Associations among sleep symptoms, physical examination, and polysomnographic findings in children with obstructive sleep apnea

  • Xiao-hong Yan
  • Yu ZhaoEmail author
  • Jing Wang
  • Tian Shen
  • Wen Yang
  • Yixin Qiao
  • Danni Cheng
  • Min Chen



The relationships among PSG findings, OSA symptoms, and tonsil and adenoid size are not clear. In this study, we aimed to investigate the associations between pediatric OSA and tonsil and adenoid size using subjective (OSA-18 questionnaire) and objective (PSG) measurements.


101 consecutive patients aged from 2 to 12 years (mean age, 5.4 ± 2.2 years; boys, 72.3%) diagnosed with OSA were enrolled in two age groups (2–6 years group and 7–12 years group) and underwent PSG and lateral cephalometric radiography. Tonsil size and the adenoid–nasopharyngeal (A/N) ratio were determined. Quality of life and sleep symptoms were measured using the Chinese version OSA-18 questionnaire. Demographic and clinical data were obtained.


75 and 26 patients were separately enrolled in 2–6 years group and 7–12 years group. In 2–6 years group, the multiple linear regression revealed that tonsil size and A/N ratio were associated with log apnea–hypopnea index (AHI), and the Spearman’s rank correlation reflected a positive correlation between log AHI and the OSA-18 sleep disturbance score (r = 0.362, P = 0.001). Log OSA-18 score was correlated with tonsil size (r = 0.349, P = 0.002) but not the A/N ratio in 2–6 years group. Finally, no significant associations were observed between log OSA-18 scores and log AHI in all patients.


As PSG stays the golden standard for diagnoses of pediatric OSA, physical examinations and quality-of-life assessments are needed to fully assess the impact of OSA on children.


Obstructive sleep apnea Physical examination Polysomnography OSA-18 questionnaire Pediatric sleep disorder 



The authors thank Xiangdong Tang, professor of the Department of Sleep Medicine Center at West China Hospital at West China Hospital, for providing data regarding admissions to the Department of Otolaryngology Head and Neck Surgery in the study period.


This study was funded by the Key Research and Development Support Programmes of Chengdu Science and Technology Bureau [Grant no. 2018-YFYF-00123-SN] and the Fundamental Research Funds for the Central Universities [Grant no. 2012017yjsy118].

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the Ethics Committee of West China Hospital (2018 (146)) and was registered at (ChiCTR1800017895).

