The effects of adeno/tonsillectomy on cardiopulmonary function based on echocardiography indices in children with primary snoring and mild obstructive sleep apnea.

BACKGROUND: The goal of this study was to evaluate the effects of adenotonsillectomy on heart function based on echocardiography indices in children with primary snoring (PS) and mild obstructive sleep apnea due to adenotonsillar hypertrophy (ATH). METHODS: 55 children (aged 7 to 11 years old) with PS and ATH who were a candidate for adenotonsillectomy from August 2018 to June 2019 evaluated. A history of Upper Respiratory Tract Obstruction was obtained, clinical examination was performed and the cases suspicious for moderate to severe degrees of Obstructive Sleep Apnea Syndrome were excluded. Echocardiography was performed one week before and 3-6 months after surgery. All data were analyzed by SPSS version 19 and P-value<0.05 was considered significant. RESULTS: From 55 enrolled cases, 42 [30 boys (71.5%) and 12 girls (28.5%)] completed the study course. Tricuspid Annular Plane Systolic Excursion (TAPSE), Ejection Fraction (EF), Right Ventricular Peak Systolic Myocardial Velocity (RVSM), Right Ventricular Fractional Area Change (RVFAC) were increased significantly and Isovolumic Contraction Time (IVCT) index was decreased significantly after surgery (P-value<0.05). The difference of indices between the two sexes was not significant after surgery (P-value>0.05). CONCLUSION: Adenotonsillectomy can improve cardiac function indices in patients with PS due to ATH especially in terms of right ventricle (RV) function and reduction in pulmonary artery pressure. So, although "subclinical", it is better to be considered PS not just as annoying noise for roommates before significant clinical cardiac problems happen.

Subclinical Changes in Cardiac Functional Parameters as Determined by Cardiovascular Magnetic Resonance (CMR) Imaging in Sleep Apnea and Snoring: Findings from UK Biobank.

Background and Objectives: Obstructive sleep apnea (OSA) is a common disorder with an increased risk for left ventricular and right ventricular dysfunction. Most studies to date have examined populations with manifest cardiovascular disease using echocardiography to analyze ventricular dysfunction with little or no reference to ventricular volumes or myocardial mass. Our aim was to explore these parameters with cardiac MRI. We hypothesized that there would be stepwise increase in left ventricular mass and right ventricular volumes from the unaffected, to the snoring and the OSA group. Materials and Methods: We analyzed cardiac MRI data from 4978 UK Biobank participants free from cardiovascular disease. Participants were allocated into three cohorts: with OSA, with self-reported snoring and without OSA or snoring (n = 118, 1886 and 2477). We analyzed cardiac parameters from balanced cine-SSFP sequences and indexed them to body surface area. Results: Patients with OSA were mostly males (47.3% vs. 79.7%; p < 0.001) with higher body mass index (25.7 ± 4.0 vs. 31.3 ± 5.3 kg/m²; p < 0.001) and higher blood pressure (135 ± 18 vs. 140 ± 17 mmHg; p = 0.012) compared to individuals without OSA or snoring. Regression analysis showed a significant effect for OSA in left ventricular end-diastolic index (LVEDVI) (ß = -4.9 ± 2.4 mL/m²; p = 0.040) and right ventricular end-diastolic index (RVEDVI) (ß = -6.2 ± 2.6 mL/m²; p = 0.016) in females and for right ventricular ejection fraction (RVEF) (ß = 1.7 ± 0.8%; p = 0.031) in males. A significant effect was discovered in snoring females for left ventricular mass index (LVMI) (ß = 3.5 ± 0.9 g/m²; p < 0.001) and in males for left ventricular ejection fraction (LVEF) (ß = 1.0 ± 0.3%; p = 0.001) and RVEF (ß = 1.2 ± 0.3%; p < 0.001). Conclusion: Our study suggests that OSA is highly underdiagnosed and that it is an evolving process with gender specific progression. Females with OSA show significantly lower ventricular volumes while males with snoring show increased ejection fractions which may be an early sign of hypertrophy. Separate prospective studies are needed to further explore the direction of causality.

