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Is it necessary to perform a follow-up study after adenotonsillectomy in all children with moderate-severe obstructive sleep apnoea?
¿Es necesario repetir el estudio de sueño de control a todos los niños con SAHOS moderado-severo tras la cirugía?
Genoveva del-Río Camachoa,c,
Corresponding author
vevirio@hotmail.com

Corresponding author.
, Roberto Torre Franciscoa, Jesús Rodríguez Catalána, Jaime Sanabria Brossartb,c, Rebeca López Gómeza, Fernanda Troncoso Acevedoc
a Servicio de Pediatría, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
b Servicio ORL, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
c Unidad Multidisciplinar de Sueño, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Adenotonsillar hypertrophy in children without any underlying pathology is the most common cause of obstructive sleep apnoea - hypopnoea syndrome &#40;OSAHS&#41;&#44; so that adenotonsillectomy is the first line of treatment&#46; Nevertheless&#44; in the last decade studies have been published which detect the persistence of residual OSAHS after surgery&#46; The rate of this in the series varies from 10&#37; to 77&#37;&#44; depending basically on the definition of residual OSAHS and the presence or not in the group studied of risk factors such as obesity or other comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Due to this several societies recommend the use of a sleep study check in children with severe or even moderate OSAHS prior to adenotonsillar surgery&#59; this is also recommended for children with obesity or craniofacial malformations which favour upper airway obstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Nevertheless&#44; some previous publications state that there may be a favourable correlation between parents&#8217; perception of symptoms after surgery and the results of polysomnography &#40;PSG&#41; monitoring&#44; so that it may be possible to eliminate the said PSG in many cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This study analyses whether in our population parents&#8217; clinical perception following adenotonsillectomy correlates sufficiently with PSG check parameters&#46; If this is the case&#44; then the second PSG can be restricted to children with comorbidities &#40;including obesity&#41; or when the parents describe symptoms that persist after surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Children were included over a 5-year period who had received total adenotonsillectomy due to a preoperative diagnosis of severe OSAHS using PSG and&#44; in those who had had a PSG check&#44; in the 12 months after surgery&#46; Children with syndromes or known neurological pathology were excluded&#44; as were those with obesity&#46; Children whose history did not clearly specify their clinical evolution after surgery were also excluded&#46; The PSG was performed and studied manually&#44; according to established recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> OSAHS was defined as when the obstructive apnoea-hypopnoea index &#40;OAHI&#41; was &#8805;2&#47;h and severe OSAHS when the OAHI was &#62;10&#47;h&#44; according to the European Respiratory Society &#40;ERS&#41; consensus document&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Data were gathered retrospectively from patients&#8217; clinical histories&#44; on their clinical evolution after surgery before their second PSG&#44; when parents were asked about the persistence of respiratory sleep disorders&#46; When the reply was that the patient now never snored and that no apnoea had been seen this was considered to be a &#8220;complete improvement&#8221;&#46; When only snoring persisted without apnoea being observed&#44; this was considered to be a &#8220;partial improvement&#8221;&#44; and when both symptoms &#40;snoring and apnoea&#41; persisted&#44; this was considered to be &#8220;no improvement&#8221;&#46; Symptoms were considered to be present when they occurred at any time of the night on any day of the week&#58; all of the time&#44; most of the time or sometimes&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The quantitative variables have been expressed as an average and 95&#37; confidence interval&#44; while the qualitative variables are shown as percentages&#46; The Student t-test was used to compare polysomnographic data before and after surgery&#46; The chi-squared test was used to compare the PSG result after treatment with the parents&#8217; clinical impression at that time&#46; Values of <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;05 were considered to be statistically significant&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Ethics Committee of the hospital gave its approval prior to the review of the clinical histories&#46; Family members were not asked to give their informed consent as this is a retrospective study which did not modify normal clinical practice&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">After applying