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Sleep-disordered breathing in early childhood includes a wide array that includes conditions ranging from primary snoring to the most severe forms of obstructive sleep apnoea syndrome. It may be associated to behavioural and cognitive alterations such as learning and memory disorders or problems with attention, even in the milder forms of the disorder. Our aim is to review the clinical manifestations of sleep-disordered breathing in early childhood, focusing on the neurocognitive and behavioural deficits, as well as the pathophysiological mechanisms involved. Sleep-disordered breathing produces alterations to a greater or lesser extent in the children's cognitive and behavioural functioning, regardless of the severity of the breathing disorder. There is evidence to show that these manifestations can be reversible when early and effective treatment is carried out. It is therefore important to enquire specifically about children's sleep and daytime behaviour, with special emphasis on the presence of snoring because even when it is resolved, there is an increased long-term risk of conduct disorders during the day.

Introduction: Treatment of obstructive sleep apnoea-hypopnoea syndrome in children with adenotonsillectomy is effective but has a moderate rate of persistent disease., Objectives: To analyse the rate of persistence of sleep apnoea-hypopnoea syndrome in a group of adenotonsillectomy-treated paediatric patients and to assess the possible prognostic factors., Methods: Prospective study of 80 patients aged between 2 and 13 years who had obstructive sleep apnoea-hypopnoea syndrome, treated with adenotonsillectomy. All patients had been followed up clinically and by polysomnography for 1 year after surgery. We analysed the epidemiological and clinical factors that could negatively affect the outcome of surgery., Results: The median age was 5.25 ± 2.05 years and the mean apnoea-hypopnoea index (AHI) was 8.13 ± 6.06. One year after surgery, all clinical parameters improved significantly and the mean AHI was 2.50. Persistent disease (AHI≥3) was present in 21 of the patients (26.3%). The comparative analysis of clinical and epidemiological factors between the group of non-persistence and persistence did not obtain statistically-significant differences in age, sex, tonsillar size, Friedman degree or severity of preoperative disease. The only significant factor was that patients without persistence were more obese., Conclusion: The results of our study about the persistence of obstructive sleep apnoea-hypopnoea syndrome after adenotonsillectomy are significant enough to recommend follow-up with polysomnography, especially in high-risk groups. In the series presented here, we were not able to demonstrate these risk factors. Our results are probably conditioned by the characteristics of the population studied: Low age, low obesity rate and less severe levels of apnoea-hypopnoea index., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

The surgical treatment of sleep-related breathing disorders in children depends on the cause of the upper airway obstruction, which can be located in the nasal fossae, pharynx (the most frequent adenotonsillar hyperplasia), or larynx (laryngomalacia, cysts…), or can be multilevel, as in syndromic diseases. Adenotonsillectomy is the most frequently performed and effective (70-80%) procedure. The aim of this technique is to normalize nocturnal respiratory parameters and daytime symptoms, as well as to revert, or at least to halt, cardiovascular complications, neurocognitive disturbances, growth delay and enuresis, which can develop if treatment is not provided or is delayed. However, despite its effectiveness, adenotonsillectomy more frequently leads to complications in children with sleep apnea-hypopnea syndrome (SAHS) than in those undergoing this procedure for other reasons. Moreover, 20-30% of children with SAHS who undergo adenotonsillectomy will show residual SAHS, and this percentage can increase to 70% in patients with severe SAHS, Down syndrome, craniofacial anomalies, neuromuscular disturbances, and morbid obesity. Consequently, both clinical and polysomnographic follow-up are recommended after adenotonsillectomy, especially in the latter risk group. Finally, other obstructive disorders of the upper airway must also be treated, although less frequently due to their lower incidence. These disorders include choanal atresia or stenosis, laryngomalacia, and hypoplasia of the midface or mandible. Tracheotomy will sometimes be required., (Copyright © 2010 Elsevier España S.L. All rights reserved.)