Relationships among retropalatal airway, pharyngeal length, and craniofacial structures determined by magnetic resonance imaging in patients with obstructive sleep apnea.

BACKGROUND: The integration of anatomical and nonanatomical parameters will improve our ability to predict the outcomes of OSA treatment. Currently, no standardized, quantitative classification of upper airway anatomical traits is available. The retropalatal (RP) airway is the most important area to consider when planning anatomical treatment. However, current evaluation methods feature qualitative conventional endoscopy. Here, we describe a quantitative magnetic resonance imaging (MRI) method used to classify RP airway patterns. METHODS: We recruited 117 males; 20 simple snorers and 97 patients with OSA. Lateral/anteroposterior ratios were calculated in three parallel planes and RP patterns were classified accordingly. Lateral wall soft tissue structures, skeletal dimensions representing those planes, pharyngeal lengths, and skeletal and vertical axis ratios were also measured. RESULTS: Both the cross-sectional area at the hard palate level and the RP lateral dimension were associated with OSA. OSA patients had longer pharynges than controls. The oblique pattern was associated with narrow lateral dimensions. The vertical pattern was associated with a narrow nasopharynx but a longer pharynx. The airway ratio at the hard palate level and the skeletal ratios of all three planes were negatively correlated with the vertical axis ratio and together explained 40.8% of the variance in the vertical axis ratio. CONCLUSIONS: The data suggest that anatomical imbalances between the craniofacial skeletal and soft tissue structures affect pharyngeal airway morphology in all three dimensions. The dimensions of the nasopharynx, the cross-sectional area at the hard palate level, and pharyngeal length were associated not only with the RP patterns but also with OSA severity. This study affords insights into upper airway anatomy and RP patterns and may help diagnose OSA patients and aid in the selection of an appropriate therapy.

Evaluation of effects of anterior palatoplasty operation on upper airway parameters in computed tomography in patients with pure snoring and obstructive sleep apnea syndrome.

AIM: To investigate changes in upper airway volume parameters measured by computerized tomography scans in patients with surgically treated by anterior palatoplasty of whom having pure snoring and mild-moderate obstructive sleep apnea. METHOD: A prospective study on consecutively anterior palatoplasty performed pure snoring and obstructive sleep apnea patients. Computerized tomography scans were obtained preoperatively and following anterior palatoplasty procedure to measure changes in upper airway volume. Patients underwent diagnostic drug induced sleep endoscopy to assess the site of obstruction. Preoperative and postoperative measurements were compared using student's t test and Chi-square test. RESULTS: Twenty-two patients (16 men and 6 women, age 48.22 ± 9.23, body mass index 25.85 ± 2.57) completed the trial. Anterior palatoplasty was associated with an increase in total upper airway volume from 4.81 ± 1.73 cm3 before treatment to 6.57 ± 2.03 cm3 after treatment (p < 0.005). Change in soft palate thickness did not vary significantly (p < 0.039). The mean soft palate length has changed from 4.13 ± 0.41 to 3.93 ± 0.51 cm (p < 0.001). The preoperative and postoperative measurements of cross-sectional areas and volumes all showed significant difference except velopharynx minimal lateral airway dimension. The operational procedure increased the total upper airway volume much more in men than in women (p < 0.05). CONCLUSION: Results of this study indicate that anterior palatoplasty operation appears to produce significant increase in upper airway volume and cross sectional area. It does not seem to have an effect on lateral airway dimension. Computerized tomography is a quick and noninvasive imaging technique that allows for quantitative assessment of the velopharyngeal patency changes.

Evaluation of morphological changes in pharynx with dynamic CT and MRI in snoring patients.