the aforesaid criteria the group studied contained 41 children &#40;65&#46;85&#37; males&#41;&#46; The average time between both PSG was 7&#46;98 months &#40;95&#37; CI&#58; 6&#46;71&#44; 9&#46;24&#41;&#46; The preoperative OAHI in all of the children was higher than the postoperative figure&#44; reducing the average OAHI from 27&#46;95 &#40;95&#37; CI&#58; 22&#46;00&#44; 33&#46;90&#41; at the basal moment to 1&#46;59 &#40;95&#37; CI&#58; 0&#46;24&#44; 2&#46;94&#41; in the PSG check &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The rate of cure &#40;OAHI&#8239;&#60;&#8239;2&#47;h after surgery&#41; was 80&#46;48&#37; &#40;33 children&#41;&#44; and the percentage of residual OSAHS was 19&#46;51&#37; &#40;8 children&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the box diagram where the average OAHI in the PSG check is displayed according to the parents&#8217; perception of the symptoms after the adenotonsillar surgery&#58; complete improvement &#40;0&#46;63&#47;h&#41;&#44; partial improvement &#40;1&#46;51&#47;h&#41; and no improvement &#40;11&#46;96&#47;h&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the parents&#8217; perception after surgery and whether the OSAHS persisted or not in the PSG check&#46; In the group of children who the parents perceived as being &#8220;complete resolution&#8221; &#40;n&#8239;&#61;&#8239;32&#41;&#44; only 3 children had a residual OAHI &#8805;&#8239;2&#44; with a maximum OAHI of 2&#46;6&#47;h &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This study seems to indicate that there is a good correlation between parents&#8217; clinical perception after surgery and the result of a PSG check&#44; given that when the said perception consisted of complete improvement&#44; in 90&#46;62&#37; of cases this was accompanied by an OAHI&#8239;&#60;&#8239;2&#47;h in the PSG check&#46; On the other hand&#44; when the parents&#8217; perception did not correspond to complete improvement&#44; more than half of the children &#40;55&#46;5&#37;&#41; were found to have residual SAHS in the PSG check&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Studies have been published which contain data similar to ours&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> Suen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> observed a good correlation between parents&#8217; perceptions &#40;which were analysed using questions similar to ours&#58; no improvement&#44; partial improvement and complete improvement&#41; after surgery and the AHI in the PSG check&#46; The curation rate cannot be compared to ours as they selected a different OAHI for the diagnosis of OSAHS &#40;&#62;5&#41;&#46; Nevertheless&#44; they do state that all of the patients with residual OSAHS had persistent snoring after surgery&#46; In 2010&#44; Nieminen et al&#46; studied 27 children with OSAHS &#40;AHI&#8239;&#62;&#8239;1&#41; and observed that none of those who had ceased to snore after surgery still had OSAHS in the PSG check&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In 2007 Mitchell studied 79 children who had been diagnosed with OSAHS &#40;AHI&#8239;&#8805;&#8239;5&#41; and had received surgery&#44; whose parents completed the OSA-18 questionnaire before and after the operation&#46; He too found a good relationship between the persistence of symptoms after surgery and the finding of persistent OSAHS in the PSG check&#44; given that when the parents awarded a score&#8239;&#62;&#8239;20 in &#8220;sleep domain&#8221; of the questionnaire or they mentioned persistent snoring&#44; this was associated with persistent OSAHS in the PSG check&#44; while none of the children whose carers awarded a score&#8239;&#60;&#8239;20 in the &#8220;sleep domain&#8221; still had OSAHS after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Lastly&#44; in 2016 Villa et al&#46; published a study in which they evaluated the usefulness of a questionnaire they had prepared &#40;SCR&#41;&#44; which combined data from ear&#44; nose and throat examination and the clinical history&#46; They state that when AHI&#8239;&#8805;&#8239;1 is found to persist in the PSG check&#44; the SCR result after treatment was positive in the majority of cases&#44; showing an excellent correlation with the PSG&#46; However&#44; a high percentage &#40;61&#46;7&#37;&#41; of children who had received adenotonsillectomy and whose questionnaire was negative were found to still have AHI&#8239;&#8805;&#8239;1 in the PSG check&#44; so that the questionnaire may not be a good tool in this respect&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Nevertheless&#44; these studies do not seem to have provided enough evidence to support any change in the recommendations by medical associations&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">On the other hand&#44; our study has many limitations&#46; Firstly&#44; the limit selected for OSAHS &#40;OAHI&#8239;&#8805;&#8239;2&#47;h&#41; does not coincide with the one used in other publications&#46; Notwithstanding