{"paper_id":"24bd5233-26ef-45fc-8d8f-9e1084b7cd3d","body_text":"Multidimensional symptoms and comprehensive diagnosis of pediatric narcolepsy combined with sleep apnea and two years follow-up: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Multidimensional symptoms and comprehensive diagnosis of pediatric narcolepsy combined with sleep apnea and two years follow-up: a case report Yiting Xiong, Jie Chen, Jiayue Si, chunqin he, Xuehua Wang, Zhe Li, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3910379/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : The characteristics of narcolepsy onset in children differs significantly from those of adults, and easily misdiagnosed for their multidimensional symptoms and concomitant diseases. Case Report and Results: A 6-year-old girl with multidimensional symptoms: typical symptoms of mood disorder, atypical symptoms of narcolepsy combined with rapid eye movement (REM) sleep behavioral disorder (RBD) and periodic limb movement (PLM), was diagnosed with narcolepsy type 1 and complex sleep apnea. Obstructive sleep apnea (OSA) caused by adenoid and tonsillar hypertrophy at baseline and central sleep apnea (CSA) after surgery of adenoid and tonsillar. After adenoidectomy and tonsillectomy, OSA remitted, excessive daytime sleepiness (EDS), RBD symptoms, mental symptoms and sleep structure were improved, but more PLMs and CSA presented and SORE multiple sleep latency test (MSLT) increased in this patient. During 2 years follow up, only behavioral managements were performed. The child had good social function, significant improvement in subjective EDS, occasional nocturnal sleep behavior abnormalities rated by scales two years later. Conclusion : It was important to monitor in time with multidimensional symptoms and follow up for a longer time during multidisciplinary treatments in children with narcolepsy. Exploration of regular personalized behavioral interventions might be benefit for them. narcolepsy mood disorder sleep apnea polysomnography (PSG) case report Figures Figure 1 Figure 2 Figure 3 Introduction The main symptoms of narcolepsy, which was first proposed by Gelineau in 1880 and is also known as Gelineau syndrome 1 , include uncontrollable brief sleep attacks, sudden collapse, sleep paralysis, sleep hallucinations, and nocturnal sleep disturbances as the main clinical features. Narcolepsy can be divided into two types depending on whether or not there is a hypocretin deficiency: narcolepsy type 1 (also known as hypothalamic hormone deficiency syndrome, or narcolepsy with cataplexy) and narcolepsy type 2 (also known as narcolepsy without cataplexy) 2 . Studies had reported that the onset of narcolepsy is usually between 10–20 years of age, with a prevalence of 0.025%-0.05% 3 . The etiology of narcolepsy may be closely related to environmental and genetic factors 4 , and the positivity rate of human leukocyte antigen DQB1*0602 in patients with episodic somnolence ranges from 88–100% 5 . It had also been suggested that narcolepsy is an autoimmune disease that may be caused by T cell-mediated attacks on appetite neurons 6–7 . The clinical presentation of narcolepsy onset in children differs significantly from those of adults because of the immaturity of their neurological development and the specific physiological characteristics. Due to limited expressive skills, children usually respond to EDS with irritability, hyperactivity, inattention, or impulsivity. Therefore, physicians can easily misdiagnose narcolepsy as a psychiatric or neurodevelopmental disorder such as mood disorder, attention-deficit/hyperactivity disorder (ADHD) 8 . The common symptoms of cataplexy in children are also atypical, including prolonged episodes, facial and intermandibular protrusion, spontaneous tongue protrusion, neck extension, and slurred speech 9 . Cataplexy symptoms are usually a response to emotional triggers and can be exacerbated by changes in mood. The difficulty in diagnosing pediatric narcolepsy is compounded by the fact that narcolepsy rarely presents with the typical five symptoms in children, and narcolepsy in pediatric population is prone to comorbidity with OSA, ADHD and mood disorders 10 , which increased the possibility of misdiagnosis. The prevalence of OSA is high in patients with narcolepsy, and studies had reported that the co-morbidity rate is higher in the pediatric population 11 . Children with OSA may exhibit two forms of breathing during sleep, one with the symptoms of periodic OSA similar to that in adults with OSA syndrome; and the other, with obstructive alveolar hypoventilation that present in younger children, prolonged and persistent partial obstruction of the upper airway with hypercapnia and decreased oxygen saturation 12 . There are various pathophysiological factors that contribute to OSA in children, the primary factors being adenoid, tonsil hypertrophy, and obesity 13 . In addition, due to the immature development of the nervous system in children, cortical arousal response is poor when the airway is obstructed 14 . In summary, the special physiological structure of children and atypical nature of their symptoms pose a great challenge to the diagnosis of narcolepsy as well as the diagnosis and treatment of concomitant diseases. This report summarizes and analyzes a case involving a child with narcolepsy and sleep apnea symptoms, offering a detailed analysis of the clinical symptoms and comprehensive diagnostic considerations, as well as the prognosis and two-year follow-up. Case Report and Results In June 2021, a 6-year-old girl complained of “sleep disturbances with daytime mood abnormalities for more than 1 year”. The child presented poor daytime energy, fatigue, long sleep durations, falling sleep fast at night with dreaming, crying, and shouting more than 1 year ago. She also exhibited open-mouth breathing and had difficulty breathing when excited. Additionally, she displayed behaviors such as sticking her tongue out and exhibited vocalization and physical activity during nighttime sleep. The child developed weakness in the limbs when she was agitated or laughed, the frequency of limb activity and vocalization of the child increased at night, accompanied by poor mood during the day. The child’s physical examination showed a height of 1.20 m, a weight of 26 kg, BMI of 18 kg/m 2 , and a second-degree enlargement of the tonsils. The Stanford Sleepiness Scale (SSS) and Epworth Sleepiness Scale (ESS) indicated that the patient had severe sleepiness, and the emotionally triggered Sudden Collapse Questionnaire (SCQ) confirmed the presence of cataplexy. MSLT showed that the patient had a mean sleep latency (SL) of 1.6 minutes and REM stage sleep occurred in four naps (see in Figure 1). PSG showed an apnea hypoventilation index (AHI) of 6.7 events/hour (1.1 events/hour for OSA, 0.7 events/hour for CSA and 4.9 events/hour for hypoventilation). Increased muscle tone was seen in the patient’s rapid eye movement (REM) stage sleep. The case was diagnosed with narcolepsy type 1, pediatric obstructive sleep apnea and hypopnea, and pediatric mood disorder secondary to sleep-wake disorder. ………….…. FIGURE 1 about here …………….. Then the child underwent bilateral tonsillectomy and adenoidectomy. After surgery, the child's daytime psychosis improved and the nocturnal limb movements reduced, during which she had taken melatonin 0.5 mg quāque nocte (qn) for half a month. MSLT at one month postoperative recheck showed that the child had a mean SL of 1.9 minutes and REM stage sleep was present on all five naps. The results of MSLT before and 1 month after surgery were shown in Table 1. Her PSG at one month after surgery showed AHI was 2.3 events/hour (0 events/hour for OSA, 2.2 events/hour for CSA and 0.1 events/hour for hypoventilation) and constant chin electromyography activity during REM sleep (see Figure 2). From the PSG recording, we still can see limb movements in the REM phase (see Video 1). The patient’s postoperative drowsiness was reduced and the patient had a decrease in AHI but an increase in periodic limb movement index (PLMI). ………… TABLE 1 about here………... ………….…. FIGURE 2 about here …………….. ………… VIDEO 1 about here………... The parameters of PSG before and 1 month after surgery are shown in Table 2. Table 3 illustrates the changes in sleep structure before and 1 month after surgery. ………… TABLE 2 about here………... ………… TABLE 3 about here………... The family refused to apply any psychoactive drug treatment because the child was basically functioning normally, and she was discharged from the hospital for regular monitoring, behavior management and outpatient follow-up. Two years later, her daytime sleepiness symptoms were improved, cataplexy still existed, and she still has bilateral lower limbs extremity tenderness and mild facial expression changes. Body activity and talking decreased significantly during her sleep at night, and the patient's social function was normal. SSS, ESS, Ullanlinna Narcolepsy Scale (UNS), Children's Depression Inventory (CDI), Spence Children's Anxiety Scale Short Version (SCAS-S) and Strengths and Difficulties Questionnaire (SDQ) scores were normal. The clinical scale assessments before surgery, 1 month and 2 years after surgery are shown in Table 4. Figure 3 demonstrates the changes in the patient's Multiple symptoms at different stages. ………… TABLE 4 about here………... ………….