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Brazilian

Journal

of

OTORHINOLARYNGOLOGY

www.bjorl.org

ORIGINAL

ARTICLE

Follow-up

of

obstructive

sleep

apnea

in

children

Emília

Leite

de

Barros

a,∗

,

Marcia

Pradella-Hallinan

b,c

,

Gustavo

Antonio

Moreira

b,c

,

Daniele

de

Oliveira

Soares

Stefanini

a

,

Sergio

Tufik

d

,

Reginaldo

Raimundo

Fujita

a

aDepartmentofOtorhinolaryngologyandHeadandNeckSurgery,UniversidadeFederaldeSãoPaulo(UNIFESP-EPM),

SãoPaulo,SP,Brazil

bUniversidadeFederaldeSãoPaulo(UNIFESP-EPM),SãoPaulo,SP,Brazil cInstitutodoSono,SãoPaulo,SP,Brazil

dDepartmentofPsychobiology,UniversidadeFederaldeSãoPaulo(UNIFESP-EPM),SãoPaulo,SP,Brazil

Received31May2012;accepted16February2014 Availableonline11June2014

KEYWORDS Sleepapnea; obstructive; Polysomnography; Clinicalevolution; Child Abstract

Introduction:theevolutionofsnoringandOSASinchildrenisnotwellestablishedsincefew studiesofpatientswithoutsurgicaltreatmenthavebeenpublished.

Objective: toevaluatetheevolution ofsleepdisorderedbreathinginchildren who hadnot beensubmittedtoupperairwaysurgery.

Method: twenty-sixchildrenwithsnoringwhohadnotundergoneupperairwaysurgerywere evaluatedprospectively. Patientswereevaluated byfullphysicalexaminationandnocturnal polysomnography,afterwhichtheyweredividedinto2groups:apnea(16children)andsnoring (10children).After6monthsfollowingtheinitialevaluation,patientsweresubmittedtoanew nocturnalpolysomnography,andalldatawerecomparedtothoseofthefirstexamination. Results:the groups didnotshow anydifferences regarding age,weight,height andairway physicalexamination.After6monthsoffollow-up,theapneaindexdidnotchange,butthe respiratory disturbance indexincreasedinthe snoringgroup andthenumber of hypopneas decreasedinthegroupapnea.

Conclusion: therewas anincrease inthepercentage ofN1sleep stageand therespiratory disturbanceindexinthepatientswithprimarysnore.TheAHIdidnotshowsignificantalteration inbothgroups,butthenumberofhypopneasdecreasedinpatientswithSAOS.

© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.

Pleasecitethisarticleas:deBarrosEL,Pradella-HallinanM,MoreiraGA,StefaniniDO,TufikS,FujitaRR.Follow-upofobstructivesleep

apneainchildren.BrazJOtorhinolaryngol.2014;80:277---84. ∗Correspondingauthor.

E-mail:emilialdebarros@yahoo.com.br(E.L.deBarros). http://dx.doi.org/10.1016/j.bjorl.2014.05.008

1808-8694/©2014Associac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.Published byElsevierEditoraLtda.Allrights reserved.

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PALAVRAS-CHAVE

Apneiadosonotipo; obstrutiva;

Polissonografia; Evoluc¸ãoclínica; Crianc¸a

Acompanhamentoclínicodecrianc¸ascomdistúrbiosrespiratóriosdosono

Resumo

Introduc¸ão:aevoluc¸ãodoroncoedasíndromedaapneia/hipoapneiaobstrutivadosono(SAOS) nainfânciaaindanãoestábemestabelecidaepoucosestudosdessespacientessemo trata-mentocirúrgicoforampublicados.

Objetivo:avaliaraevoluc¸ãodaapneiaedoroncoprimárioemcrianc¸asquenão foram sub-metidasacirurgiadasviasaéreassuperiores.

Métodos: foramavaliadasprospectivamente26crianc¸ascomroncoquenãohaviamsido sub-metidas atratamento cirúrgico. Todas foramsubmetidas a exame físico, nasofibroscopia e polissonografia,apartirdosquaisforamdivididosemdoisgrupos:SAOS(16crianc¸as)eronco(10 crianc¸as).Após6mesesdaavaliac¸ãoinicial,osexamesforamrepetidos,eosdadosencontrados foramcomparados.

