Sleep bruxism and associated physiological events in children with obstructive sleep apnea: a polysomnographic study.

STUDY OBJECTIVES: The aim of this study was to evaluate the physiological events associated with sleep bruxism (SB; presence of mandibular movement activity) and control window (4 minutes prior to SB event, where no mandibular movement activity was detected) in polysomnography study (PSG) in children with mild sleep apnea. METHODS: PSG exams data from 4 to 9 years old children diagnosed with mild sleep apnea were analyzed by two trained examiners. The mandibular movement activity (bruxism event; SB) were classified into phasic and tonic. The control window was selected 4 minutes prior to the SB event. All physiological events were recorded in both bruxism and control windows, including sleep phase (N1, N2, N3 and REM), arousal, leg movements, tachycardia, bradycardia, oxygen desaturation and number of obstructive and central sleep apnea events. The moment in which those phenomena occurred when associated with SB was also analyzed (before/after). Data was analyzed using a 95% CI (α=5%). RESULTS: A total of 661 mandibular movements were analyzed and classified as tonic (n=372) or phasic (n=289). The mean apnea-hypopnea index (AHI) was 1.99 (SD=1.27). The frequency of leg movements, microarousal and tachycardia were increased in BS events when compared to the control window (p<0.05). There was an increase in bradycardia frequency in the control window when compared to BS (in both tonic and phasic events). The frequency of obstructive and central apnea and central apnea during SB were lower when compared to the other physiological phenomena. CONCLUSIONS: There is a difference in the physiological parameters evaluated in children with mild sleep apnea when comparing the two windows (SB and control). Sleep bruxism is associated with other physiological phenomena such as leg movements, tachycardia and microarousal. The use of a control window (where no mandibular activity was detected) was representative since it did not show activation of the sympathetic nervous system.

Clinical and anatomical characteristics associated with obstructive sleep apnea severity in children.

PURPOSE: To determine the clinical and anatomical characteristics associated with obstructive sleep apnea severity in children with adenotonsillar hypertrophy. METHODS: The authors conducted a cross-sectional multidisciplinary survey and selected 58 Brazilian children (4‒9 years old) with adenotonsillar hypertrophy, parental complaints of snoring, mouth-breathing, and witnessed apnea episodes. The authors excluded children with known genetic, craniofacial, neurological, or psychiatric conditions. Children with a parafunctional habit or early dental loss and those receiving orthodontic treatment were not selected. All children underwent polysomnography, and three were excluded because they showed an apnea-hypopnea index lower than one or minimal oxygen saturation higher than 92%. The sample consisted of 55 children classified into mild (33 children) and moderate/severe (22 children) obstructive sleep apnea groups. Detailed clinical and anatomical evaluations were performed, and anthropometric, otorhinolaryngological, and orthodontic variables were analyzed. Sleep disorder symptoms were assessed using the Sleep Disturbance Scale for Children questionnaire. All children also underwent teleradiography exams and Rickett's and Jarabak's cephalometric analyses. RESULTS: The mild and moderate/severe obstructive sleep apnea groups showed no significant differences in clinical criteria. Facial depth angle, based on Ricketts cephalometric analysis, was significantly different between the groups (p = 0.010), but this measurement by itself does not express the child's growth pattern, as it is established by the arithmetic mean of the differences between the obtained angles and the normal values of five cephalometric measurements. CONCLUSIONS: The clinical criteria and craniofacial characteristics evaluated did not influence the disease severity.

Tonsillotomy by a Fractional Carbon Dioxide Laser: A New Technique in the Treatment of Chronic Tonsillitis.

