Using standardized ultrasound imaging to correlate OSA severity with tongue morphology.

BACKGROUND: Ultrasound imaging has been explored as a potential diagnostic tool for obstructive sleep apnea (OSA); we reported backscatter ultrasound imaging (BUI) of the tongue correlates with OSA severity in adults. We focus on anatomical features of the tongue using standardized ultrasonography and hypothesize that differences in morphology correlate with OSA severity. METHODS: This prospective study was IRB approved (53,172) and conducted at Stanford University Sleep Surgery Clinic. Patients ≥18 years with polysomnography (PSG) underwent a standardized submental ultrasound scan using a laser alignment tool to observe the upper airway in supine position during tidal respiration. Images acquired from this scan were divided into 4 equiangular regions (A-D). RESULTS: A total of 144 patients (30 women) July 2020-December 2022 were included with mean age 41.6 years (±12.9 SD), BMI 27.2 kg/m2(±4.7 SD), and AHI 19.7 (±20.0 SD). Moderate-to-severe OSA patients had significantly narrower airspace at regions A, B and C with p-values ranging from <0.0001 to 0.0003. These patients had a significantly wider (p = 0.0021-0.0045 for regions A, B and C) tongue and thicker (p = 0.0403 for region B) deep tissue. The predictive model to assess the risk of moderate-to-severe OSA achieved an area under the receiver operating characteristic curve of 0.839 (95 % CI: 0.769 to 0.895). CONCLUSIONS: With standardized, computerized ultrasound imaging of the shape and configuration of the tongue, we identified regions that correlated well with OSA severity. Further research is needed to determine the clinical implications of such pathophysiological findings.

The readability of online patient education materials on maxillomandibular advancement surgery.

STUDY OBJECTIVES: Maxillomandibular advancement (MMA) is an effective surgical option for patients suffering from obstructive sleep apnea (OSA). As a relatively new treatment option, patients may turn to the Internet to learn more. However, online patient education materials (OPEMs) on MMA may be written at a higher literacy level than recommended for patients. The aim of this study was to analyze the readability of OPEMs on MMA. METHODS: A Google search of "maxillomandibular advancement" was performed, and the first 100 results were screened. Websites that met eligibility criteria were analyzed for their readability using the Automated Readability Index (ARI), Coleman-Liau Index (CLI), Flesch-Kincaid Grade Level (FKGL), Gunning Fog (GF), and Simple Measure of Gobbledygook (SMOG) and compared to the recommended sixth-grade reading level using one-tailed t tests. Readability scores were compared based on the type of website, including hospitals/universities or physician clinics, using ANOVA tests. RESULTS: The mean (SD) for ARI, CLI, FKGL, GF, and SMOG was 11.91 (2.43), 13.42 (1.81), 11.91 (2.06), 14.32 (2.34), and 13.99 (1.56), respectively. All readability scores were significantly higher than a sixth-grade reading level (p < 0.001). After comparing readability scores between different website types (university/hospital, clinic, and other), there was no statistical difference found. CONCLUSIONS: The available OPEMs on MMA surgery for OSA are above the recommended sixth-grade reading level. Identifying and reducing the gap between the reading levels of OPEMs and the reading level of the patient are needed to encourage a more active role, informed decisions, and better patient satisfaction.

Spatial subsetting enables integrative modeling of oral squamous cell carcinoma multiplex imaging data.

Oral squamous cell carcinoma (OSCC), a prevalent and aggressive neoplasm, poses a significant challenge due to poor prognosis and limited prognostic biomarkers. Leveraging highly multiplexed imaging mass cytometry, we investigated the tumor immune microenvironment (TIME) in OSCC biopsies, characterizing immune cell distribution and signaling activity at the tumor-invasive front. Our spatial subsetting approach standardized cellular populations by tissue zone, improving feature reproducibility and revealing TIME patterns accompanying loss-of-differentiation. Employing a machine-learning pipeline combining reliable feature selection with multivariable modeling, we achieved accurate histological grade classification (AUC = 0.88). Three model features correlated with clinical outcomes in an independent cohort: granulocyte MAPKAPK2 signaling at the tumor front, stromal CD4+ memory T cell size, and the distance of fibroblasts from the tumor border. This study establishes a robust modeling framework for distilling complex imaging data, uncovering sentinel characteristics of the OSCC TIME to facilitate prognostic biomarkers discovery for recurrence risk stratification and immunomodulatory therapy development.

Maxillomandibular Advancement Efficacy in Obstructive Sleep Apnea Patients With Class 2 Versus 3 Dentofacial Deformity.

