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Jessadapornchai T, Samruajbenjakun B, Chanmanee P, Chalidapongse P. 3D analysis of upper airway morphology related to obstructive sleep apnea severity. J World Fed Orthod 2024; 13:175-180. [PMID: 38688739 DOI: 10.1016/j.ejwf.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/07/2024] [Accepted: 03/09/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder characterized by repetitive collapse of the upper airway during sleep. However, little evidence is available on the differences between the sub-regions of the upper airway morphology and OSA severity. Since orthodontists frequently perform cone beam computed tomography (CBCT) in the neck area, we aimed to investigate the relationship and the differences between upper airway morphology and OSA severity using CBCT. MATERIALS AND METHODS The medical records, CBCT imaging of 21 OSA patients diagnosed by polysomnography, and the apnea-hypopnea index (AHI) results were included to classify OSA severity as mild, moderate, or severe. The minimum cross-sectional areas (MCA) and volumes of the upper pharyngeal airway boundaries in four sub-regions: nasopharynx, retropalatal, retroglossal, and hypopharynx were measured. Dolphin Imaging software was used for upper airway segmentation. The correlation coefficient (r), one-way ANOVA, and the least significant difference post hoc multiple comparison test were applied to fulfill the objectives. RESULTS A statistically significant relationship was found between the MCA of the nasopharynx and the AHI (r = -0.473, P < 0.05). Furthermore, a difference was found between mild and moderate and moderate and severe OSA severity in the MCA results of the retroglossal region (P < 0.05). However, no relationship was found between the upper airway volume and OSA severity. CONCLUSIONS MCA was moderately negatively correlated to AHI only in the nasopharynx subregion. Moderate OSA presented significantly less MCA than mild and severe OSA only in the oropharynx and retroglossal subregions.
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Affiliation(s)
- Tuangporn Jessadapornchai
- Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Bancha Samruajbenjakun
- Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
| | - Pannapat Chanmanee
- Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Premthip Chalidapongse
- Department of Oral Diagnostic Sciences, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Lenze NR, Bharadwaj SR, Baldassari CM, Kirkham EM. Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Adenotonsillectomy: The Nose, Nasopharynx, and Palate. Otolaryngol Clin North Am 2024; 57:421-430. [PMID: 38508883 PMCID: PMC11060425 DOI: 10.1016/j.otc.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
While adenotonsillectomy is the primary treatment of pediatric obstructive sleep apnea (OSA), persistent OSA after surgery is common and may be due to residual obstruction at the nose, nasopharynx, and/or palate. Comprehensive evaluation for persistent pediatric OSA ideally includes clinical examination (with or without awake nasal endosocpy) as well as drug-induced sleep endoscopy in order to accurately identify sources of residual obstruction. Depending on the site of obstruction, some of the surgical management options include submucous inferior turbinate resection, septoplasty, adenoidectomy, and expansion sphincter pharyngoplasty.
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Affiliation(s)
- Nicholas R Lenze
- Department of Otolaryngology-Head & Neck Surgery, The University of Michigan, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Suhas R Bharadwaj
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive, Suite 1100, Norfolk, VA 23507, USA
| | - Christina M Baldassari
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive, Suite 1100, Norfolk, VA 23507, USA
| | - Erin M Kirkham
- Department of Otolaryngology-Head & Neck Surgery, The University of Michigan, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Schwab RJ, Lin TC, Wiemken A, Dedhia RC, Wehrli FW, Keenan BT. State-Dependent Biomechanical Behavior of Oropharyngeal Structures in Apneic and Control Subjects: A Proof-of-Concept Study. Ann Am Thorac Soc 2024; 21:949-960. [PMID: 38507612 PMCID: PMC11160136 DOI: 10.1513/annalsats.202309-847oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 03/20/2024] [Indexed: 03/22/2024] Open
Abstract
Rationale: Apneic individuals have reduced airway caliber during sleep. The biomechanical changes in upper airway anatomy contributing to this airway narrowing are largely unknown. Objectives: We sought to investigate the state-dependent (wake vs. sleep) biomechanical behavior of the upper airway soft-tissue and craniofacial structures. Methods: Upper airway magnetic resonance imaging was performed in 15 sleep-deprived control subjects (apnea-hypopnea index, <5; 0.3 ± 0.5 events per hour) and 12 sleep-deprived apneic subjects (apnea-hypopnea index, ⩾5; 35.2 ± 18.1 events per hour) during wake and sleep and analyzed for airway measures and soft-tissue/mandibular movement. Results: In the retropalatal region, control subjects showed sleep-dependent reductions (P ⩽ 0.037) in average cross-sectional airway area (CSA), minimum CSA, and anteroposterior and lateral dimensions. Apneic subjects showed sleep-dependent reductions (P ⩽ 0.002) in average CSA, minimum CSA, and anteroposterior and lateral dimensions. In the retroglossal region, control subjects had no sleep-dependent airway reductions. However, apneic subjects had sleep-dependent reductions in minimal CSA (P = 0.001) and lateral dimensions (P = 0.014). Control subjects only showed sleep-dependent posterior movement of the anterior-inferior tongue octant (P = 0.039), whereas apneic subjects showed posterior movement of the soft palate (P = 0.006) and all tongue octants (P ⩽ 0.012). Sleep-dependent medial movement of the lateral walls was seen at the retropalatal minimum level (P = 0.013) in control subjects and at the retropalatal and retroglossal minimum levels (P ⩽ 0.017) in apneic subjects. There was posterior movement of the mandible in apneic subjects (P ⩽ 0.017). Conclusions: During sleep, control and apneic subjects showed reductions in retropalatal airway caliber, but only the apneic subjects showed retroglossal airway narrowing. Reductions in anteroposterior and lateral airway dimensions were primarily due to posterior soft palate, tongue and mandibular movement and to medial lateral wall movement. These data provide important initial insights into obstructive sleep apnea pathogenesis.
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Affiliation(s)
| | - Theodore C. Lin
- Division of Sleep Medicine, Department of Medicine
- Department of Otorhinolaryngology – Head and Neck Surgery, Temple University, Philadelphia, Pennsylvania
| | | | - Raj C. Dedhia
- Division of Sleep Medicine, Department of Medicine
- Department of Otorhinolaryngology – Head and Neck Surgery, and
| | - Felix W. Wehrli
- Laboratory for Structural, Physiologic, and Functional Imaging, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Zreaqat M, Hassan R, Alforaidi S, Kassim NK. Effects of rapid maxillary expansion on upper airway parameters in OSA children with maxillary restriction: A CBCT study. Pediatr Pulmonol 2024. [PMID: 38771201 DOI: 10.1002/ppul.27050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/16/2024] [Accepted: 04/27/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Rapid maxillary expansion (RME) has been proposed as an effective treatment for pediatric obstructive sleep apnea (OSA) and maxillary restriction in children. This study aimed to evaluate the effect of RME appliances on the nasomaxillary complex dimensions in children with OSA and maxillary constriction. METHODS This prospective longitudinal study included 34 children aged 8-12 years with maxillary restriction and OSA confirmed by polysomnography who had completed RME therapy. The nasomaxillary complex is segmented into the nasal cavity, maxillary sinuses, and nasopharynx. The effect of RME on nasomaxillary complex dimensions was assessed pre and posttreatment using cone-beam computed tomography, analysis, while a second standard overnight polysomnography (PSG) was performed to assess changes in respiratory parameters. RESULTS Significant improvements were observed, including inferior maxillary dislocation (S-S1 distance and N-ANS), increased anterior and posterior facial height, and a 5.43 events/h reduction in Apnea-Hypopnea Index (p < .001). The nasal cavity volume increased by 2439 (±584) mm3 (p < .001), nasopharynx size increased by 883 (±479) mm3 (p = .008), mid cross-sectional area increased by 31.74 (±14.50) mm2 (p < .001), and the distance between the right and left maxillary sinuses increased by 8.37 (±3.67) mm (p < .001) all exhibited positive changes, with some insignificant variations in volume change (p = .254). CONCLUSION RME treatment was found to be effective in improving nasal cavity and nasopharyngeal dimensions, leading to improved respiratory parameters in children with OSA and maxillary constriction. While these results are promising, considerations about the potential long-term benefits of RME on future growth are important. The study provides valuable insights into the efficacy of RME as a treatment option for this pediatric population.
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Affiliation(s)
- Maen Zreaqat
- Department of Orthodontic, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Rozita Hassan
- Department of Orthodontic, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Sahal Alforaidi
- Department of Pediatric Dentistry and Orthodontics, College of Dentistry, Taiba University, Medina, Kelantan, Saudi Arabia
| | - Nur Karyatee Kassim
- Department of Orthodontic, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
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Tavsanli ME, Zeynalova A, Seckin M. The effect of pharyngeal structures on the severity of obstructive sleep apnea. Sleep Breath 2024; 28:849-857. [PMID: 38135771 DOI: 10.1007/s11325-023-02973-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 11/12/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND/OBJECTIVE Obstructive sleep apnea (OSA) is characterized by complete or partial cessation of breathing during sleep. The tongue is suggested as a possible anatomical site causing airway obstruction. However, the role of other pharyngeal structures in the development of OSA remains unclear. We designed a study using both the apnea-hypopnea index (AHI) and the oxygen saturation measurements to assess the severity of OSA. We aimed to identify critical anatomical structures of the upper airway that correlate with the severity of OSA and to evaluate the utility of magnetic resonance imaging (MRI) markers to detect possible OSA in patients without overt symptoms. MATERIALS AND METHODS The study included participants referred to the neurology outpatient clinic from the check-up unit. Participants were grouped as controls, mild, moderate, or severe OSA according to the AHI. A cranial MRI with a field of view (FOV) encompassing the upper airway structures was obtained from all participants. The areas of the tongue and the uvula were measured on the sagittal images by drawing the boundaries of the tissues manually. The posterior air space (PAS) area was evaluated from regions of interest in five parallel planes. RESULTS Of 105 participants, 30 were controls, 27 had mild, 25 had moderate, and 23 had severe OSA. The moderate and severe OSA groups did not differ in oxygen saturation levels during sleep. Therefore, patients with moderate and severe OSA were combined into one group (moderate/severe OSA). The area of the tongue was significantly larger in the moderate/severe OSA group compared to the control group. Both the tongue and the uvula areas showed a significant positive correlation with the AHI. CONCLUSION Our findings suggest that the tongue and uvula have prominent roles in the severity of OSAS. It may be useful to measure these structures with MRI to screen for at-risk individuals without overt OSA symptoms.
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Affiliation(s)
- Mustafa Emir Tavsanli
- Electroneurophysiology Department, Vocational School of Health Services, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
- Acibadem Taksim Hastanesi, İnönü Mah, Nizamiye Cad No 9/1, Sisli, Istanbul, Turkey.
| | - Amalya Zeynalova
- Radiology Department, Acibadem Taksim Hospital, Istanbul, Turkey
| | - Mustafa Seckin
- Department of Neurology, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
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Zhang Z, Sun D, Jia Y, Fei N, Li Y, Han D. Facial Contour Features Measured on CT Reflects Upper Airway Morphology in Patients With OSA. J Craniofac Surg 2023; 34:2399-2404. [PMID: 37462196 DOI: 10.1097/scs.0000000000009532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 05/19/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE To determine facial contour features, measured on computed tomography (CT), related to upper airway morphology in patients with obstructive sleep apnea (OSA); certain phenotype of facial abnormalities implying restriction of craniofacial skeleton and adipose tissue nimiety has predicted the value of the severity of OSA. MATERIALS AND METHOD Sixty-four male patients with OSA [apnea-hypopnea index (AHI) ≥10/h] who had upper airway CT were randomly selected to quantitatively measure indicators of facial contour and upper airway structures. Pearson correlation analyses were performed. Partial correlation procedure was used to examine correlations while controlling body mass index (BMI). RESULTS Upper airway anatomy can nearly all be reflected in the face, except retroglossal airway. Upper face width can be measured to assess the overall skeletal structures of the airway. Lower face width can be used to represent how much adipose tissue deposited. Hard palate, retropalatal, and hypopharyngeal airways have corresponding face indicators respectively. Midface width is a better predictor of AHI severity and minimum blood oxygen even than neck circumference because it contains the most anatomical information about the airway, including RP airway condition, soft palate length, tongue volume, etc. These correlations persisted even after correction for BMI. CONCLUSIONS All anatomical features of the upper airway except retroglossal airway can be reflected in the face, and midface width is the best predictor of AHI severity and minimum blood oxygen, even better than neck circumference and BMI.
