Influence of gender and age on upper-airway length during development

Morphometric variation in central airways of ten different human lung

The prevailing scarcity of accurate lung models poses challenges to predicting airborne particle deposition across genders. The present work demonstrates the details of the geometrical specifications of central airways for ten healthy humans (male and female). The data were extracted from HRCT scan images with a minimum resolution of 1 mm. The images cover the trachea to all branches of the G6-G8 generations. The presented data include airway segment diameters, lengths, branching angles, and angles of inclination to gravity, in addition to their average and standard deviation. Our first goal in this study is to generate an average lung model exclusively for humans in laboratory and 1D numerical inhalation investigations. Thus, our primary emphasis in this work is to find the average suitable inclination angle in all generations of central airways for men and women by comparing the available data from previous studies. In the second part of the paper, we have also investigated the particle deposition efficiency in these ten models using the Mimetikos PreludiumTM software package. We compared the regional deposition between males and females and the available respiratory system models.

Risk and Protective Factors for Obstructive Sleep Apnea Syndrome Throughout Lifespan: From Pregnancy to Adolescence

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) in children is indeed a significant and often underdiagnosed condition. The risk factors for OSAS vary across different stages of life.

OBJECTIVES

Identifying risk factors early can help in taking preventive measures to reduce the likelihood of developing OSAS, and different life stages may require different interventions.

RESULTS

During pregnancy, maternal factors such as obesity, smoking, and genetic predispositions can increase the risk of OSAS, while breastfeeding serves as a protective factor. For children aged 2 to 12, adenotonsillar hypertrophy is the primary cause of airway narrowing, with other contributing factors including obesity, craniofacial abnormalities, and increased nasal resistance. In adolescence, obesity and craniofacial abnormalities remain the main risk factors.

CONCLUSIONS

By reviewing and understanding these risk factors, healthcare providers can offer more personalized and effective care, ultimately leading to better health outcomes for individuals at all stages of life.

Obstructive sleep apnoea-associated factors in children and adolescents diagnosed by polysomnography: A scoping review

PURPOSE

This scoping review aimed to map research on factors associated with obstructive sleep apnoea (OSA) in children and adolescents undergoing overnight polysomnography (PSG) and questionnaire-based diagnostic assessments.

METHODS

Searches were conducted in three electronic databases up to May 2023, including nine observational studies, including 3482 individuals.

RESULTS

Among the included studies, nine reported on sex, six on obesity, five on tonsillar hypertrophy, three on mouth breathing, two on allergic rhinitis, and three on smoking exposure. The sample comprised 3482 children, with subsets analyzed for sex (n = 3482), obesity (n = 2752), and tonsillar hypertrophy (n = 794). Meta-analysis demonstrated a significantly higher prevalence of OSA in males compared to females [P < 0.0001; I2 = 49 %], with a pooled relative risk (RR) of 1.15 (95 % confidence interval [CI]: 1.07-1.23). Associations were found between obesity and OSA [RR: 1.42; 95 % CI: 1.20-1.68; P = 0.02; I2 = 61 %], and tonsillar size and OSA [RR: 1.61; 95 % CI: 1.35-1.92; P = 0.06; I2 = 60 %].

CONCLUSION

Considering the study's limitations, these findings underscore the importance of considering sex, obesity, and tonsillar size when evaluating OSA in children and adolescents.

Prevalence of sleep-disordered breathing in children and adolescents with large horizontal maxillary overjet due to mandibular retrognathia: a case-control study

STUDY OBJECTIVES

The aim of the study was to examine the prevalence of sleep-disordered breathing (SDB) in children and adolescents with large overjet due to mandibular retrognathia compared to a control group.

METHODS

In this case-control study children with large overjet ≥ 6 mm due to mandibular retrognathia (study group) were compared to a group with neutral occlusion (controls). All participants underwent respiratory polygraphy (PG) and questionnaires regarding sleepiness and snoring. Differences across groups were tested by chi-square test; a general linear model adjusted for age, sex, and body mass index; and a Mann-Whitney U test. Differences in results of PG were also tested by a general linear model adjusted for age, sex, and body mass index according to severity of mandibular retrognathia.

RESULTS

Thirty-seven (19 male;18 female; median age 12.3 years) participants were included in the study group and 32 (16 male;16 female; median age 12.2 years) in the control group. No significant difference in SDB assessed by PG or questionnaires between the groups was found, even though the snore index was higher in the study group (P = .051). The snore index was higher than the parent-reported snoring. Respiration rate was significantly reduced in the study group (P = .043), and estimated sleep time efficiency was significantly reduced in males compared with females (P < .001).