BACKGROUND: Identifying the craniofacial abnormalities that cause snoring and the narrowest area of the upper airway creating obstructions can help to determine the proper method of treatment. AIM: To identify the factors that can cause snoring and the areas of the airway that are the most likely to collapse with upper airway imaging. MATERIAL AND METHODS: Axial pharynx examinations with CT (computerized tomography) and magnetic resonance imaging (MRI) were performed to 38 patients complaining of snoring and 12 patients who did not complain of snoring. The narrowest areas of nasopharynx, hypophraynx, oropharynx, bilateral para-pharyngeal fat pad and para-pharyngeal muscle thickness were measured. RESULTS: In snoring patients, the narrowest part of the upper airway was the retro-palatal region in the oropharynx, as measured with both imaging methods. When patients with and without snoring were compared, the former that a higher body mass index and neck diameter and a narrower oropharynx area. In dynamic examinations, we determined that as para-pharyngeal muscle thickness increased, medial-lateral airway diameter and the oropharynx area decreased. CONCLUSIONS: The narrowest section of the airway is the retro-palatal region of the oropharynx, measured both with CT and MRI.

The Association of Upper Airway Anatomy with Brain Structure: The Multi-Ethnic Study of Atherosclerosis.

Sleep apnea, affecting an estimated 1 in 4 American adults, has been reported to be associated with both brain structural abnormality and impaired cognitive function. Obstructive sleep apnea is known to be affected by upper airway anatomy. To better understand the contribution of upper airway anatomy to pathways linking sleep apnea with impaired cognitive function, we investigated the association of upper airway anatomy with structural brain abnormalities. Based in the Multi-Ethnic Study of Atherosclerosis, a longitudinal cohort study of community-dwelling adults, a comprehensive sleep study and an MRI of the upper airway and brain were performed on 578 participants. Machine learning models were used to select from 74 upper airway measures those measures most associated with selected regional brain volumes and white matter hyperintensity volume. Linear regression assessed associations between the selected upper airway measures, sleep measures, and brain structure. Maxillary divergence was positively associated with hippocampus volume, and mandible length was negatively associated with total white and gray matter volume. Both coefficients were small (coefficients per standard deviation 0.063 mL, p = 0.04, and - 7.0 mL, p < 0.001 respectively), and not affected by adjustment for sleep study measures. Self-reported snoring >2 times per week was associated with larger hippocampus volume (coefficient 0.164 mL, p = 0.007), and higher percentage of time in the N3 sleep stage was associated with larger total white and gray matter volume (4.8 mL, p = 0.004). Despite associations of two upper airway anatomy measures with brain volume, the evidence did not suggest that these upper airway and brain structure associations were acting primarily through the pathway of sleep disturbance.

Carotid intima-media thickness increase in patients with habitual simple snoring and obstructive sleep apnea syndrome is associated with metabolic syndrome.

OBJECTIVES: Sleep disorders are emerging risk factors for atherosclerosis. Increased carotid intima-media thickness (CCA-IMT) is a surrogate marker of cardiovascular risk. The aim of the present study was to investigate the relationship between CCA-IMT and habitual simple snoring or obstructive sleep apnea syndrome (OSAS) and the other cardiovascular risk factors. METHODS: Sleep disorders were diagnosed and staged by polysomnography. Patients were then classified into either habitual simple snoring (n = 20, group 1) or OSAS (n = 67, group 2), which was subclassified as mild-moderate (n = 27) or severe (n = 40). CCA-IMT was measured by B-mode ultrasonography. The other major risk factors were investigated. RESULTS: The mean CCA-IMT was 0.65 ± 0.02 mm (mean ± SD) in group 1 versus 0.75 ± 0.02 mm in group 2 (p = 0.03). Using CCA-IMT ≥ 0. 9 mm as the threshold value also yielded significant results between the two groups (p = 0.03). The mean CCA-IMT did not differ between patients with mild-moderate and severe OSAS, whereas metabolic risk factors and metabolic syndrome (MS) were more prominent in the latter. Age, MS, neck and waist circumference, waist/ hip circumference, and fasting glucose level were higher in patients with CCA-IMT ≥ 0.9 mm. CONCLUSIONS: CCA-IMT increase was associated with OSAS, but did not correlate with its severity, which could be due to the higher incidence of MS in this group.

