Airways and craniofacial assessment in children affected by achondroplasia with and without sleep-disordered breathing: quantitative magnetic resonance study.

PURPOSE: To identify MRI-based quantitative craniofacial variables linked to airways narrowing and obstructive sleep apnea (OSA) development in children with achondroplasia. METHODS: We evaluated skull base and midface MRI in two cohorts of children affected by achondroplasia, with (group 1) or without OSA (group 2). 3DFSPGR-T1weighted images were used to assess airways volume (nasopharynx, oropharynx, and laryngopharynx), jugular foramina (JF) and hypoglossal foramina (HF) areas, foramen magnum area, cervical cord area, and maxillary retrusion (SNA angle). RESULTS: Nineteen out of 27 children with achondroplasia exhibited different degrees of obstructive respiratory impairment (n.4 mild, n.8 moderate, n.7 severe), while 8 children did not show OSA. Each group was compared with age-matched controls without neuroimaging abnormalities. Both groups showed reduced nasopharynx volume, JF areas, and SNA angle, while group 1 showed also reduced oropharynx volume, ratio of FM/cervical cord areas, and HF areas (p < 0.05). A positive correlation between nasopharynx volume and SNA angle was found in both groups, while a positive correlation among upper airways volume, JF and HF areas was found only in group 1. No correlation between upper airways volume and OSA severity was found. CONCLUSION: In children with achondroplasia, multifaced craniofacial abnormalities contribute to airways volume reduction predisposing to sleep disordered breathing. MRI-based quantitative assessment allows the appraisal of craniofacial variables linked to the development of sleep-disordered breathing such as FM stenosis, jugular and hypoglossal foramina stenosis, and retruded maxillary position and may be a valuable tool for clinical surveillance.

Sleep-disordered breathing and its management in children with rare skeletal dysplasias.

Sleep-disordered breathing (SDB) is common in patients with skeletal dysplasias. The aim of our study was to analyze SDB and respiratory management in children with rare skeletal dysplasias. We performed a retrospective analysis of patients with spondyloepiphyseal dysplasia congenita (SEDC), metatropic dysplasia (MD), spondyloepimetaphyseal dysplasia (SEMD), acrodysostosis (ADO), geleophysic dysplasia (GD), acromicric dysplasia (AD), and spondylocostal dysplasia (SCD) between April 2014 and October 2020. Polygraphic data, clinical management, and patients' outcome were analyzed. Thirty-one patients were included (8 SEDC, 3 MD, 4 SEMD, 1 ADO, 4 GD, 3 AD, and 8 SCD). Sixteen patients had obstructive sleep apnea (OSA): 11 patients (2 with SEDC, 1 with SEMD, 1 with ADO, 1 with GD, 2 with AD, and 4 with SCD) had mild OSA, 2 (1 SEMD and 1 GD) had moderate OSA, and 3 (1 SEDC, 1 MD, 1 SEMD) had severe OSA. Adenotonsillectomy was performed in one patient with SCD and mild OSA, and at a later age in two other patients with ADO and AD. The two patients with moderate OSA were treated with noninvasive ventilation (NIV) because of nocturnal hypoxemia. The three patients with severe OSA were treated with adenotonsillectomy (1 SEDC), adeno-turbinectomy and continuous positive airway pressure (CPAP; 1 MD), and with NIV (1 SEMD) because of nocturnal hypoventilation. OSA and/or alveolar hypoventilation is common in patients with skeletal dysplasias, underlining the importance of systematic screening for SDB. CPAP and NIV are effective treatments for OSA and nocturnal hypoventilation/hypoxemia.

Relating three-dimensional airway measurements to the apnea-hypopnea index in pediatric sleep apnea patients.