Introduction: Chronic tonsillitis has a global prevalence, ranging from 5% to 12%. Its clinical manifestations, like recurrent acute tonsillitis, tonsils hypertrophy, caseum and halitosis, can lead adult patients to be submitted to palatine tonsillectomy, surgery that has morbidity and the potential risk of complications, including severe bleeding. This article proposes a new therapy for chronic tonsillitis in adult patients using a fractional carbon dioxide (CO2) laser, which is a fast, minimally invasive procedure capable of removing the need for the traditional tonsillectomy in many patients. The present research aimed to verify the efficacy of tonsillotomy by fractional ablation using the CO2 laser by comparing the number of bacterial infections, tonsils hypertrophy, halitosis and caseum; it is also aimed at analyzing the benefits, risks and complications of the technique. Methods: In this clinical prospective study, 20 patients were subjected to one session of tonsillotomy by fractional ablation and were followed up for a year. The control group was formed by the same patients in the pre-procedure period (one year) without treatment. Statistical analysis: The Wilcoxon paired test, Friedman tests, and multiple non-parametric comparisons were utilized to analyze the data (significance level of 5%). Results: No complications occurred, and the procedure was fast (30 seconds), safe and tolerated well without general anesthesia. After 1 year, there was a total remission of recurrent acute tonsillitis in 95% of the patients, and after 6 months there was a statistically significant improvement in halitosis and caseum, and tonsils size reduction (P<0.05). The level of satisfaction average was 10 after 3 months and 8 after one year. Conclusion: tonsillotomy by fractional ablation using the CO2 laser is a safe, efficient procedure for chronic tonsillitis in adults, and it can be incorporated into daily clinical practice.

Clinical and anatomical characteristics associated with obstructive sleep apnea severity in children

Abstract Purpose To determine the clinical and anatomical characteristics associated with obstructive sleep apnea severity in children with adenotonsillar hypertrophy. Methods The authors conducted a cross-sectional multidisciplinary survey and selected 58 Brazilian children (4‒9 years old) with adenotonsillar hypertrophy, parental complaints of snoring, mouth-breathing, and witnessed apnea episodes. The authors excluded children with known genetic, craniofacial, neurological, or psychiatric conditions. Children with a parafunctional habit or early dental loss and those receiving orthodontic treatment were not selected. All children underwent polysomnography, and three were excluded because they showed an apnea-hypopnea index lower than one or minimal oxygen saturation higher than 92%. The sample consisted of 55 children classified into mild (33 children) and moderate/severe (22 children) obstructive sleep apnea groups. Detailed clinical and anatomical evaluations were performed, and anthropometric, otorhinolaryngological, and orthodontic variables were analyzed. Sleep disorder symptoms were assessed using the Sleep Disturbance Scale for Children questionnaire. All children also underwent teleradiography exams and Rickett's and Jarabak's cephalometric analyses. Results The mild and moderate/severe obstructive sleep apnea groups showed no significant differences in clinical criteria. Facial depth angle, based on Ricketts cephalometric analysis, was significantly different between the groups (p= 0.010), but this measurement by itself does not express the child's growth pattern, as it is established by the arithmetic mean of the differences between the obtained angles and the normal values of five cephalometric measurements. Conclusions The clinical criteria and craniofacial characteristics evaluated did not influence the disease severity.

Chemosensory Dysfunction in COVID-19: Prevalences, Recovery Rates, and Clinical Associations on a Large Brazilian Sample.

OBJECTIVE: Our study aimed to measure the percentage of reported olfactory or taste losses and their severity, recovery time, and association with other features in a large cohort of patients with COVID-19. STUDY DESIGN: Prospective survey. SETTING: Quaternary medical center and online survey. METHODS: The perceived chemosensory capacities of 655 patients with confirmed COVID-19 were assessed with 11-point category rating scales (0, no function; 10, normal function). Patients were contacted in hospital, by phone calls, or by internet regarding their ability to smell or taste, and 143 were interviewed by phone 1 to 4 months later to assess the recovery of their chemosensory abilities. RESULTS: The prevalence of self-reported olfactory, general taste, and taste quality-specific disturbances (sweet, sour, bitter, and salty) in the patients with COVID-19 were 82.4% (95% CI, 79.5%-85.3%), 76.2% (95% CI, 72.9%-79.4%), and 52.2% (95% CI, 48.3%-56.1%), respectively. The majority reported anosmia (42.9%). The presence of chemosensory symptoms was not associated with COVID-19 severity. At a median time >2 months after the onset of symptoms, rates of total and partial olfaction recovery were 53.8% and 44.7%, while complete or partial return to previous taste function was 68.3% and 27.6%. Less than 5% of the patients reported no chemosensory function improvement at all. CONCLUSION: The prevalence of self-reported chemosensory dysfunction is high among patients with COVID-19. Almost all patients seem to recover a significant part of their smell and taste abilities in the first 4 months after the onset of symptoms.