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE (2006) Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 117(4):e769–778. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Society. AT (1996) Standards and indications for cardiopulmonary sleep studies in children. American Thoracic Society. Am J Respir Crit Care Med 153(866):78Google Scholar
  3. 3.
    Xu Z, Gutiérrez-Tobal GC, Wu Y, Kheirandish-Gozal L, Ni X, Hornero R, Gozal D (2019) Cloud algorithm-driven oximetry-based diagnosis of obstructive sleep apnoea in symptomatic habitually snoring children. Eur Resp J. CrossRefGoogle Scholar
  4. 4.
    Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN, American Academy of P (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130(3):576–584. CrossRefPubMedGoogle Scholar
  5. 5.
    Tarasiuk A, Simon T, Fau-Tal A, Tal A, Fau-Reuveni H, Reuveni H (2004) Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization. Pediatrics 113:351–356CrossRefGoogle Scholar
  6. 6.
    Torretta S, Rosazza C, Pace ME, Iofrida E, Marchisio P (2017) Impact of adenotonsillectomy on pediatric quality of life: review of the literature. Ital J Pediatr. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Zhao G, Li Y, Wang X, Ding X, Wang C, Xu W, Han D (2018) The predictive value of polysomnography combined with quality of life for treatment decision of children with habitual snoring related to adenotonsillar hypertrophy. Eur Arch Otorhinolaryngol 275(6):1579–1586. CrossRefPubMedGoogle Scholar
  8. 8.
    Kaditis AG, Alonso Alvarez ML, Boudewyns A, Alexopoulos EI, Ersu R, Joosten K, Larramona H, Miano S, Narang I, Trang H, Tsaoussoglou M, Vandenbussche N, Villa MP, Van Waardenburg D, Weber S, Verhulst S (2016) Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J 47(1):69–94. CrossRefPubMedGoogle Scholar
  9. 9.
    Pateron B, Marianowski R, Monteyrol PJ, Couloigner V, Akkari M, Chalumeau F, Fayoux P, Leboulanger N, Franco P, Mondain M (2018) French Society of ENT (SFORL) guidelines (short version) on the roles of the various treatment options in childhood obstructive sleep apnea-hypopnea syndrome. Eur Ann Otorhinolaryngol Head Neck Dis 135(4):265–268. CrossRefPubMedGoogle Scholar
  10. 10.
    Kirk V, Baughn J, D'Andrea L, Friedman N, Galion A, Garetz S, Hassan F, Wrede J, Harrod CG, Malhotra RK (2017) American Academy of sleep medicine position paper for the use of a home sleep apnea test for the diagnosis of OSA in children. J Clin Sleep Med 13(10):1199–1203. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Montgomery-Downs HE, O'Brien LM, Holbrook CR, Gozal D (2004) Snoring and sleep- disordered breathing in young children: Subjective and objective correlates. Sleep 27:87–94CrossRefGoogle Scholar
  12. 12.
    Greenfeld M, Tauman R, DeRowe A, Sivan Y (2003) Obstructive sleep apnea syndrome due to adenotonsillar hypertrophy in infants. Int J Pediatr Otorhinolaryngol 67(10):1055–1060. CrossRefPubMedGoogle Scholar
  13. 13.
    Frank Y, Kravath RE, Pollak CP, Weitzman ED (1983) Obstructive sleep apnea and its therapy: clinical and polysomnographic manifestations. Pediatrics 71(5):737–742PubMedGoogle Scholar
  14. 14.
    Nolan J, Brietzke SE (2011) Systematic review of pediatric tonsil size and polysomnogram-measured obstructive sleep apnea severity. Otolaryngol Head Neck Surg 144(6):844–850. CrossRefPubMedGoogle Scholar
  15. 15.
    Howard NS, Brietzke SE (2009) Pediatric tonsil size: objective vs subjective measurements correlated to overnight polysomnogram. Otolaryngol Head Neck Surg 140(5):675–681. CrossRefPubMedGoogle Scholar
  16. 16.
    Wang JH, Chung Y-S, Jang YJ, Lee B-J (2009) Palatine tonsil size and its correlation with subjective tonsil size in patients with sleep-disordered breathing. Otolaryngol Head Neck Surg 141(6):716–721. CrossRefPubMedGoogle Scholar
  17. 17.
    Franco RA Jr, Rosenfeld RM, Rao M (2000) First place–resident clinical science award 1999. Quality of life for children with obstructive sleep apnea. Otolaryngol Head Neck Surg 123(1 Pt 1):9–16. CrossRefPubMedGoogle Scholar
  18. 18.
    Baldassari CM, Alam L, Vigilar M, Benke J, Martin C, Ishman S (2014) Correlation between REM AHI and quality-of-life scores in children with sleep-disordered breathing. Otolaryngol Head Neck Surg 151(4):687–691. CrossRefPubMedGoogle Scholar
  19. 19.
    Hwang SH, Guilleminault C, Park CS, Kim TW, Hong SC (2013) Usefulness of adenotonsillar size for prediction of severity of obstructive sleep apnea and flow limitation. Otolaryngol Head Neck Surg 149(2):326–334. CrossRefPubMedGoogle Scholar
  20. 20.
    Kang KT, Weng WC, Yeh TH, Lee PL, Hsu WC (2014) Validation of the Chinese version OSA-18 quality of life questionnaire in Taiwanese children with obstructive sleep apnea. J Formos Med Assoc 113(7):454–462. CrossRefPubMedGoogle Scholar
  21. 21.
    Fujioka M, Young LW, Girdany BR (1979) Radiographic evaluation of adenoidal size in children: adenoidal-nasopharyngeal ratio. AJR Am J Roentgenol 133(3):401–404CrossRefGoogle Scholar
  22. 22.
    Brodsky L, Moore L, Stanievich JF (1987) A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 13(2):149–156CrossRefGoogle Scholar
  23. 23.
    Kaditis AG, Alexopoulos EI, Hatzi F, Karadonta I, Chaidas K, Gourgoulianis K, Zintzaras E, Syrogiannopoulos GA (2007) Adiposity in relation to age as predictor of severity of sleep apnea in children with snoring. Sleep Breath 12(1):25–31. CrossRefGoogle Scholar
  24. 24.
    Li AM, Au CT, Ng SK, Abdullah VJ, Ho C, Fok TF, Ng PC, Wing YK (2009) Natural history and predictors for progression of mild childhood obstructive sleep apnoea. Thorax 65(1):27–31. CrossRefPubMedGoogle Scholar
  25. 25.
    Lam Y-Y, Chan EYT, Ng DK, Chan C-H, Cheung JMY, Leung S-Y, Chow P-y, Kwok K-l (2006) The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest 130(6):1751–1756. CrossRefPubMedGoogle Scholar
  26. 26.
    Dayyat E, Kheirandish-Gozal L, Sans Capdevila O, Maarafeya MMA, Gozal D (2009) Obstructive sleep apnea in children: relative contributions of body mass index and adenotonsillar hypertrophy. Chest 136(1):137–144. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Tripuraneni M, Paruthi S, Armbrecht ES, Mitchell RB (2013) Obstructive sleep apnea in children. Laryngoscope 123(5):1289–1293. CrossRefPubMedGoogle Scholar
  28. 28.
    Gozal D, Pope DW Jr (2001) Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics 107(6):1394–1399. CrossRefPubMedGoogle Scholar
  29. 29.
    Isaiah A, Kiss E, Olomu P, Koral K, Mitchell RB (2018) Characterization of upper airway obstruction using cine MRI in children with residual obstructive sleep apnea after adenotonsillectomy. Sleep Med 50:79–86CrossRefGoogle Scholar
  30. 30.
    Marrugo Pardo G, Romero Moreno LF, Beltrán Erazo P, Villalobos Aguirre C (2018) Respiratory complications of adenotonsillectomy for obstructive sleep apnea in the pediatric population. Sleep Disord. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Malhotra A, Huang Y, Fogel RB, Pillar G, Edwards JK, Kikinis R, Loring SH, White DP (2002) The male predisposition to pharyngeal collapse: importance of airway length. Am J Respir Crit Care Med 166(10):1388–1395CrossRefGoogle Scholar
  32. 32.
    Ronen O, Malhotra A, Pillar G (2007) Influence of gender and age on upper-airway length during development. Pediatrics 120(4):e1028–e1034CrossRefGoogle Scholar
  33. 33.
    Nguyen HL, Bonadurer GF 3rd, Tollefson MM (2018) Vascular malformations and health-related quality of life: a systematic review and meta-analysis. JAMA Dermatol 154(6):661–669. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Taylor HG, Bowen SR, Beebe DW, Hodges E, Amin R, Arens R, Chervin RD (2016) Cognitive effects of adenotonsillectomy for obstructive sleep apnea. Pediatrics. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical SchoolSichuan UniversityChengduChina
  2. 2.Department of Oto-Rhino-Laryngology, Chengdu Shangjin Nanfu Hospital, West China Hospital, West China Medical SchoolSichuan UniversityChengduChina

Personalised recommendations