Medline ® Abstracts for References 23,68,74-76
of 'Evaluation of suspected obstructive sleep apnea in children'
Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children.
Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM
STUDY OBJECTIVE: To determine whether primary snoring (PS) could be distinguished from childhood obstructive sleep apnea syndrome (OSAS) by clinical history.
DESIGN: Retrospective study of clinical history of 83 children with snoring and/or sleep disordered breathing who were referred for polysomnography.
SETTING: Tertiary referral center; pediatric pulmonary sleep apnea clinic.
MEASUREMENTS: We evaluated the ability of a clinical obstructive sleep apnea (OSA) score and other questions about sleep, breathing, and daytime symptoms to distinguish PS from OSAS in children. Parents were asked about the child's snoring, difficulty breathing, observed apnea, cyanosis, struggling to breathe, shaking the child to "make him or her breathe," watching the child sleep, afraid of apnea, the frequency and loudness of snoring, and daytime symptoms such as excessive daytime sleepiness (EDS).
RESULTS: Based on polysomnography results, 48 patients were classified as PS and 35 as OSAS. Peak endtidal CO2 (49 +/- 3.2 vs 55 +/- 8.2 [SD]mm Hg); lowest arterial oxygen saturation measured by pulse oximetry (95 +/- 1.9 vs 82 +/- 14%); and apnea/hypopnea index (0.27 +/- .3 vs 8.4 +/- 6 events/h) indicated that the diagnostic criteria for PS versus OSA were reasonable. There were no differences between PS and OSA patients with respect to age, sex, race, failure to thrive, obesity, history of EDS, snoring history, history of cyanosis during sleep, or daytime symptoms except for mouth breathing. There were no significant differences in sleep variables between PS patients and those with any severity of OSAS. The OSA score misclassified about one of four patients. Comparing PS and OSA patients, significant findings were daytime mouth breathing (61 vs 85%; p = 0.024); observed apnea (46 vs 74%; p = 0.013); shaking the child (31 vs. 60%; p = 0.01); struggling to breathe (58 vs 89%; p = 0.003); and afraid of apnea (71 vs 91%; p = 0.028). However, none of these were sufficiently discriminatory to predict OSAS.
CONCLUSION: We conclude that PS in children cannot be reliably distinguished from OSAS by clinical history alone.
Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Children's Center, Baltimore, MD 21287-2533, USA.
Polysomnographic and clinical findings in children with obstructive sleep apnea.
Leach J, Olson J, Hermann J, Manning S
Arch Otolaryngol Head Neck Surg. 1992;118(7):741.
A retrospective study was conducted to determine which types of children might have polysomnographic findings that are most compatible with obstructive sleep apnea (OSA). The charts of 93 patients who were aged 18 months to 12 years were examined. All 93 patients had symptoms that were initially suggestive of OSA, and they underwent polysomnography. The types of presenting symptoms and associated illnesses were noted. Physical findings, including height, weight, and tonsil size, were examined. Of 93 patients with symptoms that were suggestive of OSA, 34 met sleep study criteria for OSA. In 44 patients, OSA was not demonstrated, and 15 patients had other results. On the basis of age, sex, and symptoms, no significant differences could be found between the group with OSA and the group with normal polysomnographic findings. Cor pulmonale, tonsil hypertrophy, and failure to thrive were associated with OSA. Surprisingly, obesity was not significantly associated with OSA.
Department of Otolaryngology, University of Texas Southwestern Medical School, Dallas 75235.
Accuracy of clinical evaluation in pediatric obstructive sleep apnea.
Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D
Otolaryngol Head Neck Surg. 1998;118(1):69.
Eighty-two children underwent polysomnography (PSG) for symptoms suggestive of obstructive sleep apnea (OSA). Symptoms reported included snoring, witnessed apneic episodes, daytime somnolence, mouth breathing, and enuresis. Tonsillar size, nasal airway patency, and percentile weight were recorded. OSA was diagnosed on PSG when obstructive events were noted and apnea + hypopnea index was five or more per hour. The overall predictive accuracy of clinical suspicion of OSA was 25 (30%) of 82. Predictive accuracies (as a percentage of those with symptoms/signs who have OSA) and prevalences (as a percentage of those with OSA who have the symptom/sign), respectively, were for moderate snoring 29% (12 of 41), 48%; loud snoring 31% (11 of 35), 44%; witnessed apneas 32% (22 of 69), 88%; enuresis 46% (11 of 24), 44%; 2+ tonsillar size 37% (21 of 57), 84%; 3+ tonsillar size 33% (3 of 9), 12%; 90th percentile weight or greater 26% (7 of 27), 28%; 10th percentile weight or less 33% (5 of 15), 20%. Multiple regression analysis did not reveal a significant association between clinical parameters and the presence of OSA as defined by PSG.