CONCLUSIONS

No significant differences in SDB were found between the groups even though the snore index was higher in the study group. The snore index of the PG was higher than the parent-reported snoring. Estimated sleep time efficiency was reduced in males. The study improves the understanding of risk of SDB in nonobese children with large overjet due to mandibular retrognathia and may contribute to an interdisciplinary approach to risk assessment of SDB in children with malocclusion.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Sleep, Upper Airway and Dental Occlusion in Children With Large Overjet; URL: https://clinicaltrials.gov/study/NCT04964830?term=NCT04964830&rank=1; Identifier: NCT04964830.

CITATION

Hansen C, Sonnesen L, Bakke M, Markström A. Prevalence of sleep-disordered breathing in children and adolescents with large horizontal maxillary overjet due to mandibular retrognathia: a case-control study. J Clin Sleep Med. 2024;20(12):1871-1878.

Accidental tracheostomy decannulation: Risk factors and complications in pediatric patients using the NSQIP-P database

BACKGROUND

Accidental tracheostomy decannulation (ATD) is a life-threatening event in pediatric patients. The factors associated with ATD in children are largely unknown. Utilizing the National Surgical Quality Improvement Pediatric (NSQIP-P) dataset, we sought to identify the incidence of ATD and associated factors.

METHODS

Patients who underwent surgery at continuously enrolled American College of Surgeons NSQIP-P hospitals from January 1, 2012, to December 31, 2021, were included. Those who underwent a tracheostomy (CPT 31600 or 31601) as a primary or concurrent procedure were analyzed. ATD was defined by the NSQIP-P REINTUB variable. Multivariable logistic regression analysis and propensity score matching were performed to identify independent associations between demographic variables, relevant comorbidities, intraoperative factors, and ATD. Multivariable regression analyses were performed to identify any association between ATD and unplanned reoperation, pneumonia, extended length of stay, and death in 30 days in both pre-matched and matched cohorts.

RESULTS

A total of 5229 patients undergoing tracheostomy were included in the final analysis for the pre-matched cohort. ATD occurred in 93 (1.8 %) patients, with 42 % (n = 39) of these cases occurring within the first two postoperative days. In the matched cohort, female gender (P = 0.002) and structural pulmonary/airway abnormality (P = 0.016) were independently associated with ATD. Additionally, ATD was associated with unplanned reoperation (P < 0.001) and pneumonia (P = 0.024). The pre-matched cohort showed consistent results with the matched cohort.

DISCUSSION

Accidental decannulation is a serious complication following pediatric tracheostomy. By identifying patients at higher risk for ATD and the timing of its occurrence, providers can employ measures targeting these patients during their highest risk period. The sequelae associated with ATD further emphasize the importance of preventing this complication.

The 100 ml-Timed Water Swallow Test: Pilot Data from Children with No Dysphagia

Dysphagia screening tests are useful in identifying possible dysphagia for further evaluation and in supporting feeding recommendations. This study aimed to investigate swallowing parameters in children, while widening the pool of data available, using the '100 ml-Timed Water Swallow Test' (100 ml-TWST). Sixty Singaporean children aged 4 to 18 years old completed the 100 ml-TWST via a cup and a straw. Task completion, presence of cough, choke or throat clear, post-swallow voice quality, total time taken and number of swallows were observed. Subsequently, analysis of time per swallow (T/S), volume per swallow (V/S) and volume per time or swallowing capacity (V/T) were performed. Higher tendencies for coughing and task incompletion were observed in younger participants. A shorter time taken, fewer number of swallows, greater V/S and greater swallowing capacity were observed for adolescent or male participants, or via the mode of cup drinking. These could be due to oropharyngeal structural changes and swallow maturation with age, an increased capacity of oropharyngeal structures for swallowing in adolescent males, and more controlled or paced drinking from a straw. A plateau in time taken, number of swallows and swallowing capacity in adolescence were also observed, possibly indicating an emerging maturation of swallow functions during that period. Interestingly, speed of bolus movement was largely unaffected by age, gender and mode of drinking. Pilot data for children with no dysphagia have been established, while gaining insight into the swallowing parameters and maturation process in the paediatric population.

Risk of sleep-disordered breathing in orthodontic patients: comparison between children and adolescents

OBJECTIVE

The aim of this study was to assess the risk of sleep-disordered breathing (SDB) in orthodontic patients and to evaluate the influence of sex, age, and orthodontic treatment in a cohort of subjects using the Pediatric Sleep Questionnaire (PSQ) screening tool.

METHODS

Parents of 245 patients aged 5-18 years (11.4 ± 3.3 years) were invited to participate in the study by answering the PSQ, which has 22 questions about snoring, sleepiness, and behavior. The frequency of high and low risk was calculated for the full sample. Multiple logistic regression was used to assess the association among sex, age, orthodontic treatment, rapid maxillary expansion (RME), and body mass index (BMI) with SDB. A significance level of 5% (P < .05) was adopted in all tests.