OBJECTIVES: (a) To evaluate three-dimensional radiographic airway analysis as it relates to the pre-test probability for sleep apnea in pediatric patients, and (b) to develop cut-off values for measurements showing promising results. SETTING AND SAMPLE POPULATION: A consecutive series of pediatric patients between the ages of 7 and 17 years, referred for a sleep study were recruited. Cone beam computed tomography (CBCT) scans were acquired for 103 subjects within one month following the sleep study. METHODS: Three-dimensional airway analysis was performed including volumetric, area and linear measurements. Correlations with the apnea-hypopnea index (AHI) and receiver operating characteristic (ROC) curves were constructed. Sensitivity and specificity were calculated for prediction of AHI ≥ 5 and AHI ≥ 10. RESULTS: 99 CBCT scans were included (median age = 11 years). The nasopharyngeal volume (NPV) significantly correlated with AHI (rho≈-0.4, P < .05). In subjects aged 7-11 years, proposed cut-off values for NPV are 2400mm3 and 1600mm3 for AHI ≥ 5 and AHI ≥ 10, respectively. In subjects aged 12-17 years, proposed cut-off values for NPV are 3500mm3 and 2700mm3 for AHI ≥ 5 and AHI ≥ 10, respectively. Oropharyngeal cross-sectional area (OCSA) demonstrated significant predictive value in ROC curve analysis, and cut-off values for this airway measure are also proposed. CONCLUSIONS: Contrary to findings in adults, the NPV shows promise when screening for sleep apnea in children when CBCT scans are available. The OCSA might also be of value when screening for sleep apnea especially in older children.

A radiologic parameter that could be applied in the development of sleep apnea in rheumatoid arthritis patients undergoing occipitocervical fusion.

BACKGROUND: The prevalence of sleep apnea in rheumatoid arthritis (RA) patients with occipitocervical lesions was 79%. Occipitocervical fusion (OCF) could incur sleep apnea or worsen this condition. Recent studies reported that this complication is caused by stenosis of the oropharyngeal airway accompanying a decrease in the occipitoaxial angle (O-C2a). However, there are several limitations to the application of the O-C2a, which decreases its effectiveness. Therefore, we aimed to evaluate the association between a new radiologic parameter, the CVT/NSL angle (CVT: craniocervical inclination in the second and fourth vertebrae; NSL: Nasion-Sella line), and sleep apnea in RA patients accepting OCF. METHODS: A total of 35 patients who underwent OCF due to upper cervical lesions secondary to RA and had sleep apnea before surgery were analyzed. Those who have a postoperative apnea-hypopnea index (AHI) < 15 and a ΔAHI ≥50% were considered "responders"; patients were otherwise considered "non-responders." They were analyzed whether pre- and postoperative radiologic parameters and their differences in plain lateral radiographs were correlated to the parameter related to sleep apnea. RESULTS: The included patients have a mean AHI of 21.9 (range, 10 to 52) before surgery. The mean postoperative CVT/NSLa, ΔCVT/NSLa, andΔO-C2a in complete responders were significantly greater compared with non-responders (p < 0.05). Both the changes in the CVT/NSLa and O-C2a were linearly correlated within patients. However, the R2 value for the CVT/NSLa was greater compared with the O-C2a (0.403 vs. 0.203). CONCLUSIONS: The usefulness of the new craniovertebral angle, CVT/NSLa, as an intraoperative indicator during OCF, is more valuable in comparison with the conventional method of measuring the O-C2a. Measuring the craniovertebral angle is extremely important in the planning of surgical treatment for the development of sleep apnea in rheumatoid arthritis patients undergoing occipitocervical fusion.

Sleep-disordered breathing and nocturnal hypoventilation in children with the MECP2 duplication syndrome: A case series and review of the literature.

There is limited knowledge on the occurrence of respiratory manifestations and sleep-disordered breathing in particular in children with the MECP2 duplication syndrome. Although sleep-disordered breathing and nocturnal hypoventilation are currently not cited as an important symptom in these children, we present three cases who all had an abnormal breathing during sleep. In view of the consequences associated with sleep apnea and hypoventilation, we advise to perform a polysomnography in children with MECP2 duplication. Different treatment modalities (ENT surgery, CPAP, and non-invasive ventilation) can be applied to successfully treat these conditions.

