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Lam DJ, Hildebrand A, Nguyen T, Quintanilla-Dieck L, Tan GX, Hargunani CA, Macarthur CJ, Milczuk HA. Drug-Induced Sleep Endoscopy Predicts Subjective Outcomes of Adenotonsillectomy. Laryngoscope 2024. [PMID: 39166775 DOI: 10.1002/lary.31704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/19/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES Persistent obstructive sleep apnea (OSA) after adenotonsillectomy (AT) has been reported in 20%-30% of children. The aim of this study was to determine the predictive value of drug-induced sleep endoscopy (DISE) at the time of AT on subjective AT outcomes. METHODS This was a prospective cohort study of children aged 2-18 years being treated with AT for sleep disordered breathing (SDB) with one or more risk factors for AT failure: age >7 years, obesity, severe baseline OSA, Black race. All underwent DISE at the time of AT. Potential predictors of subjective AT outcome included age, sex, obesity, and DISE patterns. Multivariable linear regression was used to model predictors of post-AT Pediatric Sleep Questionnaire (PSQ) and OSA-18 outcomes. RESULTS Pre- and post-AT PSQ/OSA-18 responses were available from 194 children. Mean age was 9.3 ± 3.5 years, with 59% obese, 50% female, and 67% White. After AT, mean PSQ score decreased from 0.60 ± 0.19 to 0.28 ± 0.22, p < 0.001 and mean OSA-18 score decreased from 66 ± 21 to 37 ± 18, p < 0.001. The most frequent sites of obstruction were the tonsils (92%), nasal airway (77%), adenoids (64%), and velopharynx (65%). Multivariable regression modeling demonstrated worse outcomes with obesity, male gender, and multilevel obstruction that included the nasal airway and tongue base in addition to adenotonsillar obstruction. CONCLUSIONS Persistent OSA and symptom burden after AT was common in this population. Obesity, male gender, and multilevel obstruction during DISE were all associated with worse subjective outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 2024.
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Affiliation(s)
- Derek J Lam
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Andrea Hildebrand
- Biostatistics and Design Program, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Thuan Nguyen
- Biostatistics and Design Program, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Lourdes Quintanilla-Dieck
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Grace X Tan
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Chris A Hargunani
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Carol J Macarthur
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Henry A Milczuk
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
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Sigaard RK, Bertelsen JB, Ovesen T. Does DISE increase the success rate of surgery for obstructive sleep apnea in children? A systematic review of DISE directed treatment of children with OSAS. Am J Otolaryngol 2023; 44:103992. [PMID: 37480683 DOI: 10.1016/j.amjoto.2023.103992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/04/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVE A systematic review of the evidence on the success of Drug-Induced Sleep Endoscopy (DISE) directed surgery in children with obstructive sleep apnea (OSA) defined as cure rate. DATA SOURCES The PRISMA guidelines were followed and three databases (PubMed, Embase and Cochrane Library) were searched for studies on DISE directed surgery in children. ENDPOINTS Pre- and post-surgical change in polysomnography (PSG); change in surgical target; side effects. REVIEW METHODS Study quality was assessed using the modified Delphi technique quality appraisal tool for case series. Risk of bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS A total of 1805 studies were found. The most important reasons for exclusion were as follows: none-DISE studies, reports on adults, conflation of results on syndromic and healthy patients, no relevant outcome measurements. Five studies with a total of 376 patients (range: 26-126) were included. The surgeons changed the planned strategy in 50.4 % of patients according to the DISE findings. Comparison of pre- and post-surgical sleep monitoring revealed an average decrease in apnea-hypopnea index (AHI) of 11.1 and a treatment success (AHI < 5) and cure (AHI < 2) of 78 % and 53 %, respectively. The quality of the included studies was moderate especially due to small populations, designs without randomization or control groups, lack of analysis of drop outs, short follow-up, and considerable level of bias. CONCLUSION DISE directed surgery has been shown to change the surgical approach when treating children with OSA. If this can be transferred into a better outcome compared to standard surgical treatment is unknown, due to the current poor level of evidence. To decide whether or not DISE should be included in the treatment of children with OSA, we suggest further data, preferably an RCT, to increase the level of evidence.
