Surface cephalometric and anthropometric variables in OSA patients: statistical models for the OSA phenotype

Can intraoral and facial photos predict obstructive sleep apnea in the general and clinical population?

STUDY OBJECTIVES

This study aimed to evaluate and compare measurements of standardized craniofacial and intraoral photographs between clinical and general population samples, between groups of individuals with an apnea-hypopnea index (AHI) ≥ 15 and AHI < 15, and their interaction, as well as the relationship with the presence and severity of obstructive sleep apnea (OSA).

METHODS

We used data from 929 participants from Sleep Apnea Global Interdisciplinary Consortium, in which 309 patients from a clinical setting and 620 volunteers from a general population.

RESULTS

AHI ≥ 15 were observed in 30.3% of the total sample and there were some interactions between facial/intraoral measures with OSA and both samples. Mandibular volume (p < 0.01) and lateral face height (p = 0.04) were higher in the AHI ≥ 15 group in the clinical sample compared to the AHI ≥ 15 group in the general population and AHI < 15 group in the clinical sample. When adjusted for sex and age, greater mandible width (p < 0.01) differed both in the clinical and in the general population samples, reflecting AHI severity and the likelihood of OSA. The measure of smaller tongue curvature (p < 0.01) reflected the severity and probability of OSA in the clinical sample and the higher posterior mandibular height (p = 0.04) showed a relationship with higher AHI and higher risk of OSA in the general population. When adjusted for sex, age, and body mass index, only smaller tongue curvature (p < 0.01) was associated with moderate/severe OSA.

CONCLUSIONS

Measures of greater tongue and mandible were associated with increased OSA risk in the clinical sample and craniofacial measurement was associated in the general population sample.

Novel clinical screening method to identify patients at risk of obstructive sleep apnea

OBJECTIVE

To investigate whether the distance between the two retromolar trigones (RMTs) with the distance between the two posterior plicas (PPs) affects obstructive sleep apnea syndrome (OSAS) and to determine a physical examination method that can be used in the selection of patients to be referred to polysomnography (PSG).

METHODS

The study included 86 OSAS patients and 29 healthy controls. RMTs and PPs were measured using a caliper-like device. The values obtained from these measurements were evaluated in both groups.

RESULTS

The PPs were narrower, and the RMTs-PPs, RMTs-PPs/RMTs, and RMTs/PPs values were greater in the OSAS group (p < .05) compared to the control group. The cut-off values were 0.612 for RMTs-PPs/RMTs and 2.589 for RMTs/PPs. The specificity of these values for OSAS was 97%, and sensitivity was 57% and 58%, respectively.

CONCLUSION

The presented method may play a role in preventing unnecessary PSG among patients with suspected OSAS.

Predicting obstructive sleep apnea hypopnea syndrome using three-dimensional optical devices: A systematic review

Purpose

As a global health concern, the diagnosis of obstructive sleep apnea hypopnea syndrome (OSAHS), characterized by partial reductions and complete pauses in ventilation, has garnered significant scientific and public attention. With the advancement of digital technology, the utilization of three-dimensional (3D) optical devices demonstrates unparalleled potential in diagnosing OSAHS. This study aimed to review the current literature to assess the accuracy of 3D optical devices in identifying the prevalence and severity of OSAHS.

Methods

A systematic literature search was conducted in the Web of Science, Scopus, PubMed/MEDLINE, and Cochrane Library databases for English studies published up to April 2024. Peer-reviewed researches assessing the diagnostic utility of 3D optical devices for OSAHS were included. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) guideline was employed to appraise the risk of bias.

Results

The search yielded 3216 results, with 10 articles meeting the inclusion criteria for this study. Selected studies utilized structured light scanners, stereophotogrammetry, and red, green, blue-depth (RGB-D) cameras. Stereophotogrammetry-based 3D optical devices exhibited promising potential in OSAHS prediction.

Conclusions

The utilization of 3D optical devices holds considerable promise for OSAHS diagnosis, offering potential improvements in accuracy, cost reduction, and time efficiency. However, further clinical data are essential to assist clinicians in the early detection of OSAHS using 3D optical devices.

Anthropometric 3D evaluation of the face in patients with sleep related breathing disorders

PURPOSE

To evaluate craniofacial measurements on 3D-stereophotogrammetry and see if particular measurements are more typical in obstructive sleep apnea (OSA) and have a correlation with its severity.