Predicting polysomnographic severity thresholds in children using machine learning.

BACKGROUND: Approximately 500,000 children undergo tonsillectomy and adenoidectomy (T&A) annually for treatment of obstructive sleep disordered breathing (oSDB). Although polysomnography is beneficial for preoperative risk stratification in these children, its expanded use is limited by the associated costs and resources needed. Therefore, we used machine learning and data from potentially wearable sensors to identify children needing postoperative overnight monitoring based on the polysomnographic severity of oSDB. METHODS: Children aged 2-17 years undergoing polysomnography were included. Six machine learning models were created using (i) clinical parameters and (ii) nocturnal actigraphy and oxygen desaturation index. The prediction performance for polysomnography-derived severity of oSDB measured by apnea hypopnea index (AHI) >2 and >10 were evaluated. RESULTS: One hundred and ninety children were included. One hundred and eight were male (57%), mean age was 6.7 years [95% confidence interval; 6.1, 7.2], and mean AHI was 10.6 [7.8, 13.4]. Predictive performance utilizing clinical parameters was poor for both AHI > 2 (accuracy range: 48-56% for all models) and AHI > 10 (50-61%). Combining oximetry and actigraphy improved the accuracy to 87-89% for AHI > 2 and 95-96% for AHI > 10. CONCLUSIONS: Machine learning with oximetry and actigraphy identifies most children needing overnight monitoring as determined by polysomnographic severity of oSDB, supporting a potential resource-conscious screening pathway for children undergoing T&A. IMPACT: We provide proof of principle for the utility of machine learning, oximetry, and actigraphy to screen for severe obstructive sleep apnea syndrome (OSAS) in children. Clinical parameters perform poorly in predicting the severity of OSAS, which is confirmed in the current study. The predictive accuracy for severe OSAS was improved by a smaller subset of quantifiable physiologic parameters, such as oximetry. The results of this study support a lower cost, patient-friendly screening pathway to identify children in need of in-hospital observation after surgery.

El paciente ortodóncico en dentición mixta y los trastornos del sueño / The orthodontic patient with mixed dentition and sleep disorders

Los desórdenes respiratorios del sueño (DRS) y, principalmente, roncopatías y apneas obstructivas afectan aproximadamente al 7% de los pacientes ortodóncicos. Los DRS no solo son importantes por la cantidad de pacientes afectados, sino por la gravedad de los posibles efectos secundarios a nivel de la salud general del paciente. La obstrucción de las vías aéreas superiores (VAS) provoca alteraciones del crecimiento y deformaciones craneofaciales importantes, por lo que el tratamiento temprano y la prevención de la respiración oral es muy importante.El papel del ortodoncista es muy importante en el diagnóstico y en el tratamiento de los DRS, pero también en su prevención, realizando tratamientos que aumenten la dimensión y la permeabilidad de las VAS. El protocolo de exploración interdisciplinar en niños y adolescentes y la cefalometría de vías aéreas son importantes en el diagnóstico y deben ser tenidos en cuenta en el plan de tratamiento. Pero las pruebas más significativas, el CBCT de vías aéreas y la polisomnografía no son pruebas rutinarias por la dificultad logística y el precio de estas pruebas. En este artículo también se recomiendan los tratamientos de ortodoncia más indicados en estos casos y que tienden al aumento de la dimensión de las VAS (AU)

Sleep breathing disorders (SBD) and in the first place, roncopathy and obstructive apnea, affect approximately 7% of orthodontic patients. The SBD are not only important for the number of affected patients, but also for the severity of the possible side effects at the level of general health of a patient. The upper air ways (UAW) obstruction provokes important alterations in growth and craniofacial deformations, and this is why the early treatment and prevention of mouth breathing are very important. The role of an orthodontist in diagnosis and treatment of SBD is very important, but it is also in its prevention, carrying out the treatments which increase the dimension and permeability of UAW. The protocol of interdisciplinary examination.In children and adolescents and the air ways cephalometry analysis have an important role in diagnosis and they should be taken into account in treatment planning. But the most important tests, the air ways CBCT and polysomnography, are not routine tests due to the complicated logistics and their cost. In this article, the orthodontic treatments most indicated in these cases are recommended, because they tend to increase the UAW dimension (AU)

High-Frequency Ultrasound: A Novel Diagnostic Tool to Measure Pediatric Tonsils in 3 Dimensions.