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Affiliation(s)
- Rasmus Krarup Sigaard
- Department of Otorhinolaryngology, Head and Neck Surgery, Goedstrup Hospital, Hospitalsparken 15, DK-7400 Herning, Denmark.
| | - Jannik Buus Bertelsen
- Department of Otorhinolaryngology, Head and Neck Surgery, Goedstrup Hospital, Hospitalsparken 15, DK-7400 Herning, Denmark
| | - Therese Ovesen
- Department of Otorhinolaryngology, Head and Neck Surgery, Goedstrup Hospital, Hospitalsparken 15, DK-7400 Herning, Denmark
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Lam DJ, Friedman NR, Chan KC, Kirkham EM, Smith DF, Benedek P, Boudewyns A. Development and validation of the international pediatric sleep endoscopy scale (IPSES). Int J Pediatr Otorhinolaryngol 2023; 174:111748. [PMID: 37820572 DOI: 10.1016/j.ijporl.2023.111748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES To develop and validate a consensus international pediatric sleep endoscopy scale (IPSES) for pediatric drug-induced sleep endoscopy (DISE). METHODS Existing published DISE ratings scales were reviewed in order to develop a consensus rating scale synthesizing the most common features and adding new elements to address areas of controversy. Samples of 30 de-identified DISE video recordings were reviewed to develop and refine the scale. After the consensus scale was defined, a separate sample of 25 de-identified DISE videos were scored with the new consensus scale by the development group and a panel of independent raters. A weighted kappa statistic was used to quantify the inter-rater and intra-rater reliability of the consensus scale at each anatomic level. RESULTS Among all raters, intra-rater reliability was most variable for the nasal airway (kappa range 0.33-0.94) and best for the lateral oropharynx (kappa range 0.68-0.95). Inter-rater reliability ranged from 0.43 for the nasal airway to 0.57 at the soft palate. CONCLUSION The IPSES is a reliable consensus scale that reflects the most common features of existing scales and can be adopted as a universal scoring scale for pediatric DISE.
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Affiliation(s)
- Derek J Lam
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR, 97239, USA.
| | - Norman R Friedman
- Pediatric Otolaryngology, Children's Hospital of Colorado (CHCO), Department of Otolaryngology-Head and Neck Surgery, University of Colorado, Anschutz Medical Campus, USA
| | - Kate C Chan
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Erin M Kirkham
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David F Smith
- Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital, Cincinnati, OH, 45229, USA
| | - Palma Benedek
- Division of Sleep Laboratory and Sleep Surgery, Heim Pal National Pediatric Institute, Budapest, Hungary
| | - An Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Translational Neurosciences, University of Antwerp, Antwerp, Belgium
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Herzig MX, Hildebrand AD, Nguyen T, Lam DJ. Drug-Induced Sleep Endoscopy Differences by Age in Surgically Naive Children With Sleep-Disordered Breathing. JAMA Otolaryngol Head Neck Surg 2023; 149:327-333. [PMID: 36821100 PMCID: PMC9951097 DOI: 10.1001/jamaoto.2022.5187] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 12/29/2022] [Indexed: 02/24/2023]
Abstract
Importance Drug-induced sleep endoscopy (DISE) is increasingly used to guide treatment decisions in children with sleep-disordered breathing (SDB). Previous reports of DISE findings in children have typically included a broad age range, but it is unclear how these patterns of obstruction vary with age. Objective To compare patterns of airway obstruction observed during DISE in 3 age groups of surgically naive children with SDB. Design, Setting, and Participants This cross-sectional analysis of a prospective cohort of surgically naive nonsyndromic children with SDB or obstructive sleep apnea [OSA] at risk for residual disease after adenotonsillectomy (defined as having at least 1 of these criteria: severe OSA, older than 7 years, obesity, or Black race) who were recruited between May 1, 2015, and February 28, 2020, was conducted at a tertiary children's hospital. Data analysis was conducted from September 2021 to February 2022. Exposures DISE. Main Outcomes and Measures DISE findings were rated at 6 anatomic sites using the Sleep Endoscopy Rating Scale (SERS). The association between age and severity of obstruction at each anatomic site and overall were compared using correlation (Kendall τ) and ordinal logistic regression analysis. Results Data from 288 children (144 girls [50%]; 20 American Indian/Alaska Native [7%], 4 Asian [1%], 19 Black [7%], 93 Hispanic [33%], 2 Middle Eastern [1%], 6 Native Hawaiian/Pacific Islander [2%], and 203 White [70%] individuals; median [IQR] age, 9.2 [7.0-11.7] years) were stratified by participant age into preschool (age 2-5 years; 27 [9%]), younger school-aged (age 5-10 years; 146 [51%]), and older school-aged (age 10-18 years; 115 [40%]). Among these subgroups, the prevalence of multilevel obstruction was 59%, 51%, and 30%, respectively. Increasing age was inversely correlated with obstruction of the nasal airway (τb, -0.19; 95% CI, -0.29 to -0.09), nasopharynx (τb, -0.20; 95% CI, -0.31 to -0.10), velopharynx (τb, -0.16; 95% CI, -0.26 to -0.06), and overall obstruction (SERS total score: τb, -0.24; 95% CI, -0.33 to -0.14). An adjusted analysis demonstrated an inverse association between age and nasopharyngeal obstruction (odds ratio [OR], 0.84; 95% CI, 0.76 to 0.92), SERS total score (OR, 0.83; 95% CI, 0.76 to 0.90), and the number of sites of complete obstruction (OR, 0.87; 95% CI, 0.87 to 0.95). Conclusions and Relevance This cross-sectional analysis of data from a prospective cohort study of surgically naive children with SDB found that preschool-aged children had more frequent multilevel obstruction, more severe overall obstruction, and nasopharyngeal obstruction compared with older children. Understanding the most common sites of obstruction and expected changes with age could inform personalized treatment for children with SDB.