Resultados: osgruposnãoapresentaramdiferenc¸aentresicomparandoidade,peso,alturae examefísico.Quandocomparamososresultadosdasduaspolissonografias,houveumaumento daporcentagemdoestágiodosonoN1nogruporonco.Oíndicedeapneia/hipoapnéeia(IAH)não apresentoualterac¸ãoemambososgrupos,oíndicededistúrbiosrespiratórios(IDR)aumentou nogruporonco,eonúmerodehipopneiasdiminuiunogrupoSAOS.

Conclusão:houveaumentodaporcentagemdoestágio1dosononão-REMedoIDRnospacientes comroncoprimário; oIAH nãoapresentou alterac¸ãosignificante;o númerode hipoapneias diminuiunospacientescomSAOS.

©2014Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

The obstructive sleepapnea syndrome (OSAS), character-ized by repeated episodes of upper airway obstruction, associatedwithintermittenthypoxia and hypercapnia,1 is

a respiratory sleep disorder that affects both adults and children.Thesleep-disorderedbreathing(SDB)isvery com-moninchildhood,anditisestimatedthat3---26%ofyoung childrenhavehabitual snoringand1---3%haveOSAS.1,2The

SDB includes primarysnoring,increased airwayresistance syndromeandOSASasmorerelevantconditions.3

The main risk factors for childhood OSAS are ade-notonsillarhypertrophy, obesity,neuromuscular disorders, craniofacialabnormalitiesandgeneticdiseases.1,4---7Among

allthesefactors,tonsillarandadenoidhypertrophy predom-inatesasthemainetiology.8---10

Themost commonsymptom ishabitualsnoringandthe occurrenceofOSASintheabsenceofsnoringisconsidered unlikely.11 Snoring, alone or associated with other

symp-toms cannotdifferentiate OSASfrom primarysnoring and theincreasedupperairwayresistancesyndrome.12

SDB and especially childhood OSAS are comorbidities that can affect the central nervous system by causing hyperactivity, daytime sleepiness, cognitive impairment and poor school performance,13---17 as well as the

car-diovascular system by altering blood pressure, causing ventricular hypertrophy and endothelial dysfunction,18---20

andthemetabolicsystem,contributingtoinsulinresistance, increasedleptinandalteringserumlipids,21,22 growthand

development.23,24

The diagnosisofOSASin childrenremains problematic. Theattempteduseofacombinationofsignsandsymptoms todistinguishbetweenprimarysnoringandobstructivesleep

apneaproved tobeineffectiveandthegoldstandardtest forthediagnosisisthepolysomnography.3,12,25,26

Despiteitsimportance,currentlythenatural historyof snoringandOSASinchildrenisnotwellestablishedandfew studieshavebeenpublishedthatevaluatedtheoutcomeof thesepatientswithoutsurgicaltreatment.Snoringisa com-monsymptom and onedoes not know whichchildren will improvespontaneouslyandwhichoneswillprogresstoOSAS. Ali,in1993,carriedoutaresearchstudythrougha ques-tionnaireappliedto782 childrentoassesstheprevalence of snoring and related symptoms.27 After two years, 507

ofthesechildrenwerereassessedand,althoughthe preva-lenceofhabitualsnoringshowednodifference,morethan halfofthechildrenwhoreportedsnoringinthefirst assess-mentnolongerreportedthatcomplaint.2

Marcus, in 1998, evaluated a cohort of 20 children withprimary snoring,1---3 whowere submittedtorepeated

polysomnographicassessmentyearsafterthefirst examina-tionandfoundnosignificantchangesintheapnea-hypopnea index(AHI)andventilatoryparameters,whereastwo chil-dren(10%)hadOSASinthesecondexamination.18However,

itisnotwellestablishedwhetherthechildrenwho under-went surgical treatment before the second examination wereincludedinthecomparativeanalysis.