OBJECTIVE: To compare the efficacy of maxillomandibular advancement (MMA) for patients with obstructive sleep apnea (OSA) with class 2 versus 3 dentofacial deformities (DFDs). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary sleep surgery center. METHODS: Patients with OSA and DFD class 2 versus 3 undergoing MMA at Stanford Sleep Surgery between 2014 and 2021 were matched by preoperative body mass index (BMI), age, and sex. Postoperative outcome was compared with polysomnography measures and patient-reported outcome measures (PROMs). RESULTS: Twenty-eight matched subjects, 14 in each deformity group were identified and assessed. The mean age (standard deviation) was 34.29 (10.21) and 33.86 (10.23) for classes 2 and 3, respectively. The apnea-hypopnea index (AHI) decreased from 43.42 (28.30) to 9.6 (5.29) (p < .001) and 37.17 (35.77) to 11.81 (15.74) (p = .042) in class 2 and 3 subjects, respectively. The oxygen desaturation index (ODI) changed from 30.48 (24.02) to 6.88 (3.39) (p = .024) and 11.43 (11.40) to 5.44 (7.96) (p = .85) in class 2 and 3 subjects, respectively. The Epworth sleepiness scale changed from 8.93 (5.28) to 3.91 (2.70) (p = .018) and 10.23 (4.38) to 4.22 (3.07) (p = .006) in class 2 and 3 subjects, respectively. CONCLUSION: Among age, sex, and BMI-matched subjects, MMA is equally effective in both dentofacial class 2 and 3 groups, both objectively and subjectively. Preoperatively, dentofacial class 2 patients with OSA presented with the more severe disease with higher AHI and ODI. Dentofacial class 3 patients with OSA may require additional attention to improve nasal function outcomes.

Association of Backscattered Ultrasonographic Imaging of the Tongue With Severity of Obstructive Sleep Apnea in Adults.

Importance: Determining interventions to manage obstructive sleep apnea (OSA) depends on clinical examination, polysomnography (PSG) results, and imaging analysis. There remains the need of a noninvasive and cost-effective way to correlate relevant upper airway anatomy with severity of OSA to direct treatment and optimize outcome. Objective: To determine whether backscattered ultrasonographic imaging (BUI) analysis of the tongue is associated with severity of OSA in adults. Design, Setting, and Participants: In this prospective, single-center, diagnostic study of a consecutive series of patients (aged ≥18 years) at a sleep surgery clinic, the 89 included patients had a PSG within 3 years at the time of ultrasonography and BUI analysis between July 2020 and March 2022. Patients were excluded if body mass index had changed more than 10% since time of PSG. A standardized submental ultrasonographic scan with laser alignment was used with B-mode and BUI analysis applied to the tongue. The B-mode and BUI intensity were associated with the apnea-hypopnea index (AHI), a measure of severity of apnea from normal (no OSA) to severe OSA. Exposures: Ultrasonography and PSG. Main Outcomes and Measures: The main outcomes were BUI parameters and their association with AHI value. Results: Eighty-nine patients were included between July 2020 and March 2022. A total of 70 (78.7%) male patients were included; and distribution by race and ethnicity was 46 (52%) White participants, 22 (25%) Asian participants, and 2 (2%) African American participants, and 19 (21%) others. Median (IQR) age was 37.0 (29.0-48.3) years; median (IQR) BMI was 25.3 (23.2-29.8); and median (IQR) AHI was 11.1 (5.6-23.1) events per hour. At the middle to posterior tongue region, the 4 OSA severity levels explained a significant portion of the BUI variance (η2 = 0.153-0.236), and a significant difference in BUI values was found between the subgroups with AHI values of less than 15 (no OSA and mild OSA) and greater than or equal to 15 (moderate OSA and severe OSA) events per hour. The echo intensity showed no significant differences. The BUI values showed a positive association with AHI, with a Spearman correlation coefficient of up to 0.43. Higher BUI values remained associated with higher AHI after correction for the covariates of BMI and age. Conclusions and Relevance: In this prospective diagnostic study, standardized BUI analysis of the tongue was associated with OSA severity. With the practicality of ultrasonography, this analysis is pivotal in connecting anatomy with physiology in treatment planning for patients with OSA.

Automatic scoring of drug-induced sleep endoscopy for obstructive sleep apnea using deep learning.

