Discussion
SDB in pediatric age differ both in the definition, diagnosis and
treatment in relation to the adult. The child presents anatomical and
functional peculiarities in the airway along with maturational
characteristics from the point of view of sleep
neurophysiology2.
Tonsillar hypertrophy is the main nasal and oropharyngeal anatomical
pathogenesis´ factors of childhood OSA. Also included in the different
factors that cause this pathogenesis are less frequent ones such as
obesity, dental malocclusion or craniofacial
malformations2.
The clinical manifestations of OSA are very varied depending on the
severity, etiologies and the different degree of development, but the
most frequent are snoring, evidence of nocturnal apnea, daytime
hyperactivity or hypersomnolence, poor school performance and
neurocognitive alterations1. In the case of CSAS, the
symptoms are less florid and usually occur asymptomatically.
Although PSG and CRP are the diagnostic techniques of choice, it is
important to know that other methods are also interesting. A brain MRI
may be an important diagnostic tool for unexplained sleep disorders in
nonsyndromic and syndromic children, and it should be considered in the
context of an unexplained SDB, including OSA in the absence of
adenotonsillar hypertrophy, persistent OSA following adenotonsillar,
central sleep apnea, and nocturnal hypoventilation syndrome4.
In our case, the realization of a brain MRI showed a probable origin of
the pathology. The malformation of Chiari type I is characterized by the
existence of a decrease in the cerebellar tonsils that are located below
the foramen magnum, associated with compressive phenomena of the
brainstem and upper spinal cord. Ferré et al 2described that the most frequent clinical manifestations are usually
occipitonucal headaches, dizziness and nocturnal respiratory
disturbances, such as central apneas.
Adeno-tonsillectomy is the most frequent technique of treatment in
children´s OSA, with an improvement in AHI of 75%1.
Other non-surgical treatments would be the use of CPAP, weight loss,
maxillary expansion and / or orthodontic and other methods aimed at
eliminating the possible etiological trigger1. In the
case of CSAS, it is important to identificate the underlying pathology.
In Arnold Chiari malformation, it is usually decompressive
neurosurgery5.
In summary, the Arnold Chiari malformation is a rare cause of central
apneas in the pediatric patient, which requires an MRI study for
diagnosis. It is important to assess these possible causes in a case of
pediatric SAC. Also we think that it would be useful to carry out
studies in Chiari malformation´s patients to evaluate respiratory
alterations before and after surgery to determine whether surgery treats
SDB.
Image 1 : PSG where multiple apneas of central origin are
evident.
Image 2 : MRI of T2 sagittal brain showing a 9 mm decrease in
cerebellar tonsils below the plane of the great hole compatible with
Arnold Chiari type I malformation (red arrow), with association to
cervical syringomyelia that extends from C5 until D9 (yellow arrow).