METHODS

Subjects included were adults undergoing a diagnostic polysomnography. Age, BMI, neck, abdominal and hip circumference (cm) were recorded. 3D-stereophotogrammetry was performed and landmarks were placed on the 3D-image. Different linear, angular and volume measurements were performed to gauge facial and neck anatomy. The relationship between these measurements and the severity of OSA, based on the obstructive apnea/hypopnea index (OAHI, events/h), was assessed by multiple linear regression, and adjusted for BMI and sex.

RESULTS

Of 91 subjects included (61 male), mean age was 46 ± 12 years, BMI 30.1 ± 6.5 kg/m2, OAHI 19.3 ± 18.8/h. BMI was higher (p = 0.0145) in females (32.9 ± 7.7) than in males (28.6 ± 5.3). This was also true for hip circumference (118 ± 15 vs 107 ± 10, p = 0.0006), while the neck circumference was higher (p < 0.0001) in males (41 ± 4 vs 37 ± 4). The following parameters could predict the logOAHI (r2-adjusted = 0.51): sex (p < 0.0001), BMI (p = 0.0116), neck-depth/mandibular-length (p = 0.0002), mandibular-width angle (p = 0.0118), neck-depth euclidean distance/surface distance (E/S) (p = 0.0001) and the interaction terms between sex and neck-depth/mandibular-length (p = 0.0034), sex and neck-depth E/S (p = 0.0276) and BMI and neck-depth E/S (p = 0.0118). The interaction between sex and neck-depth/mandibular-length showed a steeper linear course in females. This is also true for the interaction term BMI with neck-depth E/S in patients with a higher BMI. With a same neck-depth ratio, the OAHI is larger in men.

CONCLUSION

Measurements involving the width of the face and addressing the soft tissue in the upper neck were found to have a significant relation with OSA severity. We found remarkable differences between non-obese/obese subjects and between males and females.

Correlations between Morphology, the Functional Properties of Upper Airways, and the Severity of Sleep Apnea

Obstructive sleep apnea (OSA) is considered the silent killer pathology of the new millennium. This is due to increased risk factors such as obesity. Healthcare systems face an increasing burden from severe cases of OSA. We performed a study on a group of 152 Romanian patients with OSA recording data obtained through polysomnography and cephalometric variables, recorded in lateral plain X-rays. The results confirmed some of the data available from previous studies worldwide, but some of the variables presented a positive statistical correlation specific to our study group. For example, the apnea-hypopnea index (AHI) correlated with the uvula length but surprisingly did not correlate with body mass index (BMI) because obesity tends to become endemic in Romania. To our knowledge, this is one of the first studies focusing on cephalometric data in Romanian OSA patients. The results obtained through this study will be further analyzed in research on larger groups of Romanian OSA patients.

Three-dimensional craniofacial characteristics associated with obstructive sleep apnea severity and treatment outcomes

OBJECTIVES

This study aims to assess craniofacial dimensions in obstructive sleep apnea (OSA) patients treated with a mandibular advancement device (MAD) and to identify anatomic influences on OSA severity and MAD therapy outcomes.

MATERIALS AND METHODS

Twenty patients with OSA were prospectively treated with MAD. Clinical, cone-beam computed tomography, and polysomnography exams were performed before treatment and 4-6 months after achieving the MAD therapeutic position. Polysomnographic exams and three-dimensional maxillary, mandibular, and upper airway (UA) measurements were evaluated. Pearson's correlation and t-tests were applied.

RESULTS

Before MAD treatment, the transverse width measured at the frontomaxillary suture and the angle between the mandibular ramus and Frankfurt horizontal were statistically correlated with apnea and the hypopnea index (AHI), while the gonial angle was correlated with therapeutic protrusion. After MAD treatment, all patients showed a significant AHI reduction and an improvement in minimum oxyhemoglobin saturation. The UA total volume, superior and inferior oropharynx volume, and area were statistically correlated with MAD therapeutic protrusion. The UA total area showed a statistical correlation with the improvement in AHI, and the superior oropharynx volume and area increased significantly.

CONCLUSIONS

The transversal frontomaxillary suture width and the mandibular ramus facial angle may influence OSA severity. The gonial angle, volume, and area of all UA regions may indicate the amount of protrusion needed for successful MAD treatment.

CLINICAL RELEVANCE

The craniofacial characteristics reported as important factors for OSA severity and MAD treatment outcomes impact therapy planning for OSA patients, considering individual anatomic characteristics, prognosis, and cost benefits.

