Craniofacial Phenotyping in Chinese and Caucasian Patients With Sleep Apnea: Influence of Ethnicity and Sex

Two-dimensional facial photography for assessment of craniofacial morphology in sleep breathing disorders: a systematic review

PURPOSE

Craniofacial morphology is integral to Sleep Breathing Disorders (SBD), particularly Obstructive Sleep Apnea (OSA), informing treatment strategies. This review assesses the utility of two-dimensional (2D) photogrammetry in evaluating these metrics among OSA patients.

METHODS

Following PRISMA guidelines, a systematic review was conducted. PubMed, Embase, and Lilacs databases were systematically searched for studies utilizing 2D photography in SBD. Findings were narratively synthesized.

RESULTS

Thirteen studies involving 2,328 patients were included. Significant correlations were found between craniofacial measurements-specifically neck parameters and facial width-and OSA severity, even after BMI adjustment. Ethnic disparities in craniofacial morphology were observed, with photogrammetry effective in predicting OSA in Caucasians and Asians, though data for other ethnicities were limited. Pediatric studies suggest the potential of craniofacial measurements as predictors of childhood OSA, with certain caveats.

CONCLUSION

2D photogrammetry emerges as a practical and non-invasive tool correlating with OSA severity across diverse populations. However, further validation in various ethnic cohorts is essential to enhance the generalizability of these findings.

Obstructive sleep apnea and obesity: A review of epidemiology, pathophysiology and the effect of weight-loss treatments

Despite the commonly-accepted paradigm that patients with obstructive sleep apnea (OSA) also invariably have obesity, OSA prevalence extends beyond obesity. This necessitates a reevaluation of screening strategies, biomarkers of increased OSA risk, and heightened awareness among healthcare providers about the array of OSA treatments for diverse adult populations. While obesity contributes importantly to OSA pathogenesis, there is substantial evidence that non-anatomical factors also play a crucial role, especially in patients who do not have obesity. In recent years, notwithstanding the recognition of diverse contributors to OSA pathogenesis, research has frequently focused on weight reduction to address OSA. Insights from past experiences with bariatric surgery in OSA serve as a lens to anticipate potential outcomes of emerging anti-obesity pharmacotherapies. Pharmacological alternatives, particularly incretin agonists, exhibit promise in weight reduction and OSA improvement, but encounter obstacles such as potential side effects and high costs. With this comprehensive narrative review, we delve into the complex epidemiological and pathophysiological connections between OSA and obesity. Additionally, we emphasize the importance of a multifaceted approach to OSA treatment, recognizing that while weight management is crucial, there is a need for comprehensive strategies that go beyond traditional weight-centric perspectives.

The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study

BACKGROUND

Difficult airway remains a great challenge in pediatric anesthesia practice. Previously published data show the prevalence of difficult airways in pediatric population varies in a wide range. However, there is a lack of studies in the Asian region.

METHODS

This cross-sectional single-center study was conducted in a tertiary pediatric hospital in China from October 2022 to October 2023. The patients who underwent elective surgery under general anesthesia with tracheal intubation were recruited consecutively. Data on patient characteristics, airway assessment, and airway management information were collected. Multivariable logistic regression analysis was performed to detect the independent variables of difficult airway in pediatric patients.

RESULTS

A total of 18,491 pediatric patients were included in this study. The overall incidence of difficult airways was 0.22%, 39% of whom were unanticipated. Very few previous airway management information was available in the patients presented with a known difficult airway. Patients with younger age, higher American Society of Anesthesiologists (ASA) physical status classification grade, and presented for craniofacial and thoracic surgery were associated with higher incidence of difficult airway. Further multivariable logistic regression analysis revealed that age ≤28 days (OR=50.48), age between 28days and 1 year (OR=6.053), craniofacial surgery (OR=1.81), and thoracic surgery (OR=0.2465) were independent risk factors of increased incidence of difficult airway.

CONCLUSIONS

Our study showed the prevalence of difficult airways in pediatric surgical patients. Patient characteristics, age, and type of surgery were identified as the independent factors associated with increased occurrence of difficult airways. Unanticipated difficult airway was not unusual in our study population, even for the patients with previous surgical history.

Cheeks appearance as a novel predictor of obstructive sleep apnea: the CASA score study

STUDY OBJECTIVES

Four well-established predictors of obstructive sleep apnea (OSA) risk are body mass index, age, sex, and neck circumference. We have previously reported cheeks appearance as an OSA predictor, which may represent a combination of such predictors in a single, readily available feature. This study sought to answer the question: Is cheeks appearance an OSA risk predictor?

