2.1

Study subjects

From August 2007 to January 2009, in the otolaryngology ward of a tertiary referral hospital (Imam Khomeini hospital), 96 patients were selected among children who had symptoms related to chronic mouth breathing such as snoring, nasal obstruction, and sleep apnea (at least 3 months before diagnosis) and who did not have the following: tonsillar hypertrophy (grade II and more), age older 3 years, septal deviation, allergic rhinitis, choanal atresia, craniofacial anomaly, inflammatory disease of the airway (in the past 2 weeks), history of previous surgery, current medical treatment, and neuromuscular disorders.

Among 96 patients who participated in this study, 7 (7.2%) patients refused to undergo diagnostic nasal endoscopy and were therefore excluded from the study. The rest of the patients were 50 (56.2%) boys and 39 (43.8%) girls. The age distribution of patients is summarized in Fig. 1 .

Patients’ age distribution.

2.2

Ethical approval

The protocol of this study was approved by the Institutional Review Board of the Tehran University of Medical Science. Detailed information about the study was given to the participants’ parents, and a written informed consent was obtained from each one. All aspects of the study were conducted according to the Declaration of Helsinki.

2.3

Variable measurement

Demographic data, history of snoring, recurrent pharyngitis, nasal obstruction, sleep apnea, and recurrent acute otitis media were recorded. History was taken from parents or children themselves if they were reliable. Each symptom (depending on severity) was categorized into 4 groups according to patients’ or their parents’ statements. The details of the classification are as follows: snoring (grade 0 = absent, grade 1 = 1–2 night[s] per week, grade 2 = 3–5 nights per week, grade 3 = 6–7 nights per week), nasal obstruction (chronic mouth breathing) (grade 0 = absent, grade 1 = one fourth to one half of a day, grade 2 = one half to three fourths of a day, and grade 3 = three fourths to all of the day), sleep apnea (grade 0 = absent, grade 1 = 1–2 night[s] per week, grade 2 = 3–5 nights per week, and grade 3 = 6–7 nights per week), otitis media (grade 0 = absent, grade 1 = 1–3 episode[s] per year, grade 2 = 4–6 episodes per year, and grade 3 = >6 episodes per year), and recurrent pharyngitis (grade 0 = absent, grade 1 = 1–3 episode[s] per year, grade 2 = 4–6 episodes per year, and grade 4 = >6 episodes per year). All symptoms scores were analyzed separately, and the relationship between the sum of all scores and other variables was also evaluated.

All patients underwent tympanometry.

2.1

Study subjects

From August 2007 to January 2009, in the otolaryngology ward of a tertiary referral hospital (Imam Khomeini hospital), 96 patients were selected among children who had symptoms related to chronic mouth breathing such as snoring, nasal obstruction, and sleep apnea (at least 3 months before diagnosis) and who did not have the following: tonsillar hypertrophy (grade II and more), age older 3 years, septal deviation, allergic rhinitis, choanal atresia, craniofacial anomaly, inflammatory disease of the airway (in the past 2 weeks), history of previous surgery, current medical treatment, and neuromuscular disorders.

Among 96 patients who participated in this study, 7 (7.2%) patients refused to undergo diagnostic nasal endoscopy and were therefore excluded from the study. The rest of the patients were 50 (56.2%) boys and 39 (43.8%) girls. The age distribution of patients is summarized in Fig. 1 .

Patients’ age distribution.

2.2

Ethical approval

The protocol of this study was approved by the Institutional Review Board of the Tehran University of Medical Science. Detailed information about the study was given to the participants’ parents, and a written informed consent was obtained from each one. All aspects of the study were conducted according to the Declaration of Helsinki.

2.3

Variable measurement

Demographic data, history of snoring, recurrent pharyngitis, nasal obstruction, sleep apnea, and recurrent acute otitis media were recorded. History was taken from parents or children themselves if they were reliable. Each symptom (depending on severity) was categorized into 4 groups according to patients’ or their parents’ statements. The details of the classification are as follows: snoring (grade 0 = absent, grade 1 = 1–2 night[s] per week, grade 2 = 3–5 nights per week, grade 3 = 6–7 nights per week), nasal obstruction (chronic mouth breathing) (grade 0 = absent, grade 1 = one fourth to one half of a day, grade 2 = one half to three fourths of a day, and grade 3 = three fourths to all of the day), sleep apnea (grade 0 = absent, grade 1 = 1–2 night[s] per week, grade 2 = 3–5 nights per week, and grade 3 = 6–7 nights per week), otitis media (grade 0 = absent, grade 1 = 1–3 episode[s] per year, grade 2 = 4–6 episodes per year, and grade 3 = >6 episodes per year), and recurrent pharyngitis (grade 0 = absent, grade 1 = 1–3 episode[s] per year, grade 2 = 4–6 episodes per year, and grade 4 = >6 episodes per year). All symptoms scores were analyzed separately, and the relationship between the sum of all scores and other variables was also evaluated.

All patients underwent tympanometry.

3.1

Nasal endoscopy

Nasal endoscopy (using 2.7-mm Karl Störz [Germany] 0 rigid endoscope) was used to obtain a full choanal image by the same physician in all evaluations. Before performing nasal endoscopy, topical anesthesia and vasoconstriction were administered in all patients using a topical solution composed of 5% Xylocaine (Osveh, Teheran, Iran) and 0.5% phenyl ephedrine without any sedation.

The amount of obstruction was categorized using 2 methods: the first one was through dividing the amount of obstruction to the full choanal surface that was expressed in 4 grades (grade 0 = 0–25%, grade 1 = 25–50%, grade 2 = 50–75%, grade 3 = 75–100%). The second method was according to the anatomical relationship between surrounding anatomical structures such as torus tubarius, vomer, and the soft palate (grade 0 = none, grade 1 = torus tubarius, grade 2 = torus tubarius and vomer, and grade 3 = vomer and soft palate) .

Nasal endoscopy was recorded using a DVD recorder. Afterward, only images of the adenoid were captured with a camera (Störz telecam). Pictures used for the calculation of the occupied parts were the pictures of the adenoid in which a full view of choana could be seen. A special software was designed to calculate the occupied portion of choana with adenoid to the full surface of it using images in which all parts of adenoid could be evaluated. This software can be downloaded for free from our Web site ( www.tums.ac.ir ).