Síndrome PFAPA (febre periódica, aftas orais, faringite e adenite cervical) em crianças e adultos / PFAPA (periodic fevers with aphthous stomatitis, pharyngitis, and adenitis) syndrome in children and adults

A síndrome PFAPA (febre periódica, aftas orais, faringite e adenite cervical) é a forma mais comum das doenças autoinflamatórias. Trata-se de uma doença rara, não genética, bimodal, usualmente com início dos sintomas antes dos 5 anos de vida, que também pode prolongar-se ou iniciar-se na vida adulta. A prevalência é variável em todo o mundo, e não há dados estatísticos da doença no Brasil. Diversos pontos da doença são discutíveis, como os critérios diagnósticos, as avaliações laboratoriais, a ausência de mutações genéticas específicas e a abordagem terapêutica e prognóstica. Este trabalho tem como objetivo rever, de forma narrativa e crítica, aspectos relacionados ao diagnóstico e tratamento da síndrome PFAPA em adultos e crianças. Foram feitas buscas nas redes de dados PubMed, Bireme e Cochrane, utilizando o acrônimo PFAPA sem auxílio de qualquer filtro. Quanto ao diagnóstico, os critérios pediátricos foram adaptados para os adultos, com análises variadas e divergentes. Há a necessidade pujante de desenvolver um consenso com diretrizes de diagnóstico de pacientes em populações bem caracterizadas para melhor diagnosticar a doença. Já em relação ao tratamento, a cirurgia com remoção das tonsilas é considerada curativa, com necessidade de se manter acompanhamento após o procedimento para confirmação da remissão da doença. As drogas poupadoras de corticoide ainda são incertas, e o uso de imunobiológicos deve ser reservado somente para pacientes refratários ao tratamento cirúrgico e com grande impacto na qualidade de vida.

PFAPA (periodic fevers with aphthous stomatitis, pharyngitis, and adenitis) syndrome is the most common form of autoinflammatory disease. It is a rare, non-genetic, bi-modal disease, usually with onset of symptoms before the age of 5 years, which may also be prolonged or start in adult life. The prevalence varies worldwide and there are no specific statistical data in Brazil. Several aspects of the disease are debatable, such as diagnostic criteria, laboratory evaluations, absence of specific genetic mutations, and therapeutic and prognostic approach. This paper aims to review in a narrative and critical manner aspects related to diagnosis and treatment of PFAPA syndrome in adults and children. PubMed, Bireme and Cochrane databases were searched using the acronym PFAPA without any filter. Regarding diagnosis, pediatric criteria were adapted for use in adults, with varied and divergent analyses. There is a strong need to develop consensus diagnostic guidelines for patients in well-characterized populations to better diagnose the disease. Regarding treatment, tonsillectomy is considered curative, requiring follow-up after the procedure to confirm remission of the disease. Corticosteroid-sparing agents remain uncertain, and the use of immunobiological agents should be reserved only for patients who are refractory to surgical treatment and experience a great impact on quality of life.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel / Como evitar o uso inadequado de antibióticos nas infecções de vias aéreas superiores? Posição de um painel de especialistas