METHODS

This was a prospective cross-sectional diagnostic accuracy study based on STARD (standards for reporting diagnostic accuracy studies). Patients undergoing polysomnography to investigate sleep complaints at a sleep clinic affiliated with a university hospital were assessed using cheeks appearance scored 0-3 for volume and 0-3 for flaccidity to create the Cheeks Appearance for Sleep Apnea (CASA) score ranging from 0 to 6. Appearance was judged by 3 blinded and independent evaluators.

RESULTS

Among 265 patients evaluated, 248 were included. Fifty-seven patients had a CASA score of 0 and 191 had a CASA score between 1 and 6. Polysomnography diagnosed 177 of the individuals with OSA; of these, 167 had an altered CASA score. Sensitivity was 87%, specificity was 82%, positive-predictive value was 94%, negative-predictive value was 66%, and accuracy was 86%.

CONCLUSIONS

Our results suggest that combining volume and flaccidity of cheeks appearance in a single index may constitute a reliable OSA predictor. CASA score is a novel predictor of OSA with internal validity in a sleep laboratory adult population. Our findings support further studies to confirm the external validity of this practical diagnostic tool.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Cheeks Appearance as a Novel Predictor of Obstructive Sleep Apnea: The CASA Score Study (CASA); URL: https://clinicaltrials.gov/study/NCT04980586; Identifier: NCT04980586.

CITATION

Prikladnicki A, Gomes E, Sousa LCCR, Gonçalves SC, Martinez D. Cheeks appearance as a novel predictor of obstructive sleep apnea: the CASA score study. J Clin Sleep Med. 2024;20(6):879-885.

Correlation analysis of airway-facial phenotype in Crouzon syndrome by geometric morphometrics: A promising method for non-radiation airway evaluation

AIM

This study aimed to verify the correlation of the airway-facial phenotype and visualize the morphological variation in Crouzon syndrome patients. Additionally, to develop a non-radiation methodology for airway assessments.

METHOD

In this study, 22 patients diagnosed with Crouzon syndrome (Age: 7.80 ± 5.63 years; Gender distribution: 11 females and 11 males) were analysed. The soft tissue surface and airway were three-dimensionally reconstructed, and the entire facial phenotype was topologized and converted into spatial coordinates. Geometric morphometrics was employed to verify the correlation and visualize dynamic phenotypic variation associated with airway volume. A total of 276 linear variables were automatically derived from 24 anatomical landmarks, and principal component analysis (PCA) identified the 20 most significant parameters for airway evaluation. Correlation analyses between parameters and airway volume were performed. Then, patients were classified into three groups based on airway volume, and the differences among the groups were compared for evaluating the differentiating effectiveness of parameters.

RESULTS

The facial phenotype was strongly correlated with the airway (coefficient: 0.758). Morphological variation was characterized by (i) mandibular protrusion and anticlockwise rotation; (ii) midface retrusion; (iii) supraorbital frontward and (iv) lengthening of the facial height. All the anthropometric parameters were strongly associated with the airway, and the differences among the groups were statistically significant.

CONCLUSION

This study confirmed the strong correlation between facial phenotype and airway parameters in Crouzon syndrome patients. Despite the development of the airway, pathological midface retrusion was still aggravated, suggesting that surgical intervention was inevitable. Three-dimensional facial anthropometry has potential as a non-radiation examination for airway evaluation.

Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring

Obstructive sleep apnea is a highly prevalent sleep-related breathing disorder, resulting in a disturbed breathing pattern, changes in blood gases, abnormal autonomic regulation, metabolic fluctuation, poor neurocognitive performance, and increased cardiovascular risk. With broad inter-individual differences recognised in risk factors, clinical symptoms, gene expression, physiological characteristics, and health outcomes, various obstructive sleep apnea subtypes have been identified. Therapeutic efficacy and its impact on outcomes, particularly for cardiovascular consequences, may also vary depending on these features in obstructive sleep apnea. A number of interventions such as positive airway pressure therapies, oral appliance, surgical treatment, and pharmaceutical options are available in clinical practice. Selecting an effective obstructive sleep apnea treatment and therapy is a challenging medical decision due to obstructive sleep apnea heterogeneity and numerous treatment modalities. Thus, an objective marker for clinical evaluation is warranted to estimate the treatment response in patients with obstructive sleep apnea. Currently, while the Apnea-Hypopnea Index is used for severity assessment of obstructive sleep apnea and still considered a major guide to diagnosis and managements of obstructive sleep apnea, the Apnea-Hypopnea Index is not a robust marker of symptoms, function, or outcome improvement. Abnormal cardiac autonomic modulation can provide additional insight to better understand obstructive sleep apnea phenotyping. Heart rate variability is a reliable neurocardiac tool to assess altered autonomic function and can also provide cardiovascular information in obstructive sleep apnea. Beyond the Apnea-Hypopnea Index, this review aims to discuss the role of heart rate variability as an indicator and predictor of therapeutic efficacy to different modalities in order to optimise tailored treatment for obstructive sleep apnea.

Self-helped detection of obstructive sleep apnea based on automated facial recognition and machine learning

PURPOSE

The diagnosis of obstructive sleep apnea (OSA) relies on time-consuming and complicated procedures which are not always readily available and may delay diagnosis. With the widespread use of artificial intelligence, we presumed that the combination of simple clinical information and imaging recognition based on facial photos may be a useful tool to screen for OSA.

METHODS

We recruited consecutive subjects suspected of OSA who had received sleep examination and photographing. Sixty-eight points from 2-dimensional facial photos were labelled by automated identification. An optimized model with facial features and basic clinical information was established and tenfold cross-validation was performed. Area under the receiver operating characteristic curve (AUC) indicated the model's performance using sleep monitoring as the reference standard.

RESULTS

A total of 653 subjects (77.2% males, 55.3% OSA) were analyzed. CATBOOST was the most suitable algorithm for OSA classification with a sensitivity, specificity, accuracy, and AUC of 0.75, 0.66, 0.71, and 0.76 respectively (P < 0.05), which was better than STOP-Bang questionnaire, NoSAS scores, and Epworth scale. Witnessed apnea by sleep partner was the most powerful variable, followed by body mass index, neck circumference, facial parameters, and hypertension. The model's performance became more robust with a sensitivity of 0.94, for patients with frequent supine sleep apnea.

CONCLUSION

The findings suggest that craniofacial features extracted from 2-dimensional frontal photos, especially in the mandibular segment, have the potential to become predictors of OSA in the Chinese population. Machine learning-derived automatic recognition may facilitate the self-help screening for OSA in a quick, radiation-free, and repeatable manner.

Frontal Sinus Anatomy Variations in Race and Sex Using the International Frontal Sinus Anatomy Classification

Objective: To identify frontal sinus anatomical variations grouped by patient sex, race, and presence of chronic rhinosinusitis with frontal sinus involvement (CRFS) using the International Frontal Sinus Anatomy Classification (IFAC) system. Methods: A retrospective review from 2015 to 2020 was performed of consecutive adult patients with computed tomography sinus imaging. Prevalence of frontal sinus cells using the IFAC system was recorded. Comparisons were made between patient race, sex, and CRFS groups. Results: A total of 184 patients (368 sides) were included, 90 (48.9%) of which had CRFS. The racial distribution was 50 white (27.2%), 50 black (27.2%), 45 Hispanic/Latino (24.5%), and 39 Asian (21.2%) patients. The supra agger cell was most prevalent in the white population (P = 0.009), and supraorbital ethmoid cells were more prevalent in the Asian population (P = 0.017). Patients with frontal sinus disease were more likely to have a supraorbital ethmoid cell (P = 0.024). Overall, CRFS was more prevalent in the Asian population (P = 0.013). Conclusion: Significant differences in frontal sinus anatomy and disease exist between patient race and sex. Supraorbital ethmoid cells are associated with the development of CRFS. These patterns in frontal sinus anatomy should be noted prior to frontal sinus surgery to improve surgical awareness and outcomes.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Causal associations between obstructive sleep apnea and COVID-19: A bidirectional Mendelian randomization study

BACKGROUNDS

The COVID-19 pandemic has caused significant impact on human health. Whether obstructive sleep apnea (OSA) increases the risk of COVID-19 remains unclear. We sought to clarify this issue using two-sample Mendelian randomization (TSMR) analysis in large cohorts.

