Which oral and maxillofacial findings are characteristic of childhood obstructive sleep apnea (OSA)?

Updated: Feb 13, 2019
  • Author: Mary E Cataletto, MD; Chief Editor: Denise Serebrisky, MD  more...
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Answer

Determine if the child's face appears normal or if craniofacial anomalies are present. Inspect for midfacial hypoplasia, a flat nasal bridge, or facial asymmetry. Determine if the jaw is abnormally small (micrognathia) or the jaw is recessed (retrognathia). Look for adenoid facies with mouth breathing, nasal speech, and periorbital swelling, which may be present in as many as 15-20% of younger children with obstructive sleep apnea.

Assess nasal patency. Evaluate for signs of allergic rhinitis, nasal polyps and growths, and septal deviation. Determine if the child can breathe through the nose. Carefully examine the nasal passages for mucosal swelling, cobblestone pattern of the mucosa, and reduced nasal airflow. Carefully evaluate the size and position of tonsils and uvula, particularly noting hypertrophy or malformation. Unfortunately, although tonsillar hypertrophy may contribute to the severity of obstructive sleep apnea, the data available to date have not established a clear relationship between tonsillar size and frequency or severity of apneic events. Furthermore, although more prevalent in patients with obstructive sleep apnea, tonsillar hypertrophy is also common in healthy children without obstructive sleep apnea, with a prevalence as high as 57%.

Document the width and height of the hard palate, as well as the overall appearance of the soft palate, looking for evidence of cleft or pharyngeal narrowing or compression.

Although not extensively evaluated in children, the Mallampati classification may help quantify the degree of oropharyngeal anatomical obstruction. This classification is based on the structures visualized with maximal mouth opening and the tongue extended. The classes are determined by the visible structures. In class I, the soft palate, fauces, uvula, and pillars are visible. In class II, the soft palate, fauces, and a portion of uvula are visible. In class III, the soft palate and base of uvula are visible. In class IV, only the hard palate is visible. The higher the Mallampati classification, the greater the likelihood of oropharyngeal obstruction, and the greater the risk of persistent obstruction following tonsillectomy and adenoidectomy. [8]

Assess whether the child can open his or her mouth fully or if jaw movement is limited. Assess the size of the oral pharynx and note whether it seems crowded by a large tongue, tonsil hypertrophy, a redundant soft palate, or by the dentition. Determine if space is present between the end of the soft palate and the posterior pharyngeal wall or if the palate and uvula abut the back of the throat. Often, repetitive episodes of obstructive apnea lead to painless edema of the uvula, which is worse in the morning and subsides as the day goes on. Listen to the voice for weakness or hoarseness, suggesting vocal cord problems. Obstructive sleep apnea is most commonly associated with adenotonsillar hypertrophy in children.

Look at the shape of the neck. Short, thick necks predispose adults and older adolescents to obstructive apnea. Palpate for masses and thyromegaly, keeping in mind that obstructive apnea is more common in patients with hypothyroidism. Assess for jugular venous distention that might accompany heart failure. Look for head and neck swelling; obstruction of venous return from the head as seen in superior vena caval obstruction predisposes individuals to obstructive apnea.


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