…. FIGURE 3 about here …………….. Discussion 1. Childhood narcolepsy with multidimensional clinical symptoms and atypical onset was easily misdiagnosed. We summarized the patient's multidimensional clinical symptoms as follows: ( 1 ) EDS, persistent daytime sleepiness, poor mental performance, and symptoms like dull eyes and drooping eyelids. These symptoms can return to normal after reminders; ( 2 ) cataplexy symptoms, such as cataplexy symptoms when emotionally excited; ( 3 ) abnormal nocturnal sleep symptoms, such as sleep talking, shouting, crying and vigorous physical activity accompanied by vivid dream experiences; ( 4 ) airway obstruction symptoms, such as open mouth breathing; ( 5 ) emotional symptoms, such as dull facial expressions, emotional irritability, tantrums, and reluctance to speak; ( 6 ) attention deficit symptoms, such as inattention and sluggishness; ( 7 ) abnormal neurobehavior, such as grimacing, tongue out, and unsteady walking. Our case showcased a complex clinical presentation encompassing sleep, mood, and behavior, highlighting the multifaceted symptoms and co-morbidities of childhood narcolepsy. These multidimensional symptoms are consistent with the reviews of Claudio L. A. & Bassetti et al. They had reported that the clinical manifestations of narcolepsy are not only related to sleep-arousal but also related to motor, mental, emotional, cognitive, metabolic and autonomic functions 15 . The authors of this study also showed that patients with narcolepsy developed secondary problems such as depressive disorders, restless legs syndrome (RLS) and ADHD 15 . At the same time, some studies had observed abnormalities in reward function and emotion processing in patients, which may be able to provide new perspectives to explain the vulnerability of the disorder to comorbidity with other psychiatric disorders 16 . In summary, the results of PSG monitoring and MSLT are important to clarify the diagnosis. Yet, we should consider the possibility of other concomitant sleep-wake disorders and psychiatric disorders, so strengthening the monitoring during the treatment was important and significant. Moreover, the diagnostic indicators of sleep apnea hypoventilation in children are different from that in adults 17 , which also needs to be accurately identified by clinicians to avoid missing diagnoses. 2. Importance to monitor the changes of symptoms, assessments, and tests during the treatment process for dynamic diagnosis. This case also differs from typical narcolepsy in that the patient had chronic tonsillitis and adenoid hypertrophy found during hospitalization, and PSG also indicated the presence of OSA. Studies have reported that the symptoms of EDS were present with prolonged exposure to sleep fragmentation associated with sleep apnea, sleep deprivation, and changes in melatonin secretion and hypoventilation syndrome 18 . Therefore, before diagnosing narcolepsy, it is important to analyze whether EDS is closely related to OSA. After bilateral tonsillectomy and adenoidectomy, the child’s ventilation improved significantly, and EDS and nocturnal sleep disturbances were less severe than before. However, although there was a decrease in obstructive respiratory events after surgical treatment of OSA, the CSA index increased, the reasons for which deserved our consideration. In patients with obstructive and central sleep disordered breathing, the ventilatory response to CO 2 is more sensitive between normal obstructive apnea thresholds, with narrower PaCO 2 reserve, thus also leading to lower stability of respiratory control 19 . Typically, unstable respiratory control will cause the patient's body to gradually establish a new, higher PaCO 2 setting during sleep, with relative hypercapnia, leading to awakening after hyperventilation. However, as the patient returns to sleep and ventilation during awakening causes PaCO 2 to fall below the apnea threshold, central sleep apnea occurs, which is the cause of most central events in patients with OSA 20 . Studies have shown that after the postoperative OSA problem is resolved, the stimulus for CSA (arousal/microarousal secondary to obstructive events) would disappear in most children and so did CSA 21 . This was not the case in our case, and we speculated that this might be for two reasons: firstly, in some younger children, CSA may be physiologic rather than a post-arousal effect of OSA. The younger the child, the more likely it is that physiological central sleep apnea occurs and does not disappear with improvement of airway problems, but rather becomes more prominent 22 . Secondly, a central event may also be treatment emergent central sleep apnea (TECSA), also known as treatment-induced central sleep apnea 23 . A possible mechanism of occurrence is that sudden normalization of nighttime CO 2 partial pressure after surgery can trigger TECSA in patients with reduced chemosensitivity due to prolonged exposure to nocturnal hypercapnia 24 . The study showed that physiological central sleep apnea gradually resolves with age, and TECSA has the possibility of spontaneous remission 25 . Considering the improvement of somnolence and other symptoms after tonsillectomy and adenoidectomy, PSG needs to be done after 3–6 months to dynamically monitor the occurrence of apnea events. 3. Diagnostic issues in the concomitant parasomnia and sleep-related movement symptoms In the result of PSG, clinicians found that the patient’s sleep video showed abnormal behaviors throughout the night, specifically abnormal vocalizations, arm tapping on the edge of the bed, stirring, and semi-sitting up. These movements occurred both in NREM stage and REM stage, but more frequently in REM stage, while in NREM stage, the movements all occurred in N2 stage. The loss of atonia and elevated chin muscle tone occurred in the REM stage, which may be associated with REM sleep behavioral disorder (RBD) secondary to narcolepsy. Related studies claimed that narcolepsy is the most common cause of a secondary RBD 26 . It has been suggested that it is closely related to hypothalamic secretin deficiency 27 , but there is still a lack of sufficient evidence and needs to be studied further. In addition, there is no clear study of the specificity of the behaviors that appear in the N2 stage, perhaps this could be the subject for future studies. Meanwhile, the nocturnal motor behaviors that appeared in patients with narcolepsy were simple and stereotyped, which were less complex and varied than those in patients with primary RBD. In addition, the patient’s PSG was also consistent with manifestations of PLMs that may be associated with OSA and narcolepsy. After tonsillectomy and adenoidectomy, the PLMI increased and AHI decreased; such a phenomenon is often a rebound manifestation of improved sleep 28 . Previous studies suggested that PLMs are caused by dopamine system dysfunction and may also be associated with dysfunctional iron metabolism in the central nervous system 29 . It has been suggested that hypothalamic secretin deficiency may also be associated with PLM symptoms through secondary dopamine dysfunction and possibly narcolepsy 30 . 4. Application of medication and behavior management The European guideline and expert statements on narcolepsy published in 2021 recommend that the management of narcolepsy involves both pharmacological and non-pharmacological treatments, and that treatment decisions should take into account the patient's clinical symptoms, comorbidities, tolerance to medications, and potential risks of medication use 31 . The consensus considers planned daytime naps and administration of sodium oxybate (SXB), modafinil, solriamfetol and pitolisant for excessive daytime sleepiness in children 31 . Modafinil is commonly used to treat residual EDS 32 . Studies have also reported the effectiveness of solriamfetol, a dopamine-norepinephrine reuptake inhibitor, and pitolisant, a histamine H 3 receptor inverse agonist, in the treatment of EDS 33 . Solriamfetol has been tested in a randomized controlled trial (RCT) for the treatment of EDS associated with OSA and narcolepsy 34 . Pitolisant has been tested in several RCTs for narcolepsy showing improvement in subjective and objective EDS, and another trial for OSA showed improvement in subjective EDS 35 . The European guideline and expert statements also recommend that narcolepsy combined with other sleep disorders should be treated in accordance with the treatment recommendations for patients with non- narcolepsy 31 . Several randomized controlled trials have demonstrated that treatment of comorbid other sleep disorders can also improve daytime sleepiness 36 . Continuous positive airway pressure (CPAP) ventilation treatment for 6–12 months can also improve daytime sleepiness 37 . In addition, clonazepam can be used for treatment of narcolepsy with abnormal REM sleep behavior 38 , but the use of clonazepam may exacerbate