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.

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.

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.

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%.

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