Topol,in 2001, also carriedout a study in a cohort of 13 children with primary snoring using polysomnography andfoundnodifferencesinthere-examinationafterthree years.28

Anuntaseree, in 2001, carried out an epidemiological studythroughaquestionnaireappliedto1088childrenaged seven years,and anew studythree yearslater (2005)on those children without treatment showed that there had beenareductionofsnoringin65%ofcases,whereas4.5%of

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children without snoring startedto snore,and9% of chil-dren developed OSAS.29,30 However, the polysomnography

wasonlyperformedinsixchildrenwhoalreadyhada diagno-sisofOSASinthefirststudyandsevenmorechildrenwhohad sleep-related symptoms, which may have underestimated thenumberofnewcasesofOSAS.

Li,in2010, alsocarriedoutastudyrecruitingpatients from a previous epidemiological study and re-evaluated 45 children that had OSAS after two years. Worsening of OSAS was observed in 29% of the children, and, in this groupofpatients,therewasanincreaseinwaist circumfer-ence,higherprevalenceofhypertrophictonsilsandhabitual snoring.31

Noprospectivestudywasperformedtoevaluatethe evo-lution of OSAS and primary snoring in patients who did notundergo surgical treatment.All previous studies were performedbyreassessingthepatientsyearsafterthefirst evaluation.

The aim of this study wastoevaluate thevariationof sleep disordered breathing (OSAS and primarysnoring) in childrenwhowerenotsubmittedtoupperairwaysurgery.

Materials

and

methods

A total of 26 patients, aged 2---12 years of both genders, who complained of snoring or difficulty breathing during sleepand who had notundergone surgery for removalof tonsils and/or adenoids, or nasal cavity surgeries, were prospectivelyassessedatthePediatricOtorhinolaryngology OutpatientClinicfromNovember2009toNovember2011. Procedure

Atbaseline, thechildrenwereevaluatedby the otorhino-laryngologist(theauthorofthisstudy),whoperformedthe medicalhistory,generalphysicalexamination, otorhinolar-yngologyassessmentandnasalendoscopy.Allchildrenwith a history of habitual snoring were selected (more than 5 times a week for a periodlonger than 6 months), associ-ated withtonsillar andadenoidhypertrophy and whohad notundergoneanysurgicalprocedureoftheupperairways. The children’s parents or guardians received informa-tiononthestudyandsignedthefreeandinformedconsent formapprovedbytheEthicsCommittee,protocol number 0237/10.Then,thechildrenwereevaluatedwitha noctur-nal polysomnography. Patientswho complainedof rhinitis started treatment with nasal corticosteroids prior to the firstpolysomnographyandremainedontreatmentwhilethe complaintpersisted.

Allchildrenwhohadsurgicalindicationfor adenotonsil-lectomywerereferredtopre-operativeandpre-anesthetic evaluation. Due to the large number of patients in the service,thesurgerycanbedelayedfor6---8months.During thefollow-upperiod,anewpolysomnographywasrequested to be performed six months after the first examination. All children were re-evaluated before the second polyso-mnography and none showed any significant alterationin BMI(e.g.,overweighttoobesity)orotorhinolaryngological examination.

Noneofthepatientshadthesurgerydatechangeddueto theresearchprotocol.Allpatientswhohadthesurgerydate priortothepolysomnographywereautomaticallyexcluded.

Inclusioncriteria Habitualsnoring.

Hypertrophicpalatinetonsils. Hypertrophicadenoids.

Childrenwhounderwenttheassessmentatpre-scheduled timesaccordingtothisstudy protocol(initialandafter6 months).

Exclusioncriteria

Childrenorparents/guardianswhorefusedtoparticipate inthestudy.

Thosewhodidnotunderstandtheinitialinstructions. Orofacial abnormality syndrome already established and/orundergoinginvestigation.

Lungdisease,heartdiseaseandobesity.

Diseases ofmetabolicor myopathicorigin already estab-lishedand/orundergoinginvestigation.

Children who did not undergo assessments at pre-scheduled times according to thisstudy protocol (initial andafter6months).

Childrenwhohadsurgeryscheduledbeforethecompletion ofthesecondpolysomnography.

Presenceofinfectionordecompensationofallergic symp-toms at thetime ofthe examinations(nasofibroscopy or polysomnography).