Abstract Introduction: Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. Objectives: To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. Methods: A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. Results: Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. Conclusions: Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Resumo Introdução: A resistência bacteriana a antibióticos nos processos infecciosos é um fato crescente nos últimos anos, especialmente devido ao seu uso inapropriado. Ao longo dos anos vem se tornando um grave problema de saúde pública devido ao prolongamento do tempo de internação, elevação dos custos de tratamento e aumento da mortalidade relacionada às doenças infecciosas. Quase a metade das prescrições de antibióticos em unidades de pronto atendimento é destinada ao tratamento de alguma infecção de vias aéreas superiores, especialmente rinossinusites, otite média aguda supurada e faringotonsilites agudas, sendo que uma significativa parcela dessas prescrições é inapropriada. Nesse contexto, os otorrinolaringologistas têm um papel fundamental na orientação de pacientes e colegas não especialistas, para o uso adequado e racional de antibióticos frente a essas situações clínicas. Objetivos: Realizar uma revisão das atuais recomendações de utilização de antibióticos nas otites médias, rinossinusites e faringotonsilites agudas adaptadas à realidade nacional. Método: Revisão na base PubMed das principais recomendações internacionais de tratamentos das infecções de vias aéreas superiores, seguido de discussão com um painel de especialistas. Resultados: Os antibióticos devem ser utilizados de maneira criteriosa nas infecções agudas de vias aéreas superiores não complicadas, a depender da gravidade da apresentação clínica e dos potenciais riscos associados de complicações supurativas e não supurativas. Conclusões: Constantes revisões a respeito do tratamento das principais infecções agudas são necessárias para que sejam tomadas medidas coletivas no uso racional e apropriado de antibióticos. Somente com orientação e transformações no comportamento de médicos e pacientes é que haverá mudanças do paradigma de que toda infecção de vias aéreas superiores deva ser tratada com antibióticos, minimizando por consequência os efeitos de seu uso inadequado.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel.

INTRODUCTION: Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. OBJECTIVES: To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. METHODS: A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. RESULTS: Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. CONCLUSIONS: Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Managing obstructive sleep apnoea in children: the role of craniofacial morphology.

Obstructive sleep apnoea syndrome is a type of sleep-disordered breathing that affects 1 to 5% of all children. Pharyngeal and palatine tonsil hypertrophy is the main predisposing factor. Various abnormalities are predisposing factors for obstructive sleep apnoea, such as decreased mandibular and maxillary lengths, skeletal retrusion, increased lower facial height and, consequently, increased total anterior facial height, a larger cranio-cervical angle, small posterior airway space and an inferiorly positioned hyoid bone. The diagnosis is based on the clinical history, a physical examination and tests confirming the presence and severity of upper airway obstruction. The gold standard test for diagnosis is overnight polysomnography. Attention must be paid to identify the craniofacial characteristics. When necessary, children should be referred to orthodontists and/or sleep medicine specialists for adequate treatment in addition to undergoing an adenotonsillectomy.

Managing obstructive sleep apnoea in children: the role of craniofacial morphology

Obstructive sleep apnoea syndrome is a type of sleep-disordered breathing that affects 1 to 5% of all children. Pharyngeal and palatine tonsil hypertrophy is the main predisposing factor. Various abnormalities are predisposing factors for obstructive sleep apnoea, such as decreased mandibular and maxillary lengths, skeletal retrusion, increased lower facial height and, consequently, increased total anterior facial height, a larger cranio-cervical angle, small posterior airway space and an inferiorly positioned hyoid bone. The diagnosis is based on the clinical history, a physical examination and tests confirming the presence and severity of upper airway obstruction. The gold standard test for diagnosis is overnight polysomnography. Attention must be paid to identify the craniofacial characteristics. When necessary, children should be referred to orthodontists and/or sleep medicine specialists for adequate treatment in addition to undergoing an adenotonsillectomy.

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE: Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index. METHODS: We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room. RESULTS: Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224). CONCLUSION: Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.