OBJECTIVE: A wide variety of pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children; however, its use in tonsillar evaluation has not been widely explored. The objective of this study was to measure 3-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex vivo dimensions on pathology specimens. STUDY DESIGN: We performed a prospective cohort study. SETTING: The study was set in a tertiary care children's hospital. SUBJECTS AND METHODS: Children undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasonography (HFU) was performed prior to surgery to obtain 3-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex vivo tonsil measurements and correlations were obtained. RESULTS: Seventy-five consecutive children underwent a transcervical HFU, with a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were -0.08 cm and -0.24 cm for the right and left craniocaudal axes, -0.19 cm and -0.18 cm for the right and left mediolateral axes, and 0.05 cm and 0.03 cm for the right and left anteroposterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5. CONCLUSION: HFU can accurately measure the size of pediatric tonsils in 3 dimensions.

Differences in dentofacial morphology in children with sleep disordered breathing are detected with routine orthodontic records.

BACKGROUND: Residual snoring in children with obstructive sleep disordered breathing (SDB) may continue post-adenotonsillectomy. This study aims to identify baseline dentofacial differences in children with SDB using routine orthodontic records that might aid effective early intervention for the upper airway to prevent continued obstruction. METHODS: Children (6-16 years) with clinically diagnosed SDB from a paediatric Otolaryngology Clinic who required adenotonsillectomy were participants (n = 10). The control group (n = 9) comprised healthy non-snoring children from the community. Baseline overnight polysomnography (PSG), standardised frontal and right profile photographs and alginate impressions were taken of all children. Facial width, length, depth, convexity and mandibular position were measured from the photographs. The occlusion, arch width, arch depth, maxillary arch form, palatal height and volume were recorded from digitised dental models. Inter-group differences were compared. RESULTS: SDB patients had a significantly increased lower face height, maxillo-mandibular angle (1.73°; 95% CI 0.45-3.0) and a narrower maxillary arch in the upper posterior region. There was a trend towards a decreased palatal volume, increased posterior crossbite and Class II molar relationship. CONCLUSION: Dentofacial phenotypic differences between children with SDB and controls can be detected using facial photographs and dental models. Increased awareness of these features may help to identify children who to continue to snore post adenotonsillectomy.

Correlation between gonial angle and dynamic tongue collapse in children with snoring/sleep disordered breathing - an exploratory pilot study.

BACKGROUND: Drug induced sleep endoscopy (DISE) is hoped to identify reasons of failure of adenotonsillectomy (AT) in treating pediatric sleep disordered breathing (SDB). Maxillomandibular disproportion has been studied as another association which may explain alternative pathogenesis of SDB. We aimed to explore the relation between the size of the gonial angle and inclination of the epiglottis measured from cone beam CT (CBCT) and tongue base collapse based on DISE in children with SDB. METHOD: A retrospective chart review was conducted at a tertiary pediatric center. Children (6-17 years old) assessed at a multi-disciplinary Upper Airway Clinic, diagnosed with SDB and maxillo-mandibular disproportion (MMD), and who underwent DISE were eligible. Variables obtained from the electronic medical records of the clinic and prospective database included demographics, comorbidities, surgeries performed, investigations, DISE findings and CBCT findings. The gonial angle of subjects with and without tongue base collapse (TBC) on SNP were compared. RESULTS: In total 29 patients (13 male, 8 female) age 6-17 (median= 9) were eligible for the study from January 2009 - July 2016. We included 11 subjects, and 10 comparators. The mean gonial angle of the TBC group was 139.3°± 7.6°, while that of the comparison group was 129.4°±3.5 (mean difference -9.937, 95% CI of -15.454 to - 4.421, P = 0.001, power of test 0.95). Additionally, the mean inclination of the epiglottis had a mild positive correlation (r=0.32, p<0.05) with the gonial angle, in the whole cohort. CONCLUSIONS: This pilot study suggests that TBC may be mediated by a wider gonial angle in children with SDB patients. The posterior tilt of the epiglottis on CBCT may be a surrogate sign of TBC.