Comparison of the pharyngeal airway in snoring and non-snoring patients based on the lateral cephalometric study: A case-control study.

BACKGROUND: Normal airways are a key factor during the craniofacial growth of the young. Therefore, sleep-disordered breathing (SDB) without treatment can have harmful consequences for development and health. OBJECTIVES: This study aimed to evaluate the cephalometric characteristics in non-snoring individuals and snoring subjects, and investigate differences in the pharyngeal airway space between the 2 groups. MATERIAL AND METHODS: This case-control study included 70 patients aged over 18 years, selected from a radiology center. The patients were divided into 2 groups: case (35 patients with a history of habitual snoring); and control (35 healthy patients). The Berlin sleep questionnaire was administered to the parents of the patients. The nasopharyngeal airway was measured according to the analysis of Linder-Aronson (1970), and 4 indices were measured and analyzed in each of the lateral cephalometric radiographs. RESULTS: No statistically significant differences were observed in the pharyngeal measurements between the 2 groups, although all means in the control group were higher than in the experimental group. However, there was a significant relationship between gender and the Ba-S-PNS and PNS-AD2 indices. CONCLUSIONS: Although the patients with nocturnal snoring had smaller airway dimensions, their pharyngeal measurements were not significantly different from the control group.

Association of self-reported snoring with carotid artery intima-media thickness and plaque.

Previous studies have suggested that self-reported snoring is associated with atherosclerotic vascular diseases. However, the role of self-reported snoring as an independent risk factor for subclinical atherosclerosis has not been well established. This study aimed to evaluate whether and to what extent self-reported snoring is associated with subclinical carotid atherosclerosis after adjusting for traditional cardiovascular risk factors. Carotid intima-media thickness and plaque were investigated with ultrasonography in 1245 urban Chinese aged 50-79 years between September 2007 and November 2007. Information on self-reported snoring and measurements of traditional cardiovascular risk factors was also collected. A total of 1050 participants were involved in the final analysis. The prevalence of self-reported snoring habitually (snoring frequency ≥5 days per week) was 31.5, and 64.3% of the participants in this population had a history of snoring. The mean values of the maximum intima-media thickness of bifurcation and common carotid arteries in snorers were significantly higher than in non-snorers (1.08 ± 0.14 mm versus 1.04 ± 0.14 mm, P < 0.001, in carotid bifurcation; 1.03 ± 0.15 mm versus 1.00 ± 0.15 mm, P = 0.002, in common carotid artery). After adjustment for traditional cardiovascular risk factors, logistic regression analysis showed that the odds ratio of self-reported snoring habitually for increased intima-media thickness and carotid bifurcation plaque was 1.71 [95% confidence interval (CI): 1.22-2.39; P = 0.002] and 3.63 (95% CI: 2.57-5.12; P < 0.001), respectively. In conclusion, the current study suggested that self-reported snoring is associated significantly with carotid bifurcation intima-media thickness and the presence of plaque, independent of traditional cardiovascular risk factors.

A clinical trial on 3D CT scan and polysomnographyc changes after rapid maxillary expansion in children with snoring.

