Renata Cantisani Di Francesco

Respiração oral na criança: repercussões diferentes de acordo com o diagnóstico

A respiracao oral e um sintoma frequente na infância. A sindrome do respirador oral caracteriza-se por cansaco frequente, sonolencia diurna, adinamia, baixo apetite, enurese noturna e ate deficit de aprendizado e atencao. Entretanto este sintoma apresenta diversas causas. Faz-se necessario, portanto, esclarecer detalhes sobre estes aspectos clinicos de acordo com suas causas. OBJETIVO: Comparar os achados de sonolencia diurna, cefaleia, agitacao noturna, enurese, problemas escolares e bruxismo em individuos com respiracao oral; de acordo com os seguintes diagnosticos: rinite alergica, hiperplasia adenoideana, hiperplasia adenoamigdaliana. FORMA DE ESTUDO: Estudo de coorte transversal. MATERIAL E METODO: Estudo prospectivo com 142 pacientes de 2 a 16 anos, classificados em tres grupos: rinite alergica, hiperplasia adenoideana isolada e hiperplasia adenoamigdaliana. Os responsaveis dos pacientes responderam a questionario padronizado sobre os sintomas noturnos para caracterizacao da presenca de apneia do sono e sobre os aspectos estudados: cefaleia matinal, desempenho escolar e atencao, sonolencia diurna, agitacao noturna, enurese, bruxismo. RESULTADOS: A respiracao oral e mais frequente em meninos. Criancas com hiperplasia adenoamigdaliana sao mais jovens. Este grupo apresenta maior frequencia de roncos e apneia do sono, assim como mau desempenho escolar, bruxismo, enurese e agitacao noturna, sendo estes sintomas relacionados com a apneia, diferenciando-se do grupo com rinite alergica. Nao se observou sonolencia diurna e cefaleia matinal significante nos grupos estudados. CONCLUSAO: Bruxismo, enurese, agitacao noturna e cefaleia estao relacionados com a apneia do sono, sendo mais frequente na hiperplasia adenoamigdaliana. Assim, a investigacao de apneia do sono na crianca com respiracao oral e fundamental e assim como a determinacao da causa da respiracao oral.Mouth breathing is very common in children. Mouthbreathing syndrome is characterized by tiredness, daytime sleepiness, failure to thrive, restless sleep, nocturnal enuresis and poor school performance. However, this symptom has several causes and it is necessary to elucidate more details about this entity. AIM: Compare the findings of daytime sleepiness, headache, nocturnal enuresis, poor school performance and attention deficit and bruxism in subjects that present mouth breathing according to the following diagnosis: allergic rhinitis, adenoidal hyperplasia and adenotonsillar hyperplasia. STUDY DESIGN: Transversal cohort study. MATERIAL AND METHOD: This is a prospective study of 142 patients from 2 to 16 years old. After ENT evaluation, patients were classified in 3 groups according to the following diagnosis: allergic rhinitis, adenoidal hyperplasia, adenotonsillar hyperplasia. Parents and caregivers answered a questionnaire about night symptoms in order to describe the presence of sleep apnea and specific questions about: morning headaches, school performance and attention deficit, daytime sleepiness, restless sleep, nocturnal enuresis and bruxism. RESULTS: Mouth breathing is common in boys. Children with adenotonsillar hyperplasia are younger and present more snoring and sleep apnea. They present also poor school performance, bruxism, nocturnal enuresis and restless sleep, which are correlated to sleep apnea, differing from the allergic rhinitis group. Significant findings of daytime sleepiness and morning headaches were not found. CONCLUSION: Bruxism, enuresis, restless sleep and poor school performance are related to sleep apnea and more frequent in subjects with adenotonsillar hyperplasia. The investigation of sleep apnea in children with mouth breathing is mandatory, as well as the determination of its cause.