this&#44; our study is of normal clinical practice&#44; and this is the level of AHI over which in our practice we consider pathology to exist&#44; based on the recommendation of the ERS&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> If we re-analyse our sample considering an AHI&#8239;&#8805;&#8239;1&#47;h to be pathological &#40;as this limit has habitually been used in the literature in recent years&#41;&#44; we find that OSAHS persists in 13 of the 41 children&#44; which would be equivalent to a curation rate of 68&#46;29&#37;&#44; which is higher than the rate found in other publications&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> With this change&#44; of the 32 children whose parents described the disappearance of snoring as well as episodes of apnoea&#44; 7 &#40;21&#46;8&#37;&#41; of them would still have an AHI&#8239;&#8805;&#8239;1&#47;h after surgery&#46; This would mean that 78&#46;12&#37; of the children would have an AHI&#8239;&#60;&#8239;1&#47;h in the PSG check when the parents had described the complete absence of symptoms&#44; and this would still be a good correlation&#46; Moreover&#44; the maximum AHI in this group would still stand at 2&#46;6&#47;h&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Another limitation&#44; and without doubt a more important one&#44; is the retrospective nature of the study&#46; This meant that many children had to be excluded because their clinical history did not specifically mention the evaluation of the persistence of snoring and&#47;or episodes of apnoea after surgery&#46; Additionally&#44; not all of the children diagnosed with severe OSAHS were subjected to a subsequent study&#44; in some cases because this was not requested&#44; and in others because the parents did not attend&#46; On the other hand&#44; we lack data that would allow us to analyse the evolution of the obese patients&#46; This is because very few obese children were studied&#44; and they were excluded from the final analysis&#44; so that no conclusion could be drawn&#46; The number of subjects was also drastically reduced by the attempt to homogenise the sample by excluding patients who had not been subjected to a PSG&#44; or when the surgery did not consist of total adenotonsillectomy&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nevertheless&#44; our greatest limitation was paradoxically the high curation rate&#44; as this meant that only 7 patients &#40;19&#46;51&#37;&#41; had residual OSAHS&#44; which is a very small group for the purpose of analysing their parents&#8217; perception&#46; Therefore&#44; although our data seem to indicate that when parents describe the absence of symptoms after surgery&#44; the PSG check is practically always normal&#44; we believe that more prospective studies are therefore required&#44; with a higher number of subjects&#44; to confirm our data and to determine which children should be monitored after surgical treatment&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Our work does not in any way wish to suggest that adenotonsillar surgery resolves OSAHS in all of the children who receive this treatment&#59; in fact&#44; OSAHS remained after surgery in 19&#46;51&#37; or 21&#46;8&#37; of the patients in the sample studied &#40;depending on whether we select OAHI&#8239;&#8805;&#8239;2 or &#62;1&#44; respectively&#41;&#46; It simply tries to show that&#44; in a child without underlying pathology or obesity&#44; the information supplied by parents about their clinical evolution after surgery may be of value and even decisive when selecting the patients who should be subjected to monitoring&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We are unaware of the reason why parents&#8217; perception changes and ceases to be useful in predicting the result of the basal PSG&#44; as other studies have shown&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> when it is a good guide for predicting the result of the subsequent PSG check&#46; This may be because the sample is composed of children diagnosed with OSAHS whose parents are able to detect a change following treatment&#44; although other theories may be possible&#46; We nevertheless believe that our study will be useful at the least in encouraging the performance of similar studies which are prospective&#44; with a more appropriate methodology&#44; repeating the questionnaire instead of reviewing clinical histories and with more subjects&#44; to confirm our findings&#46; This would help to reduce the number of sleep studies&#44; reducing waiting lists and thereby optimizing the workload of our sleep units&#44; restricting PSG after treatment to those children with an underlying pathology &#40;including obesity&#41; or when the clinical improvement described by the parents is incomplete following surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We therefore conclude that in a child without underlying pathology&#44; the information supplied by the parents about their clinical evolution after surgery may be decisive in the selection of those patients for whom subsequent monitoring should be requested&#44; preventing work overload in sleep units&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2021-04-10"