Physicalexamination

Theoverallphysicalexaminationincludedheightandweight measurements.Theupperairwayphysicalexamination eval-uated the palatine tonsils and adenoids, as well as the modifiedMallampatiindex.

Thepalatinetonsilsweredividedinto4grades,according totheclassificationofBrodsky32:GradeI---tonsilsare

situ-atedslightlyoutofthetonsillarfossa,occupyinglessthan 25%oftheareabetweentheoropharynx;GradeII---tonsils arereadilyvisible,occupying25%to50%oftheoropharynx; GradeIII --- tonsils occupy50---75% of the oropharynx; and GradeIV---tonsilsoccupymorethan75%oftheoropharynx. The adenoids were classified based on the nasal endoscopyassessmentregardingthepercentageof obstruc-tion of the paranasal sinuses, with 0 being absence of adenoidtissue,and100%completeobstruction.

The modified Mallampati index usedwas the one pro-posedbyFriedmann,33beingdividedinto4classes;inclass

I,theentireoropharynxcanvisualized,includingthe infe-riorpoleofthepalatinetonsils,and,inclassIV,onlypart ofthehardpalateandthesoftpalatearevisualized,being impossibletovisualizetheposteriororopharynxwallandthe insertionoftheuvula.

Nasalendoscopy

Nasalendoscopywasperformedusingaflexiblefiberoptic cable(Machida),axenonlightsource(Styker,OthobeanII), avideo camera(ToshibaCCDIK M30AK),andavideo mon-itor(SonyKV --- CR).All testswere performed after prior treatmentofallergicrhinitis,ifnecessary.Theexamination

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Table1 Comparisonbetweenapneaandsnoringgroupsregardingage,weightandheight.

Group Mean Median SD Min Max n CI pvalue

Age Apnea 5.5 4.5 3.44 2 12 16 1.69 0.932 Snoring 5.4 5.5 1.58 3 8 10 0.98 Weight Apnea 24.1 18 14.3 12.5 59 16 7 0.982 Snoring 24.2 23.4 11.2 10 44 10 6.9 Height Apnea 1.16 1.09 0.23 0.92 1.62 16 0.11 0.786 Snoring 1.18 1.17 0.14 1.01 1.39 10 0.08

SD,standarddeviation;Apneagroup,patientsthathadobstructivesleepapneasyndrome;Snoringgroup,patientsthathadprimary snoring;n,numberofchildren;p,descriptivelevel,ANOVAstatisticaltest.

wasperformed withthe child sittingonthe lapof a par-ent or guardian and a 2% lidocaine spray was applied to both nostrils. The fiber wasinserted into the right nasal cavity through the inferior meatus until the choana was visualized.The sameprocedurewasperformedontheleft side, but with visualization of the laryngeal tonsils and adenoids.

Polysomnography

The polysomnography was performed at night in a dark and quiet room with ambient air, and in the presence of the child’s parent/guardian. No sleep deprivation or sedationmethodswereused.Electrophysiologicaland car-diorespiratoryparameterswererecordedinacomputerized system,usingdatafromtheelectroencephalogram(F4/M1, F3/M2, C4/M1, C3/M2, O2/M1, O1/M2), submental and bilateraltibialelectromyogram,right andleft electroocu-logram,nasalairflowthroughoronasalpressurecannulaand thermistor, thoracic and abdominal respiratory effort by uncalibrated inductance plethysmography, oxyhemoglobin saturation(SpO2)bypulseoximetry,snoringsensor (micro-phone) and sleeping position. The data were evaluated accordingtothecriteriaoftheAmericanAcademyofSleep Medicine2007manual.34

OSAS was considered: obstructive apnea index (AI)>1 event per hour or apnea and hypopnea index (AHI)>1.5 events per hour, minimum oxygen saturation (SpO2 peak)≤92%.PatientswithAI<1eventperhourorAHI<1.5 eventsperhour,SpO2peak>92%withsnoringwereclassified ashavingprimarysnoring.35

Patientswere reassessed according tothe same treat-ment protocol and underwent a new polysomnography 6

monthsafterthefirstevaluation,whilewaitingtoundergo surgicaltreatment.