Influence of Bimaxillary Surgery on Pharyngeal Airway in Class III Deformities and Effect on Sleep Apnea: A STOP-BANG Questionnaire and Cone-Beam Computed Tomography Study.

PURPOSE: To evaluate pharyngeal airway space (PAS; nasopharyngeal, oropharyngeal, and total airway) volume and the correlation of an obstructive sleep apnea (OSA) and hypopnea syndrome screening questionnaire (STOP-BANG) with various mandibular setbacks during bimaxillary surgery and compare these findings with an age- and gender-matched skeletal Class I control group. PATIENTS AND METHODS: This retrospective cohort study was composed of patients with skeletal Class III discrepancy who underwent bimaxillary jaw surgery and were assessed with STOP-BANG score, cephalometry, and cone-beam computed tomography (of the PAS). The predictor variable was bimaxillary jaw surgery and included 4-, 6-, and 8-mm setbacks. The primary outcome variables were PAS volume, body mass index, and STOP-BANG score evaluated at 1 week before surgery and after comprehensive orthodontic treatment (11.25 ± 1.95 months). Other variables were grouped into the following categories: demographic and cephalometric parameters. Statistical intragroup and intergroup differences were assessed by paired t and independent t tests (P < .05), respectively. RESULTS: The study sample was composed of 48 patients (18 to 25 yr old); group I received 4-mm setback (n = 16), group II received 6-mm setback (n = 16), and group III received 8-mm setback (n = 16) mandibular surgery, and all test groups received 4-mm maxillary advancement. The entire study group was compared with a skeletal Class I control group (n = 16). The total PAS volume after orthodontic treatment in groups I and II showed a significant decrease compared with the presurgical PAS (P < .001), but the decrease was not less than that in the control group (P > .05). In contrast, the total PAS volume in group III after orthodontic treatment (23,574 ± 1,394 mm3) was less than that in the control group (23,884 ± 1,543 mm3). CONCLUSION: After surgery, patients with Class III discrepancy exhibited a decrease in oropharynx volume; however, the STOP-BANG score showed no change in risk factors scores for OSA at 4- to 8-mm setback surgery of the mandible in bimaxillary jaw surgery.

The structural changes of upper airway and newly developed sleep breathing disorders after surgical treatment in class III malocclusion subjects.

Bimaxillary surgery is the traditional treatment of choice for correcting class III malocclusion which is reported to cause an alteration of oropharyngeal structures and upper airway narrowing that might be a predisposing factor for obstructive sleep apnea (OSA). This study aimed to analyze sleep parameters in class III malocclusion subjects and ascertain the prevalence of snoring or OSA following bimaxillary surgery.A total of 22 patients with Le Fort I osteotomy and mandibular setback for class III malocclusion were prospectively enrolled. All patients received endoscopic examination, cephalometry, 3-dimensional computed tomography (3D-CT), and sleep study twice at 1 month before and 3 months after surgery.The patient population consisted of 5 males and 17 females with a mean body mass index of 22.5 kg/m and mean age of 22.1 years. No patients complained of sleep-related symptoms, and the results of sleep study showed normal values before surgery. Three patients (13%) were newly diagnosed with mild or moderate OSA and 6 patients (27%) showed increased loudness of snoring (over 40 dB) after bimaxillary surgery. According to cephalometric analysis and 3D-CT results, the retropalatal and retroglossal areas were significantly narrowed in class III malocclusion patients, showing snoring and sleep apnea after surgery. In addition, the total volume of the upper airway was considerably reduced following surgery in the same patients.Postoperative narrowing of the upper airway and a reduction of total upper airway volume can be induced, and causes snoring and OSA in class III malocclusion subjects following bimaxillary surgery.

