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Kids ENT: Tonsils and Apnea
Enlarged tonsils and adenoids contribute to sleep apnea in children. Dr. Gerard O'Halloran, ENT specialist, discusses the relationship between these glands and this condition.
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Learn more about Gerard O'Halloran, MD
Gerard O'Halloran, MD
Gerard O'Halloran, MD is a Mayo Clinic-trained ENT specialist who cares for adults and children with ear, nose and throat conditions. His philosophy of care: "I care for people the way I'd like my family to be treated. All of my surgery patients are given my direct cell phone number." Dr. O'Halloran sees patients in Northfield, Faribault and Lakeville and performs surgery at Northfield Hospital.Learn more about Gerard O'Halloran, MD
Transcription:
Prakash Chandran (Host): In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge making breathing during sleep more difficult. I’m Prakash Chandran and in this episode of Northfield Hospital & Clinics podcast series/ kids ENT, we’ll talk about tonsils and sleep apnea in kids. Here with us to discuss is Dr. Gerard O’Halloran, an Ear, Nose and Throat doctor at Northfield Hospital and board certified in sleep medicine. Dr. O’Halloran, thanks so much for educating us today.
Gerard O’Halloran, MD (Guest): Well, thanks so much for having me.
Host: Of course. So, the first thing that I want to know, is why children develop swollen tonsils in the first place and how that can lead to sleep apnea?
Dr. O’Halloran: Everyone has tonsils and adenoids. The tonsils most people are familiar with are on either side of the palate. Adenoids are essentially a lump of tonsil tissue on the back wall of the throat up behind the palate. So, they are out of sight, sort of in the back of your nose. They can enlarge from infections whether they are viral or bacterial infections and sometimes they are just enlarged genetically.
Sometimes large tonsils and adenoids run in families. The issue with sleep then is if you have anything taking up space in your throat, when we fall asleep our throat muscles relax and the throat gets smaller. But if there’s large tonsils taking up space, or the adenoids are blocking the airflow through the nose; then the throat may fall all the way shut or nearly shut and cause sleep related breathing problems, sleep apnea is the main one.
Snoring is sort of one step below sleep apnea where the throat is partially blocked, but sleep apnea is when the throat really falls all the way shut.
Host: Yeah, I was going to ask you what signs you should look for that tells you that your child may have sleep apnea? Is it normal for a child to snore? What do you – what signs or symptoms would your child exhibit?
Dr. O’Halloran: Well, snoring is a partial obstruction and it’s fairly common. It’s not technically normal, because it’s a sign of partial airway obstruction. There is some evidence linking snoring even to some of the same symptoms that cause sleep apnea which I’ll go forward with. But the physical things people could watch for would be most parents never actually see the apnea episode, but an apnea episode would be roughly a five or more second pause in breathing where the child would be quiet followed by a little bit of a snort, kind of a (gasp) as they catch their breath again. Most people wont see that because it happens more frequently maybe at two to four a.m. when you are in deeper sleep.
Parents do often notice the children with sleep apnea are very restless sleepers. These are the kids that often tear up the bed because every time their throat falls shut, they sort of struggle to breath again and move and that regains their muscle tone and then they are able to breathe. Children with sleep apnea often, but not always, prop up on pillows.
My daughter had sleep apnea when she was five. She had her tonsils and adenoids removed and the only way we could tell she would have it other than of course I knew she had fairly large tonsils, was she had to prop up on a pillow to sleep, which she has never done since the surgery and once we were sharing a room in a hotel and I happened to wake up at three in the morning and I actually heard her stop breathing. But otherwise, she seemed very quiet. She didn’t snore or anything like that.
A hyperextended neck during sleep is fairly common in kids with sleep apnea. They tilt their chin upward and sort of arch their neck and that’s something that people who have taken CPR will know, the chin lift where you lift up someone who is unconscious, lift their chin up to stretch their throat out so it wont fall shut. Children can figure that out and they’ll do it themselves so that they can sleep better. And no one would sleep that way normally. It’s very uncomfortable. But they sleep that way so they can breathe.
The signs that you might see during the daytime are pretty varied. Children, - some children that have apnea are very tired. Most children tend more towards almost hyperactivity or moodiness that have sleep apnea. These are the kids that will – all kids maybe fall apart around 8 o’clock when it’s bedtime, where they might get cranky. These are the kids that are like that right after school. About a quarter or more of kids with attention deficit disorder have been shown to have signs and symptoms of sleep apnea. So, there’s a big link there. If you Google that, there’s well over a million hits on that.