Early maxillary orthopedics can improve jaw relations and the jaw-skull base relationship. The objectives are clear: to correct the shape and improve function. A better proportioned skeletal framework is achieved, in which the underlying soft tissues become more resistant to collapse., (Copyright © 2010 Elsevier España S.L. All rights reserved.)

In recent years, consolidation of tonsillar hypertrophy as the principal surgical procedure has led to the emergence of new techniques. Most aim to reduce volume (tonsillectomy or tonsil reduction). These techniques have considerably decreased intra- and postoperative hemorrhages and pain intensity. The present article describes the mechanisms and the advantages and disadvantages of the various techniques, including electro-dissection using electrical scalpels, reduction using a microdebrider, ultrasonic scalpel, radiofrequency (with its different variations) and CO(2) laser. When techniques that reduce tonsil volume are used, the possibility of recurrence of the tonsillar hypertrophy is high if less than 85% of the tonsil is removed. There is also a considerable possibility of infection of the remaining tonsils, whichever technique is used, and therefore these techniques are not valid in the case of repetitive tonsillitis. Recently, alternatives to classical adenoidectomy using adenoid curette have also appeared. Bleeding can be minimized by using a microdebrider, radiofrequency or a blood coagulator. We also discuss the concept of partial adenoidectomy, which is preferred in patients at risk of velopharyngeal insufficiency., (Copyright © 2010 Elsevier España S.L. All rights reserved.)

Introduction: If sleep-related breathing disorders in children are not treated quickly, they may be harmful to the child's future development. The best diagnostic test is polysomnography, since clinical assessments alone are not enough. Adenotonsillectomy is the most effective and widespread treatment for such disorders., Objective: To assess clinical data on sleep-related breathing disorders, particularly in relation to behaviour and neurocognition, their long-term resolution with surgery and correlation with PSG data., Method: Prospective study with 73 children between 3 and 11 years of age, attending a special clinic for sleep-related breathing disorders. A medical history questionnaire was given to the parents, which included questions on the child's sleep patterns, respiratory disorders and behavioural and neurocognitive changes, and a polysomnography was carried out. Cases requiring surgery were monitored after 9 months by means of a further questionnaire and a follow-up polysomnography., Results: Of the 73 children tested, 100 % snore, 87.5 % display objective apnoeas and 89 % suffer from nasal congestion. Drowsiness during the day was reported in only 28 %. Over 50 % of cases report aggressiveness or hyperactivity, while 41 % have concentration difficulties. In 61 of the 73 cases (83.6 %) given a pre-operative polysomnography, the mean apnoea-hypopnoea index was 6.44 (4.44). Postoperative follow-up is available for 44 cases, 29 of them with polysomnography. The resolution of clinical symptoms is highly satisfactory in these cases, but 5 patients (17.2 %) still have an apnoea-hypopnoea index of more than 3., Conclusions: Adenotonsillectomy is effective in curing the majority of sleep-related respiratory disorder symptoms in children. However, a significant percentage of cases display a persistent polysomnographic change. Long-term postoperative monitoring is recommended in such cases.

Nasal continuous positive airway pressure (CPAP) is considered an ideal treatment for treating Obstructive Sleep Apnea Syndrome (OSAS), due to its being conservative and reversible; however, there is a poor rate of adherence in its long-term use. Surgery can significantly complement those cases where CPAP is not tolerated. Surgery for OSAS must be carried out taking into account the degree of obstructive apnea, the place of greatest obstruction and the experience of the medical team. The more severe the OSAS, the more aggressive the surgical therapy can be. The place of obstruction must not be considered in a simplistic way, in which only one place of obstruction is defined, but as a general alteration of the airway where the surgeon must act in order to carry out an effective remodelling. This paper describes different types of surgery and their efficacy in OSAS according to the anatomical area involved (nose, adenoidal surgery, tonsils, soft palate, base of the tongue, hypopharynx and bimaxillary protrusion). The scientific evidence shows that at present reconstructive surgery of the airway competes effectively with medical treatment.