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Affiliation(s)
- Zishanbai Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University
| | - Dance Sun
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University
| | - Yajie Jia
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University
| | - Nanxi Fei
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yanru Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University
| | - Demin Han
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University
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Redline S, Azarbarzin A, Peker Y. Obstructive sleep apnoea heterogeneity and cardiovascular disease. Nat Rev Cardiol 2023; 20:560-573. [PMID: 36899115 DOI: 10.1038/s41569-023-00846-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/12/2023]
Abstract
Obstructive sleep apnoea (OSA), characterized by recurrent periods of upper airway obstruction and intermittent hypoxaemia, is prevalent in patients with cardiovascular disease (CVD), and is therefore important to consider in the prevention and management of CVD. Observational studies indicate that OSA is a risk factor for incident hypertension, poorly controlled blood pressure, stroke, myocardial infarction, heart failure, cardiac arrhythmias, sudden cardiac death and all-cause death. However, clinical trials have not provided consistent evidence that treatment with continuous positive airway pressure (CPAP) improves cardiovascular outcomes. These overall null findings might be explained by limitations in trial design and low levels of adherence to CPAP. Studies have also been limited by the failure to consider OSA as a heterogeneous disorder that consists of multiple subtypes resulting from variable contributions from anatomical, physiological, inflammatory and obesity-related risk factors, and resulting in different physiological disturbances. Novel markers of sleep apnoea-associated hypoxic burden and cardiac autonomic response have emerged as predictors of OSA-related susceptibility to adverse health outcomes and treatment response. In this Review, we summarize our understanding of the shared risk factors and causal links between OSA and CVD and emerging knowledge on the heterogeneity of OSA. We discuss the varied mechanistic pathways that result in CVD that also vary across subgroups of OSA, as well as the potential role of new biomarkers for CVD risk stratification.
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Affiliation(s)
- Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yüksel Peker
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Koc University School of Medicine, Istanbul, Turkey
- University of Gothenburg, Gothenburg, Sweden
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Lund University School of Medicine, Lund, Sweden
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Hartfield PJ, Janczy J, Sharma A, Newsome HA, Sparapani RA, Rhee JS, Woodson BT, Garcia GJM. Anatomical determinants of upper airway collapsibility in obstructive sleep apnea: A systematic review and meta-analysis. Sleep Med Rev 2022; 68:101741. [PMID: 36634409 DOI: 10.1016/j.smrv.2022.101741] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Abstract
Upper airway (UA) collapsibility is one of the key factors that determine the severity of obstructive sleep apnea (OSA). Interventions for OSA are aimed at reducing UA collapsibility, but selecting the optimal alternative intervention for patients who fail CPAP is challenging because currently no validated method predicts how anatomical changes affect UA collapsibility. The gold standard objective measure of UA collapsibility is the pharyngeal critical pressure (Pcrit). A systematic literature review and meta-analysis were performed to identify the anatomical factors with the strongest correlation with Pcrit. A search using the PRISMA methodology was performed on PubMed for English language scientific papers that correlated Pcrit to anatomic variables and OSA severity as measured by the apnea-hypopnea index (AHI). A total of 29 papers that matched eligibility criteria were included in the quantitative synthesis. The meta-analysis suggested that AHI has only a moderate correlation with Pcrit (estimated Pearson correlation coefficient r = 0.46). The meta-analysis identified four key anatomical variables associated with UA collapsibility, namely hyoid position (r = 0.53), tongue volume (r = 0.51), pharyngeal length (r = 0.50), and waist circumference (r = 0.49). In the future, biomechanical models that quantify the relative importance of these anatomical factors in determining UA collapsibility may help identify the optimal intervention for each patient. Many anatomical and structural factors such as airspace cross-sectional areas, epiglottic collapse, and palatal prolapse have inadequate data and require further research.
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Affiliation(s)
- Phillip J Hartfield
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA; Joint Department of Biomedical Engineering, Marquette University & Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jaroslaw Janczy
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA; Joint Department of Biomedical Engineering, Marquette University & Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abhay Sharma
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hillary A Newsome
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rodney A Sparapani
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John S Rhee
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Guilherme J M Garcia
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA; Joint Department of Biomedical Engineering, Marquette University & Medical College of Wisconsin, Milwaukee, WI, USA.
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Ye Min Soe KT, Ishiyama H, Nishiyama A, Shimada M, Maeda S. Effect of Different Maxillary Oral Appliance Designs on Respiratory Variables during Sleep. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116714. [PMID: 35682298 PMCID: PMC9180795 DOI: 10.3390/ijerph19116714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 12/03/2022]
Abstract
This study aimed to analyze the efficacy of maxillary oral appliance (MOA) designs on respiratory variables during sleep. At baseline, 23 participants underwent a sleep test with a portable device for two nights and were categorized as participants with mild obstructive sleep apnea (mild-OSA) (n = 13) and without OSA (w/o-OSA) (n = 10). Three types of MOAs, standard-OA (S-OA), palatal covering-OA (PC-OA), and vertically increasing-OA (VI-OA), were each worn for three nights, and sleep tests with each MOA were performed with a portable device for two nights. Based on the average of the respiratory event index (REI) values for the two nights for each MOA, w/o-OSA participants with an REI ≥ 5.0 were defined as the exacerbation group and those with an REI < 5.0 as the non-exacerbation group. In mild-OSA participants, an REI ≥ 15.0 or REI ≥ baseline REI × 1.5 were defined as the exacerbation group and those with an REI < 15.0 and REI < baseline REI × 1.5 were defined as the non-exacerbation group. The percentage of the exacerbation and non-exacerbation groups with MOA was evaluated in the w/o-OSA and mild-OSA participants. The maxillary and mandibular dental-arch dimension was compared by dentition model analysis. The exacerbation group in w/o-OSA participants (n = 10) comprised 10.0% participants (n = 1) with S-OA, 40.0% (n = 4) with PC-OA, and 30.0% (n = 3) with VI-OA. The exacerbation group in the mild-OSA participants (n = 13) comprised 15.4% subjects (n = 2) with S-OA, 23.1% (n = 3) with PC-OA, and 23.1% (n = 3) in VI-OA. In the model analysis for w/o-OSA, the posterior dental arch width was significantly greater in the exacerbation group than in the non-exacerbation group wearing S-OA (p < 0.05). In addition, the ratio of the maxillary to mandibular dental arch width (anterior dental arch width) was significantly greater in the exacerbation group than in the non-exacerbation group for both PC-OA and VI-OA (p < 0.05). In mild-OSA, the maxillary and mandibular dental arch lengths and the ratio of maxillary to mandibular dental arch width (posterior dental arch width) were significantly smaller in the exacerbation group than in the non-exacerbation group for S-OA (p < 0.05). This study confirmed that wearing an MOA by w/o-OSA and mild-OSA participants may increase the REI during sleep and that PC-OA and VI-OA may increase the REI more than S-OA. The maxillary and mandibular dental-arch dimensions may affect the REI when using an MOA.
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Affiliation(s)
- Kay Thwe Ye Min Soe
- Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan; (K.T.Y.M.S.); (H.I.)
| | - Hiroyuki Ishiyama
- Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan; (K.T.Y.M.S.); (H.I.)
| | - Akira Nishiyama
- Department of General Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
- Correspondence: ; Tel.: +81-3-5803-5568
| | - Masahiko Shimada
- Dental Anesthesiology and Orofacial Pain Management, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan; (M.S.); (S.M.)
| | - Shigeru Maeda
- Dental Anesthesiology and Orofacial Pain Management, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan; (M.S.); (S.M.)
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10
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Effects of respiratory rate on the fluid mechanics of a reconstructed upper airway. Med Eng Phys 2022; 100:103746. [DOI: 10.1016/j.medengphy.2021.103746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 11/25/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022]
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11
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Yuen HM, Lai ACY, Liu EKH, Lee MC, Chu WCW, Chan JWY, Chan NY, Wing YK, Li AM, Chan KC, Au CT. Validation of the Sonographic Measurement of Lateral Parapharyngeal Wall Thickness in Childhood Obstructive Sleep Apnea. Nat Sci Sleep 2022; 14:2013-2021. [PMID: 36394067 PMCID: PMC9642859 DOI: 10.2147/nss.s369727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Lateral parapharyngeal wall (LPW) thickness is a potentially useful anatomical marker of childhood obstructive sleep apnea (OSA). Measuring LPW thickness by ultrasonography (USG) is technically feasible but its use in children has not been validated. Therefore, this study aimed to assess the intra- and inter-operator reliability of the sonographic measurements of LPW thickness in children and to assess its validity against magnetic resonance imaging (MRI) measurements. METHODS Prepubertal children aged 6-11 years suspected to suffer from OSA were recruited. Repeated measurements of LPW thickness by USG were conducted to evaluate the intra- and inter-operator reliability, examined by intraclass correlation coefficient (ICC). LPW thickness was measured as the distance between the internal carotid artery and the echogenic surface of the pharynx in an oblique coronal plane by USG. LPW thickness was measured by MRI at the retropalatal level. The agreement between the LPW thickness measured by USG and MRI was assessed by ICC and Bland-Altman plot. RESULTS Thirty-four children (mean age: 8.66 ± 1.61, 26 male) were recruited. The intra- and inter-operator reliability of the LPW thickness by USG was good (ICC = 0.84 and 0.82, respectively). The agreement between the USG-measured and MRI-measured LPW thickness was moderate (ICC = 0.72). he Bland-Altman plot demonstrated a mean difference of 0.061 cm and a 95% limit of agreement from 0.91 to 1.12 cm. CONCLUSION In this study, we demonstrated that ultrasonography is a valid and reliable method to assess LPW thickness in children. This study was supported by the Direct Grant for Research from the Research Committee of the Chinese University of Hong Kong (Project no. 2020.073).
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Affiliation(s)
- Hoi Man Yuen
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Andy C Y Lai
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Eric K H Liu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Ming Chung Lee
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Winnie C W Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Joey W Y Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Ngan Yin Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Yun Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Albert M Li
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.,Laboratory for Pediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.,Hong Kong Hub of Pediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Kate C Chan
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.,Laboratory for Pediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.,Hong Kong Hub of Pediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Chun Ting Au
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.,Laboratory for Pediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China.,Hong Kong Hub of Pediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
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12
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Ferlias N, Gjørup H, Doherty MA, Haagerup A, Pedersen TK. Obstructive Sleep Apnoea in pycnodysostosis; a three-dimensional upper airway analysis. Orthod Craniofac Res 2021; 25:494-501. [PMID: 34963019 DOI: 10.1111/ocr.12561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/04/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
AIM To assess the upper airway (UA) morphology in patients with pycnodysostosis with a 3D analysis, compare results with normative data and investigate correlation of the total volume (TV) to other UA morphology variables. MATERIALS AND METHODS Cone beam computed tomography (CBCT) images of eight Danish patients with pycnodysostosis (4 males, 4 females with a mean age of 31.8 years, SD:16.3 years), were analysed using Mimics® (Materialise®, Belgium) and compared with a sex- and age-matched control group (6 males, 8 females with a mean age of 33.6 years, SD:18.6 years). RESULTS The distance from the tip of the epiglottis (E) to the Frankfurt horizontal plane (Fp) was significantly shorter in the pycnodysostosis group (p < 0.042). Regarding the cross-sectional measurements, at the "maximum constriction" (p < 0.005), the "upper airway limit" (p < 0.001) and the "lower airway limit" (p < 0.035) cross-sections were significantly smaller in the pycnodysostosis group. The volumes "nasopharynx" (p < 0.002) and "total airway" (TV) (p < 0.01) were also significantly smaller. CONCLUSION Patients with pycnodysostosis have a reduced total airway as well as nasopharyngeal volume compared with matched controls. Additionally, they have a reduced cross-sectional area in the upper and lower borders of the UA, and the area of maximum constriction is also reduced. These factors might explain the high prevalence of obstructive sleep apnoea in pycnodysostosis. TV is positively correlated to total length and cross-sections at all levels including the maximum constriction area as well as the anteroposterior dimension at the upper and lower airway borders.