The other things that I look for and sometimes it will be – if it’s difficult to tell and sometimes it is, if there’s any airway obstruction during sleep while they are sleeping; have the parent watch the child when they have a cold, because it will all be exaggerated then.
Mouth breathing at night is high correlation with sleep apnea but obviously doesn’t prove it.
Host: Got it, so there’s little symptoms here and there that you’re discussing kind of like when they mess up the bed because of that restless sleep that they are getting. The attention deficit disorder also could lead to that. Their fatigue levels, like all of those little things are signs that you might want to get things checked out. Let’s actually talk a little bit about that process. Let’s say you decide that your child may suffer from sleep apnea, what should a parent do at that point?
Dr. O’Halloran: Most of the time, the parents would see their regular doctor, but of course they are welcome to see me too, just to talk about it and have it evaluated. Children are a little trickier than adults. Adults, we have home sleep studies that are really nice and convenient to do. With children, there is not great evidence yet, at least, that the home studies are valid and very accurate. Oftentimes, I’ll make the decision with the parents just based on what they have seen.
If they’ve witnessed the apnea, it makes it very easy. Snoring, by itself, is a relatively valid reason to take tonsils and adenoids out, although much softer than if you see the apnea. But if the child has large tonsils, behavioral issues, another sign that I failed to mention previously was wetting the bed. Older children that wet the bed. That often is caused by sleep apnea. So, we’ll make the judgement based on the examination and all the signs and things parents have noted.
Sometimes it’s difficult because if the parents are like me, once the kid is asleep, you don’t really want to disturb that and mess with success. So, they sometimes will have to go watch the child a little bit more frequently at night or even get up early in the morning, if they are up before their child or intentionally get up early to check them in the early morning because we sleep in cycles and half the time we are in lighter sleep, so you may not have apnea then. So, they have to watch sort of consistently to see if there are signs of airway obstruction or labored breathing during sleep.
We can do sleep studies in children. We don’t do those here in Northfield. Those are usually done either at Mayo or up at one of the children’s hospitals. They are a big hassle to do. You have to go – a parent has to spend the night with their child and sometimes the kids won’t sleep well, but if the issue is really in doubt, it’s a reasonable thing to do. Because you want to make the right decision.
Host: Yeah, I can imagine. So, you were saying that the sleep studies aren’t necessarily proven to be so accurate with children. So, I kind of want to move –
Dr. O’Halloran: The home studies aren’t so accurate.
Host: Got it. Okay the home studies aren’t so accurate. But something that I wanted more clarification on is the removal of the tonsils and the adenoids. You mentioned with your daughter, did you notice those problems in the hotel room like you said and then you had those removed and then that helped? Is that what happened?
Dr. O’Halloran: Correct. Yes. We were able to witness the apnea and so we saw the apnea. She had to sleep propped up on pillows. Tonsils were big. So, I did not myself take them out, but I had a friend take her tonsils and adenoids out and since then, she’s slept – sleeps better, isn’t as restless and one pillow instead of two.
Host: Got it.
Dr. O’Halloran: She’s still a wild kid, but it helped the breathing.
Host: Of course. So, when you normally hear children getting their tonsils removed; is it normally because of sleep apnea? I’ve always thought that it was related to tonsillitis or some other disease. But it sounds like removing the tonsils and the adenoids really can help prevent sleep apnea in children.
Dr. O’Halloran: So, there are really three common reasons the tonsils and or adenoids are removed. And I’ll talk about adenoids separately in a moment. The most common reason now is not tonsillitis or recurrent sore throats. It is sleep related breathing obstruction. In my practice, probably 85-90% of the tonsils I remove are for sleep related breathing issues.
Chronic tonsillitis is also a separate reason to remove them. Don’t need to have both reasons. You only need one or the other. But the current guidelines and there are several different guidelines for how much, how many episodes of tonsillitis are enough, but typically, patients that are having three bad episodes of tonsillitis a year for three years in a row or five or six or seven episodes in one year; that’s considered by most medical care guidelines a valid reason to remove the tonsils.