Características do sistema estomatognático de crianças respiradoras orais: enfoque antroposcópico

BACKGROUND the use of anthroposcopy in the assessment of posture and morphology of the stomatognathic system of mouth breathing children. AIM to describe the postural and morphologic characteristics of the stomatognathic system of mouth breathing children, according to age. METHOD participants were 100 children, of both genders, with ages ranging from 7 to 11 years and 11 months, leukoderms, in mixed dentition and with the diagnosis of mouth breathing. The investigated postural and morphologic characteristics of the stomatognathic system were labial and lingual resting position, possibility of labial occlusion, hyperfunction of the mentalis muscle during labial occlusion, bite and morphology of the lower lip, cheeks and hard palate, using the anthroposcopy methodology. RESULTS the results referring to the characterization of the studied population, according to the most frequent otorhinolaryngologic diagnosis, was of enlarged pharyngeal and palatine tonsils. A statistically significant difference was found between the percentages of each otorhinolaryngologic diagnosis, according to age. The results of the characteristics of the stomatognathic system indicated that the most common aspects in the studied sample were: half-open lips when in the resting position, tongue lowered on the mouths floor in the resting position, possibility of labial occlusion, hyperfunction of the mentalis muscle during labial occlusion, alterations of bite, labioverted, symmetry of the cheeks and alteration of the hard palate. All of the studied characteristics presented the same frequency with the increase in age, with no statistically significant difference. CONCLUSION mouth breathing children presented pathologic adaptations in the postural and morphological characteristics of the stomatognathic system. This suggests the importance of early diagnosis in order to avoid orofacial alterations.

Craniofacial morphology and otitis media with effusion in children.

Otitis media with effusion (OME) affects 28-38% of pre-school children, and it occurs due to the dysfunction of the auditory tube. Anatomical development of the auditory tube depends on the craniofacial growth and development. Deviations of normal craniofacial morphology and growth using cephalometric studies, may predict the evolution of otitis. Our goal in this paper is to determine if there are differences in craniofacial morphology between children with adenoid enlargement, with and without otitis media with effusion. This is a prospective study in which the sample consisted of 67 children (male and female) from 5 to 10 years old. All patients presented chronic upper airway obstruction due to tonsil and adenoid enlargement (>80% degree of obstruction). Thirty-three patients presented otitis media with effusion, for more than 3 months and 34 did not. The latter composed the control group. Standardized lateral head radiographs were obtained for all subjects. Radiographs were taken with patient positioned by a cephalostat and stayed with mandibles in centric occlusion and lips at rest. Radiographs were digitalized and specific landmarks were identified using a computer program Radiocef 2003, 5th edition. Measurements, angles and lines were taken of the basicranium, maxilla and mandible according to the modified Ricketts analysis. In addition, facial height and facial axis were determined. Children with otitis media with effusion present differences in the morphology of the face, regarding these measures: N-S (anterior cranial base length), N-ANS (upper facial height), ANS-PNS (size of the hard palate), Po-Or.N-Pog (facial depth), Ba-N.Ptm-Gn (facial axis), Go-Me (mandibular length) and Vaia--Vaip (inferior pharyngeal airway).

Melhora da qualidade de vida em crianças após adenoamigdalectomia

O aumento de volume das tonsilas palatina e faringea e um dos problemas mais frequentes do consultorio do otorrinolaringologista e e a principal causa de apneia obstrutiva do sono em criancas. OBJETIVO: Avaliar o impacto da adenoamigdalectomia na qualidade de vida em criancas com hiperplasia adenoamigdaliana. FORMA DE ESTUDO: Clinico prospectivo. MATERIAL E METODO: Trinta e seis pais ou responsaveis de criancas submetidas a adenoamigdalectomia foram entrevistados antes e apos a cirurgia atraves do questionario sobre qualidade de vida especifica desenvolvido por Serres et al., 2000, que inclui os dominios: sofrimento fisico, disturbios do sono, problemas de fala e degluticao, desconforto emocional, limitacao das atividades e preocupacao do responsavel. RESULTADOS: A qualidade de vida de todas as criancas melhorou apos a cirurgia. Foi observada correlacao direta entre o grau de obstrucao e disturbios do sono, preocupacao paterna, e na media dos dominios. Correlacionando-se os dominios entre si, observamos relacao estatistica entre sofrimento emocional e disturbios do sono, preocupacao paterna e disturbios do sono, limitacao das atividades fisicas e desconforto emocional. CONCLUSAO: O aumento das tonsilas e a apneia obstrutiva do sono pioram a qualidade de vida das criancas, principalmente pelo sofrimento fisico e disturbios do sono. A adenoamigdalectomia realmente traz uma melhora importante na qualidade de vida destes pacientes.