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            0 => "Obstructive sleep apnoea"
            1 => "Adenotonsillectomy"
            2 => "Polysomnography"
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          "palabras" => array:3 [
            0 => "S&#237;ndrome de apnea-hipopnea de sue&#241;o"
            1 => "Adenoamigdalectom&#237;a"
            2 => "Polisomnograf&#237;a"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hypertrophy of adenotonsillar tissue is the most common cause of OSAS in otherwise healthy children&#44; and therefore adenotonsillectomy is the first line treatment&#46; Scientific societies recommend nocturnal follow-up PSG to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS&#44; obesity&#44; craniofacial anomalies that obstruct the upper airway and neurological disorders&#44; based on the increasing trend of publications reporting residual OSAS after adenotonsillectomy&#46; Follow-up PSG values in children with a pre-operative diagnosis of severe OSAS were analysed retrospectively&#44; and compared to the parents&#8217; impression after ENT surgery&#46; The study population included 41 healthy children with severe OSAS and adenotonsillar surgery&#46; The percentage of children with normal PSG parameters &#40;AHI&#8239;&#60;&#8239;2&#47;h&#41; after adenotonsillectomy was 80&#46;48&#37;&#46; A very good correlation was observed between the parents&#8217; perception after treatment and the follow-up PSG parameters&#44; specifically when the parents perceived that the patient had shown &#8220;complete resolution&#8221; &#40;no snoring or apnoea&#41;&#44; 90&#46;62&#37; of the children had an AHI&#8239;&#60;&#8239;2&#47;h in the follow-up PSG&#44; the maximum residual AHI being 2&#46;6&#47;h&#46; In healthy children with no underlying pathology&#44; the information provided by the parents on clinical progression after surgery could be useful and might enable the selection of those patients who require a follow-up study&#44; avoiding overload in sleep units&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La hipertrofia adenoamigdalar es&#44; en ni&#241;os sin patolog&#237;a de base&#44; la causa m&#225;s frecuente de SAHOS y&#44; por tanto&#44; la adenoamigdalectom&#237;a constituye la primera l&#237;nea de tratamiento&#46; Diferentes sociedades cient&#237;ficas recomiendan la realizaci&#243;n de una PSG de control en el seguimiento&#44; en caso de ni&#241;os con patolog&#237;a de base o si el diagn&#243;stico previo a la cirug&#237;a era de SAHOS moderado o severo&#44; debido a la tendencia creciente de publicaciones con SAHOS residual tras adenoamigdalectom&#237;a&#46; Se analiza retrospectivamente la correlaci&#243;n entre la percepci&#243;n de los padres tras cirug&#237;a ORL y el resultado de la PSG de control en ni&#241;os con diagn&#243;stico de SAHOS severo en los que se ha realizado tratamiento quir&#250;rgico&#46; Se incluyeron 41 ni&#241;os con SAHOS severo y cirug&#237;a adenoamigdalar&#44; cuya tasa de curaci&#243;n ha sido del 80&#44;48&#37;&#46; Se observa muy buena correlaci&#243;n entre la percepci&#243;n de los padres tras el tratamiento y los &#237;ndices en la PSG de control&#44; destacando que cuando los padres percib&#237;an que el paciente hab&#237;a experimentado una &#171;resoluci&#243;n completa&#187; &#40;no ronquido ni apneas&#41;&#44; el 90&#44;62&#37; de los ni&#241;os presentaban un IAHO&#8239;&#60;&#8239;2&#47;h en el control posterior al tratamiento&#44; siendo el IAHO residual m&#225;ximo de 2&#44;6&#47;h&#46; Concluimos que&#44; en un ni&#241;o sin patolog&#237;a de base&#44; la informaci&#243;n aportada por los padres acerca de la evoluci&#243;n cl&#237;nica tras la cirug&#237;a podr&#237;a ser discriminativa para elegir a aquellos pacientes a los que solicitar un estudio de control&#44; evitando sobrecargas en las unidades de sue&#241;o&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; del-R&#237;o Camacho G&#44; Torre Francisco R&#44; Rodr&#237;guez Catal&#225;n J&#44; Sanabria Brossart J&#44; L&#243;pez G&#243;mez R&#44; Troncoso Acevedo F&#46; &#191;Es necesario repetir el estudio de sue&#241;o de control a todos los ni&#241;os con SAHOS moderado-severo tras la cirug&#237;a&#63; Acta Otorrinolaringol Esp&#46; 2022&#59;73&#58;191&#8211;195&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Box diagram showing the average obstructive apnoea-hypopnoea index &#40;OAHI&#41; score according to the parents&#8217; perception after adenotonsillectomy &#40;complete improvement&#44; partial improvement and no improvement&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">OAHI&#58; obstructive apnoea-hypopnoea index&#59; IC&#58; central apnoea index&#59; IDO&#58; desaturations index&#59; BMI&#58; body mass index&#46;</p>"
