Yakov Sivan

Obstructive sleep apnea syndrome due to adenotonsillar hypertrophy in infants

OBJECTIVEnAdenotonsillar hypertrophy (ATH) is the leading cause for obstructive sleep apnea syndrome (OSAS) in children. The peak age for adenoid and tonsillar hypertrophy and related OSAS is 3-6 years. It has been suggested that OSAS due to ATH is extremely rare in infants. The purpose of the present study was to delineate OSAS due to ATH in infants.nnnMETHODSnTwenty-nine consecutive infants <18 months of age who underwent polysomnography (PSG) and were diagnosed with OSAS due to ATH were studied. A pediatric sleep questionnaire was completed by parents of all infants. Information regarding demographic variables, referring physician specialty, assessment of infants development and recurrence of symptoms post treatment was collected. Pre and post surgery body weight and developmental assessment by parents were evaluated.nnnRESULTSnThe mean age of adenotonsillectomy was 12.3+/-3.9 months with the mean duration of symptoms ranging 6.2+/-3.0 months. 24% of the infants were born preterm. Snoring was the most common finding and appeared in all infants. Other symptoms were sleep apnea (72%), frequent movements during sleep (69%), mouth breathing (62%) and recurrent awakenings (38%). During the preoperative period, mean body weight decreased from the 67th+/-25 percentile to the 42nd+/-32 percentile (P<0.00001). 14/29 (48%) of the infants dropped two or more major percentiles before treatment. A significant weight gain to the 59th+/-31 percentile was observed post surgery (P<0.0001). 5/29 (17%) infants were considered by their parents as having a developmental delay preoperatively, which resolved in 3/5 (60%) post treatment. Clinical symptoms resolved or improved significantly after surgery. Recurrence of symptoms was documented in 6/23 (26%) of infants.nnnCONCLUSIONSnInfantile OSAS due to hypertrophic adenoids and tonsils does occur in infants. Unique characteristics for this age group include: male predominance, high incidence of preterm infants, failure to gain weight and high recurrence rate after surgery. Otolaryngologists and pediatricians should be aware to the existence of the early OSAS in small infants.

The Use of Exhaled Nitric Oxide in the Diagnosis of Asthma in School Children

OBJECTIVESnTo evaluate the yield of the fractional exhaled nitric oxide (FeNO) in the diagnosis of asthma compared with spirometry and induced sputum cytologic study in school-age children.nnnSTUDY DESIGNnConsecutive children referred for evaluation of possible asthma were included. At referral, all children completed FeNO measurement, sputum induction for eosinophil count (eos%) and spirometry. The diagnosis of asthma was performed after 18 months with conventional criteria. Receiver operating curves were used to determine cutoff points for disease status, and accuracy was calculated.nnnRESULTSnA total of 150 children were included: 69 with steroid-naïve asthma, 44 without asthma, and 37 with asthma treated with controllers. FeNO and eos% levels were significantly higher in those with steroid-naïve asthma (P < .0001). The area under the receiver operating curve for FeNO and eos% were very high compared with forced expiratory volume in 1 second (0.906, 0.921, 0.606, respectively). The sensitivity, specificity, and positive and negative predictive values for best cutoff points of FeNO (19 parts per billion) were 80%, 92%, 89%, and 86%, respectively, and were similar to eos% (best cutoff = 2.7%): 81%, 92%, 89%, 85%, respectively.nnnCONCLUSIONSnFeNO measurement is useful in early diagnosis of pediatric asthma. We suggest considering FeNO measurement in the evaluation of children suspected of having asthma, especially in cases where the diagnosis is not clear.

The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the Test of Variables of Attention (TOVA) in children with obstructive sleep apnea syndrome

OBJECTIVE: To evaluate children with obstructive sleep apnea syndrome (OSAS) for features of attention deficit disorder (ADD) using an objective test of inattention and impulsivity: Test of Variables of Attention (TOVA) and then to determine whether tonsillectomy and adenoidectomy (T+A) results in an improvement in TOVA scores. STUDY DESIGN AND SETTING: This study was a prospective interventional comparative trial in a tertiary care childrens hospital. Nineteen children ages 5 to 14 years with OSAS, and otherwise healthy, with a clinical indication for T+A. Preoperative and 2 months postoperative OSA-18, CBCL questionnaires, and TOVA scores were evaluated. RESULTS: The preoperative TOVA scores were in the abnormal range in 12/19 (63%) of the children. The mean preoperative TOVA score was −2.9 (± 3.1). The mean postoperative TOVA score was −0.4 (±2.8). The improvement in the TOVA scores was significant (P < 0.0001, t-test). CONCLUSION: This preliminary data suggests that treatment of OSAS with T+A results in significant improvement in objective parameters of inattention and impulsivity. SIGNIFICANCE: These findings may be important in understanding the impact of OSAS and therapeutic interventions on behavioral problems in children.

Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma.

Objective: To asses the yield and contribution of a routine predetermined repeat head computed tomographic (CT) scan within 24‐36 hrs in pediatric patients with moderate to severe head trauma. Design: Records review. Setting: Five pediatric intensive care units. Patients: We reviewed the charts of 173 consecutive pediatric patients with moderate to severe head trauma (Glasgow Coma Scale score of ≤ 11) that survived the first 24 hrs after being admitted to five Israeli trauma centers. Clinical data collected included status at admission, at the time between the first and second CT scans, and after the second scan. Head details of the first, second, and, if performed, third CT scan were collected. Treatment strategy during each period was recorded, including any change in treatment after each CT scan. Measurements and Main Results: A total of 47 (27%) of the second CT scans showed new lesions including six intracranial hemorrhages, 17 cases of worsening brain edema, and 18 newly diagnosed brain contusions. However, none of these findings necessitated surgical intervention or any change in therapy. Of the 67 patients who underwent a third CT scan, two cases required surgical intervention because of new findings in the third CT. Conclusions: A second routine prescheduled head CT scan within 24‐36 hrs after admission in pediatric patients with moderate to severe head trauma is unlikely to yield any change in therapy. Clinically and intracranial pressure‐oriented CT scan may better select and diagnose patients who require changes in therapy, including surgery. Studies aimed to determine the ideal timing for the second are warranted.

Treatment of loculated pleural effusion with intrapleural urokinase in children.

BACKGROUND/PURPOSEnThe use of fibrinolytic agents such as urokinase and streptokinase has been reported in cases of empyema in adults. In pediatric patients the experience is, however, very limited.nnnMETHODSnA series of seven consecutive children who had loculated pleural effusion that did not respond to drainage and antibiotics is reported.nnnRESULTSnIn all cases, the effusion was found to be multiloculated. Urokinase (UK) instillation through the already existing chest tube was started. A dose of 100,000 U of UK diluted in 100 mL of normal saline was instilled through the chest tube, which was clamped for 12 hours and then was left open for another 12 hours. In six of seven children, the treatment was terminated after complete or almost complete resolution was attained. This was achieved within 5 treatment days (mean, 3.3). There was one failure which was attributed to relatively late initiation of treatment. No complications were observed.nnnCONCLUSIONSnThe authors conclude that intrapleural administration of UK is a safe and efficient method of treatment in cases of loculated pleural effusions in children. UK instillation to the intrapleural space should be considered early before initiating surgical intervention. Starting intrapleural UK treatment should not be delayed.

Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: Inter-observer correlation and comparison with awake endoscopy

OBJECTIVEnEvaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy.nnnMETHODnnnnDESIGNnretrospective case series; blinded review.nnnSETTINGntertiary care childrens hospital.nnnPATIENTSnChildren with persistent obstructive sleep apnea.nnnINTERVENTIONSnBoth awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey.nnnMAIN OUTCOME MEASURESnreviewers scored the following parameters: each structures contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good).nnnRESULTSnWhen reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value<0.05). Level of confidence among the four observers was higher in older children and lower in children with severe OSA.nnnCONCLUSIONSnSleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy.

Synchronous airway lesions in laryngomalacia.