METHODS

Bidirectional two-sample Mendelian randomization (MR) was used to evaluate the potential causality between OSA and COVID-19 by selecting single-nucleotide polymorphisms (SNPs) as instrumental variables (IVs) from genome-wide association studies (GWAS). The inverse-variance weighted (IVW) method was selected as the main approach for data analysis to estimate the possible causal effects. Alternative methods such as MR-Egger, the MR pleiotropy residual sum and outlier (MR-PRESSO), and leave-one-out analysis methods were implemented as sensitivity analysis approaches to ensure the robustness of the results.

RESULTS

All forward MR analyses consistently indicated the absence of a causal relationship between OSA and any COVID-19 phenotype. In the reverse MR analysis, the IVW mode demonstrated that severe respiratory confirmed COVID-19 was correlated with a 4.9% higher risk of OSA (OR, 1.049; 95%CI, 1.018-1.081; P = 0.002), consistent in MR-PRESSO (OR = 1.049, 95%CI 1.018-1.081, P = 0.004), weighted median (OR = 1.048, 95%CI 1.003-1.095, P = 0.035), and MR-Egger (OR = 1.083, 95%CI 1.012-1.190, P = 0.041) methods.

CONCLUSIONS

There is no significant evidence supporting a causal association between OSA and any COVID phenotype, while we identified potential evidence for a causal effect of severe COVID-19 on an increased risk of OSA.

Clinical Characteristics Combined with Craniofacial Photographic Analysis in Children with Obstructive Sleep Apnea

Purpose

Distinguishing obstructive sleep apnea (OSA) in a high-risk population remains challenging. This study aimed to investigate clinical features to identify children with OSA combined with craniofacial photographic analysis.

Methods

One hundred and forty-five children (30 controls, 62 with primary snoring, and 53 with OSA) were included. Differences in general demographic characteristics and surface facial morphology among the groups were compared. Risk factors and prediction models for determining the presence of OSA (obstructive sleep apnea-hypopnea index>1) were developed using logistic regression analysis.

Results

The BMI (z-score), tonsil hypertrophy, and lower face width (adjusted age, gender, and BMI z-score) were showed significantly different in children with OSA compared with primary snoring and controls (adjusted p<0.05). The screening model based on clinical features and photography measurements correctly classified 79.3% of the children with 64.2% sensitivity and 89.1% specificity. The area under the curve of the model was 81.0 (95% CI, 73.5-98.4%).

Conclusion

A screening model based on clinical features and photography measurements would be helpful in clinical decision-making for children with highly suspected OSA if polysomnography remains inaccessible in resource-stretched healthcare systems.

Mediating Effect of Self-Cognitive Oral Health Status on the Effect of Obstructive Sleep Apnea Risk Factors on Quality of Life (HINT-8) in Middle-Aged Korean Women: The Korea National Health and Nutrition Examination Survey

Background: Obstructive sleep apnea and oral health are highly correlated with quality of life. The purpose of this study is to determine the mediating effect of self-cognitive oral health status on the effect of obstructive sleep apnea (OSA) risk factors on quality of life in middle-aged Korean women using the 2019 National Health and Nutrition Examination Survey data. Methods: A hierarchical regression analysis was performed on the mediating effect of self-cognitive oral health status on the effects of OSA risk factors on health-related quality of life (Korean health-related quality of life instrument with 8 items; HINT-8). Results: Self-cognitive oral health status as a parameter had a significant effect on quality of life (β = 0.713, p < 0.001). Compared to the effect of the OSA risk factor of the second stage on the quality of life (β = −1.329, p < 0.001), the input of the third stage of self-cognitive oral health was partially mediated (β = −1.280, p <0.001). Conclusions: Therefore, if middle-aged women have OSA risk factors, they should try to improve their quality of life by managing oral health as well as OSA treatment.

Prevalence of sleep apnea and lung function abnormalities in patients with acromegaly

Background:

Sleep apnea (SA) is highly prevalent in acromegaly. Ethnicity influences the prevalence of SA in the general population. We studied the prevalence of SA and other respiratory comorbidities in North Indian patients with active acromegaly.

Design:

Prospective, observational.

Materials and Methods:

Consecutive adult patients with active acromegaly (n = 35, age 39.7 ± 13.2 years) and hypersomatotropism (nonsuppression of serum growth hormone after oral glucose and elevated serum insulin-like growth factor-1 [IGF-1]) were evaluated for respiratory symptoms, scoring for SA (Epworth Sleepiness Score [ESS] and STOP-BANG), pulmonary function tests (PFT), high-resolution computerized tomography (HRCT) of the thorax, polysomnography (PSG), and transthoracic echocardiography. Age- and sex-matched healthy individuals (n = 34) served as controls.