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Affiliation(s)
- Maya X. Herzig
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland
| | - Andrea D. Hildebrand
- Biostatistics and Design Program, Oregon Health and Science University, Portland
| | - Thuan Nguyen
- Biostatistics and Design Program, Oregon Health and Science University, Portland
| | - Derek J. Lam
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland
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Frederick RM, Brandt J, Sheyn A. Drug-induced sleep endoscopy effect on intraoperative decision making in pediatric sleep surgery: A 2-year follow up. Laryngoscope Investig Otolaryngol 2022; 7:2112-2118. [PMID: 36544916 PMCID: PMC9764739 DOI: 10.1002/lio2.918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To further demonstrate sleep endoscopy's utility in improving surgical outcomes for pediatric OSA. Methods This is a retrospective review of surgically naïve patients <18 years old with diagnosed moderate-severe OSA who underwent DISE at the time of initial sleep surgery. Patients included in final analysis had both preoperative and postoperative polysomnograms. Surgical success was defined as an oAHI decrease by at least one diagnostic category. Residual OSA was defined as any patient with postoperative oAHI >1. Results A total of 106 patients had preoperative and postoperative polysomnograms. Patients with comorbidities comprised 53.8% of the group. Average BMI% was 88.2, with 75.5% classified as obese. The most common area of collapse was the base of tongue, occurring in 32.1% of patients. There was a statistically significant decrease from the mean preoperative oAHI of 29.7 to the mean postoperative oAHI of 6.6 (p < 0.001). Surgical success occurred in 76.4% of patients. A postoperative oAHI of <5 was achieved in 57.7% of patients with moderate or severe OSA. The average BMI% of patients who met surgical success was 86.4, while the average BMI% of patients who did not was 90.8. A postoperative oAHI of <5 was achieved in 68.4% of patients with a BMI% < 85, compared with 55.2% of patients with a BMI% ≥ 85. Conclusion This study supports the utilization of DISE during initial surgery for severe sleep apnea in the pediatric population. It was found to effectively aid in significantly reducing surgically naïve patients' mean oAHI. Level of Evidence Level III.
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Affiliation(s)
- Robert M Frederick
- Department of Otolaryngology, College of Medicine University of Tennessee Health Science Center Memphis Tennessee USA
| | - Josiah Brandt
- Department of Otolaryngology, College of Medicine University of Tennessee Health Science Center Memphis Tennessee USA
| | - Anthony Sheyn
- Department of Otolaryngology, College of Medicine University of Tennessee Health Science Center Memphis Tennessee USA
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DeJarnette K, Frederick RM, Harris AJ, Bashir A, Wood J, Sheyn A. Use of VOTE score in predicting outcomes in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2022; 162:111256. [PMID: 35994833 DOI: 10.1016/j.ijporl.2022.111256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 06/18/2022] [Accepted: 07/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Obstructive Sleep Apnea (OSA) affects 1-4% of the pediatric population in the U.S. Drug-Induced Sleep Endoscopy (DISE) is widely used to localize the level(s) of obstruction. The VOTE classification system is used to grade obstructions found at the velum, oropharynx, base of tongue, and epiglottis and has been validated in adults. This study aims to determine if the VOTE score has any predictive value in pediatric OSA postoperative outcomes. METHODS A retrospective chart review of 129 patients from January 7, 2016 to 05/30/2020 was performed. Included patients were between the ages of 2 and 17, undergoing DISE, and if they had preoperative and postoperative polysomnography (PSG) data. Excluded patients did not meet one of the above or had other comorbidities contributing to their sleep apnea. 53 patients were included. RESULTS Pearson's Correlation tests compared intraoperative VOTE score to postoperative BMI, AHI, and O2 nadir and their relationships. We found a weakly positive correlation between the VOTE and postoperative AHI with a coefficient of 0.35 and a p-value of 0.01. We found a relationship between postoperative O2 nadir and AHI, with a coefficient of -0.627 and a p-value <0.0001. Finally, a paired, two-tailed t-test compared the mean change between preoperative and postoperative BMIs (+1.6), oAHIs (-23.5), and O2 nadirs (+14), all with p-value <0.0001. CONCLUSION We demonstrated a correlation between VOTE and improved postoperative AHI and a relationship between improved postoperative AHI and postoperative O2 nadir. The validity of VOTE may be proven with larger sample size. Alternatively, a different scoring system may be required for pediatric OSA.