OBJECTIVEnLaryngomalacia is the most common cause of congenital stridor. Laryngomalacia may be associated with other structural and functional airway lesions. While previous studies suggested a 10-45% rate of synchronous airway lesions (SALs), the exact rate and its clinical significance is unknown. The purpose of this study was to determine the prevalence of SALs below the glottic level in congenital laryngomalacia, and to investigate possible relations with other clinical findings.nnnMETHODSnA cohort of 228 infants with congenital stridor who underwent fiberoptic flexible bronchoscopy (FFB) was analyzed. Data was collected from the hospital records. All procedures were reevaluated from the video recordings.nnnRESULTSnSALs below the vocal cords were observed in 7.5% of the case (17/228). The most common SAL was tracheal bronchus followed by tracheomalacia and stenosis of the left main bronchus. No correlation was found between the presence of a SAL below the vocal cords and any other medical condition except for neurodevelopmental disorders. Except for one patient, all cases with SAL did not have any clinical symptoms or signs that would have suggested an accompanying airway lesion.nnnCONCLUSIONSnThe rate of SALs in infants with congenital stridor due to laryngomalacia is low and most of the additional lesions are benign. The yield of discovering clinically significant SALs below the glottic level is low and the routine search for a synchronous lesion below the vocal cords should be questioned. Except for underlying neurodevelopmental problems, no clear risk factors for the existence of SALs were identified.

HsCRP levels: Measurement of airway inflammation in asthmatic children

Background: The inflammatory marker, high‐sensitivity C‐reactive protein (HsCRP), is known to be related to non‐allergic asthma, obesity, cardiovascular disease and smoking in adults. The aim of the present study was to determine whether HsCRP is related to respiratory symptoms and pulmonary function test findings in asthmatic children.

Sleep Disturbances in Children Recovered from Central Nervous System Neoplasms

OBJECTIVESnTo identify the prevalence of long-term sleep disturbances in children successfully treated for central nervous system tumors by use of subjective and objective tools.nnnSTUDY DESIGNnChildren diagnosed and treated for central nervous system tumors and age-matched control subjects were studied. Information on demographics, tumor type, location, and therapies were collected. Parents completed a 28-item sleep questionnaire. Sleep was also evaluated with a sleep-log and actigraphy.nnnRESULTSnForty patients (52% males) and 61 matched control subjects (48% males) were evaluated. The mean ages were 9.9 ± 3.8 and 11.4 ± 3.8 years, respectively (P = NS). The mean time from diagnosis to participation was 4.1 ± 1.4 years. Children in the study group reported longer nighttime sleep compared with control subjects (572 ± 66 minutes vs 519 ± 79 minutes, P < .001; respectively). This was confirmed by actigraphy. These differences disappeared when comparison by age groups was performed. Two patients compared with none in the control subjects resumed daytime napping. No significant sleep disturbances were observed in the study group. No effect was found for tumor type, anatomic site, or adjuvant therapy.nnnCONCLUSIONSnRecovered children with a history of brain tumor do not have significant sleep disorders. Their sleep is generally well preserved years after diagnosis and treatment. The possibility that excessive daytime somnolence affects a minority of these children needs further investigation.

The effect of seasonality on sleep-disordered breathing severity in children

OBJECTIVEnSleep-disordered breathing (SDB) is a common disorder associated with substantial morbidity that occurs in otherwise healthy children. Atopy, asthma, and viral upper respiratory tract infections are known risk factors for pediatric SDB that exhibit seasonal variability. The aim of our study was to investigate the effect of seasonality on SDB severity in children and adolescents referred for polysomnographic evaluation for suspected SDB and to examine the effect of atopy/asthma on this variability.nnnMETHODSnThe medical records of all children and adolescents referred for a polysomnography (PSG) for suspected SDB between 2008 and 2010 were retrospectively assessed for seasonal patterns. The effect of atopy/asthma, age, and obesity on seasonal variability was investigated.nnnRESULTSnA total of 2178 children and adolescents (65% boys) were included. The mean age of the cohort was 4.9±3.5 years (range, 3 months-18 years). Eighteen percent of patients had a history of asthma/atopy. The mean obstructive apnea-hypopnea index (OAHI) in the winter was significantly higher compared to the summer (9.1±9.6 vs. 7.5±7.0; P=.01; Cohen d=0.19), particularly in children younger than the age of 5 years (10.2±10.5 vs. 7.9±7.3; P=.008; Cohen d=0.25). Asthma/atopy had no significant effect on seasonal variability.nnnCONCLUSIONSnSDB severity alters in a season-dependent manner in children and adolescents referred for polysomnographic evaluation for suspected SDB. These alterations are more prominent in children younger than the age of 5 years. The presence of asthma/atopy does not contribute to this seasonal variability. These findings suggest that viral respiratory infections are most likely the major contributor for the seasonal variability observed in pediatric SDB; additionally, the time of the year when a child is evaluated for suspected SDB may affect the clinical management and outcome in borderline cases.