RESULTS

A high risk of SDB was found in 34.3% of the sample. No sex and BMI difference was found for the risk of SDB. The high risk of SDB was significantly associated with younger ages (OR = 1.889, P = .047), pre-orthodontic treatment phase (OR = 3.754, P = .02), and RME (OR = 4.157, P = .001).

LIMITATIONS

Lack of ear, nose and throat-related medical history.

CONCLUSION

Children showed a 1.8 higher probability of having a high risk of SDB compared with adolescents. Patients before orthodontic treatment and patients submitted to RME showed a high risk of SDB.

Adults with Treacher Collins Syndrome Share Comparable 3D Upper Airway Dimensions with Nonsyndromic Individuals

Purpose

Sleep apnea symptoms, such as snoring and daytime somnolence, are commonly observed in individuals with Treacher Collins Syndrome (TCS) and may be related to airway obstruction due to micro- and retro-gnathia. This study aims to three-dimensionally evaluate the upper airway using cone-beam computed tomography (CBCT) exams of adolescents (TCS-ADOL) and adults (TCS-ADUL) with TCS compared to a nonsyndromic group (CON).

Materials and Methods

Twenty-six CBCT exams were divided into three groups: TCS-ADOL (n = 7) (13.14 ± 1.67 years): CBCT exams of TCS adolescents; TCS-ADUL (n = 10) (21.80 ± 4.39 years): CBCT exams of TCS adults; and CON (n = 9) (25.33 ± 8.57 years): CBCT exams of adult nonsyndromic individuals with Class II skeletal pattern. The variables analyzed were (1) total upper airway volume; (2) nasal cavity volume; (3) total pharyngeal volume; (4) nasopharyngeal volume; (5) oropharyngeal volume; (6) pharyngeal minimal cross-sectional area; (7) pharyngeal length; and (8) pharyngeal depth. Scans were analyzed by two examiners, and intra- and inter-rater agreement was calculated. A p-value of ≤0.05 was considered significant.

Results

Although not statistically significant, the TCS-ADUL group showed decreased airway volume and minimal cross-sectional areas compared to the CON group. There were also significant differences between TCS-ADOL and TCS-ADUL, with significantly lower airway volumes in the TCS-ADOL group. Strong positive correlations were found between certain airway measurements in the TCS-ADOL group, which were not observed in adults.

Conclusions

The upper airways of adults with TCS are dimensionally similar to those of nonsyndromic individuals, despite absolute value reductions found in the syndromic group. The reduced airway in the adolescent population suggests significant potential for growth, mainly in pharyngeal dimensions.

Effect of obesity on sleep apnea pathogenesis differs in women versus men: multiple mediation analyses in the retrospective SNOOzzzE cohort

There are multiple mechanisms underlying obstructive sleep apnea (OSA) development. However, how classic OSA risk factors such as body mass index (BMI) and sex portend to OSA development has not been fully described. Thus we sought to evaluate how obesity leads to OSA and assess how these mechanisms differ between men and women. The San Diego Multi-Outcome OSA Endophenotype (SNOOzzzE) cohort includes 3,319 consecutive adults who underwent a clinical in-laboratory polysomnography at the University of California, San Diego, sleep clinic between January 2017 and December 2019. Using routine polysomnography signals, we determined OSA endotypes. We then performed mediation analyses stratified by sex to determine how BMI influenced the apnea-hypopnea index (AHI) using OSA pathophysiological traits as mediators, adjusting for age, race, and ethnicity. We included 2,146 patients of whom 919 (43%) were women and 1,227 (57%) were obese [body mass index (BMI) > 30 kg/m2]. BMI was significantly associated with AHI in both women and men. In men, the adjusted effect of BMI on AHI was partially mediated by a reduction in upper airway stiffness (βstandardized = 0.124), a reduction in circulatory delay (βstandardized = 0.063), and an increase in arousal threshold (βstandardized = 0.029; Pboot-strapped,all < 0.05). In women, the adjusted effect of BMI on AHI was partially mediated by a reduction in upper airway stiffness (βstandardized = 0.05) and circulatory delay (βstandardized = 0.037; Pboot-strapped,all < 0.05). BMI-related OSA pathogenesis differs by sex. An increase in upper airway collapsibility is consistent with prior studies. A reduction in circulatory delay may lead to shorter and thus more events per hour (higher AHI), while the relationship between arousal threshold and OSA is likely complex.NEW & NOTEWORTHY Our data provide important insights into obesity-related obstructive sleep apnea (OSA) pathogenesis, thereby validating, and extending, prior research findings. This is the largest sample size study to examine the relationships between obesity and gender on OSA pathogenesis. The influence of obesity on sleep apnea severity is mediated by different mechanistic traits (endotypes).

