Children with breathing difficulties early in life are special cases and have to be treated with that in mind. A birth trauma resulting in luxation of the nasal septum can create breathing problems and the septum should be lifted into position as soon as possible.
Pierre Robin syndrome and Down syndrome and other genetic syndromes often exhibit breathing problems early in life. In those cases, CPAP may be a good solution until the child has grown enough. A temporary tracheostomy may be life-saving, especially if organic heart disease coexists.
Laryngomalasia produces, as does tracheomala-sia, an increased breathing effort and may cause apneas. With mild symptoms, no treatment is indicated as the softness will grow away and the symptoms disappear after the age of 2 years. However, suction of the inner parts of the larynx may result in redundant tissue in the laryngeal entrance which successively increases the child's problem with apneas and desatura-
A child who starts to develop obstructive problems between 2 and 4 years of age usually has a hyper-trophied adenoid as the main cause of obstruction and an adenoidectomy helps in most cases. Even if the tonsils are large (which they rarely are at that age), a full tonsillectomy is not recommended in the same surgical setting. The child needs the immunological-ly active tissue and the breathing problems will be at least partially resolved with the adenoidectomy. A small child with its smaller blood volume is also at greater risk from postoperative bleedings if both surgical procedures are performed together.
If the tonsils are voluminous, a partial resection can be performed. Another reason to avoid a full ton-sillectomy is that when it is performed in early age, Waldeyers' ring will compensate by hypertrophy of the lingual tonsils. That may result in a later recurrence of the OSA, which is more difficult to treat . The only reason for a full tonsillectomy would be recurrent tonsillar infections or peritonsillitis, which, however, are unusual in this age group.
Distraction treatment is possible at this age as shown in Fig. 43.2 . This 2-year-old boy had suffered from sepsis postnatally with purulent infections in both mandibular joints, causing retarded growth of the mandible and a progressive OSA. After distract-
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