symptoms of EDS, and the paradoxical nature of the treatment is the reason for the limitation of pharmacological treatment. Conclusion In summary, this case reports a child with narcolepsy combined with sleep apnea and shares the difficulties encountered in this case, including the analysis of multidimensional symptoms from narcolepsy, mood disorders, OSA and CSA, PLMs, and parasomnia.. Follow-up at two years has demonstrated the benefit of behavioral management for patients, and future efforts to increase the prevalence of behavioral management should be strengthened. Related studies have also confirmed the long-term efficacy of behavioral management in patients 39 . Limitations There are still limitations in this case. Our follow-up of the patient mainly focused on the detection of behaviors and sleep, including subjective scale assessment and objective PSG monitoring, but the detection of specific biochemical indicators of narcolepsy was lacking. HLA DQB1*0606 and hypothalamic secretin-1 tests of cerebrospinal fluid have not been detected in the patient, so genetic testing and lumbar puncture can be improved in the future for subsequent basic research to explore the possible molecular and genetic mechanisms of narcolepsy. Declarations Author Contributions Yiting Xiong, Yu Bai, and Xueqin Wang wrote and modified the medical record of the child; Jie Chen and Chunqin He conducted PSGs and MSLTs, and Jie Chen issued these reports; Yiting Xiong, Jiayue Si and Xueqin Wang drafted the case report; Xueqin Wang and Xuehua Wang guided the clinical diagnosis and treatment of the patient, and the modification of the case report; Suxia Li, Xuehua Wang, Zhe Li, Xinyang Zhang, Tong Na and Rong Zhou contributed to the manuscript revision; Xueqin Wang and Zifeng Zhang organized and coordinated the research work; Lin Lu undertook a comprehensive review and guidance of the manuscript. All the authors reviewed and approved the final manuscript. Funding Supported by STI2030-Major Projects 2021ZD0201900 (2021ZD0201905); the Beijing Municipal Science & Technology Commission, No. Z191107006619091; Capital’s Funds for Health Improvement and Research, No. 2022-2-4115. Acknowledgement Thanks to the child and her family for their support in collecting and reporting this case, and to all investigators for their contributions to the manuscript of this case. Conflict-of-Interest Statement All authors declare no competing interests. Ethical Statement The patient’s father signed an informed consent form on August 27, 2021, and permitted doctors to collect and report anonymous clinical data of his child for publication. The article was reviewed and approved by the Medical Ethics Committee of Peking University Sixth Hospital (Institute of Mental Health) on January 24, 2023. Availability of Data and Materials Statement The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. 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CNS Drugs. 2020 Jan;34(1):9-27. doi: 10.1007/s40263-019-00689-1. PMID: 31953791; PMCID: PMC6982634. Thorpy MJ, Shapiro C, Mayer G, et al. A randomized study of solriamfetol for excessive sleepiness in narcolepsy [published correction appears in Ann Neurol. 2020 Jan;87(1):157]. Ann Neurol . 2019;85(3):359-370. doi:10.1002/ana.25423. PMID: 30694576; PMCID: PMC6593450. Lamb YN. Pitolisant: A Review in Narcolepsy with or without Cataplexy. CNS Drugs. 2020 Feb;34(2):207-218. doi: 10.1007/s40263-020-00703-x. PMID: 31997137. Biyani S, Cunningham TD, Baldassari CM. Adenotonsillectomy outcomes in children with sleep apnea and narcolepsy. Int J Pediatr Otorhinolaryngol. 2017 Sep;100:62-65. doi: 10.1016/j.ijporl.2017.06.018. Epub 2017 Jun 16. PMID: 28802388. Javaheri S, Javaheri S. Update on Persistent Excessive Daytime Sleepiness in OSA. Chest. 2020 Aug;158(2):776-786. doi: 10.1016/j.chest.2020.02.036. Epub 2020 Mar 6. PMID: 32147246. St Louis EK, Boeve BF. REM Sleep Behavior Disorder: Diagnosis, Clinical Implications, and Future Directions. Mayo Clin Proc. 2017 Nov;92(11):1723-1736. doi: 10.1016/j.mayocp.2017.09.007. Epub 2017 Nov 1. PMID: 29101940; PMCID: PMC6095693. Blackmer AB, Feinstein JA. Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review. Pharmacotherapy. 2016 Jan;36(1):84-98. doi: 10.1002/phar.1686. PMID: 26799351. Tables TABLE 1. Parameters of MSLTs before and after surgery MSLT Before Surgery After Surgery Mean Sleep Latency（minutes） 1.60 1.90 Mean REM Latency（minutes） 1.30 1.10 Number of REM Episodes 11 8 Number of MLST with REM Episodes 4 5 MSLT, Multiple Sleep Latency Test; REM, Rapid Eye Movement. TABLE 2. Parameters of PSG and clinical scale assessments before and after surgery Parameters Before Surgery After Surgery PSG Sleep-related Breathing Event Total Apnea-Hypopnea Index (Events/hour) 6.70 2.30 Hypopnea Index (Events/hour) 4.60 0.10 Apnea Index (Events/hour) 2.10 2.20 Central Apnea Index (Events/hour) 0.70 2.20 Obstructive Apnea Index (Events/hour) 1.10 0.00 Mixed Apnea Index (Events/hour) 0.30 0.00 Oxygen Desaturations index 0.80 0.40 Lowest SpO2 (%) 80 86 Leg Movement Number of Leg Movement 128 176 Leg Movement Index (Events/hour) 16.80 23.30 Number of PLM 21 98 PLMI (Events/hour) 2.80 13.00 Clinical Scales SSS 6 4 ESS 23 13 UNS 27 12 PSG, Polysomnography; PLM, Periodic Leg Movement; PLMI, Periodic Leg Movement Index; SSS, Stanford Sleepiness Scale; ESS, The Epworth Sleeping Scale; UNS, Ullanlinna Narcolepsy Scale. Table 3. Changes in sleep structure of patients before and after surgery. TST (%) Before surgery 1 month after surgery REM 25.6 23.9 NREM1 4.8 13.7 NREM2 31.9 30.9 NREM3 37.6 31.5 TST, Total Sleep Time; REM, Rapid Eye Movement; NREM, Non-Rapid Eye Movement. Table 4. clinical scale assessments before surgery, 1 month and 2 years after surgery. Before surgery 1month after surgery 2 years after surgery CDI 16 14 5 SCAS- S 5 6 5 SDQ 19 17 13 SSS 6 4 2 ESS 23 13 8 UNS 27 12 10 Children’s Depression Inventory, CDI; Spence Children’s Anxiety Scale- Short Version, SCAS-S; Strengths and Difficulties Questionnaire, SDQ; SSS, Stanford Sleepiness Scale; ESS, The Epworth Sleeping Scale; UNS, Ullanlinna Narcolepsy Scale. Additional Declarations No competing interests reported. Supplementary Files video.mp4 VIDEO 1. Polysomnography recording from the patient after bilateral tonsil and adenoidectomy. Body activities occurring in the REM phase are shown in the video. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-3910379\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":272872343,\"identity\":\"70c01b8b-8537-48a2-9f5a-b08a58612bbc\",\"order_by\":0,\"name\":\"Yiting Xiong\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking University Sixth Hospital, Peking University Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth 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Davis\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jiayue\",\"middleName\":\"\",\"lastName\":\"Si\",\"suffix\":\"\"},{\"id\":272872346,\"identity\":\"2e46de90-2e06-429f-af7b-067f13ced85c\",\"order_by\":3,\"name\":\"chunqin he\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Yan'an Third People's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"chunqin\",\"middleName\":\"\",\"lastName\":\"he\",\"suffix\":\"\"},{\"id\":272872347,\"identity\":\"d1fc6b85-7558-4efd-890d-f515024246be\",\"order_by\":4,\"name\":\"Xuehua Wang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Beijing United Family Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xuehua\",\"middleName\":\"\",\"lastName\":\"Wang\",\"suffix\":\"\"},{\"id\":272872348,\"identity\":\"30b92072-3506-4370-9e07-bb620673db38\",\"order_by\":5,\"name\":\"Zhe Li\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Beijing Normal 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11:16:00\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-3910379/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-3910379/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":51185193,\"identity\":\"121ccb6a-1c81-4b76-ad2e-821a1772c0bc\",\"added_by\":\"auto\",\"created_at\":\"2024-02-15 15:50:35\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":56435,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMultiple sleep latency tests from the patient before bilateral tonsil and adenoidectomy. R: rapid eye movement; W: Wake; N: Non-rapid eye movement.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3910379/v1/ec08a4349a69857ee2880c16.png\"},{\"id\":51185191,\"identity\":\"0ba73303-f637-4ca9-8cb7-9d978038a1cd\",\"added_by\":\"auto\",\"created_at\":\"2024-02-15 15:50:35\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":385096,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePolysomnography recording from the patient after bilateral tonsil and adenoidectomy. Note that the polysomnogram epoch above shows normal Rapid eye movement (REM) atonia levels in the chin muscle, and the predominant abnormality in the epoch below is additional activations of abnormal phasic bursting in the chin muscle, as known as REM sleep without atonia (RSWA).