Craniofacial proportions in children with adenoid or adenotonsillar hypertrophy are related to disease duration and nasopharyngeal obstruction

Numerical and experimental evaluation of nasopharyngeal aerosol administration methods in children with adenoid hypertrophy

Administering aerosol drugs through the nasal pathway is a common early treatment for children with adenoid hypertrophy (AH). To enhance therapeutic efficacy, a deeper understanding of nasal drug delivery in the nasopharynx is essential. This study uses an integrated experimental, numerical modelling approach to investigate the delivery process of both the aerosol mask delivery system (MDS) and the bi-directional delivery system (BDS) in the pediatric nasal airway with AH. The combined effect of respiratory flow rates and particle size on delivery efficiency was systematically analyzed. The results showed that the nasopharyngeal peak deposition efficiency (DE) for BDS was approximately 2.25-3.73 times higher than that for MDS under low-flow, resting and high-flow respiratory conditions. Overall nasopharyngeal DEs for MDS were at a low level of below 16 %. For each respiratory flow rate, the BDS tended to achieve higher peak DEs (36.36 % vs 9.74 %, 37.80 % vs 14.01 %, 34.58 % vs 15.35 %) at smaller particle sizes (15 µm vs 17 µm, 10 µm vs 14 µm, 6 µm vs 9 µm). An optimal particle size exists for each respiratory flow rate, maximizing the drug delivery efficiency to the nasopharynx. The BDS is more effective in delivering drug aerosols to the nasal cavity and nasopharynx, which is crucial for early intervention in children with AH.

Something to consider: rapid palatal expansion for treatment of obstructive sleep apnea in pediatric patients

PURPOSE OF REVIEW

This review examines the potential of rapid palatal expansion (RPE) as a treatment for pediatric obstructive sleep apnea (OSA). The focus is on recent findings related to its efficacy, safety, patient selection, timing, appliance options, cost considerations, and long-term outcomes.

RECENT FINDINGS

Recent studies indicate that RPE can lead to significant improvements in pediatric OSA, with a 70% reduction in the Apnea Hypopnea Index (AHI) and increased oxygen saturation levels. It has been particularly effective in children with small or absent tonsils and has been found to reduce adenoid and tonsil size. Long-term follow-up studies suggest the need for ongoing monitoring, as some patients may experience relapse over time.

SUMMARY

RPE shows promise as an additional treatment for pediatric obstructive sleep apnea. It offers improvements in respiratory function and reduced symptoms in certain patients. However, long-term efficacy and safety require further investigation. Comparative studies and patient-reported outcomes are necessary to optimize treatment approaches. Collaboration between orthodontists, sleep specialists, and ear-nose-throat (ENT) specialists may be essential for optimal outcomes in pediatric OSA patients treated with RPE.

Characterization of craniofacial-based clinical phenotypes in children with suspected obstructive sleep apnea

STUDY OBJECTIVES

We conducted this study to identify phenotypes of obstructive sleep apnea (OSA) in children based on lifestyle, sleep habits, age, obesity, sex, soft tissue facial features, and specific craniofacial abnormalities.

METHODS

Seventy-three children with symptoms of pediatric OSA who underwent overnight observed polysomnography participated in this study. Soft tissue facial features were assessed using a 3-dimensional stereophotogrammetric system. Craniofacial abnormalities were evaluated based on the most common facial features associated with orthodontic treatment needs. Data regarding lifestyle, sleep habits, age, obesity, and sex were also collected. To identify phenotypes of OSA, a sequential analysis was then performed on categories of variables using fuzzy clustering with medoids.

RESULTS

Craniofacial abnormalities and soft tissue facial features defined clusters. Three clusters were identified. Cluster 1 comprised a group of younger children (5.9 ± 3.8 years) without obesity, without craniofacial abnormalities, and with smaller soft tissue facial features dimensions. Cluster 2 comprised a group of older children (9.6 ± 3.9 years) without obesity and with larger mandibular dimensions and mildly arched palates (71.4%). Cluster 3 comprised a group of older children (9.2 ± 3.9 years) with obesity and a history of health issues (68.4%), excessive lower facial height (63.2%), and midface deficiency (73.7%). No differences were observed across clusters regarding sleep features. A moderate severity of obstructive and mixed respiratory events was observed in all 3 clusters.

CONCLUSIONS

The study results did not identify distinct phenotypes of pediatric OSA based on soft tissue facial features or craniofacial abnormalities alone. Age and body mass index likely modify the effect of soft tissue facial features and craniofacial abnormalities as risk factors for OSA in children.

