OSAS in children: Correlation between endoscopic and polysomnographic findings FABIANA C. P. VALERA, MD, MELISSA A. G. AVELINO, MD, MÁRCIA B. PETTERMANN, MD, REGINALDO FUJITA, MD, SHIRLEY S. N. PIGNATARI, MD, GUSTAVO A. MOREIRA, MD, MÁRCIA L. PRADELLA-HALLINAN, MD, SÉRGIO TUFIK, MD, and LUC L. M. WECKX, MD, São Paulo, Brazil OBJECTIVES: To correlate polysomnographic find- ings 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 subdi- vided 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 hyper- trophy 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 chil- dren. CONCLUSIONS: There is little correlation between polysomnographic and clinical findings in children with OSAS. SIGNIFICANCE: Adenotonsillar hypertrophy leads to more severe polysomnographic patterns in pre- school-age children. More severe apnea is ob- served in younger children with adenotonsillar hy- pertrophy than in older ones. (Otolaryngol Head Neck Surg 2005;132:268-72.) H ypertrophy of the adenoids and/or tonsils is consid- ered to be the most important risk factor for the devel- opment of obstructive sleep apnea (OSAS) in children, particularly between 2 and 6 years of age. 1 During this time period, enlargement of the adenoid and tonsil frequently narrows the nasopharynx and oropharynx leading to a partial or total obstruction of the upper airway. Snoring is the most frequent complaint by parents seeking medical evaluation for children with OSAS. 2,3 However, there are other symptoms related to apneas that are occasionally encountered, which need to be specifically elicited. These symptoms include night sweats, night gasps, nocturnal enuresis, irritability, hy- peractivity, behavioral problems, diminished attentive- ness at school, and morning headache. 3,4 Daytime sleepiness is not a common complaint among young children with OSAS because their sleeps are not as fragmented as those of adults with OSAS. 3,5 According to Lipton, 6 8% to 27% of children snore but only 2% of them have OSAS; the majority of these children have normal breathing patterns during the day- time, 2 which makes the diagnosis more difficult to establish. The great majority of children who have OSAS snore, even though most children who snore do not have OSAS. It is important to stress that some infants with significant OSAS may not exhibit snoring. 2 OSAS in children is characterized mostly by partial and persistent obstruction of the upper airway, instead of total and intermittent obstruction observed in adults. This obstruction pattern in children is called persistent hypoventilation, and it compromises their breathing pattern during sleep. Contrary to what is observed in adults, long-lasting partial obstruction in children can be as detrimental to respiration as intermittent total obstruction. Moreover, because children have dimin- ished functional residual capacity when compared to adults, they present more severe symptoms in response to less aggressive forms of apnea. 1,5 Apnea, hypopnea, and snoring occur as a conse- quence of a narrowed airway, which causes an in- creased respiratory effort. During sleep, particularly in the rapid eye movement (REM) phase, as body mus- culature relaxes, OSAS becomes accentuated, eliciting the symptoms mentioned above. Moreover, in a small proportion of children, more severe clinical sequelae From the Division of Pediatric Otorhinolaryngology, Federal University of São Paulo (Drs Valera, Avelino, Pettermann, Fujita, Pignatari, and Weckx); the Division of Otorhinolaryngology, School of Medicine of Ribeirão Preto, University of São Paulo (Dr Valera); and the Division of Polysonmography, Federal University of São Paulo (Drs Moreira, Pradella-Hallinan, and Tufik), São Paulo, Brazil. Presented at the Annual Meeting of the American Academy of Otolaryngolo- gy–Head and Neck Surgery, San Diego, CA, September 22-25, 2003 and received the Foundation Award. Reprint requests: Fabiana C. P. Valera, Divisão de Otorrinolaringologia Pediátrica, Universidade Federal de São Paulo, Rua dos Otonis, 674 Vila Clementino, São Paulo SP Brazil; e-mail, facpvalera@uol.com.br. 0194-5998/$30.00 Copyright © 2005 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. doi:10.1016/j.otohns.2004.09.033 268