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3910379/v1/0b5bcc2e03dfb923941aca0c.png\"},{\"id\":51185188,\"identity\":\"1c700ef1-e6bf-4e48-bcae-a3575860e746\",\"added_by\":\"auto\",\"created_at\":\"2024-02-15 15:50:34\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":31843,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMultiple symptoms of reported patient. Abbreviations: MA: Mood abnormalities; SAHS: Sleep Apnea Hypopnea Syndrome; CA; cataplexy symptoms; EDS: Excessive Daytime Sleepiness; ASS: abnormal sleep symptoms; LMI: Leg Movement Index; OSA: Obstructive Apnea Index; CSA: Central Apnea Index; AHI: Apnea-Hypopnea Index; ⊕, present; ⊖, absent; ↓, Mild improvement of symptoms; ↓ ↓, Significant improvement in symptoms; ?, Situation unknown.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3910379/v1/995d2bea729ec77c0c708738.png\"},{\"id\":56868683,\"identity\":\"d6fc246b-6afb-41f0-ab75-4d26f981aa82\",\"added_by\":\"auto\",\"created_at\":\"2024-05-21 13:09:23\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":921622,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3910379/v1/6efbb280-dcd0-4c70-b0e1-61c9eef59fec.pdf\"},{\"id\":51185190,\"identity\":\"646a60e3-f73e-4555-bac6-b638fe4e9ae2\",\"added_by\":\"auto\",\"created_at\":\"2024-02-15 15:50:35\",\"extension\":\"mp4\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":2561722,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eVIDEO 1. Polysomnography recording from the patient after bilateral tonsil and adenoidectomy. Body activities occurring in the REM phase are shown in the video.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"video.mp4\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3910379/v1/76e3afb948ab7cb1b1935430.mp4\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Multidimensional symptoms and comprehensive diagnosis of pediatric narcolepsy combined with sleep apnea and two years follow-up: a case report\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe main symptoms of narcolepsy, which was first proposed by Gelineau in 1880 and is also known as Gelineau syndrome\\u003csup\\u003e1\\u003c/sup\\u003e, include uncontrollable brief sleep attacks, sudden collapse, sleep paralysis, sleep hallucinations, and nocturnal sleep disturbances as the main clinical features. Narcolepsy can be divided into two types depending on whether or not there is a hypocretin deficiency: narcolepsy type 1 (also known as hypothalamic hormone deficiency syndrome, or narcolepsy with cataplexy) and narcolepsy type 2 (also known as narcolepsy without cataplexy)\\u003csup\\u003e2\\u003c/sup\\u003e. Studies had reported that the onset of narcolepsy is usually between 10\\u0026ndash;20 years of age, with a prevalence of 0.025%-0.05%\\u003csup\\u003e3\\u003c/sup\\u003e. The etiology of narcolepsy may be closely related to environmental and genetic factors\\u003csup\\u003e4\\u003c/sup\\u003e, and the positivity rate of human leukocyte antigen DQB1*0602 in patients with episodic somnolence ranges from 88\\u0026ndash;100%\\u003csup\\u003e5\\u003c/sup\\u003e. It had also been suggested that narcolepsy is an autoimmune disease that may be caused by T cell-mediated attacks on appetite neurons\\u003csup\\u003e6\\u0026ndash;7\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe clinical presentation of narcolepsy onset in children differs significantly from those of adults because of the immaturity of their neurological development and the specific physiological characteristics. Due to limited expressive skills, children usually respond to EDS with irritability, hyperactivity, inattention, or impulsivity. Therefore, physicians can easily misdiagnose narcolepsy as a psychiatric or neurodevelopmental disorder such as mood disorder, attention-deficit/hyperactivity disorder (ADHD)\\u003csup\\u003e8\\u003c/sup\\u003e. The common symptoms of cataplexy in children are also atypical, including prolonged episodes, facial and intermandibular protrusion, spontaneous tongue protrusion, neck extension, and slurred speech\\u003csup\\u003e9\\u003c/sup\\u003e. Cataplexy symptoms are usually a response to emotional triggers and can be exacerbated by changes in mood. The difficulty in diagnosing pediatric narcolepsy is compounded by the fact that narcolepsy rarely presents with the typical five symptoms in children, and narcolepsy in pediatric population is prone to comorbidity with OSA, ADHD and mood disorders\\u003csup\\u003e10\\u003c/sup\\u003e, which increased the possibility of misdiagnosis.\\u003c/p\\u003e \\u003cp\\u003eThe prevalence of OSA is high in patients with narcolepsy, and studies had reported that the co-morbidity rate is higher in the pediatric population\\u003csup\\u003e11\\u003c/sup\\u003e. Children with OSA may exhibit two forms of breathing during sleep, one with the symptoms of periodic OSA similar to that in adults with OSA syndrome; and the other, with obstructive alveolar hypoventilation that present in younger children, prolonged and persistent partial obstruction of the upper airway with hypercapnia and decreased oxygen saturation\\u003csup\\u003e12\\u003c/sup\\u003e. There are various pathophysiological factors that contribute to OSA in children, the primary factors being adenoid, tonsil hypertrophy, and obesity \\u003csup\\u003e13\\u003c/sup\\u003e. In addition, due to the immature development of the nervous system in children, cortical arousal response is poor when the airway is obstructed\\u003csup\\u003e14\\u003c/sup\\u003e. In summary, the special physiological structure of children and atypical nature of their symptoms pose a great challenge to the diagnosis of narcolepsy as well as the diagnosis and treatment of concomitant diseases.\\u003c/p\\u003e \\u003cp\\u003eThis report summarizes and analyzes a case involving a child with narcolepsy and sleep apnea symptoms, offering a detailed analysis of the clinical symptoms and comprehensive diagnostic considerations, as well as the prognosis and two-year follow-up.\\u003c/p\\u003e\"},{\"header\":\"Case Report and Results\",\"content\":\"\\u003cp\\u003eIn June 2021, a 6-year-old girl complained of \\u0026ldquo;sleep disturbances with daytime mood abnormalities for more than 1 year\\u0026rdquo;. The child presented poor daytime energy, fatigue, long sleep durations, falling sleep fast at night with dreaming, crying, and shouting more than 1 year ago. She also exhibited open-mouth breathing and had difficulty breathing when excited. \\u0026nbsp;Additionally, she displayed behaviors such as sticking her tongue out and exhibited vocalization and physical activity during nighttime sleep. The child developed weakness in the limbs when she was agitated or laughed, the frequency of limb activity and vocalization of the child increased at night, accompanied by poor mood during the day. The child\\u0026rsquo;s physical examination showed a height of 1.20 m, a weight of 26 kg, BMI of 18 kg/m\\u003csup\\u003e2\\u003c/sup\\u003e, and a second-degree enlargement of the tonsils. The Stanford Sleepiness Scale (SSS) and Epworth Sleepiness Scale (ESS) indicated that the patient had severe sleepiness, and the emotionally triggered Sudden Collapse Questionnaire (SCQ) confirmed the presence of cataplexy. MSLT showed that the patient had a mean sleep latency (SL) of 1.6 minutes and REM stage sleep occurred in four naps (see in Figure 1). PSG showed an apnea hypoventilation index (AHI) of 6.7 events/hour (1.1 events/hour for OSA, 0.7 events/hour for CSA and 4.9 events/hour for hypoventilation). Increased muscle tone was seen in the patient\\u0026rsquo;s rapid eye movement (REM) stage sleep. The case was diagnosed with narcolepsy type 1, pediatric obstructive sleep apnea and hypopnea, and pediatric mood disorder secondary to sleep-wake disorder. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;.\\u0026hellip;. FIGURE 1 about here \\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;..\\u003c/p\\u003e\\n\\u003cp\\u003eThen the child underwent bilateral tonsillectomy and adenoidectomy. After surgery, the child\\u0026apos;s daytime psychosis improved and the nocturnal limb movements reduced, during which she had taken melatonin 0.5 mg quāque nocte (qn) for half a month. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMSLT at one month postoperative recheck showed that the child had a mean SL of 1.9 minutes and REM stage sleep was present on all five naps. The results of MSLT before and 1 month after surgery were shown in Table 1. Her PSG at one month after surgery showed AHI was 2.3 events/hour (0 events/hour for OSA, 2.2 events/hour for CSA and 0.1 events/hour for hypoventilation) and constant chin electromyography activity during REM sleep (see Figure 2). From the PSG recording, we still can see limb movements in the REM phase (see Video 1). The patient\\u0026rsquo;s postoperative drowsiness was reduced and the patient had a decrease in AHI but an increase in periodic limb movement index (PLMI). \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip; TABLE 1 about here\\u0026hellip;\\u0026hellip;\\u0026hellip;...\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;.\\u0026hellip;. FIGURE 2 about here \\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;..\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip; VIDEO 1 about here\\u0026hellip;\\u0026hellip;\\u0026hellip;...