Four-Year-Old Girl with Abnormal EEG on Routine Overnight Polysomnogram for Snoring and Behavioral Issues

Abstract

A 4-year 10-month-old female was referred to the pediatric sleep clinic for intermittent snoring with periods of observed gasping. She underwent adenoidectomy at 3 years 11 months, after which nasal congestion, snoring, and increased nighttime awakenings again recurred. Parents reported neck hyperextension, frequent mouth breathing, and daytime sleepiness, in addition to restless sleep. She frequently came to sleep in parents' bed, and mother noted intermittent episodes of hyperextension of arms and legs with associated tremors but not tonic-clonic activity.She was diagnosed with autism spectrum disorder after a developmental evaluation for delayed social skills. She was born full term via C-section without complications due to breech presentation. She has no history of seizures or other neurological disorders nor a family history of seizures. However family history was signifi cant for snoring in parents and half-brother with learning disability and tic disorder. Prior trials of antihistamines resulted in daytime sedation, and steroidal nasal sprays were associated with behavior issues.Examination showed a cooperative quiet girl with height and weight appropriate for age. She was noted to have frequent mouth breathing. On oropharyngeal exam, tonsils were graded 2-3+. Moderate nasal congestion without obvious turbinate hypertrophy was noted. Cardiorespiratory and neurologic exam were normal.Patient underwent an overnight polysomnogram. Evaluation of the respiratory component noted mild supine dependent sleep apnea, with an RDI of 4.6, and supine RDI of 8.4 with lowest oxygen saturation of 96%. On the accompanying EEG, the following was noted (see Figure 1).