Results:

Acromegaly subjects had dyspnea (34%), cough (37%), excessive daytime somnolence (43%), and fatigue (49%). Clinically significant ESS (>10) and STOP-BANG score (≥3) were present in 41% and 68.6% of subjects, respectively. PFT showed restrictive and obstructive patterns in 45.7% and 11.4% of acromegalics respectively; with higher total lung capacity (TLC), thoracic gas volume (TGV), and residual volume (RV). PSG revealed significantly higher SA events in acromegalics (central [acromegaly 24.63 ± 37.82 vs. control 3.21 ± 5.5], mixed [11 ± 19.46 vs. 3.50 ± 5.96], obstructive [34.86 ± 44.37 vs. 9.71 ± 10.48], and mean apnea-hypopnea index [AHI] [16.91 ± 18.0 vs. 7.86 ± 7.84]). Acromegalics had significantly higher prevalence of obstructive SA (71.4% [mild 31.4%, moderate 20%, severe 20%]) as compared to controls (38.2%). There was no correlation of AHI with serum IGF-1 and disease duration.

Conclusion:

Acromegaly subjects have a significantly higher prevalence of respiratory symptoms, SA, and abnormalities in PFT. Screening for respiratory comorbidities should be routinely recommended in all patients with acromegaly.

Predicting the presence and severity of obstructive sleep apnea based on mandibular measurements using quantitative analysis of facial profiles via three-dimensional photogrammetry

BACKGROUND

In obstructive sleep apnea (OSA), the upper airway is obstructed during sleep due to obesity and/or posterior collapse of the tongue root. Maxillofacial morphological abnormalities increase the risk of OSA in the Asian population. This study sought to elucidate whether three-dimensional (3D) photogrammetry measurements correlate with the severity of OSA irrespective of sex and degree of obesity.

METHODS

A prospective pilot study was performed, in which 37 consecutive adult patients (M/F = 28/9) underwent polysomnography and 3D photogrammetry in the supine position for the diagnosis of OSA. Measurements obtained from 3D photogrammetry included mandibular width (Mw), mandibular length (Ml), mandibular depth (Md), mandibular width-length angle (Mwla), and mandibular area (Ma). The effects of sex and body mass index (BMI) on the measurements and their association with the apnea-hypopnea index (AHI) were statistically analyzed. The inter-rater reliability of the measurements was evaluated using intraclass correlation coefficients (ICC).

RESULTS

Mwla (R = 0.73, p < 0.01), Mw (R = 0.39, p < 0.05), and Md (R = -0.34, p < 0.05) were significantly correlated with the severity of OSA. On multivariate analysis, Mwla (p < 0.01) and Md (p < 0.05) remained independent factors for AHI after adjusting for sex, age, BMI, and neck circumference. In addition, diagnosability analysis revealed that Mwla was useful for identifying the presence of OSA (AHI ≥5) (cutoff: 78.6°, sensitivity: 0.938, specificity: 0.800, area under the curve: 0.931). The ICC was >0.9, showing high reliability.

CONCLUSIONS

This study suggests that Mwla measured using 3D photogrammetry can predict the presence of OSA and correlates with the severity of OSA, independent of obesity and sex.

Application of personalized medicine to obstructive sleep apnea in China

Obstructive sleep apnea (OSA) is a common sleep disorder whose prevalence is increasing in China consistent with rising obesity trends. OSA is a heterogeneous disorder depends on anatomical and nonanatomical risk factors. Ethnicity differentially influences the attribution of these OSA risk factors. Chinese patients had more craniofacial bony restriction and Caucasians were more obese. This suggests ethnic differences in potential applications for diagnostics and therapeutics. However, current strategies for the management of OSA reflect a one-size-fits-all approach based on the apnea-hypopnea index (AHI). Although continuous positive airway pressure (CPAP) remains the first-line and most efficacious treatment for OSA, the acceptance is unacceptably low in China. Therefore, targeted therapies to treat OSA need to be developed. This review summarizes the differences in OSA pathogenesis of Chinese patients and analyzes the current condition of personalized medicine to patients with OSA in China. The application of personalized medicine to OSA in the Chinese population is still a long way off.