Of course, you’re treating your child, not some text book or set of guidelines. The exceptions to the guidelines would be the kids that are really – where it’s disrupting their life. I mean you might only have two episodes a year, but if your child is missing two weeks of school every year; that would be considered an exception to the guideline and you could certainly go ahead and consider getting the tonsils removed.
The third reason, much less common in children, fairly common in adults, are patients who get what are called tonsil stones and they develop bad breath from that. Some patients have little pits or crips in their tonsils and little bacteria will grow in there and it will cause bad breath. And so, if we can prove that that’s the cause, that’s also considered a valid reason, obviously, much more elective. It’s really patient’s choice on that. But that’s probably one percent or less of the tonsils that I do in children, in adults it’s maybe five or ten percent or even more.
Adenoids can be removed separately without taking the tonsils and that comes up moderately frequently because adenoids are up behind the nose, so if a child has nasal obstruction, but no sleep apnea and not particularly big tonsils; the adenoids alone can be removed which is much easier to go through and much easier to do. It’s lower risk. We will also take adenoids out for children that are needing a second set of ear tubes or older children having ear trouble because the adenoids block the eustachian tubes to the ear and so taking the adenoids out will help most but not all children with chronic ear problems.
Host: Okay. That’s helpful. I wanted to ask as we wrap up here, one last question around what is the affect of an untreated sleep apnea issue in a child? Will it get worse over time? Maybe talk a little bit about that.
Dr. O’Halloran: Sure, no one has a crystal ball as you know but some children probably do outgrow this but not very many. When they have followed these kids with large tonsils and sleep related breathing troubles, most of them don’t outgrow it. There are studies on that and then they just go on to have the same troubles as adults that they had as children. And by troubles, I mean troubles being too tired, paying attention in school and of course adults with sleep apnea have much more cardiovascular risk as well.
Host: Got it. Well I think that’s about it Dr. O’Halloran and I really appreciate you educating us on tonsils and sleep apnea in children. Is there anything else that you want to tell our audience before we wrap up?
Dr. O’Halloran: I guess the one thing I should clarify is that for children with sleep apnea, as opposed to adults, with adults with sleep apnea we would usually recommend medical treatment like a CPAP or a dental appliance. In children, the textbook recommendation is tonsils and adenoids are the first treatment because that will cure most children.
Host: Yeah, that is definitely something that I gleaned from this conversation with you and something that I didn’t know, I just assumed that they would go right to that CPAP machine, but this has been really informative. So, for more information, please visit www.northfieldhospital.org. My guest today has been Dr. Gerard O’Halloran. I’m Prakash Chandran. Thank you so much for listening.
Prakash Chandran (Host): In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge making breathing during sleep more difficult. I’m Prakash Chandran and in this episode of Northfield Hospital & Clinics podcast series/ kids ENT, we’ll talk about tonsils and sleep apnea in kids. Here with us to discuss is Dr. Gerard O’Halloran, an Ear, Nose and Throat doctor at Northfield Hospital and board certified in sleep medicine. Dr. O’Halloran, thanks so much for educating us today.
Gerard O’Halloran, MD (Guest): Well, thanks so much for having me.
Host: Of course. So, the first thing that I want to know, is why children develop swollen tonsils in the first place and how that can lead to sleep apnea?
Dr. O’Halloran: Everyone has tonsils and adenoids. The tonsils most people are familiar with are on either side of the palate. Adenoids are essentially a lump of tonsil tissue on the back wall of the throat up behind the palate. So, they are out of sight, sort of in the back of your nose. They can enlarge from infections whether they are viral or bacterial infections and sometimes they are just enlarged genetically.
Sometimes large tonsils and adenoids run in families. The issue with sleep then is if you have anything taking up space in your throat, when we fall asleep our throat muscles relax and the throat gets smaller. But if there’s large tonsils taking up space, or the adenoids are blocking the airflow through the nose; then the throat may fall all the way shut or nearly shut and cause sleep related breathing problems, sleep apnea is the main one.
Snoring is sort of one step below sleep apnea where the throat is partially blocked, but sleep apnea is when the throat really falls all the way shut.
Host: Yeah, I was going to ask you what signs you should look for that tells you that your child may have sleep apnea? Is it normal for a child to snore? What do you – what signs or symptoms would your child exhibit?