\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe parameters of PSG before and 1 month after surgery are shown in Table 2. Table 3 illustrates the changes in sleep structure before and 1 month after surgery.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip; TABLE 2 about here\\u0026hellip;\\u0026hellip;\\u0026hellip;...\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip; TABLE 3 about here\\u0026hellip;\\u0026hellip;\\u0026hellip;...\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe family refused to apply any psychoactive drug treatment because the child was basically functioning normally, and she was discharged from the hospital for regular monitoring, behavior management and outpatient follow-up. Two years later, her daytime sleepiness symptoms were improved, cataplexy still existed, and she still has bilateral lower limbs extremity tenderness and mild facial expression changes. Body activity and talking decreased significantly during her sleep at night, and the patient\\u0026apos;s social function was normal. SSS, ESS, Ullanlinna Narcolepsy Scale (UNS), Children\\u0026apos;s Depression Inventory (CDI), Spence Children\\u0026apos;s Anxiety Scale Short Version (SCAS-S) and Strengths and Difficulties Questionnaire (SDQ) scores were normal. The clinical scale assessments before surgery, 1 month and 2 years after surgery are shown in Table 4. Figure 3 demonstrates the changes in the patient\\u0026apos;s Multiple symptoms at different stages.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip; TABLE 4 about here\\u0026hellip;\\u0026hellip;\\u0026hellip;...\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;.\\u0026hellip;. FIGURE 3 about here \\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;\\u0026hellip;..\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e1. Childhood narcolepsy with multidimensional clinical symptoms and atypical onset was easily misdiagnosed.\\u003c/p\\u003e \\u003cp\\u003eWe summarized the patient's multidimensional clinical symptoms as follows: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) EDS, persistent daytime sleepiness, poor mental performance, and symptoms like dull eyes and drooping eyelids. These symptoms can return to normal after reminders; (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) cataplexy symptoms, such as cataplexy symptoms when emotionally excited; (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) abnormal nocturnal sleep symptoms, such as sleep talking, shouting, crying and vigorous physical activity accompanied by vivid dream experiences; (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) airway obstruction symptoms, such as open mouth breathing; (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e) emotional symptoms, such as dull facial expressions, emotional irritability, tantrums, and reluctance to speak; (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e) attention deficit symptoms, such as inattention and sluggishness; (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e) abnormal neurobehavior, such as grimacing, tongue out, and unsteady walking. Our case showcased a complex clinical presentation encompassing sleep, mood, and behavior, highlighting the multifaceted symptoms and co-morbidities of childhood narcolepsy. These multidimensional symptoms are consistent with the reviews of Claudio L. A. \\u0026amp; Bassetti et al. They had reported that the clinical manifestations of narcolepsy are not only related to sleep-arousal but also related to motor, mental, emotional, cognitive, metabolic and autonomic functions\\u003csup\\u003e15\\u003c/sup\\u003e. The authors of this study also showed that patients with narcolepsy developed secondary problems such as depressive disorders, restless legs syndrome (RLS) and ADHD\\u003csup\\u003e15\\u003c/sup\\u003e. At the same time, some studies had observed abnormalities in reward function and emotion processing in patients, which may be able to provide new perspectives to explain the vulnerability of the disorder to comorbidity with other psychiatric disorders\\u003csup\\u003e16\\u003c/sup\\u003e. In summary, the results of PSG monitoring and MSLT are important to clarify the diagnosis. Yet, we should consider the possibility of other concomitant sleep-wake disorders and psychiatric disorders, so strengthening the monitoring during the treatment was important and significant. Moreover, the diagnostic indicators of sleep apnea hypoventilation in children are different from that in adults\\u003csup\\u003e17\\u003c/sup\\u003e, which also needs to be accurately identified by clinicians to avoid missing diagnoses.\\u003c/p\\u003e \\u003cp\\u003e2. Importance to monitor the changes of symptoms, assessments, and tests during the treatment process for dynamic diagnosis.\\u003c/p\\u003e \\u003cp\\u003eThis case also differs from typical narcolepsy in that the patient had chronic tonsillitis and adenoid hypertrophy found during hospitalization, and PSG also indicated the presence of OSA. Studies have reported that the symptoms of EDS were present with prolonged exposure to sleep fragmentation associated with sleep apnea, sleep deprivation, and changes in melatonin secretion and hypoventilation syndrome\\u003csup\\u003e18\\u003c/sup\\u003e. Therefore, before diagnosing narcolepsy, it is important to analyze whether EDS is closely related to OSA. After bilateral tonsillectomy and adenoidectomy, the child\\u0026rsquo;s ventilation improved significantly, and EDS and nocturnal sleep disturbances were less severe than before. However, although there was a decrease in obstructive respiratory events after surgical treatment of OSA, the CSA index increased, the reasons for which deserved our consideration.\\u003c/p\\u003e \\u003cp\\u003eIn patients with obstructive and central sleep disordered breathing, the ventilatory response to CO\\u003csub\\u003e2\\u003c/sub\\u003e is more sensitive between normal obstructive apnea thresholds, with narrower PaCO\\u003csub\\u003e2\\u003c/sub\\u003e reserve, thus also leading to lower stability of respiratory control\\u003csup\\u003e19\\u003c/sup\\u003e. Typically, unstable respiratory control will cause the patient's body to gradually establish a new, higher PaCO\\u003csub\\u003e2\\u003c/sub\\u003e setting during sleep, with relative hypercapnia, leading to awakening after hyperventilation. However, as the patient returns to sleep and ventilation during awakening causes PaCO\\u003csub\\u003e2\\u003c/sub\\u003e to fall below the apnea threshold, central sleep apnea occurs, which is the cause of most central events in patients with OSA\\u003csup\\u003e20\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eStudies have shown that after the postoperative OSA problem is resolved, the stimulus for CSA (arousal/microarousal secondary to obstructive events) would disappear in most children and so did CSA\\u003csup\\u003e21\\u003c/sup\\u003e. This was not the case in our case, and we speculated that this might be for two reasons: firstly, in some younger children, CSA may be physiologic rather than a post-arousal effect of OSA. The younger the child, the more likely it is that physiological central sleep apnea occurs and does not disappear with improvement of airway problems, but rather becomes more prominent\\u003csup\\u003e22\\u003c/sup\\u003e. Secondly, a central event may also be treatment emergent central sleep apnea (TECSA), also known as treatment-induced central sleep apnea\\u003csup\\u003e23\\u003c/sup\\u003e. A possible mechanism of occurrence is that sudden normalization of nighttime CO\\u003csub\\u003e2\\u003c/sub\\u003e partial pressure after surgery can trigger TECSA in patients with reduced chemosensitivity due to prolonged exposure to nocturnal hypercapnia\\u003csup\\u003e24\\u003c/sup\\u003e. The study showed that physiological central sleep apnea gradually resolves with age, and TECSA has the possibility of spontaneous remission\\u003csup\\u003e25\\u003c/sup\\u003e. Considering the improvement of somnolence and other symptoms after tonsillectomy and adenoidectomy, PSG needs to be done after 3\\u0026ndash;6 months to dynamically monitor the occurrence of apnea events.\\u003c/p\\u003e \\u003cp\\u003e3. Diagnostic issues in the concomitant parasomnia and sleep-related movement symptoms\\u003c/p\\u003e \\u003cp\\u003eIn the result of PSG, clinicians found that the patient\\u0026rsquo;s sleep video showed abnormal behaviors throughout the night, specifically abnormal vocalizations, arm tapping on the edge of the bed, stirring, and semi-sitting up. These movements occurred both in NREM stage and REM stage, but more frequently in REM stage, while in NREM stage, the movements all occurred in N2 stage. The loss of atonia and elevated chin muscle tone occurred in the REM stage, which may be associated with REM sleep behavioral disorder (RBD) secondary to narcolepsy. Related studies claimed that narcolepsy is the most common cause of a secondary RBD\\u003csup\\u003e26\\u003c/sup\\u003e. It has been suggested that it is closely related to hypothalamic secretin deficiency\\u003csup\\u003e27\\u003c/sup\\u003e, but there is still a lack of sufficient evidence and needs to be studied further. In addition, there is no clear study of the specificity of the behaviors that appear in the N2 stage, perhaps this could be the subject for future studies. Meanwhile, the nocturnal motor behaviors that appeared in patients with narcolepsy were simple and stereotyped, which were less complex and varied than those in patients with primary RBD.