Development and validation of a model for diagnosis of obstructive sleep apnoea in primary care

BACKGROUND AND OBJECTIVE

Use of in-laboratory polysomnography (PSG) to diagnose obstructive sleep apnoea (OSA) is cost and resource intensive. Questionnaires, physical measurements and home monitors have been studied as potential simpler alternatives. This study aimed to develop a diagnostic model for OSA for use in primary care.

METHODS

Primary care practitioners were trained to recognize symptoms of sleep apnoea and recruited patients based on the clinical need to investigate OSA. Assessment was by symptom questionnaires, anthropomorphic measurements, digital facial photography, and a single-channel nasal flow monitor (Flow Wizard©, DiagnoseIT, Sydney, Australia) worn at home for 3 nights. The in-laboratory PSG was the reference test, with OSA defined as apnoea-hypopnoea index (AHI) ≥10 events/h.

RESULTS

In the model development phase, 25 primary care practitioners studied 315 patients in whom they suspected OSA, of which 57% had AHI≥10 and 22% had AHI≥30. Published OSA questionnaires provided low to moderate prediction of OSA (area under the curve [AUC] 0.53-0.73). The nasal flow monitor alone yielded high accuracy for predicting OSA with AUC of 0.87. Sensitivity was 0.87 and specificity 0.77 at a threshold respiratory event index (REI) of 18 events/h. A model adding age, gender, symptoms and BMI to the nasal flow monitor REI only modestly improved OSA prediction (AUC 0.89), with similar AUC (0.88) confirmed in the validation population of 114 patients.

CONCLUSION

Sleep apnoea can be diagnosed in the primary care setting with a combination of clinical judgement and portable monitor test outcomes.

Predicting sleep apnea from three-dimensional face photography

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep apnea and recurrent heart failure hospitalizations after coronary artery bypass grafting

STUDY OBJECTIVES

Sleep apnea is prevalent in patients undergoing coronary artery bypass grafting (CABG). We investigated the relationship between sleep apnea and recurrent heart failure hospitalizations in patient undergoing non-urgent CABG.

METHODS

Between November 2013 and December 2018, 1007 patients completed a sleep study prior to CABG and were followed up until April 2020. Recurrent heart failure hospitalizations were analyzed by Poisson, negative binomial, Andersen-Gill, and joint frailty models, with partial and full adjustment for covariates.

RESULTS

At an average follow-up of 3.3 years, the number of patients with 0, 1, or ≥2 heart failure hospitalizations were 908 (90.2%), 62 (6.2%), and 37 (3.7%), respectively. The total number of heart failure hospitalizations was 179, comprising 62 (35%) first and 117 (65%) repeat events. The numbers of heart failure hospitalizations for the sleep apnea (n = 513, 50.9%) and non-sleep apnea groups were 127 and 52, respectively. Negative binomial regression demonstrated that sleep apnea was associated with recurrent heart failure hospitalizations (fully adjusted rate ratio, 1.71; 95% confidence interval [CI], 1.12-2.62; p = 0.013). Similar results were found in Poisson (1.63; 95%CI, 1.15-2.31; p = 0.006), Andersen-Gill (1.66; 95% CI, 1.01-2.75; p = 0.047), and joint frailty models (1.72; 95% CI, 1.00-3.01; p = 0.056).

CONCLUSIONS

In patients after CABG, repeat events accounted for two-thirds of heart failure hospitalizations. Sleep apnea was independently associated with recurrent heart failure hospitalizations.

Artificial intelligence and sleep: Advancing sleep medicine

Artificial intelligence (AI) allows analysis of "big data" combining clinical, environmental and laboratory based objective measures to allow a deeper understanding of sleep and sleep disorders. This development has the potential to transform sleep medicine in coming years to the betterment of patient care and our collective understanding of human sleep. This review addresses the current state of the field starting with a broad definition of the various components and analytic methods deployed in AI. We review examples of AI use in screening, endotyping, diagnosing, and treating sleep disorders and place this in the context of precision/personalized sleep medicine. We explore the opportunities for AI to both facilitate and extend providers' clinical impact and present ethical considerations regarding AI derived prognostic information. We cover early adopting specialties of AI in the clinical realm, such as radiology and pathology, to provide a road map for the challenges sleep medicine is likely to face when deploying this technology. Finally, we discuss pitfalls to ensure clinical AI implementation proceeds in the safest and most effective manner possible.