CITATION

Fernandes Fagundes NC, Loliencar P, MacLean JE, Flores-Mir C, Heo G. Characterization of craniofacial-based clinical phenotypes in children with suspected obstructive sleep apnea. J Clin Sleep Med. 2023;19(11):1857-1865.

Prevalence of adenoid hypertrophy among 12-year-old children and its association with craniofacial characteristics: a cross-sectional study

BACKGROUND

Identifying the prevalence of adenoid hypertrophy (AH) and craniofacial factors associated with this condition requires studies with random sampling from the general population, and multiple criteria can be used for assessing AH on lateral cephalometric radiograph (LCR). The present analysis represents the first report performed according to these requirements in a large cross-sectional sample of children.

METHODS

LCRs of 517 12-year-old children (286 males, 231 females) randomly selected from the general population were retrospectively retrieved. AH was defined using three criteria (At/Nd, Ad-Ba/PNS-Ba, 1-Npaa/Npa), and twelve craniofacial variables were measured (SNA, SNB, ANB, Wits, Cd-Gn, MnP^SN, MxP^MnP, TPFH/TAFH, OPT^SN, C2ps-C4pi^SN, H-CV, H-FH). Skeletal characteristics were compared between children with and without AH using Mann-Whitney U test. Binary logistic regression (adjusted for sex and skeletal growth) was used to independently quantify the association between craniofacial factors and AH.

RESULTS

The prevalence of children with AH was 17.6% (according to At/Nd), 19.0% (according to Ad-Ba/PNS-Ba), and 13.9% (according to 1-Npaa/Npa). Children with AH presented greater antero-posterior jaw discrepancy (larger ANB, smaller SNB), greater mandibular divergence (larger MnP^SN), forward head posture (larger OPT^SN and C2ps-C4pi^SN), and anteriorly positioned hyoid bone (larger H-CV). Larger SNA (OR = 1.39-1.48), while smaller SNB (OR = 0.77-0.88) and Wits (OR = 0.85-0.87), were associated with greater likelihood of having AH, independently from the assessment method used.

CONCLUSIONS

The prevalence of children with AH ranged from 13.9 to 19.0% based on LCR. Greater antero-posterior maxillo-mandibular discrepancy and mandibular retrusion were independently associated with higher likelihood of having AH.

Age-related hypertrophy of adenoid and tonsil with its relationship with craniofacial morphology

BACKGROUND

When analyzing the relationship between adenotonsillar hypertrophy and craniofacial morphology, researchers generally regarded hypertrophied adenoids and tonsils as a whole. It remains unclear whether different enlarged sites of pharyngeal lymphoid tissue would correlate with multiple craniofacial subtypes. We hypothesized there would be craniofacial subtypes correlated with different locations of hypertrophied adenoid and tonsil.

METHODS

Lateral cephalometric radiographs were obtained from 466 children (171 boys and 295 girls, aged 12.27 ± 2.69 years). They were divided into four groups according to different sites of enlarged pharyngeal lymphoid tissue: adenoid hypertrophy group (AG, n = 126), tonsillar hypertrophy group (TG, n = 59), adenotonsillar hypertrophy group (ATG, n = 69) and control group (CG, n = 212). Five commonly used angles for cephalometric measurements were investigated: SNA (Sella-Nasion-Point A), SNB (Sella-Nasion-Point B), ANB (Point A-Nasion-Point B), mandibular plane angle (MP/SN) and Y-axis angle (SGn/FH).

RESULTS

Children with isolated tonsillar hypertrophy correlated with increased SNA (unstandardized regression coefficient B = 1.38, p = 0.009) and SNB (B = 1.99, p = 0.001) compared with controls. However, children with isolated adenoid hypertrophy correlated with decreased SNB (B=-0.94, p = 0.036), increased ANB (B = 0.74, p = 0.014) and increased MP/SN (B = 2.22, p < 0.001). Similarly, children with adenotonsillar hypertrophy correlated with decreased SNB (B=-1.36, p = 0.015), increased ANB (B = 1.35, p < 0.001) and increased MP/SN (B = 2.64, p = 0.001).

CONCLUSIONS

Isolated adenoid hypertrophy correlated with a retrognathic mandible, an increased maxillo-mandibular sagittal discrepancy, and an increased mandibular plane angle. Isolated tonsillar hypertrophy correlated with maxillary and mandibular protrusion. Adenotonsillar hypertrophy did not show a superimposed craniofacial pattern of the above two but showed the same craniofacial pattern as isolated adenoid hypertrophy.

A non-randomized concurrent controlled trial of myofunctional treatment in the mixed dentition children with functional mouth breathing assessed by cephalometric radiographs and study models

Objectives

This study aimed to examine the clinical effects of myofunctional treatment on children with functional mouth breathing by cephalometric radiographs and study models.