Asymptomatic Group A Streptococcus carriage in children with recurrent tonsillitis and tonsillar hypertrophy.

BACKGROUND: Group A Streptococcus (GAS) is the most important bacterial cause of acute tonsillitis in children. Some children are chronic GAS carriers, and this carriage is poorly understood. We determined the frequency of GAS detection using a rapid antigen detection test in pediatric patients with indications for tonsillectomy due to adenotonsillar hypertrophy or recurrent GAS infections. METHODS: Seventy-two patients underwent a tonsil swab for a rapid antigen detection test. RESULTS: The GAS rapid antigen detection test was positive in 18.1% of children. GAS was not associated with sex, age or previous history of recurrent tonsillitis. Also, the prevalence of GAS was similar between patients with either recurrent tonsillitis or tonsil hypertrophy. CONCLUSION: In our study, the GAS carriage rate was similar to other reports, and GAS carrier state was not correlated with recurrent tonsillitis.

Otitis media with effusion in children younger than 1 year / Otite média com efusão em crianças menores de um ano

Objective: To determine the prevalence of otitis media with effusion in children younger than 1 year and its association with the season of the year, artificial feeding, environmental and perinatal factors. Methods: Retrospective study of 184 randomly included medical records from a total of 982 healthy infants evaluated for hearing screening tests. Diagnosis of otitis media with effusion was based on otoscopy (amber-gold color, fluid level, handle of malleus position), type B tympanometric curves and absence of otoacoustic emissions. Incomplete medical records or those describing acute otitis media, upper respiratory tract infections on the assessment day or in the last 3 months, neuropathies and craniofacial anomalies were excluded. Data such as gestational age, birth weight, Apgar score, type of feeding and day care attendance were compared between children with and without otitis media with effusion through likelihood tests and multivariate analysis. Results: 25.3% of 184 infants had otitis media with bilateral effusion; 9.2% had unilateral. In infants with otitis media, the following were observed: chronological age of 9.6±1.7 months; gestational age >38 weeks in 43.4% and birth weight >2500g in 48.4%. Otitis media with effusion was associated with winter/fall, artificial feeding, Apgar score <7 and day care attendance. The multivariate analysis showed that artificial feeding is the factor most often associated to otitis media with effusion. Conclusions: Otitis media with effusion was found in about one third of children younger than 1 year and was mainly associated with artificial feeding.

Objetivo: Determinar prevalência de otite média com efusão em menores de um ano e sua associação com estação do ano, aleitamento artificial, fatores ambientais e perinatais. Métodos: Estudo retrospectivo com 184 prontuários incluídos de forma randomizada dentre 982 lactentes saudáveis avaliados para testes de triagem auditiva. Diagnóstico de otite média com efusão baseou-se em otoscopia (coloração âmbar-ouro, nível líquido, posição do cabo do martelo), curva timpanométrica tipo B e otoemissões acústicas ausentes. Excluíram-se prontuários incompletos ou que descreviam otite média aguda, infecções de vias aéreas superiores no dia da avaliação ou nos últimos três meses, neuropatias e anomalias craniofaciais. Dados como idade gestacional, peso ao nascimento, Apgar, tipo de aleitamento, frequência à creche foram comparados entre crianças com e sem otites com efusão por meio de testes de verossimilhança e análise multivariada. Resultados: 25,3% dos 184 lactentes apresentavam otite média com efusão bilateral; 9,2% unilateral. Nos lactentes com otite média, observou-se idade cronológica 9,6±1,7 meses; idade gestacional >38 semanas em 43,4% e peso ao nascer >2.500g em 48,4%. Otite média com efusão foi associada ao inverno/outono, aleitamento artificial, Índice de Apgar <7 e atendimento à creche. Já a análise multivariada demonstrou que o aleitamento artificial é o fator mais associado à otite média com efusão. Conclusões: A otite média com efusão foi encontrada em cerca de 1/3 dos menores de um ano e principalmente associada ao aleitamento artificial.