Dental sleep medicine: Time to incorporate sleep apnoea education in the dental curriculum

Dental sleep medicine is a discipline that includes conditions such as sleep breathing disorders (eg snoring and sleep apnoea), sleep bruxism, orofacial pain and sleep-related complaints, and to some extent gastro-oesophageal reflux disorder and/or insomnia. Obstructive sleep apnoea (OSA) is a life-threatening condition that dentists need to identify and manage when indicated in order to increase patient well-being and to be taken in consideration in the dental curriculum. The main objective of this paper is to highlight the relevance of dental sleep medicine in the context of dental education, and to discuss potential educational content for integration in the dental curriculum with a focus on OSA, a condition that is not yet integrated in many dental training curricula around the world.

Respiratory and sleep characteristics based on frequency distribution of craniofacial skeletal patterns in Korean adult patients with obstructive sleep apnea

Objective

To investigate the frequency distribution of various craniofacial skeletal patterns in a large Korean adult obstructive sleep apnea (OSA) population, and to find a relationship between craniofacial risks and respiratory and sleep characteristics.

Methods

A total of 1226 OSA patients (mean age of 44.9±13.3 years) were included in this retrospective cross-sectional study. All subjects were evaluated for gender and age using fourteen polysomnographic, five cephalometric, two comorbid variables, and three self-reported indexes. Frequency analysis was used to screen the distribution of main skeletal patterns and subtypes. Intergroup comparisons were performed using independent t-test, chi-square test or analysis of variance. Univariable regression analysis was done to find a relationship between skeletal risks and OSA characteristics.

Results

The frequency distribution of skeletal patterns was as follows: sagittally 57.2%, 32.3%, and 10.5% of Class II, Class I, and Cass III; vertically 54.0%, 26.7%, and 19.3% of hyperdivergent, normodivergent, and hypodivergent type, respectively. Polysomnographic, symptomatic, and comorbid variables showed no differences among patients with different skeletal patterns. Conversely, skeletal variables showed no differences according to OSA severity. The prevalence of highly risky skeletal pattern of hyperdivergent Class II was more likely to be females (OR 4.52, P < .01) and less obese (OR 3.21, P < .01), irrelevant to OSA and sleep characteristics.

Conclusion

Characteristic frequency distributions of skeletal patterns and subtypes were observed in adult OSA patients however, no statistical association was found between the skeletal patterns and OSA characteristics due to the large interindividual variation.

Imaging of sleep-disordered breathing in adults

Sleep-disordered breathing (SDB) is a term that includes several chronic conditions in which partial or complete cessation of breathing occurs multiple times throughout the night. Central sleep apnoea (CSA) is uncommon and defined by the episodic cessation of airflow without respiratory effort. Lesions involving the respiratory centre in the brainstem or the origin of the phrenic nerve from the mid-cervical cord are the commonest structural causes of CSA; magnetic resonance imaging (MRI) will demonstrate the lesion and frequently suggest the likely aetiology. In contrast, obstructive sleep apnoea (OSA) is defined as upper airway obstruction despite ongoing respiratory effort. Repetitive episodes of narrowing or closure of the upper airway are the predominant cause leading to snoring and OSA, respectively. OSA affects 33-40% of the adult population and is associated with multiple adverse health consequences, including a significantly increased risk of serious morbidity and mortality. The incidence is increasing proportionally to the worldwide rise in obesity. Imaging, performed primarily without the involvement of radiologists, has been integral to understanding the anatomical basis of SDB and especially OSA. This article will review the pathophysiology, imaging findings, and sequelae of these common conditions. The role of imaging both in suggesting the incidental diagnoses of SDB and in the investigation of these conditions when the diagnosis is suspected or has been established are also discussed.

A Cross-Sectional Comparison of the Prevalence of Obstructive Sleep Apnea Symptoms in Adults With Down Syndrome in Scotland and Japan

Small studies in Western populations report a high prevalence of obstructive sleep apnea (OSA) in adults with Down syndrome. To date, ethnic differences have not been explored. A questionnaire sent to 2,752 adults with Down syndrome aged ≥16 years in Scotland and Japan (789 valid responses) estimated OSA prevalence based on reported symptoms. Symptoms were common in both countries, with snoring (p = 0.001) and arousals (p = 0.04) more prevalent in Japan. Estimated OSA prevalence in adults with Down syndrome was similar in the two countries, and raised in comparison with the general adult population (19.6% in Scotland and 14.3% in Japan; p = 0.08), though BMI was a confounder. Identification and treatment of OSA is recommended in adults with Down syndrome, regardless of ethnicity.