Statisticalanalysis

Dataobtainedwerecomparedbetweenthetwogroups. Sta-tisticalanalysiswasperformedusingasignificancelevelof 5% (0.05) and identified with an * when significant. The equalityof twoproportionstest wasusedtocompare the qualitativevariables.

TheANOVA test wasusedtocompare groups for quan-titativevariablessuchasage,weight,heightandadenoid size.

Finally,anintragroupanalysiswasperformedforthe val-uesofpolysomnography,i.e.,comparingtheresultsofthe initialexaminationandafter6monthsusingthepaired Stu-dent’sttest(whenthesameindividualisstudysubjectand hisowncontrol).

StatisticalanalysiswasperformedusingSPSSV16,Minitab 15andMicrosoftOfficeExcel2007software.

Results

Atotalof26patientswereincludedinthestudy,ofwhom16 hadobstructivesleepapnea(apneagroup)and10primary snoring(snoringgroup).

Overallgroupassessment

The groups did not show any difference regarding age, weight and height as shown in Table 1. When compared regardingtheotorhinolaryngologicalphysical examination,

Table2 Comparisonbetweenapneaandsnoringgroupsregardingtonsilsize.

GradeI GradeII GradeIII GradeIV

Apnean(%) 1(6.3) 4(25) 6(37.5) 5(31.3)

Snoringn(%) 1(10) 3(30) 3(30) 3(30)

pvalue 0.727 0.78 0.696 0.946

Apneagroup,patientsthathadobstructivesleepapneasyndrome;Snoringgroup,patientsthathadprimarysnoring;tonsilsizeaccording totheclassificationofBrodsky;n,numberofchildren,%,percentageofchildren;p,descriptivelevel,statisticaltestforequalityoftwo proportions.

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Table3 ComparisonbetweenapneaandsnoringgroupsaccordingtomodifiedMallampaticlassification.

ClassI ClassII ClassIII ClassIV

Apnean(%) 3(18.8) 6(37.5) 4(25) 3(18.8)

Snoringn(%) 1(10) 5(50) 3(30) 1(10)

pvalue 0.547 0.53 0.78 0.547

Apneagroup,patientsthat hadobstructivesleep apneasyndrome;Snoringgroup,patientsthat hadprimary snoring;n,numberof children,%,percentageofchildren;p,descriptivelevel,statisticaltestforequalityoftwoproportions.

Table4 Comparisonbetweenapneaandsnoringgroupsregardingthesizeoftheadenoids(%).

n Mean Median SD CI pvalue

Apnea 16 72 82.5 23.8 11.7

0.12

Snoring 10 56 65 26.3 16.3

SD,standarddeviation;Apneagroup,patientsthathadobstructivesleepapneasyndrome;Snoringgroup,patientsthathadprimary snoring;n,numberofchildren;p,descriptivelevel,ANOVAstatisticaltest.

therewere nosignificant differencesbetween the groups either,asshowninTables2---4.

Polysomnographicassessment

Thecomparisonoftheinitialpolysomnographyandafter6 monthsin both groupsis shown inTable 5for thesnoring group,andinTable6fortheapneagroup.

Therewasnostatisticaldifferenceregardingsleep effi-ciency.There was an increase in thepercentage of sleep stage N1 in the snoring-group assessment after 6 months whencomparedtotheinitialtest, witha statistically sig-nificant difference, but this percentage remained within thenormalityrange.Thedistributionofothersleepstages showednostatisticaldifferencewhencomparingtheinitial examinationandafter6monthsineithergroup.

There was no statistical difference when the apnea-hypopneaindex(AHI)wascomparedinbothgroups.There wasnodifferencewhencomparingseparatelythenumber of central,obstructive or mixed apneas, andthe number of episodes of respiratory effort-related arousals (RERAs) inbothgroups.The numberofobstructiveapnea episodes inthesnoringgroupshoweda significantalterationinthe standarddeviationduetotheconsiderableincreaseinthe numberoftheseeventsinonepatient.