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Affiliation(s)
- Kaci DeJarnette
- University of Tennessee Health Science Center College of Medicine, 910 Madison Ave Ste. 1031, Memphis, TN, 38163, USA
| | - Robert M Frederick
- University of Tennessee Health Science Center College of Medicine, 910 Madison Ave Ste. 1031, Memphis, TN, 38163, USA
| | - Atia J Harris
- Division of Pulmonology and Sleep Medicine, Le Bonheur Children's Hospital, 848 Adams Avenue Memphis, TN, 38103, USA
| | - Ahsan Bashir
- Division of Pulmonology and Sleep Medicine, Le Bonheur Children's Hospital, 848 Adams Avenue Memphis, TN, 38103, USA
| | - Joshua Wood
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, 848 Adams Avenue Memphis, TN, 38103, USA; University of Tennessee Health Science Center Department of Otolaryngology, 910 Madison Ave Ste. 430, Memphis, TN, 38163, USA
| | - Anthony Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, 848 Adams Avenue Memphis, TN, 38103, USA; University of Tennessee Health Science Center Department of Otolaryngology, 910 Madison Ave Ste. 430, Memphis, TN, 38163, USA.
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Cheong CS, Loke W, Thong MKT, Toh ST, Lee CH. The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 14:149-158. [PMID: 33092317 PMCID: PMC8111386 DOI: 10.21053/ceo.2020.01704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 11/22/2022] Open
Abstract
Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.
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Affiliation(s)
- Crystal Sj Cheong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Weiqiang Loke
- Faculty of Dentistry, National University of Singapore, Singapore
| | - Mark Kim Thye Thong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Song Tar Toh
- Department of Otolaryngology, Singapore General Hospital, SingHealth Duke-NUS Sleep Centre, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
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Raposo D, Menezes M, Rito J, Trindade-Soares M, Adónis C, Loureiro HC, Freire F. Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2020; 164:414-421. [PMID: 32777981 DOI: 10.1177/0194599820947666] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea and to differentiate them between surgically naïve children and children who had adenotonsillectomy performed. STUDY DESIGN Retrospective case series with chart review. SETTING Secondary care hospital. SUBJECTS AND METHODS A cohort of 56 children with the diagnosis of obstructive sleep apnea was submitted to DISE and subsequent upper airway surgery: 23 were surgically naïve, and 33 had persistent obstructive sleep apnea after adenotonsillectomy. Comparisons between groups were calculated with chi-square test and Student's t test. Simple linear regression was used to model polysomnographic indices. RESULTS In surgically naïve children, the most common sites of obstruction were the adenoids (78.2%) and the lateral pharyngeal walls/tonsils (82.6%). In children with persistent obstructive sleep apnea after adenotonsillectomy, the most common sites of obstruction were the adenoids (54.5%), followed by the supraglottis (48.5%) and the tongue base (45.5%). No correlation was found between obstructive apnea-hypopnea index and DISE findings. Simple linear regression revealed that the degree of obstruction at the tongue base (β = -0.73; 95% CI, -1.22 to -0.25; P = .004) and the presence of multilevel obstruction (β = -1.75; 95% CI, -3.20 to -0.30; P = .02) predicted saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy. CONCLUSION DISE findings differed between surgically naïve children and children with persistent obstructive sleep apnea after adenotonsillectomy. Increased obstruction at the level of the tongue base and the presence of multilevel obstruction predicted a lower saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy.
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Affiliation(s)
- Diogo Raposo
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | - Marco Menezes
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | - João Rito
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | | | - Cristina Adónis
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
| | | | - Filipe Freire
- Department of Otorhinolaryngology, Hospital Prof Doutor Fernando Fonseca, Lisbon, Portugal
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