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Affiliation(s)
- Nikolaos Ferlias
- Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Denmark
| | - Hans Gjørup
- Department of Oral and Maxillofacial Surgery, Center for, Oral Health in Rare Diseases, Aarhus University Hospital, Aarhus, Denmark
| | | | - Annette Haagerup
- NIDO Denmark, Hospital Unit West and Institute of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Thomas Klit Pedersen
- Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Denmark.,Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark
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13
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Chen L, Xiao T, Ng CT. The Biomechanical Mechanism of Upper Airway Collapse in OSAHS Patients Using Clinical Monitoring Data during Natural Sleep. SENSORS 2021; 21:s21227457. [PMID: 34833533 PMCID: PMC8621213 DOI: 10.3390/s21227457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/31/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022]
Abstract
Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common sleep disorder characterized by repeated pharyngeal collapse with partial or complete obstruction of the upper airway. This study investigates the biomechanics of upper airway collapse of OSASH patients during natural sleep. Computerized tomography (CT) scans and data obtained from a device installed on OSASH patients, which is comprised of micro pressure sensors and temperature sensors, are used to develop a pseudo three-dimensional (3D) finite element (FE) model of the upper airway. With consideration of the gravity effect on the soft palate while patients are in a supine position, a fluid–solid coupling analysis is performed using the FE model for the two respiratory modes, eupnea and apnea. The results of this study show that the FE simulations can provide a satisfactory representation of a patient’s actual respiratory physiological processes during natural sleep. The one-way valve effect of the soft palate is one of the important mechanical factors causing upper airway collapse. The monitoring data and FE simulation results obtained in this study provide a comprehensive understanding of the occurrence of OSAHS and a theoretical basis for the individualized treatment of patients. The study demonstrates that biomechanical simulation is a powerful supplementation to clinical monitoring and evaluation.
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Affiliation(s)
- Liujie Chen
- School of Civil Engineering, Guangzhou University, Guangzhou 510006, China;
| | - Tan Xiao
- Center for Mechanical Teaching and Testing, Guangdong University of Petrochemical Technology, Maoming 525000, China
- Correspondence:
| | - Ching Tai Ng
- School of Civil, Environmental & Mining Engineering, The University of Adelaide, Adelaide, SA 5005, Australia;
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14
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Importance in the Occurrence Distribution of Minimum Oropharyngeal Cross-Sectional Area in the Different Skeletal Patterns Using Cone-Beam Computed Tomography. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5585629. [PMID: 33997021 PMCID: PMC8116163 DOI: 10.1155/2021/5585629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
Purpose Obstructive sleep apnea is a condition involving repetitive partial or complete collapse of the pharyngeal airway, especially in patient with mandibular hypoplasia. The present study investigated the differences between the volume of the oropharyngeal airway and the minimum axial area in three skeletal patterns through the use of cone-beam computed tomography (CBCT). Materials and Methods CBCT scans of 147 patients were collected to measure the upper oropharyngeal airway volume (UOV), lower oropharyngeal airway volume (LOV), upper oropharyngeal airway area (UOA), minimum upper oropharyngeal airway area (MUOA), lower oropharyngeal airway area (LOA), minimum lower oropharyngeal airway area (MLOA), anatomical structures (orbitale, Or; porion, Po; pogonion, Pog; hyoid, H; second cervical vertebra, C2; fourth cervical vertebra, C4), and relevant angles. Statistical analysis was performed using analysis of variance and Pearson's test. Results Compared with patients in Class II, those in Class III and Class I exhibited a significantly anterior position of H and Pog. The vertical positions of H and Pog revealed no significant difference between the three skeletal patterns. Patients in skeletal Class III exhibited significantly larger oropharyngeal area (UOA, MUOA, LOA, MLOA) and oropharyngeal airway (UOV and LOV) than those in skeletal Class II did. The horizontal position of Pog had a moderately significant correlation with UOA (r = 0.471) and MUOA (r = 0.455). Conclusion Patients in skeletal Class II had significantly smaller oropharyngeal airway areas and volumes than those in Class III did. The minimum oropharyngeal cross-sectional area had a 67% probability of occurrence in the upper oropharyngeal airway among patients in Class I and Class II and a 50% probability of occurrence among patients in Class III.
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15
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Bitners AC, Sin S, Agrawal S, Lee S, Udupa JK, Tong Y, Wootton DM, Choy KR, Wagshul ME, Arens R. Effect of sleep on upper airway dynamics in obese adolescents with obstructive sleep apnea syndrome. Sleep 2021; 43:5819384. [PMID: 32280981 DOI: 10.1093/sleep/zsaa071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
STUDY OBJECTIVES The biomechanical basis of obstructive sleep apnea syndrome (OSAS) may influence upper airway dynamics. In this study, we investigate dynamic changes during respiration in wakefulness and sleep in obese adolescents with and without OSAS. METHODS Respiratory-gated dynamic magnetic resonance imaging (MRI) at the retropalatal and retroglossal regions was performed with simultaneous measurement of SpO2 and nasal-oral mask airflow and pressure. Airway cross-sectional area (CSA) was determined using AMIRA. Percent change in CSA was calculated from five continuous tidal breaths in states of wakefulness and sleep. Mixed effects models were used to evaluate interactions between group (OSAS/control), site (retropalatal/retroglossal), and stage (wake/sleep). RESULTS We studied 24 children with OSAS (mean age 15.49 ± 2.00 years, mean apnea-hypopnea index [AHI] 16.53 ± 8.72 events/h) and 19 controls (mean age 14.86 ± 1.75 years, mean AHI 2.12 ± 1.69 events/h). Groups were similar in age, sex, height, weight, and BMI Z-score. Participants with OSAS had a 48.17% greater increase in percent change of airway CSA during sleep than controls (p < 0.0001), while there was no difference between groups during wakefulness (p = 0.6589). Additionally, participants with OSAS had a 48.80% increase in percent change of airway CSA during sleep as compared with wakefulness (p < 0.0001), whereas no such relationship was observed in controls (p = 0.5513). CONCLUSIONS This study demonstrates significant effects of sleep on upper airway dynamics in obese children with OSAS. Dynamic MRI with physiological data can potentially provide further insight into the biomechanical basis of OSAS and assist in more effective management.
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Affiliation(s)
| | - Sanghun Sin
- Department of Pediatrics, Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - Sabhyata Agrawal
- Department of Pediatrics, Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - Seonjoo Lee
- Department of Biostatistics and Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY
| | - Jayaram K Udupa
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Yubing Tong
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - David M Wootton
- Department of Mechanical Engineering, Cooper Union, New York, NY
| | - Kok Ren Choy
- Department of Mechanical Engineering, Cooper Union, New York, NY
| | - Mark E Wagshul
- Albert Einstein College of Medicine, Bronx, NY.,Department of Radiology, Montefiore Medical Center, Bronx, NY
| | - Raanan Arens
- Albert Einstein College of Medicine, Bronx, NY.,Department of Pediatrics, Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, NY
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16
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Xu L, Keenan BT, Wiemken AS, Chi L, Staley B, Wang Z, Wang J, Benedikstdottir B, Juliusson S, Pack AI, Gislason T, Schwab RJ. Differences in three-dimensional upper airway anatomy between Asian and European patients with obstructive sleep apnea. Sleep 2020; 43:zsz273. [PMID: 31735957 PMCID: PMC7215269 DOI: 10.1093/sleep/zsz273] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/01/2019] [Indexed: 12/20/2022] Open
Abstract
STUDY OBJECTIVES This study evaluated differences in upper airway, soft tissues and craniofacial structures between Asians from China and Europeans from Iceland with OSA using three-dimensional magnetic resonance imaging (MRI). METHODS Airway sizes, soft tissue volumes, and craniofacial dimensions were compared between Icelandic (N = 108) and Chinese (N = 57) patients with oxygen desaturation index (ODI) ≥ 10 events/h matched for age, gender, and ODI. Mixed effects models adjusting for height or BMI and residual differences in age and ODI were utilized. RESULTS In our matched sample, compared to Icelandic OSA patients, Chinese patients had smaller BMI (p < 0.0001) and neck circumference (p = 0.011). In covariate adjusted analyses, Chinese showed smaller retropalatal airway size (p ≤ 0.002), and smaller combined soft tissues, tongue, fat pads, and pterygoid (all p ≤ 0.0001), but male Chinese demonstrated a larger soft palate volume (p ≤ 0.001). For craniofacial dimensions, Chinese demonstrated bigger ANB angle (p ≤ 0.0196), differently shaped mandibles, including shorter corpus length (p < 0.0001) but longer ramus length (p < 0.0001), and a wider (p < 0.0001) and shallower (p ≤ 0.0001) maxilla. CONCLUSIONS Compared to Icelandic patients of similar age, gender and ODI, Chinese patients had smaller retropalatal airway and combined soft tissue, but bigger soft palate volume (in males), and differently shaped mandible and maxilla with more bony restrictions. Results support an ethnic difference in upper airway anatomy related to OSA, which may inform targeted therapies.
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Affiliation(s)
- Liyue Xu
- Department of Respiratory Medicine, Peking University People’s Hospital, Beijing, China
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrew S Wiemken
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Luqi Chi
- Sleep Medicine Center, Washington University School of Medicine, St. Louis, MO
| | - Bethany Staley
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Zhifang Wang
- Department of Respiratory Medicine, Datong, China
| | - Jianjun Wang
- Department of Radiology, Shanxi Tongcoal General Hospital, Datong, China
| | | | - Sigurdur Juliusson
- ENT Department, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Allan I Pack
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Thorarinn Gislason
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Sleep, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Richard J Schwab
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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17
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Upper airway morphological changes in obstructive sleep apnoea: effect of age on pharyngeal anatomy. The Journal of Laryngology & Otology 2020; 134:354-361. [PMID: 32284084 DOI: 10.1017/s0022215120000766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the upper airway morphology changes associated with ageing in adult Chinese patients with obstructive sleep apnoea. METHODS A total of 124 male patients diagnosed with obstructive sleep apnoea by overnight polysomnography, who underwent upper airway computed tomography, were enrolled. The linear dimensions, cross-sectional area and volume of the upper airway region and the surrounding bony frame were measured. The association between ageing and upper airway morphology was analysed. RESULTS Soft palate length, minimum cross-sectional area of the retroglossal region, lateral dimensions at the minimum cross-sectional area of the retropalatal and retroglossal regions, nasopharyngeal volume, and average cross-sectional area of the nasopharyngeal region were found to significantly increase with ageing in all patients, while the upper airway shape flattened with ageing. The volume of the retropalatal region increased with ageing among the patients with a body mass index of less than 24 kg/m2. The volume of parapharyngeal fat pad increased with ageing among patients with a body mass index greater than 28 kg/m2. CONCLUSION A number of dimensional, cross-sectional and volumetric parameters of the pharynx increased with age, indicating that non-anatomical factors may play a more important role in the pathogenesis of obstructive sleep apnoea in aged patients.