Global burden of sleep-disordered breathing and its implications

One-seventh of the world's adult population, or approximately one billion people, are estimated to have OSA. Over the past four decades, obesity, the main risk factor for OSA, has risen in striking proportion worldwide. In the past 5 years, the WHO estimates global obesity to affect almost two billion adults. A second major risk factor for OSA is advanced age. As the prevalence of the ageing population and obesity increases, the vulnerability towards having OSA increases. In addition to these traditional OSA risk factors, studies of the global population reveal select contributing features and phenotypes, including extreme phenotypes and symptom clusters that deserve further examination. Untreated OSA is associated with significant comorbidities and mortality. These represent a tremendous threat to the individual and global health. Beyond the personal toll, the economic costs of OSA are far-reaching, affecting the individual, family and society directly and indirectly, in terms of productivity and public safety. A better understanding of the pathophysiology, individual and ethnic similarities and differences is needed to better facilitate management of this chronic disease. In some countries, measures of the OSA disease burden are sparse. As the global burden of OSA and its associated comorbidities are projected to further increase, the infrastructure to diagnose and manage OSA will need to adapt. The use of novel approaches (electronic health records and artificial intelligence) to stratify risk, diagnose and affect treatment are necessary. Together, a unified multi-disciplinary, multi-organizational, global approach will be needed to manage this disease.

Evaluation of stylohyoid complex in subjects with different types of malocclusions using cone-beam computed tomography: a retrospective study in a Turkish subpopulation

PURPOSE

According to the functional matrix theory, the development of maxillomandibular complex may be affected by the surrounding tissues. The aim of this study was to evaluate the length and angulation of the styloid process in different types of malocclusions using cone-beam computed tomography (CBCT).

METHODS

Angulations and length of the styloid process were evaluated in CBCT images of 97 individuals retrospectively. The patients were classified as class I, II, and III groups according to sagittal skeletal classes. The mean length, anterior angulation, and medial angulation of the styloid process were analyzed. Statistical significance was evaluated at p < 0.05.

RESULTS

The mean styloid process length in group class III was found to be significantly longer than class I (p: 0.035). Anterior angle was significantly higher in class III group than in other groups (p < 0.05). No statistically significant difference was found in medial angle between the groups (p: 0.506).

CONCLUSION

According to present findings, class III malocclusion is associated with the stylohyoid complex morphology due to longer styloid process lengths and higher anterior angle values.

Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.

Mandibular advancement splints for the treatment of obstructive sleep apnea

Introduction: Obstructive sleep apnea (OSA) is a chronic condition which requires a comprehensive chronic disease management model, rather than a device-focused approach, so as to achieve the best possible health outcomes. Oral appliances are the main alternative to continuous positive airway pressure (CPAP) for the treatment of OSA. There has been an expansion of the research evidence to support the use of oral appliances in clinical practice and the clinical use of oral appliances for the treatment of OSA has become a mainstream practice.Areas covered: This review summarizes the evidence base for the use of oral appliances for the treatment of OSA. The types of oral appliances; their mechanism of action and clinical efficacy for the treatment of OSA; adverse effects, and the impact on patient acceptability and treatment adherence; and clinical effectiveness and health outcomes are discussed.Expert opinion: Personalization of treatment is vitally important in OSA and is a pre-requisite for optimizing adherence with treatment which, in turn, is a key determinant of clinical effectiveness. Treatment of OSA with mandibular advancement splints could provide an equivalent health benefit to CPAP despite not achieving a complete normalization of polysomnographic indices, mediated by differences in adherence profiles.

Further Development of P4 Approach to Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a heterogeneous disorder. Cluster analysis has identified different physiologic subtypes with respect to symptoms. A difference exists in cardiovascular risk from OSA between the 7 subtypes identified. There are 3 basic subtypes replicated in multiple studies: (a) a group where insomnia is the main symptom; (b) an asymptomatic group; (c) a group with marked excessive sleepiness. The symptomatic benefit from treatment with nasal CPAP varies between these 3 subtypes. Data from the Sleep Heart Health Study reveal that the increased risk of cardiovascular disease from OSA occurs only in the excessively sleepy group.