Methods

A total of 224 children (6–10 years old; 114 males and 110 females; SNA°: 82.24 ± 1.67°; ANB°: 2.79 ± 0.80°, 28° < SN-GoGn° < 37°) formed three groups: MB-M group (mouth breathers with myofunctional treatment,n = 75); MB-N group (mouth breathers with no treatment,n = 70); NB group (nasal breathers with no treatment, n = 79). A blind evaluation of cephalometric radiographs and study models was conducted at T1(pre-study) and T2 (post-study), respectively.

Results

Two hundred four children (MB-M:66, MB-N:68, NB:70) completed the present study. At T1, MB-M and MB-N groups, compared to their NB counterpart, had greater anterior lower facial height(P < 0.01) and overjet(P < 0.001) but shorter overbite and maxillary canines width (P < 0.001). At T2, the MB-N group exhibited a higher ANB angle, anterior lower facial height, and overjet, but shorter overbite and maxillary canines width (P < 0.001). From T1 to T2, the anterior lower facial height increased, overbite and the maxillary canines width further decreased in the MB-N group (P < 0.001). However, in the MB-M group, the incisors were retracted, overbite increased (P < 0.001), anterior lower facial height increased insignificantly (P > 0.05), and maxillary canines width increased slightly (P < 0.05). In the NB and MB-M groups, the mandible showed a normal tendency to grow forward, whereas, in the MB-N group, the mandible showed a tendency to grow downward (P < 0.001).

Conclusions

Mouth breathers demonstrated increased anterior facial height and overjet but reduced overbite and maxillary arch width, which improved significantly following myofunctional treatment.

Trial registration

TCTR: TCTR20220401001. Registered 1^stApril 2022-Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03559-w.

Evaluation of the effects of different rapid maxillary expansion appliances on airway by acoustic rhinometry: A randomized clinical trial

OBJECTIVE

The purpose of this 3-arm parallel trial was to compare the effects of tooth tissue-borne (TTB), tooth-borne (TB) and bone-borne (BB) rapid maxillary expansion (RME) appliances on nasal airway with acoustic rhinometry (AR).

SETTING AND SAMPLE POPULATION

Forty-six 12- to 14-year-old patients with narrow maxilla were randomly allocated into 3 study groups accordingly the type of expander: TTB, TB and BB. The participants were recruited from the Department of Orthodontics, Izmir Katip Celebi University.

MATERIALS AND METHODS

All patients had RME with an initial activation of two-quarter turns a day (0.5 mm) for an average of 8 days followed by 1 quarter turns per day for an average of 10 days. Disguised group allocation using opaque sealed envelopes was made with a computer-generated randomization program. The primary outcome was changes on the minimal nasal cross-sectional area (MCA). Secondary outcome included the assessment of nasal cavity volume. AR measurements were obtained at baseline (T0), immediately after the expansion (T1), and at 3 months-follow-up (T2). One-way analysis of variance (ANOVA) and Bonferroni test were used for inter-group comparison and two-way ANOVA was used for intra-group evaluation.

RESULTS

There were significant increases in MCA 1, 2 and nasal Vol in all groups after the treatment (95% [CI], P < 0.05) whereas in inter-group comparisons; MCA 1, 2 and nasal Vol, the changes were found to be similar (95% [CI], P > 0.05).

HARMS

No serious harm was observed except for mild gingivitis due to plaque accumulation.

CONCLUSIONS

RME treatment increased minimal nasal cross-sectional areas and nasal volume irrespective of appliance design.

TRIAL REGISTRATION

This trial was registered at Clinicaltrials.gov (Identifier NCT04529057).

PROTOCOL

The protocol was not published.

FUNDING

This trial was financed by Izmir Katip Celebi University, Scientific Research Projects Unit [grant number 2016-TDR-SABE-0024].

Use of facial stereophotogrammetry as a screening tool for pediatric obstructive sleep apnea by dental specialists

STUDY OBJECTIVES

To evaluate facial 3-dimensional (3D) stereophotogrammetry's effectiveness as a screening tool for pediatric obstructive sleep apnea (OSA) when used by dental specialists.

METHODS

One hundred forty-four participants aged 2-17 years, including children fully diagnosed with pediatric OSA through nocturnal polysomnography or at high-risk or low-risk of pediatric OSA, participated in this study. 3D stereophotogrammetry, Craniofacial Index, and Pediatric Sleep Questionnaire were obtained from all participants. Ten dental specialists with interest in pediatric sleep breathing disorders classified OSA severity twice, once based only on 3D stereophotogrammetry and then based on 3D stereophotogrammetry, Craniofacial Index, and Pediatric Sleep Questionnaire. Intrarater and interrater reliability and diagnostic accuracy of pediatric OSA classification were calculated. A cluster analysis was performed to identify potential homogeneous pediatric OSA groups based on their craniofacial features classified through the Craniofacial Index .