\\u003c/p\\u003e \\u003cp\\u003eIn addition, the patient\\u0026rsquo;s PSG was also consistent with manifestations of PLMs that may be associated with OSA and narcolepsy. After tonsillectomy and adenoidectomy, the PLMI increased and AHI decreased; such a phenomenon is often a rebound manifestation of improved sleep\\u003csup\\u003e28\\u003c/sup\\u003e. Previous studies suggested that PLMs are caused by dopamine system dysfunction and may also be associated with dysfunctional iron metabolism in the central nervous system\\u003csup\\u003e29\\u003c/sup\\u003e. It has been suggested that hypothalamic secretin deficiency may also be associated with PLM symptoms through secondary dopamine dysfunction and possibly narcolepsy\\u003csup\\u003e30\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003e4. Application of medication and behavior management\\u003c/p\\u003e \\u003cp\\u003eThe European guideline and expert statements on narcolepsy published in 2021 recommend that the management of narcolepsy involves both pharmacological and non-pharmacological treatments, and that treatment decisions should take into account the patient's clinical symptoms, comorbidities, tolerance to medications, and potential risks of medication use\\u003csup\\u003e31\\u003c/sup\\u003e. The consensus considers planned daytime naps and administration of sodium oxybate (SXB), modafinil, solriamfetol and pitolisant for excessive daytime sleepiness in children\\u003csup\\u003e31\\u003c/sup\\u003e. Modafinil is commonly used to treat residual EDS\\u003csup\\u003e32\\u003c/sup\\u003e. Studies have also reported the effectiveness of solriamfetol, a dopamine-norepinephrine reuptake inhibitor, and pitolisant, a histamine H\\u003csub\\u003e3\\u003c/sub\\u003e receptor inverse agonist, in the treatment of EDS\\u003csup\\u003e33\\u003c/sup\\u003e. Solriamfetol has been tested in a randomized controlled trial (RCT) for the treatment of EDS associated with OSA and narcolepsy\\u003csup\\u003e34\\u003c/sup\\u003e. Pitolisant has been tested in several RCTs for narcolepsy showing improvement in subjective and objective EDS, and another trial for OSA showed improvement in subjective EDS\\u003csup\\u003e35\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe European guideline and expert statements also recommend that narcolepsy combined with other sleep disorders should be treated in accordance with the treatment recommendations for patients with non- narcolepsy\\u003csup\\u003e31\\u003c/sup\\u003e. Several randomized controlled trials have demonstrated that treatment of comorbid other sleep disorders can also improve daytime sleepiness\\u003csup\\u003e36\\u003c/sup\\u003e. Continuous positive airway pressure (CPAP) ventilation treatment for 6\\u0026ndash;12 months can also improve daytime sleepiness\\u003csup\\u003e37\\u003c/sup\\u003e. In addition, clonazepam can be used for treatment of narcolepsy with abnormal REM sleep behavior\\u003csup\\u003e38\\u003c/sup\\u003e, but the use of clonazepam may exacerbate symptoms of EDS, and the paradoxical nature of the treatment is the reason for the limitation of pharmacological treatment.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn summary, this case reports a child with narcolepsy combined with sleep apnea and shares the difficulties encountered in this case, including the analysis of multidimensional symptoms from narcolepsy, mood disorders, OSA and CSA, PLMs, and parasomnia.. Follow-up at two years has demonstrated the benefit of behavioral management for patients, and future efforts to increase the prevalence of behavioral management should be strengthened. Related studies have also confirmed the long-term efficacy of behavioral management in patients\\u003csup\\u003e39\\u003c/sup\\u003e.\\u003c/p\\u003e\"},{\"header\":\"Limitations\",\"content\":\"\\u003cp\\u003eThere are still limitations in this case. Our follow-up of the patient mainly focused on the detection of behaviors and sleep, including subjective scale assessment and objective PSG monitoring, but the detection of specific biochemical indicators of narcolepsy was lacking. HLA DQB1*0606 and hypothalamic secretin-1 tests of cerebrospinal fluid have not been detected in the patient, so genetic testing and lumbar puncture can be improved in the future for subsequent basic research to explore the possible molecular and genetic mechanisms of narcolepsy.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u003c/strong\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eYiting Xiong, Yu Bai, and Xueqin Wang wrote and modified the medical record of the child; Jie Chen and Chunqin He conducted PSGs and MSLTs, and Jie Chen issued these reports; Yiting Xiong, Jiayue Si and Xueqin Wang drafted the case report; Xueqin Wang and Xuehua Wang guided the clinical diagnosis and treatment of the patient, and the modification of the case report; Suxia Li, Xuehua Wang, Zhe Li, Xinyang Zhang, Tong Na and Rong Zhou contributed to the manuscript revision; Xueqin Wang and Zifeng Zhang organized and coordinated the research work; Lin Lu undertook a comprehensive review and guidance of the manuscript. All the authors reviewed and approved the final manuscript.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSupported by STI2030-Major Projects 2021ZD0201900 (2021ZD0201905); the Beijing Municipal Science \\u0026amp; Technology Commission, No.\\u0026nbsp;Z191107006619091; Capital\\u0026rsquo;s Funds for Health Improvement and Research, No. 2022-2-4115.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThanks to the child and her family for their support in collecting and reporting this case, and to all investigators for their contributions to the manuscript of this case.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict-of-Interest Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors declare no competing interests.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe patient\\u0026rsquo;s father signed an informed consent form on August 27, 2021, and permitted doctors to collect and report anonymous clinical data of his child for publication. The article was reviewed and approved by the Medical Ethics Committee of Peking University Sixth Hospital (Institute of Mental Health) on January 24, 2023.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of Data and Materials Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eCastaigne P. Narcolepsy and cataplexy; the syndrome of Gelineau. Rev Prat. 1954;4(17):1551\\u0026ndash;1562. PMID: 13178483\\u003c/li\\u003e\\n\\u003cli\\u003eDye TJ, Gurbani N, Simakajornboon N. Epidemiology and Pathophysiology of Childhood Narcolepsy. Paediatr Respir Rev. 2018 Jan;25:14-18. doi: 10.1016/j.prrv.2016.12.005. Epub 2016 Dec 21. PMID: 28108192.\\u003c/li\\u003e\\n\\u003cli\\u003eLongstreth WT Jr, Koepsell TD, Ton TG, Hendrickson AF, van Belle G. The epidemiology of narcolepsy. Sleep. 2007 Jan;30(1):13-26. doi: 10.1093/sleep/30.1.13. PMID: 17310860.\\u003c/li\\u003e\\n\\u003cli\\u003eBassetti CLA, Adamantidis A, Burdakov D, Han F, Gay S, Kallweit U, Khatami R, Koning F, Kornum BR, Lammers GJ, Liblau RS, Luppi PH, Mayer G, Pollm\\u0026auml;cher T, Sakurai T, Sallusto F, Scammell TE, Tafti M, Dauvilliers Y. Narcolepsy - clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol. 2019 Sep;15(9):519-539. doi: 10.1038/s41582-019-0226-9. Epub 2019 Jul 19. PMID: 31324898.\\u003c/li\\u003e\\n\\u003cli\\u003eMignot E, Lin L, Rogers W, Honda Y, Qiu X, Lin X, Okun M, Hohjoh H, Miki T, Hsu S, Leffell M, Grumet F, Fernandez-Vina M, Honda M, Risch N. Complex HLA-DR and -DQ interactions confer risk of narcolepsy-cataplexy in three ethnic groups. 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PMID: 19996963.\\u003c/li\\u003e\\n\\u003cli\\u003eBassetti CLA, Adamantidis A, Burdakov D, Han F, Gay S, Kallweit U, Khatami R, Koning F, Kornum BR, Lammers GJ, Liblau RS, Luppi PH, Mayer G, Pollm\\u0026auml;cher T, Sakurai T, Sallusto F, Scammell TE, Tafti M, Dauvilliers Y. Narcolepsy - clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol. 2019 Sep;15(9):519-539. doi: 10.1038/s41582-019-0226-9. Epub 2019 Jul 19. PMID: 31324898.\\u003c/li\\u003e\\n\\u003cli\\u003eMeletti S, Vaudano AE, Pizza F, Ruggieri A, Vandi S, Teggi A, Franceschini C, Benuzzi F, Nichelli PF, Plazzi G. The Brain Correlates of Laugh and Cataplexy in Childhood Narcolepsy. J Neurosci. 2015 Aug 19;35(33):11583-94. doi: 10.1523/JNEUROSCI.0840-15.2015. PMID: 26290235; PMCID: PMC6605239.\\u003c/li\\u003e\\n\\u003cli\\u003eSateia MJ. International classification of sleep disorders-third edition: highlights and modifications. Chest. 2014 Nov;146(5):1387-1394. doi: 10.1378/chest.14-0970. PMID: 25367475.