OBJECTIVE: The present prospective clinical study aimed to investigate the effects of rapid maxillary expansion on the airway, correlating airway volumes obtained on multi-slice computed tomography and polysomnography assessment of oxygen saturation and apnea/hypopnea index. METHODS: Twenty-four patients (11 with obstructive sleep apnea and 13 with residual snoring, mean age 10.0 (1.8), were enrolled in the study. Each patient underwent multislice computed tomography and nocturnal polysomnography before rapid maxillary expansion and after removal of maxillary expansion after six months. Airway regions were segmented, and volumes were computed. RESULTS: The increase in oropharyngeal volume was significant in both groups. Oxygen saturation and apnea/hypopnea index were not statistically significant. No correlation was found between total airway volume, oxygen saturation, and apnea/hypopnea index changes between the time points examined. CONCLUSIONS: This study showed that when rapid maxillary expansion is performed in individuals with sleep-disordered breathing, there were statistically significant differences in oropharyngeal volume between pre- and post-rapid maxillary expansion, but there was no correlation between oxygen saturation values and oropharyngeal volume increase. LEVEL OF EVIDENCE: The article is classified as Evidence Level 3 (Three).

Evaluation of Upper Airway in Children with Obstructive Sleep Apnea Using Cone-Beam Computed Tomography.

OBJECTIVE: Cone-beam computed tomography (CBCT) offers three-dimensional structures in assessing upper airway of patients. This study aims to compare the cone-beam computerized tomography scan measurements between children with obstructive sleep apnea (OSA) and primary snoring. STUDY DESIGN: Case-control study. METHODS: This prospective study was conducted in a tertiary referral center. Thirty-six children with moderate-to-severe OSA (with apnea-hypopnea index [AHI] > 5 events/hour) and 36 age-, gender-, and obesity-matched children with primary snoring (AHI <1) were enrolled. The measurements in CBCT parameters were compared between children with moderate-to-severe OSA and primary snorers by conditional logistic regression model. RESULTS: A total of 72 children (mean age, 7.9 ± 2.8 years; 64% male) were included. Children with moderate-to-severe OSA had a significantly smaller nasopharyngeal (2900 ± 1400 vs. 3800 ± 1800 mm3 , P = .017) and oropharyngeal airway volume (5600 ± 2700 vs. 7400 ± 4000 mm3 , P = .026) than those with primary snoring. Children with moderate-to-severe OSA, as compared to primary snorers, also had a significantly smaller minimal airway area in nasopharynx (77.4 ± 37.7 vs. 107.7 ± 52.0 mm2 , P = .006) and oropharynx (66.6 ± 61.9 vs. 101.6 ± 65.8 mm2 , P = .023). Moreover, the airway length was not significantly different between children with moderate-to-severe OSA and primary snoring. CONCLUSIONS: The three-dimensional CBCT airway analysis could be used as a useful tool to evaluate upper airway in children with OSA. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:680-685, 2021.

Soft palate length and upper airway relationship in OSA and non-OSA subjects.

BACKGROUND: The narrowest area of the airway between the posterior nasal opening and the epiglottis is usually located in the retro palatal area. Many consider this the most likely site of airway obstruction during an obstructive sleep apnea (OSA) event. The aim of this study was to investigate the differences in soft palate and airway length between OSA and non-OSA patients. METHODS: In this study, we analyzed the ratio of the soft palate and the upper airway length in 45 consecutive patients. Twenty-five had an Apnea-Hypoapnea Index of more than five events per hour and were classified in the OSA group (male, 19; female, 6). These patients were compared with 20 normal controls (male, 12; female, 8). Controls who complained of snoring did have sleep studies (n=5). The other fifteen controls were clinically asymptomatic and did not have sleep studies. Medical computed tomography scans were taken to determine the length of the upper airway and the soft palate length measured in the midsagittal image. RESULTS: Soft palate length was significantly larger in OSA patients compared to controls (p=0.009), and in men compared to women (p=0.002). However, there were no differences in airway length. The soft palate length, as a percent of oropharyngeal airway length, was significantly larger in OSA patients compared to controls (p= <0.0001) and in men compared to women (p=0.02). Soft palate length increases significantly with age by 0.3 mm per year in males (after adjustment for body mass index (BMI) and OSA). Soft palate length as a percent of airway length is larger in OSA patients and increases significantly with BMI in males only after adjusting for age. CONCLUSION: In this study, OSA patients had a longer soft palate in proportion to their oropharyngeal airway compared to controls as well as men compared to women. This proportion could be used for identifying patients at risk for OSA in combination with age.