Relationship of ankyloglossia and obstructive sleep apnea: systematic review and meta-analysis

PURPOSE

Recent studies have highlighted the potential role of a short lingual frenulum as a risk factor for pediatric obstructive sleep apnea syndrome. A shortened frenulum may contribute to abnormal orofacial development, leading to increased upper airway resistance and susceptibility to upper airway collapsibility during sleep. Recognizing early indicators, such as a short lingual frenulum, is crucial for prompt intervention. This systematic review aims to evaluate the association between a short lingual frenulum and the risk of obstructive sleep apnea syndrome in children.

METHODS

This systematic review adheres to PRISMA criteria for a quantitative analysis. A comprehensive search was conducted on five databases until January 2024 to identify relevant studies. The selected articles underwent rigorous analysis, considering study design, sample characteristics, lingual frenulum characterization, sleep assessment methods, and key findings.

RESULTS

A total of 239 references were initially identified. Finally, six studies were included in the qualitative synthesis, with four studies eligible for the quantitative synthesis. The Newcastle-Ottawa scale was employed to assess study quality. Meta-analysis, supported by a moderate evidence profile according to the GRADE scale, revealed statistically significant differences, with odds ratios of 3.051 (confidence interval: 1.939 to 4.801) for a short frenulum and 12.304 (confidence interval: 6.141 to 24.653) for a high-arched palate.

CONCLUSION

This systematic review and meta-analysis provide evidence supporting the association between ankyloglossia and obstructive sleep apnea in children. Nevertheless, it is crucial to consider additional factors such as tongue mobility and the presence of a high-arched palate in further evaluations.

Association among craniofacial morphology, ethnicity, and risk of pediatric sleep-related breathing disorders: A multicenter study

INTRODUCTION

Craniofacial morphology and ethnicity may be risk factors for sleep-related breathing disorder (SRBD) in children but have not yet been assessed in an international multicenter study. The objectives of this study were to assess the association among craniofacial features, self-reported ethnicity, and risk of SRBD in children undergoing orthodontic treatment.

METHODS

Children aged 5-18 years who presented for orthodontic evaluation were enrolled in the United States, South Africa, South Korea, Saudi Arabia, and Japan. The risk of SRBD was defined as answering ≥0.33 positive responses to the Pediatric Sleep Questionnaire. Craniofacial features included measurements in sagittal and vertical dimensions to evaluate the cranial base, maxillomandibular and dental relationships, and nasopharyngeal airway dimensions. Logistic regression was performed to assess the association among craniofacial features, ethnicity, age, body mass index, and risk of SRBD.

RESULTS

Data were obtained from 602 patients from 5 sites. A total of 76 patients (12.6%) had a risk of SRBD. The mean age was 12.5 years. Male gender (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.0-3.4; P = 0.041), Middle Eastern ethnicity (OR, 10.2; 95% CI, 4.1-25.4; P = 0.001), body mass index (OR, 1.1; 95% CI, 1.04-1.10; P = 0.001), gonial angle (OR, 0.91; 95% CI, 0.85-0.98; P = 0.011), and inferiorly positioned hyoid (OR, 1.1; 95% CI, 1.0-1.2; P = 0.002) were significantly associated with the risk of SRBD.

CONCLUSIONS

In an ambidirectional cohort study across 5 sites, male gender, Middle Eastern ethnicity, body mass index, gonial angle, and inferiorly positioned hyoid were associated with the risk of SRBD in children undergoing orthodontic treatment.

Identification of obstructive sleep apnea in children with obesity: A cluster analysis approach

BACKGROUND

Obstructive sleep apnea (OSA) is a heterogeneous disorder with a prevalence of 25%-60% in children with obesity. There is a lack of diagnostic tools to identify those at high risk for OSA.

METHOD

Children with obesity, aged 8-19 years old, were enrolled into an ongoing multicenter, prospective cohort study related to OSA. We performed k-means cluster analysis to identify clinical variables which could help identify obesity related OSA.