\\u003c/li\\u003e\\n\\u003cli\\u003eLal C, Weaver TE, Bae CJ, Strohl KP. Excessive Daytime Sleepiness in Obstructive Sleep Apnea. Mechanisms and Clinical Management. Ann Am Thorac Soc. 2021 May;18(5):757-768. doi: 10.1513/AnnalsATS.202006-696FR. PMID: 33621163; PMCID: PMC8086534.\\u003c/li\\u003e\\n\\u003cli\\u003eBaldassari CM, Kepchar J, Bryant L, Beydoun H, Choi S. Changes in central apnea index following pediatric adenotonsillectomy. Otolaryngol Head Neck Surg. 2012 Mar;146(3):487-90. doi: 10.1177/0194599811428118. Epub 2011 Nov 10. PMID: 22075072.\\u003c/li\\u003e\\n\\u003cli\\u003eJudd RT, Mokhlesi B, Shogan A, Baroody FM. Improvement in Central Sleep Apnea Following Adenotonsillectomy in Children. Laryngoscope. 2022 Feb;132(2):478-484. doi: 10.1002/lary.29784. Epub 2021 Jul 29. PMID: 34324202.\\u003c/li\\u003e\\n\\u003cli\\u003eDel-R\\u0026iacute;o Camacho G, Medina Castillo L, Rodr\\u0026iacute;guez-Catal\\u0026aacute;n J, Soto Insuga V, G\\u0026oacute;mez Garc\\u0026iacute;a T. Central sleep apnea in children with obstructive sleep apnea syndrome and improvement following adenotonsillectomy. Pediatr Pulmonol. 2019 Nov;54(11):1670-1675. doi: 10.1002/ppul.24469. Epub 2019 Aug 2. PMID: 31373175.\\u003c/li\\u003e\\n\\u003cli\\u003eRoss KR, Rosen CL. Sleep and respiratory physiology in children. Clin Chest Med. 2014 Sep;35(3):457-67. doi: 10.1016/j.ccm.2014.06.003. Epub 2014 Jul 18. PMID: 25156762.\\u003c/li\\u003e\\n\\u003cli\\u003eTestani E, De Corso E, Losurdo A, Fiorita A, Vollono C, Marca GD, Scarano E. Treatment-emergent central sleep apnoea after surgery for obstructive sleep apnoea. Acta Otorhinolaryngol Ital. 2018 Oct;38(5):476-479. doi: 10.14639/0392-100X-1476. PMID: 30498277; PMCID: PMC6265664.\\u003c/li\\u003e\\n\\u003cli\\u003eZhang J, Wang L, Guo HJ, Wang Y, Cao J, Chen BY. Treatment-emergent central sleep apnea: a unique sleep-disordered breathing. Chin Med J (Engl). 2020 Nov 20;133(22):2721-2730. doi: 10.1097/CM9.0000000000001125. PMID: 33009018; PMCID: PMC7725531.\\u003c/li\\u003e\\n\\u003cli\\u003eBerger M, Solelhac G, Horvath C, Heinzer R, Brill AK. Treatment-emergent central sleep apnea associated with non-positive airway pressure therapies in obstructive sleep apnea patients: A systematic review. Sleep Med Rev. 2021 Aug;58:101513. doi: 10.1016/j.smrv.2021.101513. Epub 2021 Jun 5. PMID: 34166994.\\u003c/li\\u003e\\n\\u003cli\\u003eAntelmi E, Pizza F, Franceschini C, Ferri R, Plazzi G. REM sleep behavior disorder in narcolepsy: A secondary form or an intrinsic feature? Sleep Med Rev. 2020 Apr;50:101254. doi: 10.1016/j.smrv.2019.101254. Epub 2019 Dec 19. PMID: 31931470.\\u003c/li\\u003e\\n\\u003cli\\u003eMathis J, Hess CW, Bassetti C. Isolated mediotegmental lesion causing narcolepsy and rapid eye movement sleep behaviour disorder: a case evidencing a common pathway in narcolepsy and rapid eye movement sleep behaviour disorder. J Neurol Neurosurg Psychiatry. 2007 Apr;78(4):427-9. doi: 10.1136/jnnp.2006.099515. PMID: 17369596; PMCID: PMC2077786.\\u003c/li\\u003e\\n\\u003cli\\u003eLin TC, Zeng BY, Wu MN, Chen TY, Chen YW, Yeh PY, Tseng PT, Hsu CY. Changes in Periodic Limb Movements of Sleep After the Use of Continuous Positive Airway Pressure Therapy: A Meta-Analysis. Front Neurol. 2022 Jun 2;13:817009. doi: 10.3389/fneur.2022.817009. PMID: 35720099; PMCID: PMC9202316.\\u003c/li\\u003e\\n\\u003cli\\u003eSimakajornboon N, Gozal D, Vlasic V, Mack C, Sharon D, McGinley BM. Periodic limb movements in sleep and iron status in children. Sleep. 2003 Sep;26(6):735-8. doi: 10.1093/sleep/26.6.735. PMID: 14572128.\\u003c/li\\u003e\\n\\u003cli\\u003eHornyak M, Feige B, Riemann D, Voderholzer U. Periodic leg movements in sleep and periodic limb movement disorder: prevalence, clinical significance and treatment. Sleep Med Rev. 2006 Jun;10(3):169-77. doi: 10.1016/j.smrv.2005.12.003. PMID: 16762807.\\u003c/li\\u003e\\n\\u003cli\\u003eBassetti CLA, Kallweit U, Vignatelli L, Plazzi G, Lecendreux M, Baldin E, Dolenc-Groselj L, Jennum P, Khatami R, Manconi M, Mayer G, Partinen M, Pollm\\u0026auml;cher T, Reading P, Santamaria J, Sonka K, Dauvilliers Y, Lammers GJ. European guideline and expert statements on the management of narcolepsy in adults and children. J Sleep Res. 2021 Dec;30(6):e13387. doi: 10.1111/jsr.13387. Epub 2021 Jun 25. PMID: 34173288.\\u003c/li\\u003e\\n\\u003cli\\u003eGreenblatt K, Adams N. Modafinil. 2023 Feb 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan\\u0026ndash;. PMID: 30285371. \\u003c/li\\u003e\\n\\u003cli\\u003eThorpy MJ. Recently Approved and Upcoming Treatments for Narcolepsy. CNS Drugs. 2020 Jan;34(1):9-27. doi: 10.1007/s40263-019-00689-1. PMID: 31953791; PMCID: PMC6982634.\\u003c/li\\u003e\\n\\u003cli\\u003eThorpy MJ, Shapiro C, Mayer G, et al. A randomized study of solriamfetol for excessive sleepiness in narcolepsy [published correction appears in Ann Neurol. 2020 Jan;87(1):157]. \\u003cem\\u003eAnn Neurol\\u003c/em\\u003e. 2019;85(3):359-370. doi:10.1002/ana.25423. PMID: 30694576; PMCID: PMC6593450.\\u003c/li\\u003e\\n\\u003cli\\u003eLamb YN. Pitolisant: A Review in Narcolepsy with or without Cataplexy. CNS Drugs. 2020 Feb;34(2):207-218. doi: 10.1007/s40263-020-00703-x. PMID: 31997137.\\u003c/li\\u003e\\n\\u003cli\\u003eBiyani S, Cunningham TD, Baldassari CM. Adenotonsillectomy outcomes in children with sleep apnea and narcolepsy. Int J Pediatr Otorhinolaryngol. 2017 Sep;100:62-65. doi: 10.1016/j.ijporl.2017.06.018. Epub 2017 Jun 16. PMID: 28802388.\\u003c/li\\u003e\\n\\u003cli\\u003eJavaheri S, Javaheri S. Update on Persistent Excessive Daytime Sleepiness in OSA. Chest. 2020 Aug;158(2):776-786. doi: 10.1016/j.chest.2020.02.036. Epub 2020 Mar 6. PMID: 32147246.\\u003c/li\\u003e\\n\\u003cli\\u003eSt Louis EK, Boeve BF. REM Sleep Behavior Disorder: Diagnosis, Clinical Implications, and Future Directions. Mayo Clin Proc. 2017 Nov;92(11):1723-1736. doi: 10.1016/j.mayocp.2017.09.007. Epub 2017 Nov 1. PMID: 29101940; PMCID: PMC6095693.\\u003c/li\\u003e\\n\\u003cli\\u003eBlackmer AB, Feinstein JA. Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review. Pharmacotherapy. 2016 Jan;36(1):84-98. doi: 10.1002/phar.1686. PMID: 26799351.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"424\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"100%\\\" colspan=\\\"3\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eTABLE 1. Parameters of MSLTs before and after surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"56.839622641509436%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMSLT\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.641509433962263%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eBefore Surgery\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.5188679245283%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAfter Surgery\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"56.839622641509436%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eMean Sleep Latency（minutes）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.641509433962263%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e1.60\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.5188679245283%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e1.90\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"56.839622641509436%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eMean REM Latency（minutes）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.641509433962263%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e1.30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.5188679245283%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e1.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"56.839622641509436%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNumber of REM Episodes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.641509433962263%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.5188679245283%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"56.839622641509436%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNumber of MLST with REM Episodes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.641509433962263%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.5188679245283%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eMSLT, Multiple Sleep Latency Test; REM, Rapid Eye Movement.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"558\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"100%\\\" colspan=\\\"3\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eTABLE 2. Parameters of PSG and clinical scale assessments before and after surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eParameters\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eBefore Surgery\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAfter Surgery\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePSG\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSleep-related Breathing Event\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eTotal Apnea-Hypopnea Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e6.70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2.30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eHypopnea Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e4.60\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eApnea Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2.20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eCentral Apnea Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2.20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eObstructive Apnea Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e1.