Expression of cysteinyl leukotriene receptor 1 and 2 (CysLTR1 and CysLTR2) in the lymphocytes of hyperplastic tonsils: comparison between allergic and nonallergic snoring children.

BACKGROUND: Cysteinyl leukotriene receptor 1 and 2 (CysLTR1 and CysLTR2) are involved in allergic processes and play a role in adenotonsillar hyperplasia (AH). Clinically, only CysLTR1 may be blocked by montelukast. Our objective was to compare the expression of CysLTR1 and CysLTR2 in the B and T cells of hyperplasic tonsils of sensitized (SE) and control (NS) snoring children. METHODS: Sixty children, 5 to 10 years of age, referred for adenotonsillectomy, were divided into SE and NS groups, according to their responses to the skin-prick test. Cells from the removed tissues were stained for CysLTR1, CysLTR2, CD19, and CD3 and counted via flow cytometry. messenger RNA (mRNA) expression of the CysLTRs genes was measured real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR). RESULTS: The SE group showed reduced expression of the small CD3+/CysLTR1+ lymphocytes (4.6 ± 2.2 vs 6.5 ± 5.0; p = 0.04). Regarding the large lymphocytes, the SE group showed lower expression of CD3+/CysLTR1+ (40.9 ± 14.5 vs 47.6 ± 11.7; p = 0.05), CD19+/CysLTR1+ (44.6 ± 16.9 vs 54.1 ± 12.4; p = 0.01), and CD19+/CysLTR2+ (55.3 ± 11.3 vs 61.5 ± 12.6; p = 0.05) lymphocytes. Considering the total number of lymphocytes, the SE group had fewer CD3+/CysLTR1+ lymphocytes (11.1 ± 5.5 vs 13.7 ± 6.2; p = 0.04). All other cell populations exhibited reduced expression in the SE group without statistical significance. The expression of CysLTR2 was significantly higher (p < 0.05) than CysLTR1 in most studied cell populations. The mRNA expression did not show significant differences between the groups. CONCLUSION: The expression of CysLTR is higher in the lymphocytes of the NS children, and CysLTR2 shows greater expression than CysLTR1 Respiratory allergies do not appear to be a stimulus for AH occurrence. Newer drugs capable of blocking both CysLTRs warrant further study.

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE: Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index. METHODS: We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room. RESULTS: Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224). CONCLUSION: Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.

Expression of CysLTR1 and 2 in Maturating Lymphocytes of Hyperplasic Tonsils Compared to Peripheral Cells in Children.

Cysteinyl-leukotriene receptors 1 and 2 (CysLTR1 and 2) are related to allergic inflammatory responses. Recent studies demonstrated their role in lymphocyte division and maturation in the bone marrow. Few data are available about CysLTRs function in lymphocyte maturation in tonsils. The objectives of this study are to compare CysLTRs expression in peripheral blood lymphocytes with expression in maturating lymphocytes of hyperplasic tonsil and to check the influence of respiratory allergies in this process. Leukocytes of peripheral blood (PL) and hyperplasic tonsils of children were immunostained for CysLTR1, CysLTR2, CD3 (T cells), and CD19 (B cells) and read in flow cytometer. Lymphocyte of tonsils were divided in differentiating small cells (SC) and mitotic large cells (LC); percentage of B and T cells expressing CysLTRs was determined, and comparison was done using ANOVA and Tukey's tests. Data were analyzed as a whole and categorizing patients according the presence of allergies. Sixty children were enrolled in this study. There was a large expression of CysLTR1 and 2 in CD3+ LC, and such expression decreased progressively in SC and PL. In B cells, the highest expression of CysLTR1 and 2 was found in PL while SC showed the lowest and LC showed the intermediate expression. This pattern kept unchanged in groups of allergic and non-allergic individuals. CysLTRs seem to be involved in lymphocyte maturation that occurs in tonsils, without influence of allergies. New studies aiming the clinic treatment of tonsil hyperplasia must be targeted to the development of drugs capable of blocking both CysLTR1 and 2.