RESULTS

In this study, 118 participants were included in the analysis; 40.7% were diagnosed with OSA, 46.6% were female and the mean (SD) body mass index (BMI) and age were 39.7 (9.6) Kg/m², and 14.4 (2.6) years, respectively. The mean (SD) obstructive apnea-hypopnea index (OAHI) was 11.0 (21.1) events/h. We identified two distinct clusters based on three clustering variables (age, BMI z-score, and neck-height ratio [NHR]). The prevalence of OSA in clusters 1 and 2, were 22.4% and 58.3% (p = 0.001), respectively. Children in cluster 2, in comparison to cluster 1, had higher BMI z-score (4.7 (1.1) versus 3.2 (0.7), p < 0.001), higher NHR (0.3 (0.02) versus 0.2 (0.01), p < 0.001) and were older (15.0 (2.2) versus 13.7 (2.9) years, p = 0.09), respectively. However, there were no significant differences in sex and OSA symptoms between the clusters. The results from hierarchical clustering were similar to k-means analysis suggesting that the resulting OSA clusters were stable to different analysis approaches.

INTERPRETATION

BMI, NHR, and age are easily obtained in a clinical setting and can be utilized to identify children at high risk for OSA.

A Systematic Review and Meta-Analysis of Randomized Controlled Trials on Supine vs. Nonsupine Endotracheal Intubation

Background

This systematic review and meta-analysis of randomized controlled trials (RCTs) was performed to compare the safety and efficacy of supine vs. nonsupine positions during intubation.

Methods

Based on the literature from inception to October 2020, 13 studies with nonemergent intubation in supine and nonsupine positions were chosen using PRISMA and MOOSE protocols. Pooled estimates were calculated using random-effects models with 95% confidence interval (CI). The primary outcome was a successful intubation, attempt, and duration of intubation. The secondary outcome was adverse events (trauma and hypoxia). Bias was evaluated qualitatively, by visual analysis, and quantitatively through the Egger test.

Results

The final analysis included 13 clinical trials with 1,916 patients. The pooled success rates in the supine vs. lateral positions were 99.21% and 98.82%. The supine vs. semierect positions were 99.21% and 98.82%. The 1st attempt success rate in the supine vs. lateral position was 85.35% and 88.56% compared to 91.38% and 90.76% for the supine vs. semierect position. The rate of total adverse events in the supine position was 3.73% vs. 6.74% in the lateral position, and the rate of total adverse events in the supine position was 0.44% vs. 0.93% in semierect position. Low to substantial heterogeneity was noted in our analysis. Discussion. There is no significant difference between total successful intubations and success from 1st intubation attempt between supine and nonsupine positions. However, there are slightly higher rates of adverse events in nonsupine position. Addition of more recent studies on supine vs. nonsupine intubations would improve this study. Given these findings, it is important to develop more studies regarding different intubation positions and techniques with the aim of improving efficacy and decreasing adverse outcomes. Other. This review is not registered in a public database. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Anatomical determinants of upper airway collapsibility in obstructive sleep apnea: A systematic review and meta-analysis

Upper airway (UA) collapsibility is one of the key factors that determine the severity of obstructive sleep apnea (OSA). Interventions for OSA are aimed at reducing UA collapsibility, but selecting the optimal alternative intervention for patients who fail CPAP is challenging because currently no validated method predicts how anatomical changes affect UA collapsibility. The gold standard objective measure of UA collapsibility is the pharyngeal critical pressure (Pcrit). A systematic literature review and meta-analysis were performed to identify the anatomical factors with the strongest correlation with Pcrit. A search using the PRISMA methodology was performed on PubMed for English language scientific papers that correlated Pcrit to anatomic variables and OSA severity as measured by the apnea-hypopnea index (AHI). A total of 29 papers that matched eligibility criteria were included in the quantitative synthesis. The meta-analysis suggested that AHI has only a moderate correlation with Pcrit (estimated Pearson correlation coefficient r = 0.46). The meta-analysis identified four key anatomical variables associated with UA collapsibility, namely hyoid position (r = 0.53), tongue volume (r = 0.51), pharyngeal length (r = 0.50), and waist circumference (r = 0.49). In the future, biomechanical models that quantify the relative importance of these anatomical factors in determining UA collapsibility may help identify the optimal intervention for each patient. Many anatomical and structural factors such as airspace cross-sectional areas, epiglottic collapse, and palatal prolapse have inadequate data and require further research.

Early-Life Antibiotic Exposure and Childhood Asthma Trajectories: A National Population-Based Birth Cohort

INTRODUCTION

Early-life antibiotic exposure is common and impacts the development of the child's microbiome and immune system. Information on the impacts of early-life antibiotics exposure on childhood asthma is lacking.

METHODS

This study examined associations between early-life (0-24 months) antibiotics exposure with childhood (6-15 years) asthma trajectories through the Australian Longitudinal Study of Australian Children (LSAC) and their linked data from the Pharmaceutical Benefits Scheme. Asthma phenotypes were derived by group-based trajectory modeling.

