Fabiana Cardoso Pereira Valera

Muscular, functional and orthodontic changes in pre school children with enlarged adenoids and tonsils

INTRODUCTION Hypertrophy of the adenoids and palatine tonsils is the second most frequent cause of upper respiratory obstruction and, consequently, mouth breathing in children. Prolonged mouth breathing leads to muscular and postural alterations which, in turn, cause dentoskeletal changes. OBJECTIVE The aim of this study was to determine muscular, functional and dentoskeletal alterations in children aged 3-6 years. MATERIALS AND METHODS Seventy-three children, including 44 with tonsil hypertrophy and 29 controls, were submitted to otorhinolaryngologic, speech pathologic and orthodontic assessment. RESULTS Otorhinolaryngologic evaluation revealed a higher incidence of nasal obstruction, snoring, mouth breathing, apneas, nocturnal hypersalivation, itchy nose, repeated tonsillitis and bruxism in children with tonsils hypertrophy. Speech pathologic assessment showed a higher incidence of open lip and lower tongue position, and of hypotonia of the upper and lower lips, tongue and buccinator muscle in these children, accompanied by important impairment in mastication and deglutition. Orthodontic evaluation demonstrated a higher incidence of lower mandible position in relation to the cranial base, a reduction in lower posterior facial height, transverse atresia of the palate, and a dolicofacial pattern. CONCLUSION Postural and functional alterations anticipate dentoskeletal changes, except for the facial pattern. Postural alterations and the skeletal pattern seem to play an important role in infant dentofacial growth.

Influência do padrão respiratório na morfologia craniofacial

OBJETIVO: este estudo teve como objetivo avaliar por meio de analise cefalometrica as diferencas nas proporcoes faciais de criancas respiradoras bucais e nasais. FORMA DE ESTUDO: coorte transversal. MATERIAL E METODO: Foram selecionadas 60 criancas entre 6 e 10 anos que, apos avaliacao otorrinolaringologica para o diagnostico do tipo de respiracao, foram divididas em dois grupos: grupo I, constituido de criancas respiradoras bucais, com elevado grau de obstrucao das vias aereas e grupo II, composto de criancas respiradoras nasais. Os pacientes foram submetidos a avaliacao ortodontica por meio de radiografias cefalometricas em norma lateral, a fim de avaliar as proporcoes faciais, atraves das seguintes medidas cefalometricas: SN.GoGn, ArGo.GoMe, N-Me, N-ENA, ENA-Me, S-Go, S-Ar, Ar-Go; e os seguintes indices: iAF=S-Go / N-Me, iAFA=ENA-Me / N-Me e iPFA=N-ENA / ENA-Me. RESULTADO: Foi constatada que a inclinacao do plano mandibular (SN.GoGn) nos pacientes respiradores bucais foi estatisticamente maior que nos respiradores nasais, enquanto que a proporcao da altura facial posterior e anterior (iAF), e da altura facial anterior superior e inferior (iPFA) foram estatisticamente menores nos pacientes bucais, indicando altura facial posterior menor que a anterior e altura facial anterior inferior aumentada nesses pacientes. CONCLUSAO: Pode-se concluir, entao, que os respiradores bucais tendem a apresentar maior inclinacao mandibular e padrao de crescimento vertical, evidenciando a influencia da funcao respiratoria no desenvolvimento craniofacial.

Propofol-induced sleep: Polysomnographic evaluation of patients with obstructive sleep apnea and controls

Objective: The localization of upper airway obstruction in patients with obstructive sleep apnea (OSA) may optimize treatment. Nasoendoscopy during propofol sedation allows such an evaluation, but the effect of this drug on respiratory patterns and muscle relaxation is unknown. The objective of the present study was to determine through polysomnography whether propofol would change sleep parameters. Study Design: Prospective study of subjects submitted to polysomnography under sedation with propofol. Setting: Tertiary referral center. Subjects and Methods: Fifteen non-obese subjects (4 controls/11 OSA patients) were submitted to two diurnal polysomnograms (90-120 minutes of sleep), with and without the use of propofol. The parameters presence of snoring, apnea-hypopnea index (AHI), oxygen desaturation, and sleep architecture were compared. Results: The use of propofol did not induce snoring in the control subjects, whereas 100 percent of the OSA patients snored. AHI and mean oxygen saturation (SaO2) did not differ significantly between examinations with and without sedation. However, minimum SaO2 differed significantly (P < 0.05) with sedation, being lower during propofol sedation. Propofol also significantly changed the sleep architecture, with a significant increase in N3 sleep (P < 0.005) and total abolishment of rapid eye movement sleep (P < 0.0005) during propofol sedation. Conclusions: These preliminary results allow us to infer that sedation with propofol changes sleep architecture but permits respiratory evaluation, because the main respiratory parameters evaluated in OSA are maintained. These preliminary results support the view that nasoendoscopy under propofol sedation is a promising examination for management of this disease.