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18
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Three-Dimensional Assessment of Pharyngeal Volume on Computed Tomography Scans: Applications to Anesthesiology and Endoscopy. J Craniofac Surg 2020; 31:755-758. [PMID: 31985592 DOI: 10.1097/scs.0000000000006094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Pharyngeal volume is important in anesthesiology for correctly assessing intubation procedures. However, most of studies are based on patients in upright position and do not assess possible relationships between pharyngeal volume and cranial size. This study aims at measuring pharyngeal volume in CT-scans and to assess possible statistically significant differences according to sex.Eighty healthy subjects (40 males and 40 females) aged between 21 and 86 years were retrospectively chosen from a hospital database of maxillofacial CT-scans; 3D segmentation was performed separately for naso-, oro- and laryngopharyngeal portion through ITK-SNAP software, and their volume was calculated. Three cranial measurements were obtained: distance between anterior and posterior nasal spine, upper facial height (nasion-prosthion) and biorbital breadth (ectoconchion-ectoconchion distance).The effect of sex on volume for each pharyngeal portion was assessed through one-way ANCOVA test using each of the 3 cranial measurements as covariate (P < 0.05).On average, the volume of nasopharynx, oropharynx and laryngopharynx was 7.2 ± 2.7 cm, 7.5 ± 4.2 cm, 3.5 ± 2.2 cm respectively in males, and 6.4 ± 2.9 cm, 5.2 ± 2.1 cm, 3.0 ± 1.8 cm in females. Statistically significant differences according to sex were found only for oropharyngeal volume, independently from cranial measurements (P < 0.05).This study provides data concerning volume of pharyngeal air space in supine subjects: these reference standards can be useful for anaesthesiologic procedures.
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19
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Kuo CFJ, Lin CS, Chuang CH, Lin CS, Chiu FS, Liu SC. Quantitative Morphometric Measurements of the Oropharynx in Obstructive Sleep Apnea Syndrome Using a Laser Depth Measurement Module. Nat Sci Sleep 2020; 12:1181-1190. [PMID: 33363424 PMCID: PMC7754258 DOI: 10.2147/nss.s284836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/26/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Current diagnostic routines in obstructive sleep apnea syndrome (OSAS), including drug-induced sleep endoscopy (DISE), provide qualitative data. Quantitative morphometric measurements of oropharyngeal structures remain challenging. This study aims to introduce a special linear laser projection device that can facilitate computer-assisted digitalized analysis and provide important quantitative information for OSAS prediction. MATERIALS AND METHODS We used a single-wavelength green three-linear laser to provide the scaling reference, with one at an angle of 8.5 degrees with the other two which were parallel. The oropharyngeal images were divided into two groups: the non-OSAS and OSAS group, after polysomnography. A minimum of three evaluations were carried out to determine the maximum cross-sectional area of the oropharyngeal inlet (CSAOI) and the retropalatal depth. RESULTS A total of 132 subjects were enrolled in this study, with 76 subjects in the non-OSAS group and 56 cases in the OSAS group. In the non-OSAS group, the CSAOI was significantly larger in males than in females. There was a trend toward deeper retropalatal region in men than in women (14.25 vs 11.76 mm). Correlation analysis revealed that retropalatal depth is significantly related to body height and the CSAOI. The body weight and BMI of patients with OSAS were significantly higher than those of participants without OSAS. The retropalatal depth and CSAOI were significantly decreased in OSAS patients as compared to those without OSAS. Our new parameter, the oropharyngeal index, showed the most outstanding discrimination by ROC analysis to predict OSAS. CONCLUSION Our innovative module can provide reference parameters, which make it possible to directly estimate the objective absolute values of relevant oropharyngeal structures. Our non-invasive approach can be used for outpatient screening, since it allows the identification of potential OSAS patients who should be referred for polysomnography, as many patients do not require DISE early in their evaluation.
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Affiliation(s)
- Chung-Feng Jeffrey Kuo
- Department of Material Science & Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan, Republic of China
| | - Chun-Shu Lin
- Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Cheng-Hsien Chuang
- Department of Material Science & Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan, Republic of China
| | - Chung-Shen Lin
- Department of Otolaryngology-Head and Neck Surgery Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Feng-Shiang Chiu
- Department of Otolaryngology-Head and Neck Surgery Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Shao-Cheng Liu
- Department of Otolaryngology-Head and Neck Surgery Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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20
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Rees CA, Wu X, Eisen EA, Pastel DA, Halter RJ, Paydarfar JA. Radiation exposure alters airway deformability and bony structure displacement during laryngoscopy. Laryngoscope Investig Otolaryngol 2020; 4:609-616. [PMID: 31890878 PMCID: PMC6929586 DOI: 10.1002/lio2.311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/23/2019] [Accepted: 08/20/2019] [Indexed: 11/09/2022] Open
Abstract
Background Prior therapeutic radiation exposure in the setting of head and neck malignancies is associated with difficult airway instrumentation. We sought to characterize the anatomic changes that produce this phenotype. Study Design Retrospective review. Methods Five individuals with prior radiation therapy to the upper aerodigestive tract (previously irradiated) and 10 with no prior history of therapeutic radiation exposure (nonirradiated) were enrolled. Computed tomography images obtained before and during laryngoscope insertion ("uninstrumented" and "instrumented", respectively) were used to reconstruct three-dimensional representations of the pharyngeal airway, hyoid, and mandible. Results In the instrumented state, pharyngeal airway volumes were significantly greater in nonirradiated subjects relative to previously irradiated subjects (P = .01), and overall translation of both the hyoid and mandible was also greater in nonirradiated subjects (P = .01 and .04, respectively). Conclusion Individuals with prior therapeutic radiation exposure to the upper aerodigestive tract differ from nonirradiated subjects with respect to airway deformation and bony structure translation during laryngoscopy. Level of Evidence 4.
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Affiliation(s)
| | - Xiaotian Wu
- Thayer School of Engineering at Dartmouth Hanover New Hampshire U.S.A
| | - Eric A Eisen
- Section of Otolaryngology Dartmouth-Hitchcock Medical Center Lebanon New Hampshire U.S.A
| | - David A Pastel
- Geisel School of Medicine at Dartmouth Hanover New Hampshire U.S.A.,Department of Radiology Dartmouth-Hitchcock Medical Center Lebanon New Hampshire U.S.A
| | - Ryan J Halter
- Geisel School of Medicine at Dartmouth Hanover New Hampshire U.S.A.,Thayer School of Engineering at Dartmouth Hanover New Hampshire U.S.A
| | - Joseph A Paydarfar
- Geisel School of Medicine at Dartmouth Hanover New Hampshire U.S.A.,Section of Otolaryngology Dartmouth-Hitchcock Medical Center Lebanon New Hampshire U.S.A
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Lin H, Wang C, Zhang H, Xiong H, Li Z, Huang X, Ji C, Xian J, Huang Y. Threshold of the upper airway cross-section for hypopnea onset during sleep and its identification under waking condition. Respir Res 2019; 20:280. [PMID: 31829169 PMCID: PMC6907221 DOI: 10.1186/s12931-019-1250-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/25/2019] [Indexed: 01/18/2023] Open
Abstract
Background There is currently no method that can predict whether or under what condition hypopnea, even obstructive sleep apnea (OSA), will occur during sleep for individuals based on credible parameters measured under waking condition. We propose a threshold concept based on the narrowest cross-sectional area of the upper airway (CSA-UA) and aim to prove our hypothesis on the threshold of the area for hypopnea onset (TAHO), which can be used as an indicator of hypopnea onset during sleep and measured while awake. Methods We performed magnetic resonance imaging for 20 OSA patients to observe CSA-UA changes during fluid accumulation in the neck caused by elevating their legs, and identified TAHO by capturing the sudden enlargement in CSA-UA. Correlation analyses between TAHO and the body mass index (BMI), and between the reduction in CSA-UA and the increase in the neck circumference (NC) with fluid accumulation were performed. Logistic regression analysis was performed for identifying OSA patients based on the behaviors of their CSA-UA changes during leg raising. Shape changes of airway cross-section were also investigated. Results Four CSA-UA change patterns after fluid redistribution were identified. Six patients had similar CSA-UA variation behaviors observed in healthy subjects. From the other three change patterns involving 14 patients, a threshold value of CSA-UA 0.63 ± 0.21 cm2 was identified for normal breathing. Data showed a positive correlation between TAHO and BMI (r = 0.681, p = 0.0007), and a negative correlation between the reduction in CSA-UA and the increase in NC (r = − 0.513, p = 0.051) with fluid accumulation. A sigmoid function for the probability of being a OSA patient p = 1/[1 + exp. (4.836 + 3.850 t-8.4 h)] was obtained to effectively separate OSA patients from normal subjects. The upper airway narrowing occurred in anteroposterior, lateral, or both directions, suggesting different tendencies of upper airway collapse in patients. Three types of shape changes in the cross-section of the upper airway, which had different effects on airway resistance, were measured. Conclusions Our findings prove TAHO hypothesis. The threshold measured while awake for normal breathing can be used clinically as the indicator of hypopnea onset during sleep, and therefore to identify OSA patients under waking condition and design effective personalized treatments for OSA patients. Both shape and size changes in the cross-section of the upper airway affect airway resistance significantly. Shape change in the cross-section of the upper airway can provide key clinical information on the collapse patterns of the upper airway for individuals.
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Affiliation(s)
- Hongyi Lin
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Cunting Wang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Han Zhang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Huahui Xiong
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Zheng Li
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No 1 Dongjiaominxiang Street, Beijing, 100730, China
| | - Xiaoqing Huang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Changjin Ji
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Junfang Xian
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No 1 Dongjiaominxiang Street, Beijing, 100730, China.
| | - Yaqi Huang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China. .,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China.
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Cheng S, Kourmatzis A, Mekonnen T, Gholizadeh H, Raco J, Chen L, Tang P, Chan HK. Does upper airway deformation affect drug deposition? Int J Pharm 2019; 572:118773. [PMID: 31678391 DOI: 10.1016/j.ijpharm.2019.118773] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/18/2019] [Accepted: 10/07/2019] [Indexed: 12/17/2022]
Abstract
Knowledge that enables the accurate simulation of drug deposition in the human upper airway is necessary to develop robust platforms for efficient drug delivery by inhalation devices. The human upper airway is deformable during inhalation but how it could affect the deposition of inhaled drugs is unknown. We aimed to determine whether pharyngeal deformation at the soft palate level would have any significant effects on throat deposition, in vitro lung dose and fine particle fraction. In this study, dry mannitol powders were delivered to the next-generation cascade impactor (NGI) through the United States Pharmacopeia (USP) throat, and a realistic upper airway cast (RUPAC) at flow rates of 40, 60 and 80 L min-1. Deformation of the upper airway at 25%, 50%, and 75% in the lateral and antero-posterior directions were experimentally simulated in the RUPAC. Throat deposition (p = 0.04) is significantly affected when the upper airway deforms laterally but not antero-posteriorly.
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Affiliation(s)
- Shaokoon Cheng
- Macquarie University, School of Engineering, Faculty of Science and Engineering Sydney, Australia
| | - Agisilaos Kourmatzis
- University of Sydney, School of Aerospace, Mechanical and Mechatronic Engineering, Sydney, Australia
| | - Taye Mekonnen
- Macquarie University, School of Engineering, Faculty of Science and Engineering Sydney, Australia
| | - Hanieh Gholizadeh
- Macquarie University, School of Engineering, Faculty of Science and Engineering Sydney, Australia
| | - Joel Raco
- Macquarie University, School of Engineering, Faculty of Science and Engineering Sydney, Australia
| | - Lan Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Patricia Tang
- University of Sydney, Sydney Pharmacy School, Advanced Drug Delivery Group, Sydney, Australia
| | - Hak-Kim Chan
- University of Sydney, Sydney Pharmacy School, Advanced Drug Delivery Group, Sydney, Australia.