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.00\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eMixed Apnea Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.00\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eOxygen Desaturations index\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eLowest SpO2 (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eLeg Movement\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNumber of Leg Movement\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e128\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e176\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eLeg Movement Index (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e16.80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e23.30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNumber of PLM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e21\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e98\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003ePLMI (Events/hour)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2.80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13.00\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eClinical Scales\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eSSS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eESS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"52.5089605734767%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eUNS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.448028673835125%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.043010752688172%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003ePSG, Polysomnography; PLM, Periodic Leg Movement; PLMI, Periodic Leg Movement Index; SSS, Stanford Sleepiness Scale; ESS, The Epworth Sleeping Scale; UNS, Ullanlinna Narcolepsy Scale.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"435\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"100%\\\" colspan=\\\"3\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eTable 3. Changes in sleep structure of patients before and after surgery.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"17.471264367816094%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eTST (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"37.01149425287356%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eBefore surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.51724137931034%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e1 month after surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"17.471264367816094%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eREM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"37.01149425287356%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e25.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.51724137931034%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e23.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"17.471264367816094%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNREM1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"37.01149425287356%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e4.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.51724137931034%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"17.471264367816094%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNREM2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"37.01149425287356%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.51724137931034%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e30.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"17.471264367816094%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eNREM3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"37.01149425287356%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e37.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.51724137931034%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eTST, Total Sleep Time; REM, Rapid Eye Movement; NREM, Non-Rapid Eye Movement.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"540\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"96.29629629629629%\\\" colspan=\\\"4\\\" valign=\\\"bottom\\\" style=\\\"width: 72.6382%;\\\"\\u003e\\n \\u003cp\\u003eTable 4. clinical scale assessments before surgery, 1 month and 2 years after surgery.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003e \\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003eBefore surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e1month after surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e2 years after surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;CDI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;SCAS- S\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003eSDQ\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003e19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003eSSS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" valign=\\\"bottom\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" valign=\\\"bottom\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003eESS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" valign=\\\"bottom\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003e23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" valign=\\\"bottom\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"15.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 11.8964%;\\\"\\u003e\\n \\u003cp\\u003eUNS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.25925925925926%\\\" valign=\\\"bottom\\\" style=\\\"width: 14.5556%;\\\"\\u003e\\n \\u003cp\\u003e27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25.74074074074074%\\\" valign=\\\"bottom\\\" style=\\\"width: 19.4542%;\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"35.55555555555556%\\\" valign=\\\"bottom\\\" style=\\\"width: 26.8719%;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eChildren\\u0026rsquo;s Depression Inventory, CDI; Spence Children\\u0026rsquo;s Anxiety Scale- Short Version, SCAS-S; Strengths and Difficulties Questionnaire, SDQ; SSS, Stanford Sleepiness Scale; ESS, The Epworth Sleeping Scale; UNS, Ullanlinna Narcolepsy Scale.\\u0026nbsp;\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"narcolepsy, mood disorder, sleep apnea, polysomnography (PSG), case report\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-3910379/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-3910379/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eIntroduction\\u003c/strong\\u003e: The characteristics of narcolepsy onset in children differs significantly from those of adults, and easily misdiagnosed for their multidimensional symptoms and concomitant diseases.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCase Report and Results:\\u003c/strong\\u003e A 6-year-old girl with multidimensional symptoms: typical symptoms of mood disorder, atypical symptoms of narcolepsy combined with rapid eye movement (REM) sleep behavioral disorder (RBD) and periodic limb movement (PLM), was diagnosed with narcolepsy type 1 and complex sleep apnea. Obstructive sleep apnea (OSA) caused by adenoid and tonsillar hypertrophy at baseline and central sleep apnea (CSA) after surgery of adenoid and tonsillar. After adenoidectomy and tonsillectomy, OSA remitted, excessive daytime sleepiness (EDS), RBD symptoms, mental symptoms and sleep structure were improved, but more PLMs and CSA presented and SORE multiple sleep latency test (MSLT) increased in this patient. During 2 years follow up, only behavioral managements were performed. The child had good social function, significant improvement in subjective EDS, occasional nocturnal sleep behavior abnormalities rated by scales two years later.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e: It was important to monitor in time with multidimensional symptoms and follow up for a longer time during multidisciplinary treatments in children with narcolepsy. Exploration of regular personalized behavioral interventions might be benefit for them.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Multidimensional symptoms and comprehensive diagnosis of pediatric narcolepsy combined with sleep apnea and two years follow-up: a case report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-02-15 15:50:29\",\"doi\":\"10.21203/rs.3.rs-3910379/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"5d06d242-ce60-476a-9b8d-a073abb6783f\",\"owner\":[],\"postedDate\":\"February 15th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-05-21T13:01:16+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-02-15 15:50:29\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-3910379\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-3910379\",\"identity\":\"rs-3910379\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}