RESULTS

Of 5107 LSAC participants, 4318 were included in the final analyses (84.6% retention). Four asthma phenotypes were identified: Always-low-risk (79.0%), early-resolving asthma (7.1%), early-persistent asthma (7.9%), and late-onset asthma (6.0%). Any early-life antibiotic exposure increased risk 2.3-fold (95% CI: 1.47-3.67; p < 0.001) for early-persistent asthma among all children. In subgroup analyses, early-persistent asthma risk increased by 2.7-fold with any second-generation cephalosporin exposure, and by 2-fold with any β-lactam other than cephalosporin or macrolide exposure.

CONCLUSION

We concluded that early-life antibiotic exposure is associated with an increased risk of early-persistent childhood asthma. This reinforces scrutiny of early-life antibiotic use, particularly for common viral infections where no antibiotics are required.

Nasopharyngeal luminal change on cervical radiography in brachycephalic dogs without respiratory signs

This study aimed to prospectively assess nasopharyngeal luminal changes in brachycephalic dogs without respiratory signs using cervical radiography. Forty brachycephalic dogs without cardiopulmonary diseases were included. The nasopharyngeal luminal change was calculated on inspiratory and expiratory cervical lateral radiographs. The median nasopharyngeal luminal change was 21.6% (range, 0.3-85.6%). In five dogs, a nasopharyngeal luminal change of >50% was identified. There was no correlation between nasopharyngeal luminal changes and age, sex, body weight, or body condition score. These results suggest that brachycephalic dogs without cardiopulmonary diseases may be over-diagnosed with partial pharyngeal collapse. Further studies comparing nasopharyngeal luminal changes between clinically healthy brachycephalic dogs and dogs with respiratory signs are warranted.

Spatial aerosol deposition correlated to anatomic feature development in 6-year-old upper airway computational models

The upper airways of children undergo developmental changes around age 6, yielding differences between adult and pediatric anatomies. These differences include the cricoid ring area shape, the location of narrowest constriction, and the angle of the epiglottis, all of which are expected to alter local fluid dynamic profiles and subsequent upper airway deposition and downstream aerosol delivery of inhaled therapeutics. In this work, we quantify "pediatric"-like and "adult"-like geometric and fluid dynamic features of two computed tomography (CT)-scan derived models of 6-year-old upper airways in healthy subjects and compare to an idealized model. The two CT-scan models had a mixture of "adult"- and "pediatric"-like anatomic features, with Subject B exhibiting more "pediatric"-like features than Subject A, while the idealized model exhibited entirely "adult"-like features. By computational fluid-particle dynamics, these differences in anatomical features yielded distinct local fluid profiles with altered aerosol deposition between models. Notably, the idealized model better predicted deposition characteristics of Subject A, the more "adult"-like model, including the relationship between the impaction parameter, dp2Q and the fraction of deposition across a range of flow rates and particle diameters, as well as deposition of an approximate pharmaceutical particle size distribution model. Our results with even this limited dataset suggest that there are key personalized metrics that are influenced by anatomical development, which should be considered when developing pediatric inhalable therapeutics. Quantifying anatomical development and correlating to aerosol deposition has the potential for high-throughput developmental characterization and informing desired aerosol characteristics for pediatric applications.

Hyoid bone position as an indicator of severe obstructive sleep apnea

BACKGROUND

The objective of this study was to evaluate the relationship between hyoid bone position and severity of obstructive sleep apnea (OSA), and to investigate its value as a complementary diagnostic method.

METHODS

A total of 133 patients who were diagnosed as OSA with an apnea-hypopnea index ≥ 5 were included. Clinical examination, level I polysomnography (PSG) and lateral cephalographic analysis were done. Comprehensive PSG characteristics were compared according to hyoid bone position and the predictive power of the distance between the mandible and hyoid was assessed.

RESULTS

The distance between the hyoid bone and mandibular plane was significantly longer in the severe OSA group (p = 0.013). The distance from hyoid bone to third vertebrae (C3) and hyoid bone to mentum were also longer in the severe OSA group but the difference did not reach statistical significance. The distance between hyoid bone and mandibular plane was effective in predicting severe OSA, with a cut-off value of 19.45 mm (AUC = 0.623, p = 0.040). When grouped according to a distance cut-off value of 19.45 mm, those with a longer distance between the hyoid bone and mandibular plane showed more respiratory disturbance, lower oxygen saturation levels, less deep slow wave sleep, and more fragmented sleep with arousals.

CONCLUSIONS

The distance between the hyoid bone and mandibular plane derived from cephalometric analysis can be a valuable diagnostic parameter that can be easily applied in differentiating severe OSA patients.