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Al-Qawasmi R, Parsons S, Wetherill L. Heritability of the pharyngeal airway volume and dimensions as assessed from siblings with overt malocclusions. Int Orthod 2019; 17:660-666. [PMID: 31466929 DOI: 10.1016/j.ortho.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To quantify the relative contributions of genetic and environmental factors to airway volume and dimensions in orthodontic patients. MATERIALS AND METHODS One hundred and twenty-five siblings from 57 families were selected. Cone beam computed tomography scans were taken as part of the orthodontic records and the Dolphin3D © imaging software was used to determine airway volume and dimensions. SOLAR program was implemented to calculate heritability. RESULTS The heritability of the airway volume was negligible but increased significantly from 5% to 72% (95% confidence interval was 27% to 100%) when anterior-posterior (AP) dimension was controlled in the calculating model. CONCLUSION The capacity to maintain, rather than having proper AP dimension of the airway, seems to be the most critical mark of a proper airway volume.
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Affiliation(s)
- Riyad Al-Qawasmi
- Department of Orthodontics, University of Detroit Mercy School of Dentistry, 2700 Martin Luther King Jr. Blvd Detroit, MI 48208, USA.
| | - Sade Parsons
- Department of Orthodontics, University of Detroit Mercy School of Dentistry, 2700 Martin Luther King Jr. Blvd Detroit, MI 48208, USA
| | - Leah Wetherill
- Department of Statistics, Applied Statistician II, 410W, 10th St, HS 4000, Indianapolis, IN 46202, USA
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Passos UL, Genta PR, Marcondes BF, Lorenzi-Filho G, Gebrim EMMS. State-dependent changes in the upper airway assessed by multidetector CT in healthy individuals and during obstructive events in patients with sleep apnea. ACTA ACUST UNITED AC 2019; 45:e20180264. [PMID: 31432889 PMCID: PMC6733715 DOI: 10.1590/1806-3713/e20180264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/23/2019] [Indexed: 12/02/2022]
Abstract
Objective: To determine whether airway narrowing during obstructive events occurs predominantly at the retropalatal level and results from dynamic changes in the lateral pharyngeal walls and in tongue position. Methods: We evaluated 11 patients with severe obstructive sleep apnea (OSA) and 7 healthy controls without OSA during wakefulness and during natural sleep (documented by full polysomnography). Using fast multidetector CT, we obtained images of the upper airway in the waking and sleep states. Results: Upper airway narrowing during sleep was significantly greater at the retropalatal level than at the retroglossal level in the OSA group (p < 0.001) and in the control group (p < 0.05). The retropalatal airway volume was smaller in the OSA group than in the control group during wakefulness (p < 0.05) and decreased significantly from wakefulness to sleep only among the OSA group subjects. Retropalatal pharyngeal narrowing was attributed to reductions in the anteroposterior diameter (p = 0.001) and lateral diameter (p = 0.006), which correlated with an increase in lateral pharyngeal wall volume (p = 0.001) and posterior displacement of the tongue (p = 0.001), respectively. Retroglossal pharyngeal narrowing during sleep did not occur in the OSA group subjects. Conclusions: In patients with OSA, upper airway narrowing during sleep occurs predominantly at the retropalatal level, affecting the anteroposterior and lateral dimensions, being associated with lateral pharyngeal wall enlargement and posterior tongue displacement.
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Affiliation(s)
- Ula Lindoso Passos
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Pedro Rodrigues Genta
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Park D, Kim JS, Heo SJ. Obstruction Patterns During Drug-Induced Sleep Endoscopy vs Natural Sleep Endoscopy in Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2019; 145:730-734. [PMID: 31246243 DOI: 10.1001/jamaoto.2019.1437] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Drug-induced sleep endoscopy (DISE) has been suggested to be a valuable technique for identifying the obstruction site associated with sleep-disordered breathing. However, the reliability of DISE findings is controversial because the procedure uses sedative drugs, which may have implications for the obstruction patterns observed on DISE. Objective To compare the obstruction patterns during DISE with the obstruction patterns during natural sleep endoscopy (NSE). Design, Setting, and Participants This prospective cohort study was conducted between June 2013 and May 2018 in Kyungpook National University Chilgok Hospital in Daegu, South Korea. All analysis took place from June 1 to July 31, 2018. Participants had an obstructive sleep apnea diagnosis, were older than 18 years, and had an apnea hypopnea index higher than 5 on type I polysomnography. The patients initially enrolled were excluded from the study for not reaching adequate sleep depth and waking up during insertion of the nasopharyngoscope. Intervention Patients underwent DISE using midazolam and NSE without sedatives on 2 different days. Main Outcomes and Measures Obstruction findings were observed only in the same range (65-75) of the bispectral index on both days. Obstruction findings were classified according to the VOTE (velum, oropharynx lateral wall, tongue base, and epiglottis) classification. The extent of agreement between DISE and NSE findings was evaluated using Cohen weighted κ value. Results The study included 26 patients with snoring or obstructive sleep apnea (mean [SD] age, 44.7 [10.3] years; predominantly male [22 (85%)]). The mean (SD) apnea hypopnea index was 41.9 (17.2) and the lowest mean (SD) oxygen saturation was 79.8% (12.2%). The degree of agreement in upper-airway obstruction between DISE and NSE was 76.9% (Cohen weighted κ = 0.42; 95% CI, 0.02-0.83) in the velum, 88.5% (Cohen weighted κ = 0.84; 95% CI, 0.67-1.01) in the oropharynx lateral wall, 69.2% (Cohen weighted κ = 0.66; 95% CI, 0.46-0.86) in the tongue base, and 92.3% (Cohen weighted κ = 0.67; 95% CI, 0.24-1.11) in the epiglottis. Agreement of configuration of the velum was 88.5% (Cohen weighted κ = 0.50; 95% CI, -0.03 to 1.03) and the epiglottis was 92.3% (Cohen weighted κ = 0.67; 95% CI, 0.24-1.11). Conclusions and Relevance Obstruction patterns of the upper airway appeared to be in agreement between DISE and NSE, suggesting that DISE may be a reliable test; future studies of multiple positions and sleep stages with larger sample sizes may confirm these results.
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Affiliation(s)
- Donghwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Daegu, South Korea
| | - Jung Soo Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Sung Jae Heo
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
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A pilot study to determine the effects of nasal co-phenylcaine on drug-induced sleep endoscopy. Eur Arch Otorhinolaryngol 2019; 276:2603-2609. [PMID: 31218449 PMCID: PMC6682855 DOI: 10.1007/s00405-019-05519-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/11/2019] [Indexed: 12/19/2022]
Abstract
Purpose The use of nasal decongestant and nasal anaesthesia is currently not recommended during drug-induced sleep endoscopy (DISE) according to the European position paper. The evaluation of the effects of nasal decongestant/anaesthesia on DISE has not been performed before and our aim is to perform a pilot study to determine whether nasal decongestants/anaesthesia affects DISE outcomes. Methods 27 patients undergoing DISE for OSA or for simple snoring were included. On each patient, DISE was performed twice, before and approximately 10 min after the administration of two puffs of co-phenylcaine nasal spray (lidocaine hydrochloride 5%, phenylephrine 0.5%, and benzalkonium chloride 0.01%) into each nostril. A nasal peak inspiratory flow was used for the objective assessment of nasal airway obstruction. During the first and the second DISE the loudness of the snoring was also recorded. Results Change in DISE total grading after nasal spray administration was not statistically significant. For the same grading, changes in percentage of contribution to collapse were not statistically significant. Sex, AHI, BMI, tonsils grade, presence of rhinitis, turbinate hypertrophy, nasal septal deviation, or nasal peak inspiratory flow limitation had no influence on the effect of nasal spray. Co-phenylcaine did not significantly influence the loudness of snoring. Conclusions Our pilot study supports the use of co-phenylcaine nasal spray during DISE and the positive effects of the nasal spray do not influence the grading outcome. Importantly, the decongestant enhances the nasal assessment during DISE and potentially aids in the diagnosis of nasal obstruction while the nasal anaesthetic component may be beneficial by reducing nasal discomfort during DISE and thereby helping to reduce the total dose of intravenous anaesthetic administered. However, further studies on a larger population are needed to confirm our results.
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Kwan BCH, Jugé L, Gandevia SC, Bilston LE. Sagittal Measurement of Tongue Movement During Respiration: Comparison Between Ultrasonography and Magnetic Resonance Imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:921-934. [PMID: 30691918 DOI: 10.1016/j.ultrasmedbio.2018.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 12/06/2018] [Accepted: 12/08/2018] [Indexed: 06/09/2023]
Abstract
The tongue makes up the anterior pharyngeal wall and is critical for airway patency. Magnetic resonance imaging (MRI) is commonly used to study pharyngeal muscle function in pharyngeal disorders such as obstructive sleep apnoea. Tagged MRI and ultrasound studies have separately revealed ∼1 mm of anterior tongue movement during inspiration in healthy patients, but these modalities have not been directly compared. In the study described here, agreement between ultrasound and MRI in measuring regional tongue displacement in 21 healthy patients and 21 patients with obstructive sleep apnoea was evaluated. We found good consistency and agreement between the two techniques, with an intra-class correlation coefficient of 0.79 (95% confidence interval: 0.75-0.82) for anteroposterior tongue motion during inspiration. Ultrasound measurements of posterior tongue displacement were 0.24 ± 0.64 mm greater than MRI measurements (95% limits of agreement: 1.03 to -1.49). This may reflect the higher spatial and temporal resolution of the ultrasound technique. This study confirms that ultrasound is a suitable method for quantifying inspiratory tongue movement.
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Affiliation(s)
- Benjamin C H Kwan
- Neuroscience Research Australia, Sydney, New South Wales, Australia; Prince of Wales Hospital Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| | - Lauriane Jugé
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Simon C Gandevia
- Neuroscience Research Australia, Sydney, New South Wales, Australia; Prince of Wales Hospital Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Lynne E Bilston
- Neuroscience Research Australia, Sydney, New South Wales, Australia; Prince of Wales Hospital Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Hsu WE, Wu TY. Comparison of upper airway measurement by lateral cephalogram in upright position and CBCT in supine position. J Dent Sci 2019; 14:185-191. [PMID: 31205607 PMCID: PMC6558349 DOI: 10.1016/j.jds.2019.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/08/2019] [Indexed: 11/27/2022] Open
Abstract
Background/Purpose Obstructive sleep apnea syndrome (OSAS) is a common form of sleep disorder. Lateral cephalograms and cone-beam computed tomography (CBCT) have been used for evaluation. However, it is lack of position comparison for these two assessments. Therefore, this study was aimed to evaluate the difference of upper airway measurements taken from lateral cephalograms in upright position and CBCT in supine position. Material and methods This retrospective study enrolled patients with lateral cephalograms and CBCT images due to diagnostic necessity. The anterior-posterior distance of most constricted area in pharynx (PASmin) and the distance from mandibular plane to hyoid bone (MP-H) were identified and measured from 21 normal subjects without obstructive sleep apnea (9 males and 12 females, mean age 21.2 years). A paired data were measured from lateral cephalograms taken in upright position and lateral cephalometric images derived from CBCT taken in supine position. Both images were taken within two months. All data were analyzed statistically. Results No significant difference was identified in intra-examiner reliability (P > 0.05). PASmin measured from lateral cephalograms in upright position was larger than that taken from CBCT derived cephalometric images, but without statistical significant difference (P = 0.073). Significant difference of MP-H length was identified between two different image taking methods (P = 0.000), and the measurement was significantly larger in cephalograms taken from upright position. No correlations were found among the variables (Body Mass Index (BMI), age, gender) in this study. The only two variables correlated were PASmin and MP-H, and they were negatively correlated (r = −0.535). Conclusion The anterior-posterior distance of most constricted area in pharynx (PASmin) and distance of mandibular plane to hyoid bone (MP-H) can be influenced due to change of body position.