The goal of this study is to evaluate the efficacy and the safety of tissue reduction of the palate by means of radiofrequency for the treatment of snoring. Fifty-three patients were evaluated. Eight of them (15%) met criteria for mild OSAS. All of them underwent RF energy treatment with several ablation sites and the mean total energy administered was about 2500 J per treatment session. 40 patients (75%) underwent an additional RF treatment and the energy administered in the second session was the same as in the first one. We evaluated postoperative pain, snoring and the satisfaction of the patient and his enviroment. After a mean follow-up of 20 months no adverse effect was reported. The success diminishes with time as happens other surgical procedures (UPPP or LAUP) but the absence of serious adverse side-effects and the minimal postoperative pain support the use of RF as an effective procedure for reducing snoring.

A case is presented of a 48 year-old woman with symptoms of severe rhoncopathy and obstructive sleep apnea, followed by middle inspiratory stridor and dyspnea to any phisial effort. Redundant hyperplasia of the arytenoid mucosa was discovered during exploration, with vibration during inspiration and closure of the lumen as it goes closer to the epiglottis. Also, severe septal deviation, hypertrophy of the pharyngeal tonsil, soft palate and uvula, and macroglossia, were diagnosed. Neither CPAP/BIAP or triple anti-reflux therapy were effective, and laser endoscopic excision resolved the laryngeal obstruction. Currently the stridor has disappeared, whereas rhoncopathy is improved with low pressure CPAP. Pathogenesis of the giant hyperplasia of the arytenoid mucosa of unknown origin is discussed, as literature search revealed only three cases reported worldwide.

Hypertrophy of tonsils or adenoids is the commonest cause of obstructive sleep apnea (OSA) in children. Adenotonsillectomy (AT) is frequently curative in children with OSA but riskier than the same procedure without OSA. It is crucial to identify OSA among the patients programmed for AT because they require a detailed evaluation, frequently including total or limited polysomnogram. Patients with OSA need a continuous surveillance before, during, and after surgery, ideally in a referral hospital.

Obstructive sleep apnea syndrome (OSAS) in children produces serious organic consequences that affect pharyngeal breathing and functional development. The high rate of incidence of this problem is important. In children, the most frequent cause of OSAS is hypertrophy of the tonsils, adenoids, or both. We think that a new indication for pediatric adenoidectomy and tonsillectomy is pharyngeal breathing obstruction by hypertrophic lymphoid formations in the Waldeyer ring. In a statistical analysis of 180 children with OSAS who underwent tonsillectomy and adenoidectomy, the disappearance of most symptoms 7 months after surgery was significant.

We studied the effectiveness of uvulopalatopharyngoplasty under general anesthesia and classical surgery in 26 patients treated surgically for chronic snoring (CS) and obstructive sleep apnea syndrome (OSAS). Our technique is a variation of the Fujita and Quesada technique that involves partial resection of the palate and uvula with endonasal microsurgery. The criteria for inclusion were age 35 to 47 years and desire to do without C-PAP or Bi-PAP. This device, although effective, produced poor physical and psychological tolerance. After a postoperative follow-up of 3 years, good results were found in all cases.

A two-year-old boy with a history of slow growth, snoring during sleep and adenoid hypertrophy underwent adenoidectomy and transtympanic drainage under general anesthesia. Immediately after extubation, severe inspiratory stridor and shallow labored breathing began and persisted over a period of two hours, in spite of corticoid administration and oxygen therapy. The signs receded partially when the patient was seated and with a mandibular traction maneuver. As symptoms persisted, foreign body obstruction was ruled out by examination of the cavum and upper airway under general anesthesia and with orotracheal intubation. The patient was transferred to the pediatric intensive care unit, where he remained intubated for 18 hours. After extubation, stridor and shallow labored breathing reappeared but gradually receded as the residual effects of sedation disappeared. The parents mentioned symptoms suggestive of obstructive sleep apnea syndrome (OSAS) occurring since the boy was 6 months old and that had worsened in recent months. OSAS in children is characterized by intermittent obstruction of the upper airway during sleep, causing snoring and periods of apnea/hypopnea that lead to hypoxemia and hypercapnia. The most frequent cause is hypertrophy of the adenoid and tonsils, and the treatment of choice is adenotonsillectomy, although the risk of postoperative respiratory distress in such children is high. It is important to rule out OSAS in children who are candidates for adenotonsillectomy so that such patients are not scheduled for ambulatory surgery, but rather given adequate postoperative monitoring and treatment.