Dr. O’Halloran: Well, snoring is a partial obstruction and it’s fairly common. It’s not technically normal, because it’s a sign of partial airway obstruction. There is some evidence linking snoring even to some of the same symptoms that cause sleep apnea which I’ll go forward with. But the physical things people could watch for would be most parents never actually see the apnea episode, but an apnea episode would be roughly a five or more second pause in breathing where the child would be quiet followed by a little bit of a snort, kind of a (gasp) as they catch their breath again. Most people wont see that because it happens more frequently maybe at two to four a.m. when you are in deeper sleep.
Parents do often notice the children with sleep apnea are very restless sleepers. These are the kids that often tear up the bed because every time their throat falls shut, they sort of struggle to breath again and move and that regains their muscle tone and then they are able to breathe. Children with sleep apnea often, but not always, prop up on pillows.
My daughter had sleep apnea when she was five. She had her tonsils and adenoids removed and the only way we could tell she would have it other than of course I knew she had fairly large tonsils, was she had to prop up on a pillow to sleep, which she has never done since the surgery and once we were sharing a room in a hotel and I happened to wake up at three in the morning and I actually heard her stop breathing. But otherwise, she seemed very quiet. She didn’t snore or anything like that.
A hyperextended neck during sleep is fairly common in kids with sleep apnea. They tilt their chin upward and sort of arch their neck and that’s something that people who have taken CPR will know, the chin lift where you lift up someone who is unconscious, lift their chin up to stretch their throat out so it wont fall shut. Children can figure that out and they’ll do it themselves so that they can sleep better. And no one would sleep that way normally. It’s very uncomfortable. But they sleep that way so they can breathe.
The signs that you might see during the daytime are pretty varied. Children, - some children that have apnea are very tired. Most children tend more towards almost hyperactivity or moodiness that have sleep apnea. These are the kids that will – all kids maybe fall apart around 8 o’clock when it’s bedtime, where they might get cranky. These are the kids that are like that right after school. About a quarter or more of kids with attention deficit disorder have been shown to have signs and symptoms of sleep apnea. So, there’s a big link there. If you Google that, there’s well over a million hits on that.
The other things that I look for and sometimes it will be – if it’s difficult to tell and sometimes it is, if there’s any airway obstruction during sleep while they are sleeping; have the parent watch the child when they have a cold, because it will all be exaggerated then.
Mouth breathing at night is high correlation with sleep apnea but obviously doesn’t prove it.
Host: Got it, so there’s little symptoms here and there that you’re discussing kind of like when they mess up the bed because of that restless sleep that they are getting. The attention deficit disorder also could lead to that. Their fatigue levels, like all of those little things are signs that you might want to get things checked out. Let’s actually talk a little bit about that process. Let’s say you decide that your child may suffer from sleep apnea, what should a parent do at that point?
Dr. O’Halloran: Most of the time, the parents would see their regular doctor, but of course they are welcome to see me too, just to talk about it and have it evaluated. Children are a little trickier than adults. Adults, we have home sleep studies that are really nice and convenient to do. With children, there is not great evidence yet, at least, that the home studies are valid and very accurate. Oftentimes, I’ll make the decision with the parents just based on what they have seen.
If they’ve witnessed the apnea, it makes it very easy. Snoring, by itself, is a relatively valid reason to take tonsils and adenoids out, although much softer than if you see the apnea. But if the child has large tonsils, behavioral issues, another sign that I failed to mention previously was wetting the bed. Older children that wet the bed. That often is caused by sleep apnea. So, we’ll make the judgement based on the examination and all the signs and things parents have noted.
Sometimes it’s difficult because if the parents are like me, once the kid is asleep, you don’t really want to disturb that and mess with success. So, they sometimes will have to go watch the child a little bit more frequently at night or even get up early in the morning, if they are up before their child or intentionally get up early to check them in the early morning because we sleep in cycles and half the time we are in lighter sleep, so you may not have apnea then. So, they have to watch sort of consistently to see if there are signs of airway obstruction or labored breathing during sleep.
We can do sleep studies in children. We don’t do those here in Northfield. Those are usually done either at Mayo or up at one of the children’s hospitals. They are a big hassle to do. You have to go – a parent has to spend the night with their child and sometimes the kids won’t sleep well, but if the issue is really in doubt, it’s a reasonable thing to do. Because you want to make the right decision.
Host: Yeah, I can imagine. So, you were saying that the sleep studies aren’t necessarily proven to be so accurate with children. So, I kind of want to move –
Dr. O’Halloran: The home studies aren’t so accurate.