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Affiliation(s)
- Wun Eng Hsu
- Division of Orthodontic and Pediatric Dentistry, Taipei Veterans General Hospital, Taiwan.,School of Dentistry, National Yang-Ming University, Taiwan
| | - Tzu Ying Wu
- Division of Orthodontic and Pediatric Dentistry, Taipei Veterans General Hospital, Taiwan.,School of Dentistry, National Yang-Ming University, Taiwan
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29
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Carrasco-Llatas M, Martínez-Ruiz de Apodaca P, Vaz de Castro J, Matarredona-Quiles S, Dalmau-Galofre J. Drug-Induced Sleep Endoscopy as a Tool for Surgical Planning. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00220-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Drug-induced sleep endoscopy is a safe and practical technique to evaluate the dynamic upper airway collapse during sleep. We review drug-induced sleep endoscopy in adults, including its indications, technique, evaluation of upper airway collapse, and clinical application. Drug-induced sleep endoscopy is useful to improve treatment options selection for patients with obstructive sleep apnea, especially for those who are unable to accept or tolerate continuous positive airway pressure therapy. Owing to a lack of standardization for drug-induced sleep endoscopy, it is difficult to compare the published literature from different sleep centers across the world.
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Affiliation(s)
- Khai Beng Chong
- Department of Otorhinolaryngology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
| | - Andrea De Vito
- Head and Neck Department, ENT and Oral Surgery Unit, Morgagni-Pierantoni Hospital, AUSL of Romagna, Via Carlo Forlanini 34, Forlì 47121, Italy
| | - Claudio Vicini
- Head and Neck Department, ENT and Oral Surgery Unit, Morgagni-Pierantoni Hospital, AUSL of Romagna, Via Carlo Forlanini 34, Forlì 47121, Italy
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31
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Viana A, Zhao C, Rosa T, Couto A, Neves DD, Araújo-Melo MH, Capasso R. The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings. Laryngoscope 2018; 129:506-513. [PMID: 30194726 DOI: 10.1002/lary.27298] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients. STUDY DESIGN Case series prospective study. METHODS Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016. RESULTS Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O2 nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value. CONCLUSION Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O2 levels, and lower BIS index values. Propofol resulted in an O2 nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation. LEVEL OF EVIDENCE 4 Laryngoscope, 129:506-513, 2019.
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Affiliation(s)
- Alonço Viana
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital (HNMD), Rio de Janeiro, Brazil.,Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A
| | - Chen Zhao
- Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A.,Department of Otorhinolaryngology, First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Talita Rosa
- Department of Neurology, University of California, San Francisco, California, U.S.A
| | - Arnaldo Couto
- Department of Pharmacy, West Zone Rio de Janeiro State University (UEZO), Rio de Janeiro, Brazil
| | - Denise Duprat Neves
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Cardiopulmonary, Rio de Janeiro, Brazil
| | - Maria Helena Araújo-Melo
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Robson Capasso
- Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A
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Marques M, Genta PR, Azarbarzin A, Sands SA, Taranto-Montemurro L, Messineo L, White DP, Wellman A. Retropalatal and retroglossal airway compliance in patients with obstructive sleep apnea. Respir Physiol Neurobiol 2018; 258:98-103. [PMID: 29913264 DOI: 10.1016/j.resp.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/09/2018] [Accepted: 06/15/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We hypothesized that preferential retropalatal as compared to retroglossal collapse in patients with obstructive sleep apnea was due to a narrower retropalatal area and a higher retropalatal compliance. Patients with a greater retropalatal compliance would exhibit a recognizable increase in negative effort dependence (NED). METHODS Fourteen patients underwent upper airway endoscopy with simultaneous recordings of airflow and pharyngeal pressure during natural sleep. Airway areas were obtained by manually outlining the lumen. Compliance was calculated by the change of airway area from end-expiration to a pressure swing of -5 cm H2O. NED was quantified for each breath as [peak inspiratory flow minus flow at -5 cm H2O]/[peak flow] × 100. RESULTS Compared to the retroglossal airway, the retropalatal airway was smaller at end-expiration (p < 0.001), and had greater absolute and relative compliances (p < 0.001). NED was positively associated with retropalatal relative area change (r = 0.47; p < 0.001). CONCLUSIONS Retropalatal airway is narrower and more collapsible than retroglossal airway. Retropalatal compliance is reflected in the clinically-available NED value.
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Affiliation(s)
- Melania Marques
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Pedro R Genta
- Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Respiratory Medicine and Sleep Laboratory, Department of Experimental and Clinical Sciences, University of Brescia and Spedali Civili, Brescia, Italy
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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Avci S, Lakadamyali H, Lakadamyali H, Aydin E, Tekindal MA. Relationships among retropalatal airway, pharyngeal length, and craniofacial structures determined by magnetic resonance imaging in patients with obstructive sleep apnea. Sleep Breath 2018; 23:103-115. [DOI: 10.1007/s11325-018-1667-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 12/12/2022]
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Veer V, Zhang H, Beyers J, Vanderveken O, Kotecha B. The use of drug-induced sleep endoscopy in England and Belgium. Eur Arch Otorhinolaryngol 2018; 275:1335-1342. [PMID: 29556753 PMCID: PMC5893728 DOI: 10.1007/s00405-018-4939-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
Purpose The purpose of this international survey is to ascertain the current practice of drug-induced sleep endoscopy (DISE) for patients with sleep-disordered breathing (SDB) by Otolaryngologists in the United Kingdom and Belgium. We compare the results with recommendations from the European Position Paper on drug-induced sleep endoscopy. Methods An online questionnaire was circulated to Consultant Otolaryngologists, independent practitioners, and trainees across the two countries. Eleven questions were used in total. Results 181 responses from the UK and 117 responses from Belgium were received, mostly from consultants and independent practitioners. SDB was a common presentation to ENT practice, seen by over 90% of clinicians. The use of DISE varied greatly between the two countries (72.9% Belgium, 26.1% UK). 54.1% of Belgian respondents use DISE on over 50% of their patients, compared to only 32.4% of British clinicians. Attitudes of surgeons towards the diagnostic value of DISE varied; in Belgium, the majority (54%) gave a rating of 3 or more (1 = useless to 5 = essential), with no respondents giving a score of 0 (useless). In the UK only 16% of respondents felt DISE had useful clinical value, with 25 respondents deeming it ’useless’. The majority opt for DISE when non-surgical therapies fail (51.4% UK, 61.3% Belgium). The majority of participants do not use objective measures for depth of sedation (75.7% UK, 66.7% Belgium), with a marked variation on anaesthetic methods. 62.2% of UK clinicians do not use a classification system, whereas in Belgium the majority of clinicians (60.8%) use the VOTE grading system. Conclusions Clinicians in Belgium were more favourable to using DISE than in the UK. Differences in its clinical effectiveness were apparent between the two countries. A consensus on patient selection, method of sedation and an effective classification system seemed to be lacking from both countries. Further education is required to raise awareness for the use of DISE.
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Affiliation(s)
- Vik Veer
- Royal National Throat Nose and Ear Hospital, 330 Gray's Inn Rd, London, WC1X 8DA, UK
| | - Henry Zhang
- Queens Hospital, Rom Valley Way, Romford, RM7 0AG, UK
| | - Jolien Beyers
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, and, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Olivier Vanderveken
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, and, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Bhik Kotecha
- Royal National Throat Nose and Ear Hospital, 330 Gray's Inn Rd, London, WC1X 8DA, UK.
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Chousangsuntorn K, Bhongmakapat T, Apirakkittikul N, Sungkarat W, Supakul N, Laothamatas J. Upper Airway Areas, Volumes, and Linear Measurements Determined on Computed Tomography During Different Phases of Respiration Predict the Presence of Severe Obstructive Sleep Apnea. J Oral Maxillofac Surg 2017; 76:1524-1531. [PMID: 29289684 DOI: 10.1016/j.joms.2017.11.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/11/2017] [Accepted: 11/27/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE The objective of this study was to analyze the potential of using low-dose volumetric computed tomography (CT) during different phases of respiration for identifying patients likely to have severe obstructive sleep apnea (OSA), defined as a respiratory disturbance index (RDI) higher than 30. PATIENTS AND METHODS A prospective study was undertaken at the Ramathibodi Hospital (Bangkok, Thailand). Patients with diagnosed OSA (N = 82) were recruited and separated into group 1 (RDI, ≤30; n = 36) and group 2 (RDI, >30; n = 46). The 2 groups were scanned by low-dose volumetric CT while they were 1) breathing quietly, 2) at the end of inspiration, and 3) at the end of expiration. Values for CT variables were obtained from linear measurements on lateral scout images during quiet breathing and from the upper airway area and volume measurements were obtained on axial cross-sections during different phases of respiration. All CT variables were compared between study groups. A logistic regression model was constructed to calculate a patient's likelihood of having an RDI higher than 30 and the predictive value of each variable and of the final model. RESULTS The minimum cross-sectional area (MCA) measured at the end of inspiration (cutoff point, ≤0.33 cm2) was the most predictive variable for the identification of patients likely to have an RDI higher than 30 (adjusted odds ratio [OR] = 5.50; 95% confidence interval [CI], 1.76-17.20; sensitivity, 74%; specificity, 72%,), followed by the MCA measured at the end of expiration (cutoff point, ≤0.21 cm2; adjusted OR = 3.28; 95% CI, 1.05-10.24; sensitivity, 70%; specificity, 68%). CONCLUSION CT scanning at the ends of inspiration and expiration helped identify patients with an RDI higher than 30 based on measurement of the MCA. Low-dose volumetric CT can be a useful tool to help the clinician rapidly identify patients with severe OSA and decide on the urgency to obtain a full-night polysomnographic study and to start treatment.
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Affiliation(s)
- Khaisang Chousangsuntorn
- Biomedical Engineer, Department of Radiological Technology, Faculty of Medical Technology, Mahidol University, Phutthamonthon, Nakhon Pathom, Thailand
| | - Thongchai Bhongmakapat
- Assistant Professor, Department of Otolaryngology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Navarat Apirakkittikul
- Otolaryngologist, Department of Otolaryngology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Witaya Sungkarat
- Biomedical Engineer, Department of Radiology and Advanced Diagnostic Imaging Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nucharin Supakul
- Assistant Professor, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Jiraporn Laothamatas
- Professor, Advanced Diagnostic Imaging Center and Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Chousangsuntorn K, Bhongmakapat T, Apirakkittikul N, Sungkarat W, Supakul N, Laothamatas J. Computed Tomography Characterization and Comparison With Polysomnography for Obstructive Sleep Apnea Evaluation. J Oral Maxillofac Surg 2017; 76:854-872. [PMID: 28988101 DOI: 10.1016/j.joms.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/08/2017] [Accepted: 09/02/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE We hypothesized that computed tomography (CT) combined with portable polysomnography (PSG) might better visualize anatomic data related to obstructive sleep apnea (OSA). The present study evaluated the CT findings during OSA and assessed their associations with the PSG data and patient characteristics. PATIENTS AND METHODS We designed a prospective cross-sectional study of patients with OSA. The patients underwent scanning during the awake state and apneic episodes. Associations of the predictor variables (ie, PSG data, respiratory disturbance index [RDI]), patient characteristics (body mass index [BMI], neck circumference [NC], and waist circumference [WC]), and outcome variables (ie, CT findings during apneic episodes) were assessed using logistic regression analysis. The CT findings during apneic episodes were categorized regarding the level of obstruction, single level (retropalatal [RP] or retroglossal [RG]) or multilevel (mixed RP and RG), degree of obstruction (partial or complete), and pattern of collapse (complete concentric collapse [CCC] or other patterns). RESULTS A total of 58 adult patients with OSA were scanned. The mean ± standard deviation for the RDI, BMI, NC, and WC were 41.6 ± 28.55, 27.80 ± 5.43 kg/m2, 38.3 ± 4.3 cm, and 93.8 ± 13.6 cm, respectively. No variables distinguished between the presence of single- and multilevel airway obstruction in the present study. A high RDI (≥30) was associated with the presence of complete obstruction and CCC (odds ratio 6.33, 95% confidence interval 1.55 to 25.90; and odds ratio 3.77, 95% confidence interval 1.02 to 13.91, respectively) compared with those with a lesser RDI. CONCLUSIONS An increased RDI appears to be an important variable for predicting the presence of complete obstruction and CCC during OSA. Scanning during apneic episodes, using low-dose volumetric CT combined with portable PSG provided better anatomic and pathologic findings of OSA than did scans performed during the awake state.