Whenassessingpatientsindividually,weobservedthat4 patientsinthesnoringgroup(40%)developedOSAS accord-ingtothecriteriausedinthetestperformedafter6months. Intheapneagroup,6patients(37.5%)ceasedtohaveOSAS accordingtothecriteriausedand4patients(25%)showedan increaseinAHI.OfthepatientswhoshowedOSAS improve-ment, 2 had moderate, and 4 mild OSAS at the initial assessment.

Table5 Resultsoftheinitialpolysomnographyandafter6monthsforthesnoringgroup.

Initial After6months pvalue

SE(%) 83.5±6.2 85.9±8.2 0.21 N1(%) 1.96±1.75 5.65±3.53 0.015a N2(%) 40±7.6 40.2±8.4 0.958 N3(%) 34.1±14.6 32.9±10.7 0.868 REM(%) 22.0±5.4 21.3±5.6 0.778 IA 11.0±3.8 12.1±5.7 0.569 AHI 0.25±0.24 1.22±1.82 0.12 RDI 0.25±0.24 1.50±1.71 0.044a CA 0.50±1.90 0.60±1.90 0.876 MA 0 0 × OA 0.40±0.97 4.40±10.28 0.259 RERAs 0 0 × Hypopnea 0.80±0.79 3.70±6.46 0.186 PeakSPO2 94.0±2.7 92.3±5.9 0.42

Snoringgroup,patientsthathadprimarysnoring;p,descriptivelevel;StatisticalStudent’spairedt-test;SE,sleepefficiency;IA,index ofarousal;AHI,apnea-hypopneaindex;RDI,respiratorydisturbanceindex;CA,centralapnea;MA,mixedapnea;OA,obstructiveapnea; RERAs,respiratoryeffort-relatedarousals.

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Table6 Resultsoftheinitialpolysomnographyandafter6 monthsfortheapneagroup.

Initial After6months pvalue SE(%) 82.7±8.9 84.3±8.9 0.437 N1(%) 3.88±3.33 5.92±4.80 0.222 N2(%) 44.0±9.1 47.5±9.9 0.237 N3(%) 30.4±6.9 27.5±9.4 0.313 REM(%) 21.8±7.7 19.0±6.6 0.187 IA 13.6±5.2 13.4±6.2 0.927 AHI 8.61±9.76 6.99±14.12 0.358 RDI 8.64±9.74 7.65±14.09 0.554 CA 11.38±28.76 21.69±82.77 0.509 MA 12.25±31.34 1.25±2.79 0.17 OA 6.06±5.32 12.44±20.51 0.219 RERAs 0.63±1.75 2.38±5.37 0.137 Hypopnea 26.06±18.34 13.31 0.005a PeakSPO2 87.8±5.3 87.9±8.0 0.94 Apneagroup,patientsthathadtheobstructivesleepapnea syn-drome;p,descriptivelevel;Statisticalstudent’spairedt-test; SE,sleepefficiency;IA,indexofarousal;AHI,apnea-hypopnea index;RDI, respiratorydisturbanceindex;CA,central apnea; MA,mixed apnea; OA, obstructive apnea;RERAs, respiratory effort-relatedarousals.

a significantpvalue.

The number of hypopnea events showed astatistically significantdecreaseintheapneagroupatthetestafter6 monthscomparedwiththeinitialassessment,althoughthe AHIshowednostatisticallysignificantchange.

As for the respiratory disturbance index (RDI), there wasastatisticallysignificantincreaseinthesnoringgroup andtherewasnostatisticaldifferenceintheapneagroup. Regardingthepeakoxygensaturation,therewasno statis-ticaldifferencebetweenthe momentsevaluatedfor both groups.

Discussion

Thisstudyevaluatedpatientscontinuouslyaimingto iden-tifyvariationsin theclinicalandpolysomnographicprofile of children with OSAS and primary snoring, which limits thesamplesizeandstudyperiod.Furthermore,allpatients withanindicationforadenotonsillectomywerereferredfor surgery (all patients withOSAS and patients withsnoring andadenotonsillarhypertrophywithout improvementwith clinical treatment). Throughoutthe evaluation period,no significantchangesinBMIandotorhinolaryngological assess-mentofpatientswereobserved.