Host: Got it. Okay the home studies aren’t so accurate. But something that I wanted more clarification on is the removal of the tonsils and the adenoids. You mentioned with your daughter, did you notice those problems in the hotel room like you said and then you had those removed and then that helped? Is that what happened?
Dr. O’Halloran: Correct. Yes. We were able to witness the apnea and so we saw the apnea. She had to sleep propped up on pillows. Tonsils were big. So, I did not myself take them out, but I had a friend take her tonsils and adenoids out and since then, she’s slept – sleeps better, isn’t as restless and one pillow instead of two.
Host: Got it.
Dr. O’Halloran: She’s still a wild kid, but it helped the breathing.
Host: Of course. So, when you normally hear children getting their tonsils removed; is it normally because of sleep apnea? I’ve always thought that it was related to tonsillitis or some other disease. But it sounds like removing the tonsils and the adenoids really can help prevent sleep apnea in children.
Dr. O’Halloran: So, there are really three common reasons the tonsils and or adenoids are removed. And I’ll talk about adenoids separately in a moment. The most common reason now is not tonsillitis or recurrent sore throats. It is sleep related breathing obstruction. In my practice, probably 85-90% of the tonsils I remove are for sleep related breathing issues.
Chronic tonsillitis is also a separate reason to remove them. Don’t need to have both reasons. You only need one or the other. But the current guidelines and there are several different guidelines for how much, how many episodes of tonsillitis are enough, but typically, patients that are having three bad episodes of tonsillitis a year for three years in a row or five or six or seven episodes in one year; that’s considered by most medical care guidelines a valid reason to remove the tonsils.
Of course, you’re treating your child, not some text book or set of guidelines. The exceptions to the guidelines would be the kids that are really – where it’s disrupting their life. I mean you might only have two episodes a year, but if your child is missing two weeks of school every year; that would be considered an exception to the guideline and you could certainly go ahead and consider getting the tonsils removed.
The third reason, much less common in children, fairly common in adults, are patients who get what are called tonsil stones and they develop bad breath from that. Some patients have little pits or crips in their tonsils and little bacteria will grow in there and it will cause bad breath. And so, if we can prove that that’s the cause, that’s also considered a valid reason, obviously, much more elective. It’s really patient’s choice on that. But that’s probably one percent or less of the tonsils that I do in children, in adults it’s maybe five or ten percent or even more.
Adenoids can be removed separately without taking the tonsils and that comes up moderately frequently because adenoids are up behind the nose, so if a child has nasal obstruction, but no sleep apnea and not particularly big tonsils; the adenoids alone can be removed which is much easier to go through and much easier to do. It’s lower risk. We will also take adenoids out for children that are needing a second set of ear tubes or older children having ear trouble because the adenoids block the eustachian tubes to the ear and so taking the adenoids out will help most but not all children with chronic ear problems.
Host: Okay. That’s helpful. I wanted to ask as we wrap up here, one last question around what is the affect of an untreated sleep apnea issue in a child? Will it get worse over time? Maybe talk a little bit about that.
Dr. O’Halloran: Sure, no one has a crystal ball as you know but some children probably do outgrow this but not very many. When they have followed these kids with large tonsils and sleep related breathing troubles, most of them don’t outgrow it. There are studies on that and then they just go on to have the same troubles as adults that they had as children. And by troubles, I mean troubles being too tired, paying attention in school and of course adults with sleep apnea have much more cardiovascular risk as well.
Host: Got it. Well I think that’s about it Dr. O’Halloran and I really appreciate you educating us on tonsils and sleep apnea in children. Is there anything else that you want to tell our audience before we wrap up?
Dr. O’Halloran: I guess the one thing I should clarify is that for children with sleep apnea, as opposed to adults, with adults with sleep apnea we would usually recommend medical treatment like a CPAP or a dental appliance. In children, the textbook recommendation is tonsils and adenoids are the first treatment because that will cure most children.
Host: Yeah, that is definitely something that I gleaned from this conversation with you and something that I didn’t know, I just assumed that they would go right to that CPAP machine, but this has been really informative. So, for more information, please visit www.northfieldhospital.org. My guest today has been Dr. Gerard O’Halloran. I’m Prakash Chandran. Thank you so much for listening.