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Affiliation(s)
- Khaisang Chousangsuntorn
- Biomedical Engineer, Department of Radiological Technology, Faculty of Medical Technology, Mahidol University, Phutthamonthon, Nakhon Pathom, Thailand
| | - Thongchai Bhongmakapat
- Assistant Professor, Department of Otolaryngology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Navarat Apirakkittikul
- Otolaryngologist, Department of Otolaryngology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Witaya Sungkarat
- Biomedical Engineer, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, and Advanced Diagnostic Imaging Center (AIMC), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nucharin Supakul
- Assistant Professor, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Jiraporn Laothamatas
- Professor, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, and Advanced Diagnostic Imaging Center (AIMC), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Alsufyani NA, Hess A, Noga M, Ray N, Al-Saleh MAQ, Lagravère MO, Major PW. New algorithm for semiautomatic segmentation of nasal cavity and pharyngeal airway in comparison with manual segmentation using cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2017; 150:703-712. [PMID: 27692428 DOI: 10.1016/j.ajodo.2016.06.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/01/2016] [Accepted: 06/01/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Our objectives were to assess reliability, validity, and time efficiency of semiautomatic segmentation using Segura software of the nasal and pharyngeal airways, against manual segmentation with point-based analysis with color mapping. METHODS Pharyngeal and nasal airways from 10 cone-beam computed tomography image sets were segmented manually and semiautomatically using Segura (University of Alberta, Edmonton, Alberta, Canada). To test intraexaminer and interexaminer reliabilities, semiautomatic segmentation was repeated 3 times by 1 examiner and then by 3 examiners. In addition to volume and surface area, point-based analysis was completed to assess the reconstructed 3-dimensional models from Segura against manual segmentation. The times of both methods of segmentation were also recorded to assess time efficiency. RESULTS The reliability and validity of Segura were excellent (intraclass correlation coefficient, >0.9 for volume and surface area). Part analysis showed small differences between the Segura and manually segmented 3-dimensional models (greatest difference did not exceed 4.3 mm). Time of segmentation using Segura was significantly shorter than that for manual segmentation, 49 ± 11.0 vs 109 ± 9.4 minutes (P <0.001). CONCLUSIONS Semiautomatic segmentation of the pharyngeal and nasal airways using Segura was found to be reliable, valid, and time efficient. Part analysis with color mapping was the key to explaining differences in upper airway volume and provides meaningful and clinically relevant analysis of 3-dimensional changes.
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Affiliation(s)
- Noura A Alsufyani
- Assistant professor, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; assistant professor, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.
| | - Andy Hess
- Postgraduate student, Department of Computing Science, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Noga
- Associate professor, Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Nilanjan Ray
- Associate professor, Department of Computing Science, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammed A Q Al-Saleh
- Postgraduate student, Orthodontic Graduate Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Manuel O Lagravère
- Assistant professor, Orthodontic Graduate Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Major
- Professor and chair, Orthodontic Graduate Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Lambeth C, Amatoury J, Wang Z, Foster S, Amis T, Kairaitis K. Velopharyngeal mucosal surface topography in healthy subjects and subjects with obstructive sleep apnea. J Appl Physiol (1985) 2017; 122:482-491. [PMID: 28008099 DOI: 10.1152/japplphysiol.00764.2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/22/2022] Open
Abstract
Macroscopic pharyngeal anatomical abnormalities are thought to contribute to the pathogenesis of upper airway (UA) obstruction in obstructive sleep apnea (OSA). Microscopic changes in the UA mucosal lining of OSA subjects are reported; however, the impact of these changes on UA mucosal surface topography is unknown. This study aimed to 1) develop methodology to measure UA mucosal surface topography, and 2) compare findings from healthy and OSA subjects. Ten healthy and eleven OSA subjects were studied. Awake, gated (end expiration), head and neck position controlled magnetic resonance images (MRIs) of the velopharynx (VP) were obtained. VP mucosal surfaces were segmented from axial images, and three-dimensional VP mucosal surface models were constructed. Curvature analysis of the models was used to study the VP mucosal surface topography. Principal, mean, and Gaussian curvatures were used to define surface shape composition and surface roughness of the VP mucosal surface models. Significant differences were found in the surface shape composition, with more saddle/spherical and less flat/cylindrical shapes in OSA than healthy VP mucosal surface models (P < 0.01). OSA VP mucosal surface models were also found to have more mucosal surface roughness (P < 0.0001) than healthy VP mucosal surface models. Our novel methodology was utilized to model the VP mucosal surface of OSA and healthy subjects. OSA subjects were found to have different VP mucosal surface topography, composed of increased irregular shapes and increased roughness. We speculate increased irregularity in VP mucosal surface may increase pharyngeal collapsibility as a consequence of friction-related pressure loss.NEW & NOTEWORTHY A new methodology was used to model the upper airway mucosal surface topography from magnetic resonance images of patients with obstructive sleep apnea and healthy adults. Curvature analysis was used to analyze the topography of the models, and a new metric was derived to describe the mucosal surface roughness. Increased roughness was found in the obstructive sleep apnea vs. healthy group, but further research is required to determine the functional effects of the measured difference on upper airway airflow mechanics.
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Affiliation(s)
- Christopher Lambeth
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia;
| | - Jason Amatoury
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia.,Neuroscience Research Australia and School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Ziyu Wang
- University of Sydney, Sydney, New South Wales, Australia; and
| | - Sheryl Foster
- Department of Radiology, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia
| | - Terence Amis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia
| | - Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia
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Abstract
In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.
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Cephalometrics of Pharyngeal Airway Space in Lebanese Adults. Int J Dent 2017; 2017:3959456. [PMID: 28133482 PMCID: PMC5241489 DOI: 10.1155/2017/3959456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 12/21/2022] Open
Abstract
Purpose. The upper airway space is significant in orthodontic diagnosis and treatment planning. The objectives of this study are to assess the dimensions of soft tissue elements of the upper pharyngeal space and evaluate potential correlations with modifying variables such as gender, skeletal class, and anthropometric parameters. Materials and Methods. Lateral cephalograms were obtained from 117 healthy young adult Lebanese subjects. Nineteen cephalometric linear/angular measurements of the nasopharynx, oropharynx, and hypopharynx were recorded. Anthropometric parameters including body mass index and neck circumference were measured. Results. Significant differences were demonstrated for 12 out of the 19 parameters considered between genders. Uvula and tongue dimensions and the distances between epiglottis-posterior pharyngeal wall and epiglottis-posterior nasal spine were significantly larger in males. The anteroposterior inclination of the uvula and the distances between the uvula and posterior pharyngeal wall were significantly greater in females. No significant differences were found between skeletal classes relative to most of the variables. Body mass index and neck circumference were positively correlated with the dimensions of tongue and uvula. Conclusions. Sexual dimorphism relative to some cephalometric variables and anthropometric parameters may account partly for larger oronasopharyngeal spaces in females. Anthropometric data need to be accounted for in population-related comparisons.
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Abstract
OBJECTIVE The aims of this study were to describe the relationship between the scanning planes and appearance of the upper airway on sonography and to demonstrate the reliability and reproducibility of sonographic measurements of the upper airway. METHODS Airway sonoanatomy was recognized by comparing the airway images and the corresponding cadaver's anatomical specimens. Systemic sonographic examination of 267 healthy volunteers was conducted to obtain the sonographic measurement of airway lumen. The reliability and reproducibility studies were conducted in 40 healthy volunteers. RESULT The air-filled upper airway appeared as a bright heterogeneous hyperechoic line. During deep inspiration, the upper airway lumen expanded to the highest anterior-posterior dimension, whereas during deep expiration, the lateral dimension tended to increase. The sonographic measurements had good reproducibility, with intraclass correlation coefficient ranging from 0.722 to 0.887 and 0.727 to 0.882 for interobserver and intraobserver reliability, respectively. CONCLUSIONS Ultrasonography can determine the anatomy of the upper airway and perform the quantitative analysis of the upper airway lumen during respiration. The results were encouraging and support the utility of ultrasonography in future airway disorder studies.
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Somnoendoskopie. SOMNOLOGIE 2016. [DOI: 10.1007/s11818-016-0052-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chen H, Aarab G, de Ruiter MHT, de Lange J, Lobbezoo F, van der Stelt PF. Three-dimensional imaging of the upper airway anatomy in obstructive sleep apnea: a systematic review. Sleep Med 2016; 21:19-27. [PMID: 27448467 DOI: 10.1016/j.sleep.2016.01.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 11/28/2015] [Accepted: 01/16/2016] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The pathogenesis of upper airway collapse in people with obstructive sleep apnea (OSA) is not fully understood. The aim of this study was to systematically review the literature in order to assess the most relevant anatomical characteristics of the upper airway related to the pathogenesis of OSA by analyzing the three-dimensional upper airway anatomy. METHOD A PICO (population/patient, intervention, comparison, outcome) search strategy, focusing on the upper airway anatomy of people with OSA, was conducted using the following databases: MEDLINE (PubMed), Excerpta Medica database (EMBASE), Web of Science, and Cochrane Library. The studies in which three-dimensional images were made from the participants who were awake and in the supine position during quiet breathing were selected in this systematic review. RESULTS Of the 758 unique retrieved studies, eight fulfilled the criteria for this systematic review. The minimum cross-sectional area of the upper airways of people with OSA, which is influenced by many factors such as hard and soft tissues surrounding the upper airway, was significantly smaller than that of those without OSA. CONCLUSION Within the limitation of the selected studies, this systematic review suggested that a small minimum cross-sectional area is the most relevant anatomical characteristic of the upper airway related to the pathogenesis of OSA.
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Affiliation(s)
- Hui Chen
- Department of Oral and Maxillofacial Radiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, The Netherlands.
| | - Ghizlane Aarab
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands
| | - Maurits H T de Ruiter
- Department of Oral and Maxillofacial Surgery, Academic Medical Centre (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Academic Medical Centre (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Frank Lobbezoo
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands
| | - Paul F van der Stelt
- Department of Oral and Maxillofacial Radiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, The Netherlands
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Kim KB. How has our interest in the airway changed over 100 years? Am J Orthod Dentofacial Orthop 2016; 148:740-7. [PMID: 26522033 DOI: 10.1016/j.ajodo.2015.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/01/2015] [Accepted: 08/01/2015] [Indexed: 12/01/2022]
Abstract
Since the beginning of our specialty, our understanding of the link between function and facial growth and development has progressively improved. Today, we know that children with sleep-related breathing problems will often develop distinctive facial characteristics. In adults, sleep apnea can result in serious morbidity and mortality. Orthodontists can ask sleep-related questions in the health history to help identify sleep breathing disorders. Treating these patients presents unique opportunities for orthodontists to collaborate with other medical specialties to improve a patient's health and treatment outcome. Research presented in our Journal in the next century may shed new light that will help us better identify the problem and aid the specialty in developing more effective evidence-based treatment. Additional efforts are needed to understand the physiology, neurology, and genetics of sleep breathing disorders.
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Affiliation(s)
- Ki Beom Kim
- Associate professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo.