Allergic rhinitis affects the duration of rapid eye movement sleep in children with sleep-disordered breathing without sleep apnea.

BACKGROUND: Our goals were to assess whether allergic rhinitis (AR) is an aggravating factor that affects the severity of sleep apnea in children with tonsils/adenoid hypertrophy (T&A) and to compare polysomnographic data from children with and without AR. METHODS: This prospective study included 135 children (age range, 3 to 14 years) with sleep-disordered breathing (SDB) resulting from T&A. Children with lung, neurological, or craniofacial problems; septal deviations; previous pharyngeal surgeries; or orthodontic treatments were excluded. All children underwent a clinical evaluation, nasopharyngoscopy or lateral X-ray imaging, sleep study, and hypersensitivity skin-prick test. RESULTS: The mean patient age was 6.44 ± 2.55 years (83 males). AR was present in 42.2% of the children; 40% presented with sleep apnea; and 17.04% had sleep apnea and AR. The percentage of time spent in the rapid eye movement (REM) sleep stage was lower among children with AR without sleep apnea (p = 0.028); however, the percentage of REM sleep was not significantly different among children with apnea (p = 0.2922). No difference in the apnea-hypopnea index (AHI) was observed between the children with (AHI = 2.79 events/hour) and without AR (3.75 events/hour, p = 0.4427). A multivariate analysis showed that nasal congestion was an important factor that can affect the duration of the REM sleep stage. CONCLUSION: AR affects REM sleep in children with SDB without sleep apnea, and AR is not an aggravating factor regarding the severity of AHI.

[Otitis media with effusion in children younger than 1 year]. / Otite média com efusão em crianças menores de um ano.

OBJECTIVE: To determine the prevalence of otitis media with effusion in children younger than 1 year and its association with the season of the year, artificial feeding, environmental and perinatal factors. METHODS: Retrospective study of 184 randomly included medical records from a total of 982 healthy infants evaluated for hearing screening tests. Diagnosis of otitis media with effusion was based on otoscopy (amber-gold color, fluid level, handle of malleus position), type B tympanometric curves and absence of otoacoustic emissions. Incomplete medical records or those describing acute otitis media, upper respiratory tract infections on the assessment day or in the last 3 months, neuropathies and craniofacial anomalies were excluded. Data such as gestational age, birth weight, Apgar score, type of feeding and day care attendance were compared between children with and without otitis media with effusion through likelihood tests and multivariate analysis. RESULTS: 25.3% of 184 infants had otitis media with bilateral effusion; 9.2% had unilateral. In infants with otitis media, the following were observed: chronological age of 9.6±1.7 months; gestational age >38 weeks in 43.4% and birth weight >2,500g in 48.4%. Otitis media with effusion was associated with winter/fall, artificial feeding, Apgar score <7 and day care attendance. The multivariate analysis showed that artificial feeding is the factor most often associated to otitis media with effusion. CONCLUSIONS: Otitis media with effusion was found in about one third of children younger than 1 year and was mainly associated with artificial feeding.

Rinite alérgica / Allergic rhinitis

A rinite alérgica é uma doença crônica comum que acomete pessoas de diferentes idades em todas as partes do mundo. Mesmo não sendo potencialmente fatal pode comprometer sobremaneira a qualidade de vida do indivíduo afetado. O seu diagnóstico é clínico através de história, exame físico e exames complementares. O tratamento da rinite é complexo, uma vez que envolve várias medidas, como conscientização através de medidas educativas, controle ambiental, uso de medicamentos, procedimentos cirúrgicos e outras terapias. Esta atualização pretende abordar de forma prática como diagnosticar, classificar e tratar a rinite alérgica.

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.