BACKGROUND: Treatment of obstructive sleep apnea is crucial for long term health and reduced economic burden. For those considered for surgery, drug-induced sleep endoscopy (DISE) is a method to characterize location and pattern of sleep-related upper airway collapse. According to the VOTE classification system, four upper airway sites of collapse are characterized: velum (V), oropharynx (O), tongue (T), and epiglottis (E). The degree of obstruction per site is classified as 0 (no obstruction), 1 (partial obstruction), or 2 (complete obstruction). Here we propose a deep learning approach for automatic scoring of VOTE obstruction degrees from DISE videos. METHODS: We included 281 DISE videos with varying durations (6 s-16 min) from two sleep clinics: Copenhagen University Hospital and Stanford University Hospital. Examinations were split into 5-s clips, each receiving annotations of 0, 1, 2, or X (site not visible) for each site (V, O, T, and E), which was used to train a deep learning model. Predicted VOTE obstruction degrees per examination was obtained by taking the highest predicted degree per site across 5-s clips, which was evaluated against VOTE degrees annotated by surgeons. RESULTS: Mean F1 score of 70% was obtained across all DISE examinations (V: 85%, O: 72%, T: 57%, E: 65%). For each site, sensitivity was highest for degree 2 and lowest for degree 0. No bias in performance was observed between videos from different clinicians/hospitals. CONCLUSIONS: This study demonstrates that automating scoring of DISE examinations show high validity and feasibility in degree of upper airway collapse.

Passing The Scalpel: A Student Initiative in Identifying and Addressing Unmet Needs in Dental Education.

PURPOSE: Becoming an oral-maxillofacial surgeon is often challenging for young trainees. The purpose of this manuscript is to explore how a student-led group, which emphasizes networking, mentorship, and academic opportunities, may impact one's journey to becoming an oral-maxillofacial surgeon. PATIENTS AND METHODS: This was a cross-sectional descriptive study where a 5-question Likert-type survey was administered to students who matriculated into residency and participated in a student-led group called Passing The Scalpel (PTS). This survey evaluated the value of PTS in providing exposure, career decision-making, networking/mentorship, and camaraderie. The results were analyzed, and statistical outcomes were evaluated. RESULTS: There was an 80.5% response rate (n = 29). Question 1 regarding first exposure to oral-maxillofacial surgery had a mean score of 2.55 (standard deviation [SD] = 1.35; χ2 = 15.39; P < .05). Question 2 regarding choosing oral-maxillofacial surgery as a career had a mean score of 3.66 (SD = 1.11; χ2 = 10.84; P < .05). Question 3 regarding offering mentorship and networking had a mean score of 4.14 (SD = 0.92; χ2 = 27.81; P < .05). Question 4 regarding increasing applicant camaraderie had a mean score of 4.21 (SD = 0.77; χ2 = 36.71; P < .05). Question 5 regarding the importance of PTS within a dental curriculum had a score of 4.48 (SD = 0.68; χ2 = 41.89; P < .05). CONCLUSION: PTS is an effective student-led initiative that emphasizes early exposure, networking, and mentorship opportunities and encourages students in choosing oral-maxillofacial surgery as a specialty. PTS demonstrates that student-led initiatives can fulfill unmet needs in the dental curriculum.

The Upper Airway Nasal Complex: Structural Contribution to Persistent Nasal Obstruction.

OBJECTIVE: To determine the contribution of the nasal floor and hard palate morphology to nasal obstruction for nonresponders to prior intranasal surgery. STUDY DESIGN: Retrospective case-control study. SETTING: Tertiary academic center. METHODS: Institutional review board-approved, retrospective institutional database analysis was obtained of a cohort of 575 patients who presented with nasal obstruction over a 21-year period. Of the patients, 89 met inclusion criteria: 52 were placed into the experimental group, defined as having persistent nasal obstruction following endoscopic sinus surgery (ESS), septoplasty, nasal valve repair, and/or turbinoplasty using validated subjective questionnaires, and 37 were placed into the control group, defined as having resolution of subjective nasal obstruction. Computed tomography imaging was presented to 3 blinded experts, who measured numerous nasal airway and hard palate morphology parameters, including anterior nasal floor width, anterior maxillary angle, maxilla width, anterior nasal floor width, and palatal vault height. Standard demographic information, comorbidities, perioperative 22-item Sinonasal Outcome Test (SNOT-22), and follow-up time were also assessed. Wilcox rank sum analysis or t test was performed where appropriate. RESULTS: Follow-up ranged from 2 to 36 months following surgical intervention. Several skeletal characteristics within the upper airway were significantly associated with persistent nasal obstruction, including acute maxillary angle (P = .035), narrow maxillary width (P = .006), and high arched palate (P = .004). CONCLUSION: Persistent nasal obstruction may be seen in patients with narrow, high arched hard palate despite prior nasal surgical intervention and may benefit from additional skeletal remodeling procedures such as maxillary expansion.

