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Diagnosing sleep-disordered breathing in children with suspected sleep-disordered breathing Sleep questionnaires, combined sleep questionnaires and ‘protocol-driven’ clinical assessments, sleep video recordings and sleep audio recordings Children without comorbidities Recommendations The Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (SRBD-PSQ), with a cut-off of ≥0.33, or Obstructive Sleep Apnoea-18 item questionnaire (OSA-18), with a cut-off of ≥0.60, can be considered for diagnosing moderate-to-severe SDB in children of at least 2 years of age with no comorbidities. While pulse oximetry is non-discriminatory at all ages, particular caution is required in using oximetry to diagnose OSA in children under 2 years of age as children in this age group are predisposed to central sleep apnoea (CSA) (as a result of developmental immaturity) and oxygen desaturations cannot discriminate between obstructive and central events. If hypoventilation is suspected, please refer to the ‘Pulse oximetry and carbon dioxide (CO2) monitoring’ recommendations and GPPs below. The American Academy of Sleep Medicine (AASM) recommends scoring hypoventilation during sleep when >25% of the total sleep time, as measured by either the arterial PCO2 or surrogate (transcutaneous or end tidal which is more relevant in paediatrics), is spent with a PCO2 >50 mm Hg/6.7 kPa.3 Home monitoring (pulse oximetry or CRSS) Recommendation Home CRSS can be considered for diagnosing SDB in children without comorbidities where the patients and/or carers are deemed appropriate for implementing a home sleep study.

The search strategy is available for review in Online supplement appendix 12 of the full guideline.1 Critical appraisal and GRADE analysis of the evidence After an initial screening to determine relevance to the clinical questions, each paper was assessed to determine if it addressed: Following data extraction from the ‘accepted’ papers, evidence profiles were generated for each of the clinical questions and the quality of the evidence was assessed using the GRADE principles.5 Where GRADE analysis was not possible, but the evidence was deemed important enough to be included in the guideline, the evidence has been listed as (Ungraded), denoting that inclusion was reached by consensus of the Guideline Development Group (GDG). A definition of the GRADE scores is shown in table 1.Table 1 GRADE score definitions GRADE Definition High High confidence that the true effect is close to the estimated effect Moderate Moderate confidence that the true effect is close to the estimated effect Low Low confidence that the true effect is close to the estimated effect Very low Very low confidence that the true effect is close to the estimated effect Ungraded GRADE analysis not possible, but evidence deemed important GRADE, Grading of Recommendations, Assessment, Development and Evaluation. GRADE specifies two categories of strength for a recommendation as shown in table 2.Table 2 Explanation of the terminology used in BTS recommendations Strength Benefits and risks Implications Strong Recommended, so ‘offer’ Benefits appear to outweigh the risks (or vice versa) for the majority of the target group Most service users would want to, or should receive this intervention Conditional Suggested, so ‘consider’ Risks and benefits are more closely balanced, or there is more uncertainty in likely service users’ values and preferences Service users should be supported to arrive at a decision based on their values and preferences BTS, British Thoracic Society.

Abstract Introduction The impact of unilateral vocal fold palsy (UVFP) on quality of life cannot be underestimated. Management may be complicated by difficulty in determining prognosis. Currently, there is no standardized management pathway for UVFP. Surgery is considered when speech and language therapy has not been successful or when there is significant aspiration and dysphonia. Surgical options for UVFP include injection laryngoplasty, thyroplasty and laryngeal reinnervation. Methods We report the case of a 6-year-old girl with a left UVFP sustained following PDA ligation. She suffered significant voice issues, aspiration and intermittent stridor limiting activities. Following multidisciplinary team reassessment including videofluoroscopy and perceptual and objective voice measures, laryngotracheobronchoscopy (LTB) and laryngeal electromyography (LEMG) with injection of Radiesse into the left vocal fold was undertaken. Consequently, she underwent non-selective laryngeal reinnervation with the aim of providing a permanent solution by the formation of an anastomosis between the ansa cervicalis and the main stump of the recurrent laryngeal nerve (RLN) resulting in improved muscle tone. Results LEMG indicated no spontaneous recovery. The laryngeal injection allowed for temporary improvement of voice and feeding. Consequently non-selective left laryngeal reinnervation using ansa cervicalis and repeat vocal cord injection was performed. Twelve months following surgery her voice remain greatly improved and there are no feeding issues or aspiration. Conclusion In this case so far the use of LEMG and laryngeal reinnervation has proved successful. Non-selective laryngeal reinnervation techniques for UVFP may provide a permanent solution and should be considered in children as a management option in suitable cases.

Evoked otoacoustic emissions (EOAEs) are produced by the cochlea and provide an objective and non-invasive measure of cochlear function. A new technique, based on Maximum Length Sequences (MLSs) enables stimulus rates of up to 5000 clicks/s to be used, and gives increased speed and sensitivity of testing. Volterra slice otoacoustic emissions (VSOAEs) can be extracted from the response using this technique. These represent nonlinear temporal interaction components and are more sensitive to changes in cochlear pathology than the conventional response. Conventional EOAE amplitude differs between ears and sexes; female subjects having responses of greater amplitude than male subjects and right ears larger responses than left ears. As a pre-requisite to clinical use it is necessary to establish if these differences occur with the Maximum length sequence otoacoustic (MLSOAE) technique and with VSOAEs and whether they change with stimulus rate, order or slice. The relationship between VSOAEs, Spontaneous otoacoustic emissions (SOAEs), Distortion product otoacoustic emissions (DPOAEs) and the input/output function (I/O) for click-evoked OAEs (CEOAEs) recorded at the conventional rate (40 clicks/s) was also investigated to assess if these measures of cochlear nonlinearity were related to one another. In the first set of experiments 80 ears of normally hearing adults were tested. MLSOAEs were recorded at eight stimulus rates and two stimulus levels. For the second and third experiments 45 ears of normally hearing adults were tested. SOAEs, DPOAEs, the input/output function (I/O) for CEOAEs at the conventional rate (40 clicks/s) and at four stimulus levels, and VSOAEs at three stimulus rates were recorded. Female subjects were found to have statistically significantly larger MLSOAEs than male subjects and gave larger amplitude responses in their right ears. This sex difference was observed with VSOAEs. A rate effect was also demonstrated with the amplitude of the MLSOAEs decreasing with an increase in rate. The VSOAE amplitude was greater for the second order compared with the third order response, and slice one had a greater amplitude than slice two. VSOAEs of higher amplitude were obtained in SOAE-positive ears. There was a significant relationship between the slope of the I/O function of the CEOAE and the VSOAEs. The study has provided normative data for MLSOAE testing and for VSOAEs. The data obtained suggest that the amplitude (CEOAE I/O function) and temporal (VSOAEs) nonlinearities arise from the same generators, whereas the frequency domain nonlinearities (SOAEs & DPOAEs) have different generators. MLSOAEs and VSOAEs have great potential for clinical use.