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Javed A, Kim YC, Khoo MCK, Ward SLD, Nayak KS. Dynamic 3-D MR Visualization and Detection of Upper Airway Obstruction During Sleep Using Region-Growing Segmentation. IEEE Trans Biomed Eng 2015; 63:431-7. [PMID: 26258929 DOI: 10.1109/tbme.2015.2462750] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
GOAL We demonstrate a novel and robust approach for visualization of upper airway dynamics and detection of obstructive events from dynamic 3-D magnetic resonance imaging (MRI) scans of the pharyngeal airway. METHODS This approach uses 3-D region growing, where the operator selects a region of interest that includes the pharyngeal airway, places two seeds in the patent airway, and determines a threshold for the first frame. RESULTS This approach required 5 s/frame of CPU time compared to 10 min/frame of operator time for manual segmentation. It compared well with manual segmentation, resulting in Dice Coefficients of 0.84 to 0.94, whereas the Dice Coefficients for two manual segmentations by the same observer were 0.89 to 0.97. It was also able to automatically detect 83% of collapse events. CONCLUSION Use of this simple semiautomated segmentation approach improves the workflow of novel dynamic MRI studies of the pharyngeal airway and enables visualization and detection of obstructive events. SIGNIFICANCE Obstructive sleep apnea (OSA) is a significant public health issue affecting 4-9% of adults and 2% of children. Recently, 3-D dynamic MRI of the upper airway has been demonstrated during natural sleep, with sufficient spatiotemporal resolution to noninvasively study patterns of airway obstruction in young adults with OSA. This study makes it practical to analyze these long scans and visualize important factors in an MRI sleep study, such as the time, site, and extent of airway collapse.
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Correlation Between Retropalatal Collapse as Observed During Muller's Maneuver to Severity of OSA. Indian J Otolaryngol Head Neck Surg 2015; 67:135-7. [PMID: 26075167 DOI: 10.1007/s12070-015-0847-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022] Open
Abstract
Objective of the study was to evaluate the reliability of Muller's maneuver (MM) with the severity of obstructive sleep apnea (OSA) at the retropalatal level. Case series of 58 adult patients diagnosed to have OSA. Sleep apnoea clinic in a tertiary referral center in south India. Fifty-eight adult OSA patients underwent outpatient based MM under local anaesthesia. Collapse of hypopharynx and the retroglossal regions were assessed during a maximal inspiratory effort against the closed mouth and sealed nose (reverse valsalva). Correlation co efficient was used to compare MM grade with apnea-hypopnea index (AHI) scores. Severity of OSA based on AHI scores were compared with the results of Muller's maneuver at the retropalatal level. The correlation coefficient was 0.213, hence no correlation was found, p value was 0.019, which was not statistically significant. MM is an useful tool for evaluation of upper airway collapse. The advantages include simplicity, cost-effectiveness, relatively easy to perform, thorough evaluation of upper airway. The pitfalls of the procedure includes the subjectiveness of the procedure and the fact that it is performed on awake patients and therefore remains an indirect estimation of obstruction that occurs during sleep. In our study, we did not find correlation between the severity of OSA based on the AHI scores and the collapse at the retropalate level assessed by the Muller's maneuver.
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Carrasco-Llatas M, Marcano-Acuña M, Zerpa-Zerpa V, Dalmau-Galofre J. Surgical results of different palate techniques to treat oropharyngeal collapse. Eur Arch Otorhinolaryngol 2015; 272:2535-40. [PMID: 25708411 DOI: 10.1007/s00405-015-3565-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/16/2015] [Indexed: 11/29/2022]
Abstract
The aim of this study was to assess the surgical success rate of patients undergoing oropharyngeal surgery, selected through drug-induced sleep endoscopy. Secondly, to compare outcomes of the different oropharyngeal surgery techniques applied. The study design was retrospective case series of surgically treated patients from 2006 to 2013. All patients were diagnosed with either moderate or severe obstructive sleep apnea and did not tolerate conventional positive airway pressure. We performed five different surgical techniques to treat oropharyngeal collapse: partial palate resection, uvulopalatopharyngoplasty, Z-palatoplasty, lateral pharyngoplasty and expansion pharyngoplasty. Patients in whom multilevel surgery was performed were excluded. 53 patients were included in our study, 52.8 % were severe obstructive sleep apnea patients, mean age was 43.9 years, mean body mass index 27.5. The surgical success rate according to Sher's criteria was 71.7 %. 47.2 % had a postoperative apnea hypopnea index lower than 10. The highest success rate was measured in patients who underwent expansion pharyngoplasty (90 % according to Sher's criteria, 80 % with a postoperative apnea hypopnea index lower than 10) although it did not reach statistical significance. Our conclusion is that drug-induced sleep endoscopy is a good tool to select surgical candidates in patients with moderate-to-severe obstructive sleep apnea who are not compliant with the optimal therapy. Expansion pharyngoplasty was the surgical technique with the highest success rates.
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Affiliation(s)
- Marina Carrasco-Llatas
- ENT Department, University Hospital Dr. Peset, Av/ Gaspar Aguilar 90, 46017, Valencia, Spain,
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Kairaitis K, Foster S, Amatoury J, Verma M, Wheatley JR, Amis TC. Pharyngeal mucosal wall folds in subjects with obstructive sleep apnea. J Appl Physiol (1985) 2015; 118:707-15. [PMID: 25635002 DOI: 10.1152/japplphysiol.00691.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Mechanical processes underlying pharyngeal closure have not been examined. We hypothesized that the pharyngeal mucosal surface would fold during closure, and lowering the upper airway lining liquid surface tension would unfold areas of mucosal apposition, i.e., folds. We compared baseline pharyngeal fold numbers and response to reduction in upper airway liquid surface tension in healthy and obstructive sleep apnea (OSA) subjects. Awake, gated magnetic resonance pharyngeal airway images of 10 healthy and 11 OSA subjects were acquired before and after exogenous surfactant administration (beractant). Upper airway liquid surface tension was measured at the beginning and end of image acquisition and averaged. Velopharyngeal and oropharyngeal images were segmented and analyzed separately for average cross-sectional area, circumference, and fold number. Compared with healthy subjects, at baseline, velopharynx for OSA subjects had a smaller cross-sectional area (98.3 ± 32.5 mm(2) healthy, 52.3 ± 23.6 mm(2) OSA) and circumference (46.5 ± 8.1 mm healthy, 30.8 ± 6.1 mm OSA; both P < 0.05, unpaired t-test), and fewer folds (4.9 ± 1.6 healthy, 3.1 ± 1.8 OSA, P < 0.03). There were no differences in oropharynx for cross-sectional area, circumference, or folds. Reduction in upper airway liquid surface tension from 61.3 ± 1.2 to 55.3 ± 1.5 mN/m (P < 0.0001) did not change cross-sectional area or circumference for velopharynx or oropharynx in either group; however, in OSA subjects, oropharyngeal folds fell from 6.8 ± 3.1 to 4.7 ± 1.2 (n = 8, P < 0.05), and velopharyngeal folds from 3.3 ± 1.9 to 2.3 ± 1.2 (P = 0.08), and were unchanged in healthy subjects. Subjects with OSA have fewer velopharyngeal wall folds, which decrease further when surface tension falls. We speculate that reduced pharyngeal wall folds contribute to an increase in pharyngeal collapsibility.
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Affiliation(s)
- Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Sheryl Foster
- Department of Radiology, Westmead Hospital, Westmead, New South Wales, Australia; and University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Jason Amatoury
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Manisha Verma
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia
| | - John R Wheatley
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Terence C Amis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
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Walenga RL, Tian G, Hindle M, Yelverton J, Dodson K, Longest PW. Variability in Nose-to-Lung Aerosol Delivery. JOURNAL OF AEROSOL SCIENCE 2014; 78:11-29. [PMID: 25308992 PMCID: PMC4187112 DOI: 10.1016/j.jaerosci.2014.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Nasal delivery of lung targeted pharmaceutical aerosols is ideal for drugs that need to be administered during high flow nasal cannula (HFNC) gas delivery, but based on previous studies losses and variability through both the delivery system and nasal cavity are expected to be high. The objective of this study was to assess the variability in aerosol delivery through the nose to the lungs with a nasal cannula interface for conventional and excipient enhanced growth (EEG) delivery techniques. A database of nasal cavity computed tomography (CT) scans was collected and analyzed, from which four models were selected to represent a wide range of adult anatomies, quantified based on the nasal surface area-to-volume ratio (SA/V). Computational fluid dynamics (CFD) methods were validated with existing in vitro data and used to predict aerosol delivery through a streamlined nasal cannula and the four nasal models at a steady state flow rate of 30 L/min. Aerosols considered were solid particles for EEG delivery (initial 0.9 μm and 1.5 μm aerodynamic diameters) and conventional droplets (5 μm) for a control case. Use of the EEG approach was found to reduce depositional losses in the nasal cavity by an order of magnitude and substantially reduce variability. Specifically, for aerosol deposition efficiency in the four geometries, the 95% confidence intervals (CI) for 0.9 and 5 μm aerosols were 2.3-3.1 and 15.5-66.3%, respectively. Simulations showed that the use of EEG as opposed to conventional methods improved delivered dose of aerosols through the nasopharynx, expressed as penetration fraction (PF), by approximately a factor of four. Variability of PF, expressed by the coefficient of variation (CV), was reduced by a factor of four with EEG delivery compared with the control case. Penetration fraction correlated well with SA/V for larger aerosols, but smaller aerosols showed some dependence on nasopharyngeal exit hydraulic diameter. In conclusion, results indicated that the EEG technique not only improved lung aerosol delivery, but largely eliminated variability in both nasal depositional loss and lung PF in a newly developed set of nasal airway models.
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Affiliation(s)
- Ross L Walenga
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA
| | - Geng Tian
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA
| | - Joshua Yelverton
- Department of Otolaryngology – Head and Neck Surgery, Virginia Commonwealth University, Richmond, VA
| | - Kelley Dodson
- Department of Otolaryngology – Head and Neck Surgery, Virginia Commonwealth University, Richmond, VA
| | - P. Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA
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50
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Genta PR, Schorr F, Eckert DJ, Gebrim E, Kayamori F, Moriya HT, Malhotra A, Lorenzi-Filho G. Upper airway collapsibility is associated with obesity and hyoid position. Sleep 2014; 37:1673-8. [PMID: 25197805 DOI: 10.5665/sleep.4078] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 04/05/2014] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Upper airway anatomy plays a major role in obstructive sleep apnea (OSA) pathogenesis. An inferiorly displaced hyoid as measured by the mandibular plane to hyoid distance (MPH) has been consistently associated with OSA. The hyoid is also a common landmark for pharyngeal length, upper airway volume, and tongue base. Tongue dimensions, pharyngeal length, and obesity are associated with OSA severity, although the link between these anatomical variables and pharyngeal collapsibility is less well known. We hypothesized that obesity as measured by body mass index (BMI), neck and waist circumferences, and variables associated with hyoid position (pharyngeal length, upper airway volume, and tongue dimensions) would be associated with passive pharyngeal critical closing pressure (Pcrit). DESIGN Cross-sectional. SETTING Academic hospital. PATIENTS 34 Japanese-Brazilian males age 21 to 70 y. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS We performed computed tomography scans of the upper airway, overnight polysomnography, and Pcrit measurements in all subjects. On average, subjects were overweight (BMI = 28 ± 4 kg/m(2)) and OSA was moderately severe (apnea-hypopnea index = 29 [13-51], range 1-90 events/h). Factor analysis identified two factors among the studied variables: obesity (extracted from BMI, neck and waist circumferences) and hyoid position (MPH, pharyngeal length, tongue length, tongue volume, and upper airway volume). Both obesity and hyoid position correlated with Pcrit (r = 0.470 and 0.630, respectively) (P < 0.01). In addition, tongue volume, tongue length, pharyngeal length, and MPH correlated with waist and neck circumferences (P < 0.05). CONCLUSIONS Pharyngeal critical closing pressure is associated with obesity and hyoid position. Tongue dimensions, pharyngeal length, and the mandibular plane to hyoid distance are associated with obesity variables. These findings provide novel insight into the potential factors mediating upper airway collapse in obstructive sleep apnea.
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Affiliation(s)
- Pedro R Genta
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Fabiola Schorr
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA) and the School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Eloisa Gebrim
- Radiology Institute (InRad), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Fabiane Kayamori
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, University of São Paulo, São Paulo, Brazil
| | - Atul Malhotra
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard University, Boston, MA and Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, CA
| | - Geraldo Lorenzi-Filho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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