- Polysomnography remains the criterion standard for establishing the diagnosis of obstructive sleep apnea (OSA) in infants, children, and adults. Ideally, polysomnography should be performed overnight and during the patient’s usual bedtime.
- Multiple physiologic parameters are monitored during polysomnography, although the specific montage may vary slightly between sleep laboratories. Generally, electrooculography, chin and leg surface electromyography (EMG), and at least 2 EEG channels are included to confirm sleep and assess sleep architecture. Breathing is assessed using nasal/oral airflow sensors, pulse oximetry, and end-tidal (ET) CO2 measurements monitoring and by placing piezo crystal belts across the chest and abdomen to detect respiratory efforts. At least one ECG channel is necessary to determine heart rate and rhythm. Occasionally, other channels are incorporated into the study as needed. These might include additional EEG leads to better detect seizure activity, esophageal pH measurements, or transcutaneous carbon dioxide monitoring.
- Polysomnographic normal standards differ between children and adults. In the pediatric age range abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of ET CO2 measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.
- Daytime nap studies are specific, but not sensitive, in detecting sleep apnea. This is because obstructive events are more likely to occur during rapid eye movement (REM) sleep than during other sleep stages, and very little (if any) REM sleep occurs during daytime naps in noninfants. Therefore, children with symptoms of obstructive sleep apnea who have normal nap study findings must undergo nocturnal polysomnography to exclude the diagnosis. Sleep studies should be performed without sedation.
- Unattended home overnight oximetry has been proposed as a screening study. However, it may miss the child with significant obstructive sleep apnea who does not have marked episodes of oxygen desaturation.
- Multichannel studies lack reliable assessment of sleep disruption.
- Anteroposterior and lateral neck radiography: Neck radiography for soft tissue detail help define upper airway anatomy and adenoid size and exclude the possibility of rare nasal pharyngeal neoplasms.
- Cephalometric radiography and 3-dimensional CT reconstruction imaging are rarely, if ever, necessary in the pediatric age group.
- Cine MRI during sleep may be helpful in identifying specific sites of airway obstruction in the complicated patient being evaluated for surgical interventions. This technique is currently only available at a handful of specialized tertiary care facilities.
- Highly sensitive thyroid-stimulating hormone and thyroxine: Thyroid function studies are useful to exclude hypothyroidism, which is associated with tongue enlargement, weight gain, and obstructive sleep apnea .
- CBC count: Chronic hypoxia related to recurrent airway obstruction may lead to polycythemia.
- Electrocardiography and echocardiography: These studies are not necessary in all children with suspected sleep apnea. However if very severe long-standing obstruction is suspected, an ECG and echocardiography are helpful in assessing ventricular thickness and function and to check for evidence of pulmonary hypertension.
- Multiple sleep latency test (MSLT): If the clinical history suggests the possibility of narcolepsy, the MSLT should be ordered in conjunction with overnight polysomnography.
- MRI of the brain and brainstem: A history of severe snoring, headaches, neck pain, urinary frequency, or swallowing problems raises the suspicion of Chiari malformation. Chiari malformations may occur in otherwise normal children and in association with congenital myelomeningocele. If brainstem dysfunction is suspected, MRI is necessary. Cranial CT imaging is not adequate to assess for brainstem and upper cervical cord lesions.
- Polysomnography is necessary to document obstructive sleep apnea and gauge its severity. A history of snoring alone is not adequate for making a diagnosis of obstructive sleep apnea or for determining its seriousness.
- Some children with obstructive sleep apnea have primarily obstructive hypoventilation in which repetitive partial obstructions occur with some degree of relative oxygen desaturation and hypercarbia. Because of this, pediatric polysomnographic testing should include some means of determining CO2 levels, such as end-tidal (ET) CO2 monitoring or transcutaneous CO2 monitoring.
- Overnight pulse oximetry by itself is not adequate for establishing the diagnosis or excluding obstructive sleep apnea in children because it provides no information concerning sleep staging/sleep fragmentation or carbon dioxide.
- Little consistent difference in tonsil and adenoid weights and volumes is seen in individuals with obstructive sleep apnea compared with patients whose tonsils and adenoids were removed for other reasons.
- No distinct histologic findings separate adenoid and/or tonsillar hypertrophy from hypertrophy associated with obstructive sleep apnea.
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