Journal of Pulmonary Medicine & Respiratory Research Category: Medical Type: Case Report
Concealed Affair of Allergic Rhinitis and Somnambulism through a Middle Man
- Akhil Paul1*, Susana Mathew2
- 1 Department Of Pulmonary Medicine, MOSC Medical Mission Hospital, Kunnam, Kulam Kerala, India
- 2 Department Of Otorhinolaryngology, MOSC Medical Mission Hospital, Kunnam, Kulam, Kerala, India
*Corresponding Author:Akhil Paul
Department Of Pulmonary Medicine, MOSC Medical Mission Hospital, Kunnam, Kulam Kerala, India
Received Date: Jul 16, 2020 Accepted Date: Aug 18, 2020 Published Date: Aug 25, 2020
Obstructive Sleep Apnoea is common in children as well. It is strongly associated with parasomnias, including sleep terror, sleep walking etc. In this case report, we are discussing about a boy who was referred to us for the evaluation and management of sleep walking. Enlarged adenoid and tonsil, secondary to allergic disease was found to be causing Obstructive Sleep Apnoea in him, causing a trigger for the sleep walking. Here we are highlighting the importance of controlling the allergic disease in such children, which can even result in the avoidance of invasive surgical interventions like adeno-tonsillectomy.
A 12 year old boy was brought to us with history of waking up with a shriek cry, after 2-3 hours of sleep and then walking to and fro in the room with laboured breathing and coughing. He has been having similar episodes, about twice or thrice in a week, for the last 3 months. The boy did not have any memory of the event and he sleeps peacefully, once forcefully taken to the bed by his parents. There was no history of seizure like movements or micturition during the episodes. The boy was otherwise normal, active and good in studies and socially interactive. He was asymptomatic in between the episodes. On detailed history taking, it was noticed that the boy was suffering from intermittent episodes of running nose and sneezing for many years and his symptoms had increased for the last 3 months. He did not snore, but used to mouth breath while sleeping. There was no history of easy fatiguability, observed apnoea or increased day time somnolescence. He was of moderate built. There were no cranio-facial abnormalities. Naso-Pharyngeo Laryngeal (NPL) scopy showed grade 2 adenoids and tonsils.
He underwent polysomnography for the evaluation of his sleep disorder. He had a total sleep time of 370 minutes with sleep efficiency of 88.4%. But the time he spent on REM sleep was only 2.8% of the total sleep period. His Apnoea Hypopnea Index (AHI) was 9.0, which was abnormal for his age. AHI during the REM sleep period was 30. His heart rate fluctuated from 57 beats/min to 134 beats/min. His average SpO2 during the sleep was 97% and the minimum SpO2 associated with a respiratory event was 83%. There was no snoring. He did not have the somnambulism episode during the study.
As enlarged adenoids and tonsils, especially in the back ground of allergic rhinitis constitutes a major cause for sleep apnoea in children, he was advised to undergo adeno-tonsillectomy. At the same time he was initiated on Mometazone nasal spray 50 ug once daily and Montelukast, along with anti-histamines for a short duration. He was advised to follow the anti-allergy measures strictly.
The boy's allergic symptoms improved on the medication and he stopped mouth breathing while sleeping. There were no episodes of somnambulism thereafter. Re-assessment showed that the adenoids had significantly reduced in size.
Obstructive sleep apnoea is not a rare disease in children. The estimated prevalence of snoring in children is about 3 to 12 percent and the prevalence of OSA is about 1 to 10% . Most of these children will have mild symptoms and they out grow it in course of time. The symptoms can include failure to thrive, attention deficit disorder, behavior problems, enuresis, other sleep disorders like somnambulism, poor academic performance etc. Unlike adults, fewer children with OSA will have excessive daytime sleepiness, with the exception of obese children . AHI of one or more is considered as abnormal in children, where as an AHI of >5 is considered as moderate to severe.
The association between OSA and parasomnias is well established. Review of studies shows that about one half of the children referred for evaluation for sleep terror or sleep walking have underlying OSA . OSA in children is most commonly associated with adeno-tonsillar hypertrophy . But not all children with enlarged adenoids and tonsils will have OSA. For the same reason, adeno-tonsillectomy is considered as the first line of management of OSA, even in obese children . As the area of adenoids and the tonsils are more prone for airway collapse, adenotonsillectomy is offered for all children with OSA, even if there is no significant enlargement of these lymphoid tissues. Not all OSA will improve after the surgery. So a repeat sleep study is advisable after the surgery. But the persistence of OSA is usually seen in those with craniofacial abnormalities .
First line of management of enlarged tonsil and adenoid is to treat the underlying allergic disease if any, by using corticosteroid nasal spray and anti-histamine. Even though OSA is a serious complication of adeno-tonsil hypertrophy, where an adeno-tonsillectomy is indicated, this case clearly shows how the initiation of the medications for the allergic disease and its control, can just be enough to manage the situation, thus avoiding an invasive procedure, at least in a few children.
CONFLICT OF INTEREST
No conflicts of interest.
- Chan J, Edman JC, Koltai PJ (2004) Obstructive sleep apnea in children. Am Fam Physician 69: 1147-1155.
- Gozal D, Wang M, Pope DW (2001) Objective sleepiness measures in pediatric obstructive sleep apnea. Pediatrics 108: 693-697.
- Guilleminault C, Palombini L, Pelayo R, Chervin RD (2003) Sleepwalking and sleep terrors in prepubertal children: What triggers them? Pediatrics 111: 17-25.
- Marcus CL, Gipson K, Kinane TB (2019) Sleep-disordered breathing in children. Am J Respir Crit Care Med 164: 16-30.
- Stradling JR, Thomas G, Warley AR, Williams P, Freeland A (1990) Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children. Lancet 335: 249-253.
- Contencin P, Guilleminault C, Manach Y (2003) Long-term follow-up and mechanisms of Obstructive Sleep Apnea (OSA) and related syndromes through infancy and childhood. Int J Pediatr Otorhinolaryngol 67: 119-123.
Citation:Paul A, Mathew S (2020) Concealed Affair of Allergic Rhinitis and Somnambulism through a Middle Man. J Pulm Med Respir Res 6: 037.
Copyright: © 2020 Akhil Paul, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.