Dr. Smith: PLMD often accompanies sleep disordered breathing. However, since his AHI and SpO2 are relatively normal, these movements do not appear to be related to his breathing at all. One movement every minute of the night is very excessive, and since he is also aroused out of normal sleep architecture every 2 minutes, I have to think this is affecting his sleep, even though he does not admit to sleepiness.

I have picked up early Parkinsons in a patient like this, so I am a bit sensitive to the issue, and would discuss a referral to rule this out if he was may patient. As the sleep MD is a pulmonologist, and not a neurologist, he would be less likely to make the connection. However, hopefully, I am just an alarmist, and the patient has little to worry about. Maybe you can make him an appliance for his snoring, then get him retested to see if the PLMD has improved. Let me know how it goes!

Snoring and crossbite. Seems like an airway problem to me. Should I just recommend the patients mother find another ENT to go to? Can crossbite/snoring be caused by something else?

Dr. Smith: In Jankleson’s publication on posture and airway, he quotes a study saying only 1% of upper airway obstruction is due to tonsilar hypertrophy.

39% adenoid hypertrophy
34% allergic rhinitis
21% turbinate hypertrophy
21% habitual mouth breathing
19% deviated septum
8 % vasomotor rhinitis.

So don’t forget asking the ENT to check some of these if the tonsils look normal We really need to be careful and only remove the offending obstructors, and then only if nutritional therapy to remove inflammation has been considered. With tonsillar tissue specifically (which includes the adenoids), we should be careful not to remove these unless we know they are obstructing, as they play a big part in our immune system.

That being said, the newest research is showing obesity and neck size larger than the norm are playing a bigger role in adolescent snoring and OSA, so I do not want to lessen the importance of these two.

Dr. Smith: Excellent questions! I’ll address each numerically.
1. Most sleep centers are well equipped to handle children’s sleep studies, so if you suspect sleep apnea in your child, a study would be a good idea.

pediatric sleep room at Comprehensive Sleep Medicine

If they prefer no sleep study, I would suggest an allergist first, to rule out any allergens that could be disrupting the immune system, creating an inflammatory process that swells the pharyngeal tissues. It’s also a good idea to find an ENT with good knowledge of the child’s airway and the negative developmental changes that can occur when the airway is restricted during growth.

2. Tonsils (palatine – the ones you can see, out of 4 sets) should only be removed if the cost-benefits are weighed appropriately. Studies show that tonsillar tissue helps in creation of T-Cells, which are important for cancer prevention. However, if they are impeding the airway, and if inflammatory processes have been addressed, I would have them removed. Remember, the child does have 3 other sets. Oh, and one more thing. The adenoids are FAR more likely to be obstructing the child’s airway, so THIS set of tonsils should be studied by the ENT, if anything! The ENT’s organization has a set of guidelines for when they will remove tonsils. They can be found here. Finally, yes, most will “outgrow” large palatine tonsils and adenoids. Actually, the tonsillar tissues usually shrink, unless there are inflammatory processes present. The usual suspect is a mouth breather, who has to use the tonsils to trap pathogens as they enter the oral cavity. Without the valuable nose filters, which are set up to do this job with regularity and expertise, the tonsils take on this arduous responsibility, and become enlarged to house the many bad guys. This can be seen in the “pocked” tonsils with “crypts”. Does that conger up a lovely thought?

3. Can snoring in children cause ADHD? You bet. Email me or comment here if you would like to read some studies. Additionally, a Johns Hopkins study showed that children with OSA average a 16 point drop in I.Q. What parent wants this?

Dr. Smith: I realize this is the least expensive screening method, and it’s better than nothing, as the oxygen saturation closely follows (as a rule) apneic events. However, this is misused by many health practitioners. I received a report from an ENT who used pulse oximetry, but with this specific patient, he desaturated to 77% and stayed under 90% for 42 minutes. The ENT stated that the patient needed no further study, did not need CPAP and that an oral appliance was the best thing. In my opinion, that is malpractice.