Avaliação da pressão inspiratória em crianças com aumento do volume de tonsilas

Children with enlarged tonsils and adenoids usually present breathing abnormalities such as snoring, mouth breathing and sleep apnea. It is known that upper airway obstruction and consequent mouth breathing may result in pulmonary diseases. AIM: The goal of this preliminary study was to evaluate the inspiratory pressure in children with upper airway obstruction due to enlarged tonsils. STUDY DESIGN: clinical with transversal cohort. MATERIAL AND METHOD: We evaluated 37 children (4 -13 years old, female/male) with enlarged tonsils who would be submitted to a T&A surgery in the Department of Otolaryngology, Medical School, University of Sao Paulo, from October 2002 to March 2003. The control group comprised 28 children without tonsillar disease submitted to the same tests. Inspiratory pressure was obtained using a manometer and vacuum meter. RESULTS: We could observe lower inspiratory pressures in children with upper airway obstruction. The mean of inspiratory pressure in the upper airway obstruction group was 14.607cm/H2O and in the control group was of 27.580cm/H2O. CONCLUSIONS: Enlarged tonsils and adenoids were associated with poor inspiratory pressure, resulting in increased breathing effort and work of the involved muscles.

Evaluation of inspiratory pressure in children with enlarged tonsils and adenoids

UNLABELLED Children with enlarged tonsils and adenoids usually present breathing abnormalities such as snoring, mouth breathing and sleep apnea. It is known that upper airway obstruction and consequent mouth breathing may result in pulmonary diseases. AIM The goal of this preliminary study was to evaluate the inspiratory pressure in children with upper airway obstruction due to enlarged tonsils. STUDY DESIGN Clinical with transversal cohort. MATERIAL AND METHOD We evaluated 37 children (4-3 years old, female/male) with enlarged tonsils who would be submitted to a T&A surgery in the Department of Otolaryngology, Medical School, University of Sao Paulo, from October 2002 to March 2003. The control group comprised 28 children without tonsillar disease submitted to the same tests. Inspiratory pressure was obtained using a manometer and vacuum meter. RESULTS We could observe lower inspiratory pressures in children with upper airway obstruction. The mean of inspiratory pressure in the upper airway obstruction group was 14.607 cm/H2O and in the control group was of 27.580 cm/H2O. CONCLUSIONS Enlarged tonsils and adenoids were associated with poor inspiratory pressure, resulting in increased breathing effort and work of the involved muscles.

Craniofacial morphology and sleep apnea in children with obstructed upper airways: Differences between genders

OBJECTIVES To correlate sleep apnea with craniofacial characteristics and facial patterns according to gender. METHODS In this prospective survey we studied 77 male and female children (3-12 years old) with an upper airway obstruction due to tonsil and adenoid enlargement. Children with lung problems, neurological disorders and syndromes, obstructive septal deviation, previous orthodontic treatment, orthodontic surgeries or oral surgeries, or obesity were excluded. Patients were subjected to physical examinations, nasal fiberoptic endoscopy, teleradiography for cephalometric analysis, and polysomnography. Cephalometric analysis included the following skeletal craniofacial measurements: facial axis (FA), facial depth (FD), mandibular plane angle (MP), lower facial height (LFH), mandibular arch (MA), and vertical growth coefficient (VERT) index. RESULTS The prevalence of sleep apnea was 46.75% with no statistical difference between genders. Among children with obstructive sleep apnea (Apneia Hypopnea Index - AHI ≥ 1) boys had higher AHI values than girls. A predominance of the dolichofacial pattern (81.9%) was observed. The following skeletal craniofacial measurements correlated with AHI in boys: FD (r(s)=-0.336/p=0.020), MP (r(s)=0.486/p=0.00), and VERT index (r(s)=-0.337/p=0.019). No correlations between craniofacial measurements and AHI were identified in girls. CONCLUSIONS Craniofacial morphology may influence the severity of sleep apnea in boys but not in girls.

