Shirley Shizue Nagata Pignatari

The relationship between excursion of the diaphragm and curvatures of the spinal column in mouth breathing children

OBJECTIVE To investigate the relationship between excursion of the diaphragm muscle and spinal curvatures in mouth breathing children. METHODS A total of 52 children of both sexes, aged from 5 to 12 years, were studied. After otorhinolaryngological assessment, the children were divided into two groups: mouth breathers and nose breathers. All of the children underwent videofluoroscopic examination of the diaphragm muscle and postural assessment. Diaphragm excursion was analyzed using Adobe Photoshop software, and postural assessment was recorded using photographs in left lateral view, which were then analyzed using SAPO postural assessment software. RESULTS The groups studied exhibited statistically significant differences in terms of spinal curvatures (cervical lordosis: p = 0.003; lumbar lordosis: p = 0.001; thoracic kyphosis: p = 0.002; position of the pelvis: p = 0.001) and diaphragm excursion (right side diaphragm: p = 0.001; left side diaphragm: p = 0.001). The mouth breathing group exhibited reduced cervical lordosis, increased thoracic kyphosis, increased lumbar lordosis and the position of the pelvis was tilted forward. The distance traveled outwards by the diaphragm muscles of mouth breathing children was shorter than that traveled by the muscles of nose breathing children. The relationship between the behavior of spinal curvatures and diaphragm excursion had no statistical significance. CONCLUSION There was no relationship between spinal curvatures and diaphragm excursion in the groups studied here.

Ocorrência da síndrome da apneia obstrutiva do sono (SAOS) em crianças respiradoras orais

UNLABELLED It is well known that mouth breathing is associated with adenotonsillar hypertrophy - which is the main cause of obstructive sleep apnea among children. Despite the importance of this matter, there are only a handful of studies showing the relationship between OSAS and mouth breathing. AIM to determine the prevalence of obstructive sleep disorders in mouth breathing children and study its correlation with otorhinolaryngological findings. STUDY DESIGN Retrospective cohort study. METHOD Data analysis from 248 medical charts of mouth breathing children seen at the Pediatric Otolaryngologic Division of a large medical institution between the years of 2000 and 2006. All patients had nasofibroscopy and or Cavum radiographs and polysomnographic exams. According to the Apnea index, patients were classified as primary snorers (AI<1); and as OSAS (>1). RESULTS From 248 patients included in the study, 144 (58%) were primary snorers and 104 (42%) had OSAS. The most prevalent otorhinolaryngological findings were adenotonsillar hypertrophy (n=152; 61.2%), tonsilar hypertrophy (n=17; 6.8%), adenoid hypertrophy (n=37; 14.9%), rhinitis (n=155; 62.5%) and secretory otitis (n=36; 14.5%). CONCLUSIONS primary snoring and OSAS are frequent findings in mouth breathing children. The most frequent otorhinolaryngological disorder in children with OSAS is adenotonsillar hypertrophy with or without rhinitis.

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.

Detection of Group A beta-hemolytic Streptococcus employing three different detection methods: culture, rapid antigen detecting test, and molecular assay.

In order to study the prevalence of Group A beta-hemolytic Streptococcus (GABHS) pharyngotonsillitis in our pediatric population and to compare different sampling methods of GABHS detection, oropharyngeal swabs from 50 children with acute pharyngotonsillitis, between 1 and 12 years old, were used simultaneously for culture, molecular assay and rapid GABHS antigen detection tests. All children were clinically examined at the Division of Pediatric Otorhinolaryngology of the Federal University of São Paulo. Diagnostic criteria were based on signs and symptoms, including sore throat, fever and oropharyngeal purulent secretion. Children that had been treated with antibiotics were excluded. Overall, combining the three methods, the prevalence of GABHS was 34%. GABHS was diagnosed in 30% of the bacterial cultures, in 25% of the samples tested with the molecular nucleic acid hybridization method and in 26% of the cases tested with the rapid antigen detection test. There was no significant difference between these three methods.

