 11.3 arousals per hour and only achieved 9.8% REM sleep, the sleep physician declared Curtis’ sleep to be normal.
I arranged an ear, nose and throat (ENT) examination for Curtis. The sleep study results were not available until that morning. While the ENT agreed that the tonsils and adenoids were extremely large, the sleep study made him choose to place Curtis on a nasal spray and re-evaluate him after six months.
After the failure of the physicians to act, his mother chose not to pursue orthodontic or myofunctional therapy treatment. As an aside, in four years, he was never called by the ENT's office to check on the success of the nasal steroid therapy.
Curtis’ story may sound familiar to many of you. In my opinion, dentists can diagnose oropharyngeal and nasopharyngeal dysfunction much earlier and easier than our physician colleagues. Yet, after referring numerous children for PSGs that came back “normal,” it has become clear that quality of life, cognitive, behavioral and dental indicators many times do not match the PSG report. This could be related to the testing itself or the individual child’s ability to manage a compromised airway.
An interesting letter to the editor in the Journal of Clinical Sleep Medicine acknowledged this exact problem. The author noted that even with the current buzz over the future health implications of adenotonsillectomy, it will remain the first line of therapy for moderate to severe sleep apnea.
Medical treatment of mild pediatric apnea (AHI 1-5 events/hour) is typically treated with nasal topical corticosteroids. Interestingly, they reported that more than 90% of children having an adenotonsillectomy for sleep breathing issues have not had a preoperative PSG.
Further, if these children were tested, approximately half of the patients awaiting surgery would have primary snoring and not obstructive sleep apnea, according to PSG criteria. Like Curtis, those patients would be declared to be normal.
The researchers noted that the criteria that should be used for surgical decision-making is history and examination rather than PSG numbers. They are calling for effectiveness trials (also known as pragmatic trials) rather than traditional efficacy trials.
Effectiveness trials looks at what practitioners do in their clinical practice, as opposed to controlled, idealized situations. Non-PSG criteria for treatment and outcome measures, including parental satisfaction and symptom resolution, would reflect a more real-world practice.
Sleep studies appear to routinely miss children that would benefit from surgical or dental intervention to improve their airway. Unfortunately, if a child undergoes a flawed PSG, the results are very difficult to overcome with the sleep physician, surgeon or medical insurance company.
Symptomatic children can be left untreated because their sleep study said that they are “normal.” Effectiveness trials might provide parents and practitioners a better feel for which children would benefit the most from intervention and eliminate the “gold standard” PSG.
Jeffrey Rouse, D.D.S., is a member of Spear Resident Faculty.
Nixon GM, Kubba H, Perrett KP. “Time to open our eyes? A challenge to the role of polysomnography for trials in pediatric sleep-disordered breathing”. J Clin Sleep Med. 2018;14:489-490.