Tongue base ultrasound: a diagnostic tool for predicting obstructive sleep apnea.

OBJECTIVES: We assessed the value of an ultrasound (US) examination in the diagnostic workup of patients with sleep-related breathing disorders by correlating US measurements with known parameters for the presence and severity of obstructive sleep apnea. METHODS: Forty-one male patients who complained of snoring and/or daytime somnolence participated. The diagnostic protocol included history-taking, physical examination, polysomnography, and transcervical US examination of the tongue. The US results were compared with all of the other parameters. RESULTS: The US imaging was reliable for demonstrating anatomic structures of the tongue base, discriminating between muscle, mucosa, and blood vessels. The lingual arteries were clearly visualized entering the tongue base at its lower lateral borders. There was a significant relationship between the severity of sleep-related breathing disorders (measured by polysomnography) and the width of the lower tongue base (measured as the distance between the lingual arteries). The distance between the lingual arteries also correlated with physical examination findings and patient complaints of daytime somnolence and the sensation of choking during the night. CONCLUSIONS: Tongue base width, measured by US, may influence the severity of obstructive sleep apnea. This is the first demonstration of the possible role of US examination, an inexpensive, noninvasive, and non-irradiating office procedure, in the diagnostic workup for sleep-related breathing disorders.

A case of obstructive sleep apnoea with anterior cervical osteophytes.

Osteophytes of the cervical spine are usually seen in elderly adults. When prominent, they have been blamed for dysphagia, cough, dysphonia and dyspnoea. This paper reports on an obstructive sleep apnoea (OSA) patient with cervical spinal osteophytes, one cause of airway obstruction. A 75-year-old male complained of pronounced snoring. The diagnosis was mild OSA, apnoea hypopnoea index was 9.4. Patient reported no restrictions in neck movements, experiences of neck pain or neck trauma. Previously, patient underwent a tonsillectomy due to discomfort in the pharyngeal region. A lateral cephalometric image was taken to observe airway before oral appliance therapy. The image revealed the presence of large osteophytes or sclerotic enthesopathy, lying on anterior surfaces from the fourth to seventh cervical vertebrae. A computed tomography (CT) image revealed the relationship of airway position to the spine. In the reconstructed three-dimensional (3D) image, the airway appeared displaced to the right of the craniomandiblar bone, with the hyoid bone similarly displaced in a manner to that of the airway. The spine also appeared displaced to the left side ofcraniomandiblar bone. Additionally, the 3D image revealed calcification of the stylohyoideum ligament and ligamentum nuchae. This present case highlights the necessity of CT examination for OSA patients. There were several ligament calcifications in the head and neck region. Cervical spine osteophytes, as a component of Forestier's or cervical spine disease, have been associated with dysphagia and dysphonia. It was reported that bilateral vocal cord paralysis was caused by osteophytes compressing the post-cricoid area of larynx.

Associations between craniofacial morphology, head posture, and cervical vertebral body fusions in men with sleep apnea.

INTRODUCTION: The aim of this study was to analyze craniofacial profiles and head posture in patients with obstructive sleep apnea (OSA) subgrouped according to cervical column morphology. METHODS: Seventy-four white men aged 27 to 65 years (mean, 49.0 years) diagnosed with OSA in sleep studies by using overnight polysomnography were included. Only patients with apnea-hypopnea index scores between 5.1 and 92.7 (mean, 36.4) were included. Lateral profile radiographs in standardized head posture were taken, and cephalometric analyses of sagittal and vertical jaw relationships were made. The patients were divided into 4 groups according to fusion in the cervical vertebrae: group I, no fusions (42 subjects); group II, fusion of cervical vertebrae 2 and 3 (15 subjects); group III, occipitalization (10 subjects); and group IV, block fusion (11 subjects). Mean differences of craniofacial dimensions between the groups were assessed by unpaired t tests. RESULTS: No significant differences were seen between groups I and III. Between groups I and II, significant differences were seen in jaw relationship (P < 0.05). Between groups I and IV, anterior face height and mandibular length deviated significantly. No significant differences were seen in head posture. CONCLUSIONS: OSA patients with block fusions in the cervical vertebrae and fusion of 2 vertebrae differed significantly in craniofacial profile from other OSA patients.