Using cone beam CT to assess the upper airway after surgery in children with sleep disordered breathing symptoms and maxillary-mandibular disproportions: a clinical pilot.

BACKGROUND: The surgical excision of anatomic obstructions such as adenoids, palatine or lingual tonsils are commonly performed in children with sleep disordered breathing (SDB). Imaging studies measuring airway changes post-surgery in the SDB pediatric population are scarce, rarely addresses the nasal cavity, and are based on global measures (e.g. volume) that do not represent the complexity of the upper airway anatomy. The purpose of this pilot is to test the feasibility in using cone beam CT (CBCT) to analyze the nasal and pharyngeal airway space post-surgery using meaningful methods of analyses, and correlating imaging findings with clinical outcomes in children with SDB symptoms and maxillary-mandibular disproportion. METHODS: Twelve non-syndromic children with SDB symptoms and jaw disproportions were evaluated by interdisciplinary airway team before and after upper airway surgery. CBCT and OSA-18 quality of life questionnaire pre and post-operatively were completed. Conventional and new airway variables were measured based on 3D models of the upper airways and correlated with OSA-18. Conventional measures include volume, surface area, and cross-sectional area. New airway measures include constriction and patency; point-based analyses. RESULTS: Eight females and four males were 8.8 ± 2 years with mean BMI of 18.7 ± 3. OSA-18 improved, median (lower quartile-upper quartile) from 64.2 (54.7-79.5) to 37.6 (28.7-43) postoperatively, p < 0.001. The median of all airway measures improved however with very wide range. Subjects with the smallest amounts of constriction relief and/or gain in airway patency presented with least improvement in OSA-18. New airway measures show strong correlation with changes in OSA-18 (ρ = 0.44 to 0.71) whereas conventional measures showed very weak correlation (ρ = -0.04 to 0.37). CONCLUSIONS: Using point-based analyses, new airway measures better explained changes in clinical symptoms compared to conventional measures. Airway patency gained by at least 150% and constriction relief by at least 15% showed marked improvement in OSA-18 by 40-55%, after surgery in the tested cohort.

Decision aid prototype development for parents considering adenotonsillectomy for their children with sleep disordered breathing.

BACKGROUND: To describe the process involved in developing a decision aid prototype for parents considering adenotonsillectomy for their children with sleep disordered breathing. METHODS: A paper-based decision aid prototype was developed using the framework proposed by the International Patient Decision Aids Standards Collaborative. The decision aid focused on two main treatment options: watchful waiting and adenotonsillectomy. Usability was assessed with parents of pediatric patients and providers with qualitative content analysis of semi-structured interviews, which included open-ended user feedback. RESULTS: A steering committee composed of key stakeholders was assembled. A needs assessment was then performed, which confirmed the need for a decision support tool. A decision aid prototype was developed and modified based on semi-structured qualitative interviews and a scoping literature review. The prototype provided information on the condition, risk and benefits of treatments, and values clarification. The prototype underwent three cycles of accessibility, feasibility, and comprehensibility testing, incorporating feedback from all stakeholders to develop the final decision aid prototype. CONCLUSION: A standardized, iterative methodology was used to develop a decision aid prototype for parents considering adenotonsillectomy for their children with sleep disordered breathing. The decision aid prototype appeared feasible, acceptable and comprehensible, and may serve as an effective means of improving shared decision-making.

Radiology of Cleft Lip and Palate: Imaging for the Prenatal Period and throughout Life.

