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For Physicians


Sleep disordered breathing (SDB) represents a spectrum of disorders including snoring, upper airway resistance syndrome, obstructive hypoventilation and, at the extreme end of the spectrum, obstructive sleep apnea syndrome. Certain behavioral and developmental problems in children have been shown to be related to SDB including ADHD, poor school performance, neurocognitive impairment, enuresis, and daytime somnolence.1,2 Adenotonsillectomy (T&A) is potentially curative for the whole spectrum of sleep disordered breathing.3

Although polysomnography (PSG) is considered the gold standard for the diagnosis of obstructive sleep apnea, PSG may not be appropriate for routine use in screening for SDB in children. In one survey among otolaryngologists, less than 5% of school aged children received PSG before undergoing T&A. Reasons for such low usage includes cost and availability of sleep centers that can accommodate children. More importantly, there is not enough normative data on PSG in children to allow for accurate results based on the apnea-hypopnea index. Also, several studies demonstrate that there is not necessarily a direct relationship between the severity of obstructive sleep apnea syndrome (OSAS) as measured by AHI, and the degree of associated behavioral and developmental impairment. Some children may have a normal sleep study but still have significant SDB in the form of snoring or upper airway resistance syndrome that is contributing to impairment.3

Two questionnaires that the physicians at Raleigh Capitol ENT have found to be helpful are the OSA-18 and the pediatric sleep questionnaire (PSQ). The OSA-18 is a validated, disease specific quality of life (QOL) survey consisting of 18 questions.4 Parents are asked to rate each issue on a scale of 1 to 7 and then a total score is calculated. The PSQ also can be used to identify children with sleep related breathing disorders (SRBD). 5 Parents are asked to indicate which questions describe their child’s sleep or behavior. Eight or more positive responses suggest a high risk for SRBD. Adenotonsillectomy has been shown to normalize sleep parameters in up to 83% of pediatric patients with SRBD.1 Children with the combination of a positive OSA-18 or PSQ and physical exam demonstrating tonsil and/or adenoid hypertrophy may be adequate to identify those that will benefit from T&A. Raleigh Capitol ENT is pleased to offer this treatment at our six convenient locations.

  1. Garetz,S. Behavior, cognition and quality of life after adenotonsillectomy for pediatric sleep disordered breathing. Otolaryngology-HNSurgery 2008;138, S19-26
  2. Beebe, D. Neurobehavioral morbidity associated with disordered breathing during sleep. Sleep 2006;29(9): 1115-11134
  3. Wei, J., Improved behavior and sleep after adenotonsillectomy in children with sleep disordered breathing. Arch Oto/HNS 2007; 133(10):974-979
  4. Franco,Jr., R., Quality of life for children with obstructive sleep apnea. Oto-HNS 2000; 123:9-16
  5. Chervin,R., et. al. Pediatric sleep questionnaire (PSQ): validity and reliability scales for sleep-disordered breathing, snoring, sleepiness and behavioral problems. Sleep Medicine 2000; 1:21-32

Pediatric Sleep Questionnaire

Please have the parent(s) circle the numbers of those questions which apply to their child. Responses and results of history and physical exam may warrant a referral to Raleigh Capitol ENT

While sleeping, does your child . . .

  1. snore more than half the time?
  2. always snore?
  3. snore loudly?
  4. have trouble breathing, or struggle to breathe?
  5. have “heavy” or loud breathing?

Have you ever . . .

  1. seen your child stop breathing during the night?

Does your child . . .

  1. tend to breathe through the mouth during the day?
  2. have a dry mouth on waking up in the morning?
  3. occasionally wet the bed?

Does your child . . .

  1. wake up feeling unrefreshed in the morning?
  2. have a problem with sleepiness during the day?
  3. have a teacher or other supervisor commented that your child appears sleepy during the day?
  4. wake up with headaches in the morning?
  5. Is it hard to wake your child up in the morning?
  6. Did your child stop growing at a normal rate at any time since birth?

This child often . . .

  1. does not seem to listen when spoken to directly
  2. has difficulty organizing task and activities
  3. is easily distracted by extraneous stimuli
  4. fidgets with hands or feet or squirms in seat
  5. is ‘on the go’ or often acts as if ‘driven by a motor’
  6. interrupts or intrudes on others (e.g. butts into conversations or games)

More than 8 positive responses may indicate a problem with sleep related breathing disorder


  None of
the time
Hardly any
of the time
A little of
the time
Some of
the time
A good bit
of the time
Most of
the time
All of
the time
Sleep disturbance
During the past 4 weeks
how often has your child had;
Loud Snoring 1 2 3 4 5 6 7
breath holding spells or
pauses in breathing at night?
1 2 3 4 5 6 7
choking or making gasping
sounds while asleep?
1 2 3 4 5 6 7
restless sleep
or frequent awakening?
1 2 3 4 5 6 7
Physical symptoms
During the past 4 weeks
how often has your child had;
mouth breathing because
of nasal obstruction?
1 2 3 4 5 6 7
frequent colds or
upper respiratory infections?
1 2 3 4 5 6 7
nasal discharge or runny nose? 1 2 3 4 5 6 7
difficulty swallowing? 1 2 3 4 5 6 7
Emotional symptoms
During the past 4 weeks
how often has your child had;
mood swings or temper tantrums? 1 2 3 4 5 6 7
aggressive or hyperactive behavior? 1 2 3 4 5 6 7
discipline problems? 1 2 3 4 5 6 7
Daytime function
During the past 4 weeks
how often has your child had;
excessive daytime sleepiness? 1 2 3 4 5 6 7
poor attention span or concentration? 1 2 3 4 5 6 7
difficulty getting up
in the morning?
1 2 3 4 5 6 7
Caregiver concerns
During the past 4 weeks
how often has your child had;
caused you to worry about
f your childs general health?
1 2 3 4 5 6 7
created concern that your child
is not getting enough air?
1 2 3 4 5 6 7
interfered with your ability to
perform daily activities?
1 2 3 4 5 6 7
made you frustrated? 1 2 3 4 5 6 7
0-60 – small impact on health related quality of life              SCORE ___________
60-80 moderate impact
80+ severe impact