Division of Otolaryngology-Head and Neck Surgery, Texas Tech University Health Sciences Center, Lubbock, USA.
Adenotonsillectomy for treatment of obstructive sleep apnea in children.
Suen JS, Arnold JE, Brooks LJ
Arch Otolaryngol Head Neck Surg. 1995;121(5):525.
OBJECTIVES: To determine (1) the prevalence of obstructive sleep apnea (OSA) in children with a suggestive history; (2) the effectiveness of surgery in treating OSA in children; and (3) factors that may help the physician select patients who have physiologically significant OSA and are likely to respond to surgery.
DESIGN: Prospective study.
PATIENTS: Sixty-nine children aged 1 to 14 years who were referred to the otolaryngologist for evaluation of suspected OSA.
INTERVENTIONS: Thirty children with a respiratory disturbance index (RDI) greater than 5 underwent adenotosillectomy. Twenty-six of the 30 children had follow-up polysomnography.
MAIN OUTCOME MEASURES: Polysomnography after surgery.
RESULTS: Thirty-five (51%) of 69 children had an RDI greater than 5 on polysomnography. Twenty-six of the 30 children who underwent adenotonsillectomy for OSA had follow-up polysomnography. All 26 children had a lower RDI after surgery, although four patients still had an RDI greater than 5. A preoperative RDI of 19.1 or less predicted a postoperative RDI of 5 or less. History and physical findings were not useful in predicting outcome.
CONCLUSIONS: All patients improved with adenotonsillectomy, but patients with the most severe RDI often had many respiratory events after surgery. History and physical examination alone are not sufficient to assess the severity of OSA or the likelihood of an adequate response to surgical treatment.
Department of Pulmonary/Critical Care Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
Correlation between otorhinolaryngologic evaluation and severity of obstructive sleep apnea syndrome in snorers.
Dreher A, de la Chaux R, Klemens C, Werner R, Baker F, Barthlen G, Rasp G
Arch Otolaryngol Head Neck Surg. 2005;131(2):95.
OBJECTIVES: To examine whether medical history and nasopharyngeal examination are useful for predicting obstructive sleep apnea syndrome (OSAS) and to compare these findings with those of the gold standard, polysomnography.
DESIGN: Patients underwent polysomnography recordings for 2 nights and an otorhinolaryngologic examination, including flexible endoscopy and the Muller maneuver. Nasal and pharyngeal findings were scored in a semiquantitative way. The medical history of each patient was taken using a standardized questionnaire. Anatomic and functional findings and patient history were correlated with the mean apnea-hypopnea index (AHI).
SETTING: An otorhinolaryngologic clinic.
PATIENTS: A total of 101 patients presenting with a primary complaint of snoring.
MAIN OUTCOME MEASURES: Differences between patients with OSAS and primary snorers were assessed using the Mann-Whitney test (anatomic findings), t test (Muller maneuver), and chi(2) test after Pearson correlation (questionnaire). P values less than .05 were considered statistically significant.
RESULTS: The mean +/- SD AHI of the patients was 19.7 +/- 21.5); 52 patients had an AHI higher than 10, which confirmed the diagnosis of OSAS. These patients tended to report the occurrence of apneas more frequently than patients with an AHI of 10 or lower. The average ranks (Mann-Whitney findings) of patients with AHIs higher than 10 vs those with AHIs of 10 or lower were 52 vs 50 for septal deviation; 50 vs 52 for tonsil size; 53 vs 49 for low velum level; and 56 vs 46 for hyperplasia of the tongue base. None of these differences reached statistical significance. Mean +/- SD narrowing of the airway during the Müller maneuver was significantly (P<.05) more pronounced in patients with an AHI higher than 10 than in patients with an AHI of 10 or lower at the levels of the velum (80% +/- 20% vs 68% +/- 30%) and the tongue base (57% +/- 24% vs 44% +/- 27%).
CONCLUSIONS: None of the reported medical history and/or anatomic parameters alone or in combination could be used to distinguish patients with OSAS from snoring patients. Snoring patients, therefore, should be examined at least by a nocturnal screening test for OSAS before any therapeutic decision is made.
Department of Otorhinolaryngology, Ludwig-Maximilians-University, Munich, Germany. firstname.lastname@example.org