Predicting sleep apnea from three-dimensional face photography

STUDY OBJECTIVES

Craniofacial anatomy is recognized as an important predisposing factor in the pathogenesis of obstructive sleep apnea (OSA). This study used three-dimensional (3D) facial surface analysis of linear and geodesic (shortest line between points over a curved surface) distances to determine the combination of measurements that best predicts presence and severity of OSA.

METHODS

3D face photographs were obtained in 100 adults without OSA (apnea-hypopnea index [AHI] < 5 events/h), 100 with mild OSA (AHI 5 to < 15 events/h), 100 with moderate OSA (AHI 15 to < 30 events/h), and 100 with severe OSA (AHI ≥ 30 events/h). Measurements of linear distances and angles, and geodesic distances were obtained between 24 anatomical landmarks from the 3D photographs. The accuracy with which different combinations of measurements could classify an individual as having OSA or not was assessed using linear discriminant analyses and receiver operating characteristic analyses. These analyses were repeated using different AHI thresholds to define presence of OSA.

RESULTS

Relative to linear measurements, geodesic measurements of craniofacial anatomy improved the ability to identify individuals with and without OSA (classification accuracy 86% and 89% respectively, P < .01). A maximum classification accuracy of 91% was achieved when linear and geodesic measurements were combined into a single predictive algorithm. Accuracy decreased when using AHI thresholds ≥ 10 events/h and ≥ 15 events/h to define OSA although greatest accuracy was always achieved using a combination of linear and geodesic distances.

CONCLUSIONS

This study suggests that 3D photographs of the face have predictive value for OSA and that geodesic measurements enhance this capacity.

Evaluation of upper airway volume and craniofacial volumetric structures in obstructive sleep apnoea adults: A descriptive CBCT study

OBJECTIVE

The aim of this investigation was to assess, with a descriptive three-dimensional evaluation, the volume of upper airway (UAWV) and the volume of craniofacial structures in adult patients suffering from obstructive sleep apnoea (OSA) and compare them to the corresponding findings in adults with no sleep disorders.

MATERIALS AND METHODS

The sample consisted of 54 adult males, 27 suffering from OSA diagnosed by means of the Apnoea Hypopnea Index and 27 with no history of sleep disorders. All subjects had a cone beam computerized tomography scan performed with the same head position. UAWV was assessed with the Amira® software, and craniofacial volumes by means of a specially developed data-processing program, which allowed the construction of tetrahedrons using anatomical landmarks. Assessed volumes were naso-maxillary, cranium upper anterior, oral cavity, post-oral cavity, hyoid to mandible, and post-hyoid. SPSS (version 19.0) was used for the statistical analysis. The Levene's test for Equality of Variance, the t-test for Equality of Means and the Mann-Whitney test were used to evaluate the variables. The level of significance was set at P ≤ 0.05.

RESULTS

The mean value of UAWV was smaller in the OSA group. The post-hyoid volume, the calculated posterior volume, and the ratio of posterior to total volume showed differences between the groups.

CONCLUSIONS

Craniofacial structures did not show significant differences between the groups, but in the OSA group the posterior space released for upper airway was significantly bigger and UAWV was significantly smaller.

Formula for predicting OSA and the Apnea-Hypopnea Index in Koreans with suspected OSA using clinical, anthropometric, and cephalometric variables

PURPOSE

This study developed formulas to predict obstructive sleep apnea (OSA) and the Apnea-Hypopnea Index (AHI) in Korean patients with suspected OSA using clinical, anthropometric, and cephalometric variables.

METHODS

We evaluated relevant variables in 285 subjects with suspected OSA. These included demographic characteristics, sleep-related symptoms, medical history, clinical scales, anthropometric measurements including facial surface measurements, and cephalometric measurements. All participants underwent full-night laboratory polysomnography. The prediction formula for the probability of OSA was created by logistic regression analysis and confirmed by the bootstrap resampling technique. The formula for predicting the AHI was developed using multiple linear regression analysis.

RESULTS

The probability of having OSA was as follows: p = 1 / (1 + exponential (exp)^-f ), where f = -16.508 + 1.445 × loudness of snoring 4 + 0.485 × loudness of snoring 3 + 0.078 × waist circumference + 0.209 × subnasale-to-stomion distance + 0.183 × thickness of the uvula (UTH) supine + 0.041 × age. The AHI prediction formula was as follows: -112.606 + 3.516 × body mass index + 0.683 × mandibular plane-hyoid supine + 10.915 × loudness of snoring 4 + 6.933 × loudness of snoring 3 + 1.297 × UTH supine + 0.272 × age.