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.

Snoring in cleft patients with velopharyngoplasty.

Some patients with cleft lip/palate or isolated cleft palate seem to develop snoring as one possible symptom of an obstructive sleep apnoea syndrome after velopharyngoplasty (VPP). The aim of this paper was to determine whether there was a difference in the posterior airway space (PAS) between patients with a VPP who snored and those who did not. Four standard parameters were measured in lateral cephalograms of 20 patients with cleft lip/palate and isolated cleft palate, without diagnosis of further syndromes (e.g. Pierre Robin sequence), having undergone VPP, to examine the dimensions of the PAS. Data were set in correlation to the symptom of snoring, and compared with those of 40 patients without cleft undergoing orthodontic treatment and with 20 patients with cleft lip/palate or isolated cleft palate but not VPP. Metric parameters were significantly different after VPP in patients with clefting and snoring compared to the group of cleft patients without snoring. All patients with clefts exhibited at least in one dimension a constriction when compared to patients without clefting. In conclusion, cleft lip/palate and isolated cleft palate patients tend to have constrictions of the PAS. VPP may induce snoring and further narrowing. Recall and analysis for obstructive sleep apnoea syndrome should be mandatory.

The efficacy of drug induced sleep endoscopy using multimodality monitoring system.

INTRODUCTION: To overcome the limited readability of the conventional drug induced sleep endoscopy (DISE) system which only records flexible endoscopy images, we devised the Multimodality DISE System (MDS). MDS encompasses the monitoring systems for oxygen saturation, electrocardiogram, blood pressure, snoring intensity, and patient's position. It enabled to record comprehensive situation of patients who underwent DISE. In this study, we compared the efficacy of MDS with that of the conventional DISE system. METHODS AND MATERIALS: Ten patients underwent DISE at a tertiary hospital. DISE evaluated the airway of each patient in four positions; supine, supine with jaw thrust, right lateral decubitus, and left lateral decubitus. In addition, every examination was recorded by using both single monitoring system and MDS system. Five otolaryngologists interpreted the recorded examinations without knowledge of patient information (10 conventional DISE and 10 MDS). The visual analogue scale (VAS) scores for readability, reading times, ease of patient explanation and the ease of decision making were analyzed. RESULTS: Mean VAS scores for readability of conventional DISE and MDS were 4.41+2.56 and 8.42+2.07 (p<0.001). Mean reading times for conventional DISE and MDS were 238.80+61.26 sec and 81.00+44.99 sec, respectively (p<0.001). MDS showed superiority in patient communication (p<0.001). MDS was helpful in decision making regarding patients with obstructive sleep apnea (p<0.001). CONCLUSIONS: MDS enhanced the readability of previously recorded DISE and enabled easier doctor-patient communication. In addition, MDS is more effective in decision making regarding patients with OSA. MDS has laid the groundwork for separating the DISE prescriber from the DISE performer.

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.

Wake-Up Right-Sided Hemiparesis and Dysarthria in a Heavy Snorer.

CASE PRESENTATION: A 57-year-old man was referred to the ED for wake-up right-sided hemiparesis, hypoesthesia, dysarthria, and a National Institutes of Health Stroke Scale score of 7. Urgent CT brain scanning showed an ischemic lesion of the left temporal and insular lobes. The patient was admitted to the stroke unit, and acetylsalicylic acid 300 mg and low-molecular-weight heparin 6,000 IU were administered.