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                  \t\t\t\t">Average &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Average &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;88 &#40;3&#46;37&#8211;4&#46;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;67 &#40;4&#46;11&#8211;5&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;14&#46;44&#8211;17&#46;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;42 &#40;16&#46;69&#8211;20&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Height &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;33 &#40;98&#46;35&#8211;106&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105&#46;67 &#40;101&#46;89&#8211;109&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;97 &#40;14&#46;43&#8211;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;10 &#40;15&#46;54&#8211;16&#46;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Z score BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;75 &#40;&#8722;1&#46;10 to &#8722;0&#46;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;06 &#40;&#8722;0&#46;37 to 0&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OAHI &#40;&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;95 &#40;22&#46;00&#8211;33&#46;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;59 &#40;0&#46;24&#8211;2&#46;94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IC &#40;&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;05 &#40;1&#46;37&#8211;2&#46;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;69&#8211;1&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IDO &#40;&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;20 &#40;27&#46;16&#8211;41&#46;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;87 &#40;2&#46;13&#8211;5&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Average saturation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;25 &#40;95&#46;63&#8211;96&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;59 &#40;97&#46;29&#8211;97&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimum saturation &#40;nadir&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;98 &#40;72&#46;31&#8211;81&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;67 &#40;89&#46;21&#8211;92&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T90 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;63 &#40;2&#46;27&#8211;12&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;18 &#40;0&#46;13&#8211;0&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2903369.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Anthropometric values and PSG results&#44; basal and subsequent check&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          0 => array:3 [
            "identificador" => "at0015"
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            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">OAHI&#58; obstructive apnoea-hypopnoea index&#59; PSG&#58; polysomnography&#59; OSAHS&#58; obstructive sleep apnoea-hypopnoea syndrome&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complete improvement &#40;n&#8239;&#61;&#8239;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No complete improvement &#40;partial improvement&#8239;&#43;&#8239;no improvement&#41; &#40;n&#8239;&#61;&#8239;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OAHI&#8239;&#60;&#8239;2&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;90&#46;62&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;44&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OAHI&#8239;&#8805;&#8239;2&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;9&#46;37&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;55&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2903368.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Parents&#8217; perception after surgery and the persistence or otherwise of OSAHS in the PSG check &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;001&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:13 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children&#58; a multicenter retrospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Bhattacharjee"
                            1 => "L&#46; Kheirandish-Gozal"
                            2 => "K&#46; Spruyt"
                            3 => "R&#46;B&#46; Mitchell"
                            4 => "J&#46; Promchiarak"
                            5 => "N&#46; Simakajornboon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200912-1930OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2010"
                        "volumen" => "182"
                        "paginaInicial" => "676"
                        "paginaFinal" => "683"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20448096"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment outcomes of obstructive sleep apnoea in obese community-dwelling children&#58; the NANOS study"
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