Recent advances in prenatal imaging have made possible the in utero diagnosis of cleft lip and palate and associated deformities. Postnatal diagnosis of cleft lip is made clinically, but imaging still plays a role in detection of associated abnormalities, surgical treatment planning, and screening for or surveillance of secondary deformities. This article describes the clinical entities of cleft lip with or without cleft palate (CLP) and isolated cleft palate and documents their prenatal and postnatal appearances at radiography, ultrasonography (US), magnetic resonance (MR) imaging, and computed tomography (CT). Imaging protocols and findings for prenatal screening, detection of associated anomalies, and evaluation of secondary deformities throughout life are described and illustrated. CLP and isolated cleft palate are distinct entities with shared radiologic appearances. Prenatal US and MR imaging can depict clefting of the lip or palate and associated anomalies. While two- and three-dimensional US often can depict cleft lip, visualization of cleft palate is more difficult, and repeat US or fetal MR imaging should be performed if cleft palate is suspected. Postnatal imaging can assist in identifying associated abnormalities and dentofacial deformities. Dentofacial sequelae of cleft lip and palate include missing and supernumerary teeth, oronasal fistulas, velopharyngeal insufficiency, hearing loss, maxillary growth restriction, and airway abnormalities. Secondary deformities can often be found incidentally at imaging performed for other purposes, but detection is necessary because they may have considerable implications for the patient.

The usefulness of cephalometric measurement as a diagnostic tool for obstructive sleep apnea syndrome: a retrospective study.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is a disorder characterized by apnea and hypopnea maintained for over 10 seconds and occurring at least 5 times per hour, with at least 30 episodes during 7 hours of nocturnal sleep. The most important pathophysiology in OSAS is the obstruction of the upper airway during sleep. The aim of this study was to identify the correlations between lateral cephalometric parameters, which seemed to be related to OSAS severities, and polysomnography (PSG) indices and to thus determine the cephalometric parameters reflecting OSAS severity. PATIENTS AND METHODS: A total of 140 participants (122 males, 18 females) were evaluated by lateral cephalography and PSG. A total of 29 measurements (24 distances and 5 angles) were made on lateral cephalography. Cephalometric and PSG parameters were evaluated statistically to select and validate the cephalometric parameters reflecting OSAS severity. RESULT: OSAS has a significant relationship with the anatomic deformities of craniofacial and soft tissues. Lateral cephalometry revealed that patients with OSAS have a significant vertical airway length, a regrognathic mandible, a thick uvula, a large tongue, and a long mid-face length. The position of the hyoid bone had a tendency to displace inferiorly and/or posteriorly. Using the discriminant variable combination, including tongue base-posterior nasal spine (T1-PNS), sella-nasion-B point angle (SNB), maximum uvula thickness (Max U), tongue base-tongue tip (T1-TT), and nasion-anterior nasal spine (N-ANS), 102 of 140 (72.9%) patients were correctly assigned to the normal-to-mild and moderate-to-severe apnea-hypopnea index (AHI) groups. CONCLUSIONS: Lateral cephalometric radiography may be an accessible and suitable tool for evaluation of craniofacial and soft tissue deformities in their correlations with OSAS severity. Further research on the cephalometric parameters reflecting OSAS severity is needed.

Incidental findings in the maxillofacial region detected by cone beam CT.

PURPOSE: The purpose of this study was to determine the location, nature, and occurrence of incidental maxillofacial findings on cone beam computed tomography (CBCT) scans performed for maxillofacial diagnostic purposes. MATERIALS AND METHODS: CBCT images of 207 consecutive patients (129 females and 78 males) were examined. The sample consisted of 85 temporomandibular joint (TMJ) disorder patients, 45 paranasal sinusitis patients, 30 obstructive sleep apnea syndrome patients, 15 implant patients, and 32 others. RESULTS: The overall rate of incidental findings was 92.8%. The highest rate of incidental findings was in the airway area (51.8%), followed by impacted teeth (21.7%), TMJ findings (11.1%), endodontic lesions (4.3%), condensing osteitis (1%), and others (2.9%). The airway incidental findings included mucosal thickening (21.3%), deviation of the nasal septum (12.6%), conchal hypertrophy (11.1%), bullous concha (3.9%), and retention cysts (2.9%). The impacted teeth consisted of third molars (18.8%) and canines (2.9%). The incidental findings for the TMJ patients were erosion of the condyle (4.8%), osteophytes (3.4%), and bifid condyle (2.9%). CONCLUSION: Oral radiologists should be aware of possible incidental findings and should be vigilant about comprehensively evaluating possible underlying diseases.