RESULTS

Intrarater and interrater agreement suggested a poor reproducibility when only 3D facial stereophotogrammetry was used and when all tools were assessed simultaneously. Sensitivity and specificity varied among clinicians, indicating a low screening ability for both 3D facial stereophotogrammetry, ranging from 0.36-0.90 and 0.10-0.70 and all tools ranging from 0.53-1.0 and 0.01-0.49, respectively. A high arched palate and reversed or increased overjet contributed to explaining how participating dental clinicians classified pediatric OSA.

CONCLUSIONS

3D stereophotogrammetry-based facial analysis does not seem predictive for pediatric OSA screening, alone or combined with the Pediatric Sleep Questionnaire and Craniofacial Index when used by dental specialists interested in sleep-disordered breathing. Some craniofacial traits, more specifically significant sagittal overjet discrepancies and an arched palate, seem to influence participating dental specialists' classification.

CITATION

Fernandes Fagundes NC, Carlyle T, Dalci O, et al. Use of facial stereophotogrammetry as a screening tool for pediatric obstructive sleep apnea by dental specialists. J Clin Sleep Med. 2022;18(1):57-66.

Aerodynamic characteristics in upper airways among orthodontic patients and its association with adenoid nasopharyngeal ratios in lateral cephalograms

BACKGROUND

Adenoid hypertrophy among orthodontic patients may be detected in lateral cephalograms. The study investigates the aerodynamic characteristics within the upper airway (UA) by means of computational fluid dynamics (CFD) simulation. Furthermore, airflow features are compared between subgroups according to the adenoidal nasopharyngeal (AN) ratios.

METHODS

This retrospective study included thirty-five patients aged 9-15 years having both lateral cephalogram and cone beam computed tomography (CBCT) imaging that covered the UA region. The cases were divided into two subgroups according to the AN ratios measured on the lateral cephalograms: Group 1 with an AN ratio < 0.6 and Group 2 with an AN ratio ≥ 0.6. Based on the CBCT images, segmented UA models were created and the aerodynamic characteristics at inspiration and expiration were simulated by the CFD method for the two groups. The studied aerodynamic parameters were pressure drop (ΔP), maximum midsagittal velocity (V_ms), maximum wall shear stress (P_ws), and minimum wall static pressure (P_w).

RESULTS

The maximum V_ms exhibits nearly 30% increases in Group 2 at both inspiration (p = 0.013) and expiration (p = 0.045) compared to Group 1. For the other aerodynamic parameters such as ΔP, the maximum P_ws, and minimum P_w, no significant difference is found between the two groups.

CONCLUSIONS

The maximum V_ms seems to be the most sensitive aerodynamic parameter for the groups of cases. An AN ratio of more than 0.6 measured on a lateral cephalogram may associate with a noticeably increased maximum V_ms, which could assist clinicians in estimating the airflow features in the UA.

Biomonitoring of Lead Exposure in Children from Two Fishing Communities at Northern Colombia

Lead (Pb) exposure is a growing concern in developing countries, especially in vulnerable children. The objective of this study was to evaluate blood lead levels (BLL) in children from two fishing populations at Northern Colombia, Loma de Arena and Tierrabomba, as well as their association with morphometric parameters, markers of hematological status, liver function, and mRNA expression of genes related to Pb toxicity. A total of 198 blood samples were collected from participants aged 5-16 years old. The mean (± standard error) BLL for the studied sample was 3.6 ± 0.3 μg/dL, and the 97.5th percentile was 21.0 μg/dL. The participants of Loma de Arena and Tierrabomba presented BLL of 3.9 ± 0.5 and 2.9 ± 0.3 μg/dL, respectively. Children born preterm had greater BLL than those born at full term. Boys had greater BLL than girls, which also occurred for participants between 12 and 16 years old, compared with those aged 5-11 years old. The BLL were negatively correlated with body mass index in children from Loma de Arena, but an opposite behavior was observed for Tierrabomba. In Loma de Arena, the mRNA expression of interferon gamma, a pro-inflammatory cytokine, increased with the BLL, but that of δ-aminolevulinic acid dehydrogenase, a sensor for Pb poisoning, decreased. In Tierrabomba, gene expression did not change with BLL. These results show that in fishing communities, lead exposure promotes different health impacts depending on age, sex, and other site-specific factors. In any case, appropriate educational and intervention programs should be carried out to minimize Pb exposure in children.