A novel approach allowing binostril work to the sphenoid sinus

Surgical approaches to the sphenoid sinus began in the early 20th century as sellar tumors gained recognition because of advances in neurology, pathology, and radiology. Developments in the field of endoscopic surgery have prompted surgeons to attempt endoscope-assisted surgery of the pituitary gland and to use endoscopes in surgery for pituitary tumors and anterior skull base lesions, which have been particularly successful. 1 Access to the sphenoid sinus is the first step in surgery and classically has been described in three ways: transnasal direct, transseptal, and transnasal with removal of the posterior nasal septum. The transnasal direct is preferable when the lesion is unilateral. The transseptal approach is more conservative and leaves the anatomy of the nasal cavity intact. The transnasal approach with removal of the posterior nasal septum may be preferable when the patient has undergone previous septum surgery; this approach also allows concomitant binostril work. 2-4 However, to enable the binostril work, the posterior septal portion must be removed, a procedure that results in a large posterior septal perforation. Septal perforations can cause significant morbidity; associated symptoms include nasal congestion or obstruction, nasal crusting and drainage, and recurrent epistaxis, among other problems. We describe a novel endoscopic transseptal approach using a posterior nasal septal mucosal flap, which allows the surgeon to perform binostril work, cover the skull base defects, and avoid posterior nasal septal perforation. This technique was submitted to and approved by the ethical committee of our institution. SURGICAL TECHNIQUE The surgery is performed under general anesthesia. The patient is in the supine position, with the dorsum elevated approximately 30 degrees. The nasal cavity is decongested with cottonoids soaked in a vasoconstrictor solution. The surgery begins with an infiltration of the nasal septum with a lidocaine 2 percent epinephrine 1:100.000 solution. A classic anterior incision for septoplasty is made, generally at the right side of the nose. A mucoperichondrial/ mucoperiosteal dissection is made at both sides. The posterior part of the nasal septum is removed, saving the inferior portion as a landmark for midline. The sphenoid rostrum and anterior wall of the sphenoid sinus are exposed. The next step is the creation of the flap at one side of the nasal septal mucosa. We perform three incisions: 1) vertical: 2 to 3 cm anterior to the sphenoid rostrum; 2) superior horizontal: 1 to 2 cm below the most superior aspect of the nasal septum; 3) inferior horizontal: 0.5 cm above the nasal floor. These incisions can be completed with scissors or other sharp instruments as necessary, making a mucosal flap that is displaced on the nasal floor (Fig 1). This nasal septal flap preserves the posteriolateral neurovascular pedicle in the sphenopalatine neurovascular bundle. 5 The other side of the

Assessment of cognitive learning function in children with obstructive sleep breathing disorders

UNLABELLED Sleep obstructive breathing disorders are frequent in children but the impact of sleep deprivation on the cognitive learning function is unclear. AIM To establish whether patients with sleep obstructive breathing disorders show any functional change in learning, memory and attention. MATERIAL AND METHODS Eighty-one children aged from 6 to 12 years were divided into 3 groups: obstructive sleep apnea syndrome (OSAS), n=24; primary snoring (PS), n=37; and control, n=20. The groups were assessed using learning (Rey) and psychological (Digit, Code, Letter Concealing, and Symbol) tests. RESULTS OSAS and PS children showed statistically significant worse performance on the variable A1 in Rey test (learning and memory) when compared with controls (p=0.011). PS children had an even worse performance on the variables A2, A4, AT and A6 compared to OSAS participants and controls (p=0.020;p=0.050;p=0.004,p=0.05). CONCLUSION Children with obstructive sleep breathing disorders, in particular PS, show worse Rey test scores. PS and OSAS children performed similarly in attention tests.

Nasal septal cross-over flap technique: a choanal atresia micro-endoscopic surgical repair.