Assessment of Central Sleep Apnea Events in Children with Sleep-Disordered Breathing

Purpose

To determine the prevalence of central apnea (CA) events and central sleep apnea (CSA) in children with sleep-disordered breathing (SDB) and to assess the effect of tonsillectomy and adenoidectomy (TA) on CSA in children with obstructive sleep apnea (OSA). Material and Methods. The medical charts of children with SDB were reviewed to obtain information on past medical history, polysomnography (PSG) findings, and surgical management. Counts and indexes of obstructive apnea, obstructive hypopnea, and central apnea were evaluated before and after TA. The prevalence of CSA and the effect of age, gender, obesity, and comorbid conditions on CSA were assessed in children with SDB as well as in children with PSG proven OSA.

Results

Seven hundred twelve children with SDB (age range: 1 to 18 yrs, mean: 5.8 ± 3.4) were identified. CA events occurred in 640 of 712 (89.5%) patients. Of the 712 patients, 315 (44.2%) met the criteria for the diagnosis of CSA. CSA was more prevalent in toddlers and preschoolers (p < 0.001). Obese children had a higher prevalence of CSA compared to nonobese children (p < 0.001). The prevalence of CSA in patients with OSA was 45.4%. The number of CA events, CAI, and OAHI after TA was less than that of before TA (p < 0.001). Residual CSA after TA occurred in 20 children (26%).

Conclusion

Central apnea events and central sleep apnea occur in children who present to a pediatric otolaryngology clinic for evaluation of sleep disordered breathing. Central sleep apnea and obstructive sleep apnea both improve after tonsillectomy and adenoidectomy.

Anatomic development of the upper airway during the first five years of life: A three-dimensional imaging study

PURPOSE

Normative data on the growth and development of the upper airway across the sexes is needed for the diagnosis and treatment of congenital and acquired respiratory anomalies and to gain insight on developmental changes in speech acoustics and disorders with craniofacial anomalies.

METHODS

The growth of the upper airway in children ages birth to 5 years, as compared to adults, was quantified using an imaging database with computed tomography studies from typically developing individuals. Methodological criteria for scan inclusion and airway measurements included: head position, histogram-based airway segmentation, anatomic landmark placement, and development of a semi-automatic centerline for data extraction. A comprehensive set of 2D and 3D supra- and sub-glottal measurements from the choanae to tracheal opening were obtained including: naso-oro-laryngo-pharynx subregion volume and length, each subregion's superior and inferior cross-sectional-area, and antero-posterior and transverse/width distances.

RESULTS

Growth of the upper airway during the first 5 years of life was more pronounced in the vertical and transverse/lateral dimensions than in the antero-posterior dimension. By age 5 years, females have larger pharyngeal measurement than males. Prepubertal sex-differences were identified in the subglottal region.

CONCLUSIONS

Our findings demonstrate the importance of studying the growth of the upper airway in 3D. As the lumen length increases, its shape changes, becoming increasingly elliptical during the first 5 years of life. This study also emphasizes the importance of methodological considerations for both image acquisition and data extraction, as well as the use of consistent anatomic structures in defining pharyngeal regions.

Three-dimensional changes in the upper airway and craniomaxillofacial morphology of patients with Angle Class III malocclusion treated with a Frankel III appliance

BACKGROUND

Angle Class III malocclusion, characterized by a concave profile, can cause serious harm to children's physical and mental health. The Frankel III appliance is an effective treatment for Angle Class III malocclusion in mixed denition. We explored three-dimensional changes in the upper airway and craniomaxillofacial morphology, after one year of Frankel III appliance treatment, in children with Angle Class III malocclusion.

METHODS

We included 20 children (9 males), aged 8-10 years, with Angle Class III malocclusion from the Orthodontics Department of our hospital. Each child was treated with a Frankel III appliance for one year. Cone beam computed tomography was performed before and after treatment to evaluate three-dimensional changes in the upper airway and craniomaxillofacial morphology.

RESULTS

After one year of treatment, in the upper airway, we observed significant increases in the nasopharynx volume and height (P < 0.05); the velopharyngeal volume, height, and average cross-sectional area (P < 0.05); the glossopharynx volume and minimum cross-sectional area (P < 0.05); and the laryngopharynx height (P < 0.05). Accordingly, the total upper airway volume, height, and average cross sectional area increased significantly (P < 0.05). An examination of craniomaxillofacial morphology showed significant increases in some bone tissues (P < 0.05) and dental measurements, and a significant reduction in the inclination of the mandibular central incisor (P < 0.05).

CONCLUSION

Children with Angle class III malocclusion treated with a Frankel III appliance showed no upper airway narrowing, even after repositioning the mandible posteriorly. Moreover, treatment promoted forward maxilla development and increased its width, in both the dental arch and alveolar bone, which provided a more harmonious craniofacial morphology.