Medidas e proporções antropométricas orofaciais de crianças respiradoras orais

PURPOSE: To describe the orofacial measurements and proportions of mouth breathing children and to compare the average of the right side of the face to the average of the left side of the face, according to age. METHODS: One hundred children of both sexes, with ages ranging from seven to 11 years and 11 months, leukoderms, in mixed dentition period and with mouth breathing diagnosis participated in the study. The children were submitted to anthropometric assessment, and the orofacial measurements obtained were upper lip, lower lip, philtrum, upper face, middle face, lower face and sides of the face. The instrument used was the electronic digital sliding caliper Starrett Series 727. RESULTS: There was statistically no difference among the averages of the anthropometric orofacial measurements of mouth breathing children, according to age, with exception of the middle face and the sides of the face. There was also no difference among the averages of the orofacial proportions of mouth breathing children, with exception of the proportion between upper face and middle face, and between the averages of the sides of the face, according to age. CONCLUSIONS: Statistically, no differences were found among most of the averages of the orofacial measurements and proportions of mouth breathing children, according to age.

Crescimento pôndero-estatural de crianças após adenoamigdalectomia

Tonsil and adenoid hyperplasia is one of the most common causes of upper airway obstruction in children; and generally comes along with sleep apnea. It is usually associated to poor school performance, non-specific behavioral disturbs, hyperactivity, daytime sleepiness, distraction and failure to thrive. This one is a very serious consequence for the child. The purpose of this study is to compare height and weight percentiles before and after surgery. STUDY DESIGN: Clinical prospective randomized. MATERIAL AND METHOD: We studied 55 children (male and female) from 2 to 12 years old; with upper airway obstruction due to tonsil and adenoid hyperplasia. All of them were measured (height and weight) before and 6 months after adenotonsillectomy. Height and weight percentiles were plotted in graphics and compared with statistical analysis. RESULTS: Before surgery, the majority of the children, 78.2% were under p75 for height and 70.9% were under p50 for weight. Three months after surgery there was a better distribution of the children throughout the percentil ranges. For height: 34.6% were under p75; 32.85 were between p75-95 and 32.6% were above p95. For weight 35.5% were under p50; 36.4% were under p50-95 and 29.1% were above p95. CONCLUSION: After surgery, children presented an improvement in their height and weight percentiles. They develop better after the treatment of upper airway obstruction, with T&A surgery.

Distância interincisiva máxima em crianças respiradoras bucais

INTRODUCTION: The maximum interincisal distance is an important aspect in the orofacial myofunctional evaluation, because orofacial myofunctional disorders can limit the mouth opening. AIM: To describe the maximum interincisal distance of the mouth breathing children, according to age, and to compare the averages of the maximum interincisal distance of mouth breathing children to those of children with no history of speech-language pathology disorders. METHODS: Ninety-nine mouth breathing children participated, of both genders, with ages ranging from 7 to 11 years and 11 months, Caucasian, in mixed dentition. The control group was composed by 253 children, with ages ranging from 7 years to 11 years and 11 months, Caucasian, in mixed dentition period, with no history of speech-language pathology disorders. RESULTS: The results show that the average of the maximum interincisal distance of the mouth breathing children was, considering the total sample, 43.55 millimeters, and it did not show statistically significant difference between averages according to age. There is no statistically significant difference between the maximum interincisal distances averages of the mouth breathing children and the averages of this distance of the control group children. CONCLUSIONS: The maximum interincisal distance is one measure that did not modify in mouth breathing children, during mixed dentition period, according to age, and seems not to be altered in this population. It is also observed the importance of use of the caliper in objective evaluation of the maximum interincisal distance.