Publication trends and levels of evidence in obstructive sleep apnea literature.

OBJECTIVES/HYPOTHESIS: Examine trends in clinical research and levels of evidence related to obstructive sleep apnea (OSA) in the medical literature. Describe the features and trends of OSA research within otolaryngology journals. STUDY DESIGN: Retrospective analysis. METHODS: Review of OSA research articles from 2006, 2011, and 2016 in four leading medical sleep and otolaryngology journals. Level of evidence was graded, and study characteristics were measured. RESULTS: Seven hundred eight total articles were reviewed. OSA articles significantly increased in both number and proportion of total articles in the medical sleep (P < .001) and otolaryngology (P = .004) journals. Surgically focused articles did not significantly increase in either literature. There was no significant difference between medical sleep and otolaryngology literature levels of evidence regarding OSA, and no trend toward higher levels of evidence over time. Medical sleep publications had significantly higher proportions of grant-funded (P < .001) and National Institutes of Health (NIH)-funded (P < .001) publications versus otolaryngology journals. Over time, otolaryngology journals had decreasing numbers of grant-funded and NIH-funded projects. CONCLUSIONS: OSA research is increasingly present in medical sleep and otolaryngology literature. Levels of evidence are modest for the two specialties, and have shown no trend toward increasing over time. Concurrently, otolaryngologists are less likely to be grant funded than their medical colleagues, and sleep surgery has stagnated in the studied journals. This study encourages continued efforts to publish high-quality research on OSA. It may also help guide our specialty when setting priorities regarding research funding and support for sleep surgeons. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2193-2199, 2018.

Laser-Assisted Uvulopalatoplasty for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis.

Study Objectives: Laser-assisted uvulopalatoplasty (LAUP) has been used as treatment for obstructive sleep apnea (OSA). The objective of this study was to perform a systematic review and meta-analysis for LAUP alone as treatment for OSA in adults. Methods: Three authors searched five databases (including PubMed/MEDLINE) from inception through October 30, 2016 for peer-reviewed studies, with any design/language. A study quality assessment tool was used. The PRISMA statement was followed. A meta-analysis was performed. Results: Twenty-three adult studies (717 patients) reported outcomes (age: 50 ± 9 years, body mass index: 29 ± 4 kg/m2). The pre- and post-LAUP means (M) ± standard deviations (SDs) for apnea-hypopnea index (AHI) were 28 ± 13 and 19 ± 12 events/h (32% reduction). Random effects modeling for 519 patients demonstrated an AHI mean difference (MD) of -6.56 [95% CI -10.14, -2.97] events/h. Individual patient data analyses demonstrate a 23% success rate (≥50% reduction in AHI and <20 events/h) and an 8% cure rate. Additionally, 44% of patients had worsening of their AHI after LAUP. Lowest oxygen saturation (LSAT) improved from a M ± SD of 80 ± 8% to 82 ± 7%. A limitation is that most studies were case series studies and only two were randomized controlled trials. Conclusions: In this meta-analysis, LAUP reduced AHI by 32% among all patients; while the LSAT only changed minimally. Individual data demonstrated a success rate of 23%, cure rate of 8%, and worsening of the AHI among 44% of patients. We recommend that LAUP be performed with caution or not performed at all given the unfavorable results of currently published studies.

Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects.

PURPOSE: Alterations of the lingual frenulum may contribute to oromyofacial dysfunction, speech and swallowing impediments, underdevelopment of the maxillofacial skeleton, and even predispose to sleep breathing disorder. This study aims to assess the utility of existing instruments for evaluation of restricted tongue mobility, describe normal and abnormal ranges of tongue mobility, and provide evidence in support of a reliable and efficient measure of tongue mobility. METHODS: A prospective cohort study of 1052 consecutive patients was evaluated during a 3-month period. Age, gender, ethnicity, height, weight, BMI, maximal interincisal mouth opening (MIO), mouth opening with tongue tip to maxillary incisive papillae at roof of mouth (MOTTIP), Kotlow's free-tongue measurement, and presence of severe tongue-tie were recorded. Secondary outcome measures include tongue range of motion deficit (TRMD, difference between MIO and MOTTIP) and tongue range of motion ratio (TRMR, ratio of MOTTIP to MIO). RESULTS: Results indicate that MIO is dependent on age and height; MOTTIP and TRMD are dependent on MIO; Kotlow's free-tongue measurement is an independent measure of free-tongue length and tongue mobility. TRMR is the only independent measurement of tongue mobility that is directly associated with restrictions in tongue function. CONCLUSIONS: We propose the use of tongue range of motion ratio as an initial screening tool to assess for restrictions in tongue mobility. "Functional" ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50-80%, grade 3 < 50%, grade 4 < 25%.