Breathing mode influence in craniofacial development

AIM The aim of this study was to evaluate the differences in facial proportions of nose and mouth breathing children using cephalometric analysis. STUDY DESIGN Transversal cohort. MATERIAL AND METHOD Sixty cephalometric radiographs from pediatric patients aged 6 to 10 years were used. After otorhinolaryngological evaluation, patients were divided into two groups: Group I, with mouth breathing children and group II, with nose breathers. Standard lateral cephalometric radiographs were obtained to evaluate facial proportions using the following measures: SN.GoGn, ArGo.GoMe, N-Me, N-ANS, ANS-Me and S-Go; and the following indexes: PFH-AFH ratio: S-Go/N-Me; LFH-AFH ratio: ANS-Me/N-Me and UFH-LFH ratio: N-ANS/ANS-Me. RESULTS It was observed that the measurements for the inclination of the mandibular plane (SN.GoGn) in mouth breathing children were statistically higher than those in nasal breathing children. The posterior facial height was statistically smaller than the anterior one in mouth breathing children (PFH-AFH ratio). Thus, the upper anterior facial height was statistically smaller than the lower facial height (UFH-LFH ratio). CONCLUSION We concluded that mouth breathing children tend to have higher mandibular inclination and more vertical growth. These findings support the influence of the breathing mode in craniofacial development.

High rates of detection of respiratory viruses in tonsillar tissues from children with chronic adenotonsillar disease.

Chronic tonsillar diseases are an important health problem, leading to large numbers of surgical procedures worldwide. Little is known about pathogenesis of these diseases. In order to investigate the role of respiratory viruses in chronic adenotonsillar diseases, we developed a cross-sectional study to determine the rates of viral detections of common respiratory viruses detected by TaqMan real time PCR (qPCR) in nasopharyngeal secretions, tonsillar tissues and peripheral blood from 121 children with chronic tonsillar diseases, without symptoms of acute respiratory infections. At least one respiratory virus was detected in 97.5% of patients. The viral co-infection rate was 69.5%. The most frequently detected viruses were human adenovirus in 47.1%, human enterovirus in 40.5%, human rhinovirus in 38%, human bocavirus in 29.8%, human metapneumovirus in 17.4% and human respiratory syncytial virus in 15.7%. Results of qPCR varied widely between sample sites: human adenovirus, human bocavirus and human enterovirus were predominantly detected in tissues, while human rhinovirus was more frequently detected in secretions. Rates of virus detection were remarkably high in tonsil tissues: over 85% in adenoids and close to 70% in palatine tonsils. In addition, overall virus detection rates were higher in more hypertrophic than in smaller adenoids (p = 0.05), and in the particular case of human enteroviruses, they were detected more frequently (p = 0.05) in larger palatine tonsils than in smaller ones. While persistence/latency of DNA viruses in tonsillar tissues has been documented, such is not the case of RNA viruses. Respiratory viruses are highly prevalent in adenoids and palatine tonsils of patients with chronic tonsillar diseases, and persistence of these viruses in tonsils may stimulate chronic inflammation and play a role in the pathogenesis of these diseases.

Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls.

The treatment for obstructive sleep apnea syndrome (OSAS) depends on correct localization of upper airway obstruction, exception made for continuous positive airway pressure (CPAP). Drug‐induced sleep endoscopy (DISE) with propofol allows this evaluation, but the drug effects on sleep parameters are not yet well established. Our objective was to study by polysomnography (PSG) whether propofol would change sleep parameters by means of a prospective cross‐sectional clinical study in a tertiary hospital.

OSAS in children: correlation between endoscopic and polysomnographic findings.

