A Four-Year-Old Boy with Unusually Severe Obstructive Sleep Apnea

Abstract

frequent and very severe reductions in blood oxygen saturation (SpO 2 , lowest at 55%). Persistent, large-range variations in heart rate (70-140 beats/min) were associated with frequent OSA events and occurred throughout the night. The radiograph showed nasopharyngeal stenosis with tonsil and adenoid hypertrophy (adenoidal nasopharyngeal ratio (A/N): 0.92; normal range < 0.5-0.6).The patient's parents did not want to consider surgery and preferred medication as a first treatment. Therefore, montelukast (oral, 5 mg/day) was prescribed. After taking montelukast for 2 mo, the patient's frequency and severity of snoring was reduced. Repeat polysomnogram showed a surprising reduction in the AHI to 2.4 events/h during a total sleep time of 8.19 h (supine position 34%, REM 19.4%). Overnight measurements of SpO 2 and heart rate stabilized to nearly normal levels ( Figure 1B). The nasopharyngeal airway also appeared wider in the radiograph (A/N: reduced from 0.92 to 0.80).A 4-y-old boy presented with frequent snoring and mouth breathing, but no other symptoms often seen in children with obstructive sleep apnea (OSA) (e.g., observed episodes of apnea, daytime sleepiness, enuresis, and hyperactivity). His mother stated that the frequency and severity of his snoring varied from time to time. He did not frequently have colds, estimated at once or twice a year. He had normal physical and mental development (height 110 cm, body weight 19 kg, body mass index 15.7 kg/m 2 ). He appeared to have a mild adenoid face (a slightly short upper lip with mandibular hypoplasia) and obvious tonsillar hypertrophy (grade 3+ tonsils with < 75% of space between pillars) and a stage II Friedman classification.The patient underwent overnight polysomnography, and a radiograph of the lateral neck was obtained. Surprisingly, we found that the patient had unusually severe OSA based on the apnea-hypopnea index (AHI), which was as high at 102.5 events/h. During a recorded total sleep time of 7.75 h (supine position 64%, rapid eye movement (REM) sleep 25.1%), he had 713 obstructive apnea events (longest at 53 sec), 73 hypopnea events (longest at 55 sec) and 8 mixed apnea events (longest at 31 sec) but no central sleep apnea events. As demonstrated in Figure 1A, the patient experienced SLEEP MEDICINE PEARLS