Inferior alveolar nerve hemangioma.

A 14-year-old male presented with lower lip numbness and a slowly enlarging mandibular mass. Computed tomography demonstrated an expansile lesion centered in the marrow space of the left mandibular body, extending along the course of the inferior alveolar nerve (IAN), and expanding the mental foramen. Preoperative diagnosis was consistent with an IAN schwannoma. Surgical planning was performed using PROPLAN CMF software. The lesion was approached via a sagittal split osteotomy and excised en bloc with the IAN. Final pathology demonstrated a capillary hemangioma originating from the inferior alveolar nerve. Based on a detailed PubMed search, this is the first capillary hemangioma of the inferior alveolar nerve reported in the literature. Laryngoscope, 126:2168-2170, 2016.

Lateral pharyngeal wall collapse associated with hypoxemia in obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Review drug-induced sleep endoscopy (DISE) findings and correlate the patterns of airway collapse with body mass index (BMI) and objective sleep study respiratory variables, with particular emphasis on oxygen desaturation variables. STUDY DESIGN: Retrospective chart review. METHODS: From January 2010 to March 2014, 64 patients underwent DISE, and its findings were registered using the VOTE (velum, oropharynx, tongue base, epiglottis) classification system. Associations were analyzed between DISE, BMI, and polysomnographic parameters. RESULTS: Complete lateral oropharyngeal collapse was significantly associated with increased severity of obstructive sleep apnea (OSA), reflected by a higher oxygen desaturation index, apnea-hypopnea index, apnea index, the percent of the total time with oxygen saturation level lower than 90%, and minimal oxygen saturation). Complete concentric collapse of the velum and complete lateral oropharyngeal collapse were associated with higher BMI values. CONCLUSIONS: The results of this study demonstrate a strong association between complete lateral oropharyngeal wall collapse and increased OSA severity, particularly with objective oximetry measures. Patients with a complete lateral oropharyngeal wall collapse may need aggressive treatment strategies because of the high probability of subsequent cardiovascular complications. LEVEL OF EVIDENCE: 4

Brain abscess potentially secondary to odontogenic infection: case report.

Odontogenic infections are rarely implicated in the causes of brain abscess formation. As such, there are very few reports of brain abscesses secondary to odontogenic infections in the literature. This is due partly to the relative rarity of brain abscesses but also to the difficulty in matching the causative organisms of a brain abscess to an odontogenic source. The authors report a case of a 50-year-old woman whose brain abscess may potentially have been secondary to an odontogenic infection. The patient's early diagnosis, supported by imaging and microbiologic assessment, along with early minicraniotomy and extraction of infected dentition followed by a course of cephalosporins and metronidazole, contributed to a successful outcome.

Identifying risk factors for postoperative cardiovascular and respiratory complications after major oral cancer surgery.

BACKGROUND: Surgical resection of oral cancer can be associated with significant postoperative cardiovascular and respiratory complications that require more sensitive predictors. METHODS: All patients with oral squamous cell carcinoma treated from July 2005 to April 2008 were retrospectively reviewed. The Goldman Revised Cardiac Risk Index (GRCRI) was used to predict cardiovascular complications. Other evidence-based a priori predictors were applied in an h-fold cross-validation model. RESULTS: Operating room (OR) time was an independent predictor of cardiovascular complications (odds ratio = 1.54, p = .002, 95% confidence interval [CI] = 1.18-2.02) and respiratory complications (odds ratio = 1.3, p = .06, 95% CI = 0.99-1.64) after multivariate adjustment. OR time and estimated blood loss predicted cardiovascular complications with 73% sensitivity. The GRCRI achieved 37% sensitivity. OR time and tracheostomy predicted respiratory complications with 75% sensitivity. CONCLUSIONS: The GRCRI was not prognostic for cardiovascular complications in patients with oral cancer. The most sensitive predictors for cardiovascular complications were OR time and estimated blood loss; for respiratory complications they were OR time and tracheostomy.