Asforotorhinolaryngologicalalterations(sizeofthe ton-silsandadenoidsandmodifiedMallampaticlassification)the groupsshowednostatisticaldifference.Consistentwiththe literature,noneofthesedatawithoutthepolysomnography assessment was able to differentiate patients with OSAS fromprimarysnoring.3,12,25,26

The criteria for OSAS diagnosis in childhood accord-ingto theAHI are notstandardized indifferent scientific publications,18,31,36 andfurtherstudies arestillbeing

per-formedtoestablishthenormalitycriteria.37---39Toevaluate

the natural history of the disease is essential for the

consolidation of these criteria and, especially, to define whichpatientsneedamoredetailedfollow-up.

Sleeparchitectureisconsideredpreservedinmost chil-drenwithOSASwhencomparingREMandnon-REMsleep.10,11

However,lateevaluationsafteradenotonsillectomyshowed asignificantincreaseinslow-wavesleepinchildren.23,40,41

Roemmichetal.showedsignificant reductionin thestage 1 of the sleep accompanied by the improvement in AHI one year after adenotonsillectomy in children.42 In this

study, we observed a significant increase in stage 1 of the non-REM sleep in patients with primary snoring, and,although themechanismis unclear,sleep fragmenta-tion can result in behavioral changes and poor academic performance.13---16

AsfortheAHI,therewasnostatisticallysignificant dif-ference in either group. During the 6-month evaluation period,it is apparent thatthe patients had noalteration inthenaturalhistoryof thediseasein eithergroup. How-ever,whenassessingindividualpatients,weobservedthat 4 patients with primary snoring at the first examination (40%) had apnea at the examination performed after 6 months,evenwithnosignificantchangesinBMIand physi-calexamination,ahighervaluethantheonefound inthe literature.18,28,30

OfthepatientswithOSAS,4(25%)hadworseningofAHI, ofwhich3hadmoderatetosevereOSASatthefirst examina-tion(AHI≥5eventsperhour).Anuntasereeetal.observed thatchildrenwithOSAShadtheworseindicesatthesecond evaluation,andLietal.alsoobservedworseningin29%of patients withOSAS.30,31 It is noteworthy thatthere wasa

statisticallysignificantdecreaseinthenumberofhypopnea eventsinpatientswithOSAS,eveniftheydidnotinterfere withtheAHI.

Inthegroupofpatientswithprimarysnoring,RDIshowed astatisticallysignificantincrease,eveniftherewasno dif-ferencein AHIandRERAwhencomparedseparately.More recentlyintroducedinthepolysomnographicevaluation,the RDIhasnonormalitycriteriayet.

Itisunlikely thatthe differencesfound aredue tothe variability between the nights whenthe examination was performed. One factor that could affect this variation is nasalobstructioncausedbyallergicrhinitis,butallpatients with complaints of rhinitis were treated with nasal cor-ticosteroids before the examinations. Moreover,it is well establishedthatonenightofrecording,providedthatthere arenotechnicalcomplications,issufficienttoidentifySDB. Katzetal.evaluatedtheresultsofpolysomnographies per-formed on two nights with an interval of 7---27 days and observednostatisticaldifferenceinAHIorrespiratory varia-blesofpatients,concludingthattheexaminationofasingle nightis suitable for measurementof childhood OSAS.43 Li

etal.comparedthepolysomnographyofchildrenin2 con-secutive nights and concluded that the examination of a singlenightissufficienttoidentify84.6%ofcasesofSDB.44

Nodifferences were observed in AHI in patients when analyzedingroup,butwhenassessedindividually,this vari-ationcan bedecisivefor the choiceof treatment. As the findings of this study did not show an evolution of chil-drenwithprimarysnoringtoOSASwithin6months,although individualvariationswerefound,itreinforcestheneedto maintaintheclinicalfollow-upofchildrenwithSDBandbe watchfulofanychangeintheclinicalpicture.

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Conclusion

After6 months of follow-upof patients withSDB without surgicaltreatment,therewerenovariationsinSDB. 1. Therewasan increase inthe percentageof stage1of

non-REMsleepandRDIinpatientswithprimarysnoring. 2. TheAHIshowednosignificantchangeineithergroup. 3. ThenumberofhypopneasdecreasedinOSASpatients.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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