OBJECTIVES: To correlate polysomnographic findings with clinical history of apnea, the degree of obstruction caused by tonsillar hypertrophy, and to age group. STUDY DESIGN AND SETTING: 267 children with a clinical diagnosis of obstructive sleep apnea (OSAS) were evaluated. Patients were divided into preschool- and school-age categories, and subdivided in 3 additional groups, according to tonsillar hypertrophy. Polysomnographic findings were compared within groups. RESULTS: 34% of children had history of OSAS and normal polysomnographic findings. Tonsillar hypertrophy was correlated to more severe apnea among preschool-age children, but not among school-age children. Among children with tonsillar hypertrophy, more severe apnea was observed in preschool-age children than in school-age children. CONCLUSIONS: There is little correlation between polysomnographic and clinical findings in children with OSAS. SIGNIFICANCE: Adenotonsillar hypertrophy leads to more severe polysomnographic patterns in preschool-age children. More severe apnea is observed in younger children with adenotonsillar hypertrophy than in older ones.

Cephalometric evaluation of facial pattern and hyoid bone position in children with obstructive sleep apnea syndrome.

OBJECTIVES To assess the development of face and hyoid bone in children with obstructive sleep apnea syndrome (OSAS) through lateral cephalometries. MATERIALS AND METHODS Children aged 7-10 years with mixed dentition and with no previous otorhinolaryngologic, orthodontic or speech therapy treatments were studied. Twenty nasal breathers were compared to 20 mouth breathing children diagnosed as OSAS patients. All children underwent otorhinolaryngologic evaluation and cephalometries; children with OSAS also underwent nocturnal polysomnography in a sleep laboratory. RESULTS Children with OSAS presented increase in total and lower anterior heights of the face when compared to nasal breathers. In addition, children with OSAS presented a significantly more anterior and inferior position of the hyoid bone than nasal breathers. No significant differences in upper, anterior or posterior heights of the face were observed between groups. CONCLUSION The results suggest that there are evident and early changes in facial growth and development among children with OSAS, characterized by increased total and inferior anterior heights of the face, as well as more anterior and inferior position of the hyoid bone.

Prognosis of acute invasive fungal rhinosinusitis related to underlying disease.

BACKGROUND Acute invasive fungal rhinosinusitis (AIFRS) is a rare disease with high morbidity and mortality rates. The objective of this study was to correlate the initial clinical features of AIFRS to the prognosis after surgery. METHODS Thirty-two patients with AIFRS were evaluated retrospectively. The correlation of underlying disease, fungus isolated, and extent of the disease to the clinical outcome of AIFRS was also evaluated. RESULTS The most common underlying disease was hematological malignancy and aplasia (n=20). Aspergillus (n=13) and Mucoraceae (n=11) were the main fungi found in AIFRS. Mucosal biopsy confirmed fungal invasion to the nasal mucosa in all cases. Computed tomography and endoscopic findings showed a predominance of unilateral disease, with various stages of nasal involvement. All patients underwent surgical debridement and systemic antifungal therapy immediately after diagnosis. Sixteen patients died (50%) due to AIFRS. A poor prognosis was related to the extensiveness of AIFRS and to the underlying disease (patients with aplastic anemia and diabetes had the worst outcomes), but not to the fungus isolated. CONCLUSIONS Early medical and surgical treatment is essential to improve the prognosis of AIFRS patients. A poorer prognosis was associated with underlying disease and extensiveness of AIFRS, but not to the fungus isolated.

Does rapid maxillary expansion increase nasopharyngeal space and improve nasal airway resistance

OBJECTIVE To evaluate the effect of rapid maxillary expansion (RME) on the dimension of the nasopharyngeal space and its relation to nasal airway resistance. METHODS Twenty-five school-age children (from 7 to 10 year-old) with mouth and/or mixed breathing, with mixed dentition and uni- or bilateral posterior crossbite involving the deciduous canines and the first permanent molars, were evaluated. RME was placed and remained during 90 days. Rhinomanometry and orthodontic documentation were performed at four different times, i.e., before (T(1)), immediately after (T(2)), 90 days (T(3)) and 30 months (T(4)) after RME. RESULTS Differences in nasopharyngeal area and in nasal airway resistance were observed only 30 months after RME, and could be explained by facial growth, and not because of the orthodontic procedure. CONCLUSION RME does not influence on nasopharyngeal area or nasal airway resistance in long-term evaluation.