CONCLUSION

This is the first study to establish formulas to predict OSA and the AHI in Koreans with suspected OSA using cephalometric and other variables. These results will contribute to prioritizing the order in which patients with suspected OSA are referred for polysomnography.

Facial phenotype in obstructive sleep apnea-hypopnea syndrome: a systematic review and meta-analysis

This systematic review and meta-analysis explores the association between facial phenotype and obstructive sleep apnea-hypopnea syndrome in adults. A comprehensive electronic (Medline via Ovid, Scopus, and Embase) database and reference search were undertaken in relation to imaging modalities for surface craniofacial assessments in subjects with sleep apnea. The outcome measures were surface facial dimensions, morphology and profile. The quality of studies was assessed and a meta-analysis conducted. The studies were weighted using the inverse variance method, and the random effects model was used to analyse data. This systematic review identified eight case-control studies. In five studies (906 participants), adults with sleep apnea showed increased weighted mean differences in neck circumference by 1.26 mm (P = 0.0001) with extensive heterogeneity between studies (I² = 93%). Only two studies (467 participants) shared the following outcomes: mandible length, lower facial height, mandible width and anterior mandible height parameters. The pooled results demonstrated obstructive sleep apnea syndrome was associated with larger parameters than controls. In conclusion, the surface facial assessment was able to demonstrate some characteristic morphological features, facilitating a meta-analysis, in adults with obstructive sleep apnea-hypopnea syndrome. The strength of these findings, however, was limited by the heterogeneity of the studies precluding the identification of a clear phenotype.

Cephalometric risk factors associated with myocardial infarction in patients suffering from obstructive sleep apnea: A pilot case-control study

INTRODUCTION

Obstructive sleep apnea (OSA) and its craniofacial anatomic risk factors might play a role in several cardiovascular diseases, including myocardial infarction (MI). However, there are no data about cephalometric findings among OSA patients with MI.

METHODS

In this pilot case-control study, about 2000 individuals referred to the sleep center were evaluated according to apnea - hypopnea index (AHI) and other inclusion criteria. Included were 62 OSA male patients (AHI > 10), of whom 6 had an MI history. In both control (n = 56) and MI groups (n = 6), 18 cephalometric parameters were traced. Data were analyzed using independent samples t-test.

RESULTS

Compared with control OSA patients, OSA patients with MI showed a significantly larger tongue length (p = 0.015). The other cephalometric variables were not significantly different between the two groups.

CONCLUSION

An elongated tongue might be considered a risk factor for MI in OSA patients. The role of other variables remains inconclusive and open to investigation with larger samples (determined based on pilot studies such as this report) collected in longitudinal fashion.

Anthropometric and craniofacial sexual dimorphism in obstructive sleep apnea patients: is there male-female phenotypical convergence?

Obstructive sleep apnea (OSA) is more common in men than women. Body size is greater in males (sexual dimorphism), but large body habitus is associated with OSA for both genders. We speculated that male-female phenotypical convergence (reduced sexual dimorphism via identical phenotype acquisition) occurs with OSA and tested hypotheses: (1) phenotypical features pathogenic for OSA differ between OSA and healthy subjects irrespective of gender; and (2) such characteristics exhibit phenotypical convergence. Utilizing an existing database, we calculated male-female (group average) ratios for eight anthropometric and 33 surface cephalometric variables from 104 Caucasian OSA patients [72 males; apnea-hypopnea index (events h(-1) ): males: 42.3 ± 24.7 versus females: 42.6 ± 26.1 (P > 0.9)] and 85 Caucasian, healthy, non-OSA, community volunteers (36 males). Log-transformed data were analysed using a general linear model with post-hoc unpaired t-tests and significance at P < 0.0012 (Bonferroni multiple-comparison correction). OSA patients were older (56.9 ± 14.4 versus 38.0 ± 13.8 years), but there were no within-group gender-based age differences. All anthropometric variables (except height), plus cranial base width, mandibular breadth and retromandibular width diagonal were larger in gender-matched OSA versus healthy comparisons; thus satisfying hypothesis (1). Male-female ratios were mostly >1.0 across groups, but with no significant group × gender interactions no variable satisfied hypothesis (2). Thus, in this exploratory study, OSA patients had gender-common phenotypical differences to healthy subjects, but sexual dimorphism was preserved. Lack of complete phenotypical convergence may indicate gender-based critical phenotype-level attainment for OSA and/or gender-based OSA prevalence arises from factors other than those in this study.