Sleep-disordered breathing and transcranial Dopplers in sickle cell disease.

OBJECTIVES: To determine the prevalence of sleep-disordered breathing in children with sickle cell disease and whether there is an association of sleep-disordered breathing with high-risk transcranial Doppler ultrasonography (TCD) velocities. Study DESIGN: Cross-sectional. SETTING: Tertiary care academic medical center. PATIENTS: Sixty-four children (aged 2-14 years) selected for eligible genotype (type SS or Sß(0)-thalassemia) and no history of stroke. INTERVENTIONS: Parents completed the Pediatric Sleep Questionnaire. Overnight polysomnography was performed for children with snoring. The TCD was performed or existing results were obtained for all children; for children who underwent transfusion therapy, readings prior to the transfusion were analyzed. Children with abnormal or conditional TCD (flow velocity ≥170 cm/s in any vessel) were considered high risk. MAIN OUTCOME MEASURES: Prevalence of sleep-disordered breathing and TCD velocity and frequency of high-risk TCD in patients with and without sleep-disordered breathing. RESULTS: The prevalence of snoring was 37.5% (95% CI, 26.7%-49.8%), the prevalence of positive polysomnography findings was 23.7% (14.6%-36.1%), and the prevalence of positive Pediatric Sleep Questionnaire scores was 21.9% (13.4%-33.6%). There was no significant difference in TCD velocity or number of patients with high-risk TCD between nonsnorers and children with snoring but negative polysomnography findings and children with snoring and positive polysomnography findings (P = .91 and P = .66, respectively) or between nonsnorers and snorers with a negative Pediatric Sleep Questionnaire score and snorers with a positive Pediatric Sleep Questionnaire score (P = .76 and P = .33, respectively). CONCLUSION: There is a high prevalence of snoring and sleep-disordered breathing among children with sickle cell disease, but our results do not support an association with cerebrovascular risk.

Sleep apnea in rheumatoid arthritis patients with occipitocervical lesions: the prevalence and associated radiographic features.

Since sleep apnea is a risk factor for high mortality of rheumatoid arthritis (RA) patients, this study examined the prevalence in RA patients with occipitocervical lesions, and the associated radiographic features. Twenty-nine RA patients requiring surgery for progressive myelopathy due to occipitocervical lesions (3 males, 26 females, average age 65 years) were preoperatively evaluated. Twenty-three (79%) had sleep apnea defined as apnea-hypopnea index >5 events per hour measured by a portable monitoring device, and all of them were classified as the obstructive type. Among gender, age, bone mass index (BMI), and radiographic parameters related to occipitocervical lesions: atlantodental interval (ADI), cervical angles (O/C1, C1/2, and C2/6), and cervical lengths (O-C2 and O-C6), the ADI and cervical lengths were shown to be significantly associated with the presence of sleep apnea by parametric statistical analysis. Since there were positive correlations between the ADI and cervical lengths by Pearson's test, we performed a multivariate logistic regression analysis after adjustment for confounding factors and found that small ADI was the principle parameter associated with sleep apnea. We therefore conclude that the prevalence of sleep apnea is higher than that in a general RA population that was reported previously, and believe that occipitocervical lesions are an independent risk factor for this condition. Small ADI and short neck, secondary to the vertical translocation by RA, may cause obstructive sleep apnea, probably through mechanical or neurological collapse of the upper airway.