Palatopharyngeal surgery is a therapeutic option for obstructive Sleep Apnea Syndrome (OSAS). This operation is based on the assumption that the soft palate is the principal apneogenic area of the upper airways. The effectiveness of palatopharyngeal surgery and of correcting nasal obstruction (co-adjuvant factor of SAOS), when present, was evaluated. Thirty patients were selected by cephalometry for surgery (3 women, 27 men; age 45.3 +/- 7.5 years). The success rate was 60%, which justifies the inclusion of surgery as a useful option for treating SAOS.

Techniques for surgical correction of the soft palate are used commonly to treat obstructive sleep apnea syndrome (OSAS), but a satisfactory cure cannot be ensured because such techniques usually involve localized correction of the upper airways (UA) whereas UA collapse during sleep involves the entire length. The development of correction techniques for the entire extension of the UA may help to solve this problem. We report the first two cases of multilevel UA surgical reconstruction in OSAS performed in Spain. The excellent results obtained favor routine use of this type of surgery once it has been validated in clinical practice.

The cephalometric indexes of 16 patients with obstructive sleep apnea syndrome (OSAS) were compared with those of 12 controls in order to determine if fundamental anatomical changes were present in the patients and to identify a pattern of facial features that might be characteristic of individuals with OSAS. Our results point to micrognathia of the upper maxilla in OSAS patients (indicated by significantly lower indexes for convexity, Mx 1, and the angles SNA and ANB). We also found a longer soft palate and a functionally shallower pharynx. Together theses features reduce the permeability of the posterior pharyngeal air space. Additionally, we observed a dolichocephalic facial pattern in OSAS patients, along with a tendency to morbid anterior opening. We analyze the limitations of conventional cephalometry. While recognizing its usefulness in establishing baseline indexes before treatment and in postsurgical assessment, we nevertheless point out that it cannot be relied upon as the only test for evaluating surgical correction in OSAS patients.

Background: The aim of this study was to determine the result of partial resection of the soft palate (SPR) as a treatment of the obstructive apnea syndrome during sleep (OASS)., Methods: Fifty-seven patients diagnosed of OASS treated with SPR were studied. The clinical and polysomnographic results prior to surgery and after 6 months were compared., Results: Prior to SPR the 57 patients had a mean index of apnea plus hypopnea per hour of 57 (IAH) and following surgery the same was of 19.2 (p < 0.0001). IAH improved more than 50% in 42 patients (74%), 30 of whom were cured (IAH < or = 10). Daily hypersomnia and snoring disappeared in 58% of the patients and decreased in intensity in most of the remaining cases. The secondary effects observed following SPR were: rhinolalia, nasal fluid reflux, and oropharyngeal disturbances, being present in 32 patients (56%) and permanent, although slight, in only 13 (23%)., Conclusions: Soft palate resection is a good surgical procedure for therapy of obstructive apnea during sleep, with only slight secondary effects.

Seven patients suffering from obstructive sleeping sickness syndrome and operated on U-P-P-P-., were controlled, one year later, through the polysomnographic test. The tracings showed a clear improvement compared with the preoperative records. Best results are gained in those cases with lesser apneic degree.

The paper deals with the polysomnographic issues from 7 patients diagnosed of obstructive sleeping illness and treated with an UPPP. Tracings were recorded after 3 and 12 months. The comparison between pre- and postoperative findings showed the improvement, being the higher apneic index decrease 50 per cent, among 57 per cent of the cases.