Choanal atresia is a congenital malformation of the posterior portion of the nasal cavity, which is usually unilateral. The incidence is estimated to be 1 in 5,000 to 8,000 live births. Several surgical approaches have been described to correct choanal atresia since Emmerts initial trocar perforation in 1853, including transnasal, transpalatal, transseptal, sublabial transseptal, transantral, and external rhinoplasty. Although the micro-endoscopic transnasal access is a more conservative technique, it allows greater surgical precision, and is currently recommended by many authors; choanal atresia repair is still considered a challenge, with risks of intraoperative and postoperative complications and re-stenosis. This paper reports the results of a series of 33 patients operated via the transnasal micro-endoscopic surgical approach, and describes a new endoscopic technique that the authors call “nasal septal cross-over flap technique.”

Avaliação da função cognitiva da aprendizagem em crianças com distúrbios obstrutivos do sono

Sleep obstructive breathing disorders are frequent in children but the impact of sleep deprivation on the cognitive learning function is unclear. AIM: To establish whether patients with sleep obstructive breathing disorders show any functional change in learning, memory and attention. MATERIAL AND METHODS: Eighty-one children aged from 6 to 12 years were divided into 3 groups: obstructive sleep apnea syndrome (OSAS), n=24; primary snoring (PS), n=37; and control, n=20. The groups were assessed using learning (Rey) and psychological (Digit, Code, Letter Concealing, and Symbol) tests. RESULTS: OSAS and PS children showed statistically significant worse performance on the variable A1 in Rey test (learning and memory) when compared with controls (p=0.011). PS children had an even worse performance on the variables A2, A4, AT and A6 compared to OSAS participants and controls (p=0.020;p=0.050;p=0.004,p=0.05). Conclusion: Children with obstructive sleep breathing disorders, in particular PS, show worse Rey test scores. PS and OSAS children performed similarly in attention tests.

Effect of local application of cidofovir on the control of recurrences in recurrent laryngeal papillomatosis

OBJECTIVE: To study the effect of local application of cidofovir in patients with recurrent laryngeal papillomatosis (RLP) by measuring the interval between recurrences and the extent of disease at each recurrence. STUDY DESIGN AND SETTING: The study group included 10 patients with RLP. Videolaryngoscopic analysis of previous RLP operations for each patient before starting cidofovir and the number and timing of pre-cidofovir recurrences of the disease provided data for a self-control group. The cidofovir was injected with a laryngeal needle during papilloma resection operations. To evaluate the changes and the extent of the disease, the authors developed a staging system based on anatomic topography. The extent of the disease and the intervals between recurrences were analyzed and statistically compared. RESULTS: The median interval between recurrences significantly increased from 102 days before cidofovir to 239 days after treatment. No local or systemic side effects were observed. CONCLUSIONS: The study supports the hypothesis that cidofovir is an effective adjunct in treating recurrences of RLP. EBM rating: C-4

Gastroesophageal Reflux in patients with Recurrent Laryngeal Papillomatosis

UNLABELLED Evidence of a relation between gastroesophaeal reflux and pediatric respiratory disorders increases every year. Many respiratory symptoms and clinical conditions such as stridor, chronic cough, and recurrent pneumonia and bronchitis appear to be related to gastroesophageal reflux. Some studies have also suggested that gastroesophageal reflux may be associated with recurrent laryngeal papillomatosis, contributing to its recurrence and severity. AIM the aim of this study was to verify the frequency and intensity of gastroesophageal reflux in children with recurrent laryngeal papillomatosis. MATERIAL AND METHODS ten children of both genders, aged between 3 and 12 years, presenting laryngeal papillomatosis, were included in this study. The children underwent 24-hour double-probe pH-metry. RESULTS fifty percent of the patients had evidence of gastroesophageal reflux at the distal sphincter; 90% presented reflux at the proximal sphincter. CONCLUSION the frequency of proximal gastroesophageal reflux is significantly increased in patients with recurrent laryngeal papillomatosis.