Risk Factors in Acute Stroke Patients With and Without Sleep Apnea

BACKGROUND

More than 50% of stroke patients have sleep-disordered breathing (SDB), mostly in the form of obstructive sleep apnea (OSA). SDB represents both a risk factor and a consequence of stroke. The presence of SDB has been linked with the poorer long-term outcome and increased long-term stroke mortality. About 20 to 40% of stroke patients have sleep-wake disorders (SWD), mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs).

OBJECTIVE

The aim of this study was to analyze the frequency of risk factors in patients with acute stroke and sleep apnea.

METHODS

The study included patients without cognitive impairment or with mild cognitive impairment. The diagnosis of apnea syndrome was made on the basis of the Snoring and Apnea Syndrome Questionnaire, the Epworth Sleep Scale, the Berlin Questionnaire, the Stanford Sleepiness Scale, and the General Sleep Questionnaire. The severity of stroke was assessed by the National Institutes of Health Stroke Scale and the Rankin Disability Scale. Patients with a Glasgow score <8 on the day of neuropsychiatric examination were excluded from the study, as well as patients with epileptic seizures at the onset of stroke, with aphasia, with Mini - mental test <23, with verified previous dementia / cognitive impairment.

RESULTS

There is no statistically significant difference in the age of men and women, both with apnea and without apnea. In patients with apnea, heart disease was in the first place 91.8%, followed by hypertension 86.4%, Body mass index 79.1%, hyperlipidemia 50%, smoking 38.2 % and diabetes mellitus 20.9%. Hypertension was the most common risk factor in patients without apnea 83.6%, followed by heart disease 81.0%, Body mass index 60.9%, hyperlipidemia 48.21%, smoking 28.2 % and diabetes mellitus 20%.

CONCLUSION

Heart diseases, hypertension and body mass index are significantly more frequent in patients with than in patients without sleep apnea.

Much Ado about Sleep: Current Concepts on Mechanisms and Predisposition to Pediatric Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a form of sleep-disordered breathing characterized by upper airway collapse during sleep resulting in recurring arousals and desaturations. However, many aspects of this syndrome in children remain unclear. Understanding underlying pathogenic mechanisms of OSA is critical for the development of therapeutic strategies. In this article, we review current concepts surrounding the mechanism, pathogenesis, and predisposing factors of pediatric OSA. Specifically, we discuss the biomechanical properties of the upper airway that contribute to its primary role in OSA pathogenesis and examine the anatomical and neuromuscular factors that predispose to upper airway narrowing and collapsibility.

Risk Factors of Influenza-Associated Respiratory Illnesses Reported to a Sentinel Hospital of Lahore, Pakistan: 2015-2016

Epidemiological data about determinants of influenza A virus (IAV) in the Pakistani population is scarce. We aimed to conduct a prospective hospital-based active surveillance study from October 2015 to May 2016 to identify potential risk factors associated with IAV infection among patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI). Surveillance was conducted in Lahore General Hospital, selected as a sentinel site in Lahore District, Pakistan. Nasal/throat samples were collected along with epidemiological and clinical data from enrolled patients. Real-time reverse-transcription polymerase chain reaction (rRT-PCR) was performed to identify IAV and its subtypes (H1N1pdm09, H3N2). Data were analyzed to determine risk factors and risk markers associated with IAV infections. A total of 311 suspected ILI and SARI cases were enrolled in the study, and among these 50 were IAV-positive. Of these 50 confirmed cases of IAV, 14 were subtyped as H1N1pdm09 and 15 were H3N2; the remaining 21 were untyped. A final multivariable model identified four independent risk factors/markers for IAV infection: exposure history to ILI patients within last 7 days and gender being male were identified as risk factors of IAV infection, while use of antibiotics prior to hospital consultation and presence of fever were identified as risk markers. We concluded that adopting nonpharmaceutical interventions like hand hygiene, masks, social distancing, and where possible, avoiding identified risk factors could decrease the risk of IAV infection and may prevent imminent outbreaks of IAV in the community.

Magnetic Resonance Imaging Evaluation of Distance Between Adenoid Tissue and Internal Carotid Artery in Children With Adenoid Hypertrophy

OBJECTIVES

In the present study, we investigated the distance between adenoid tissue and internal carotid artery (ICA) in children with adenoid hypertrophy by magnetic resonance imaging.

METHODS

Cranial magnetic resonance images of 200 children with adenoid hypertrophy between the ages of 5 and 15 were included. In group 1 (5-9 years of age), there were 100 children, and in group 2 (10-15 years of age), there were 100 children. In both groups, adenoid thickness, adenoid/nasopharynx) ratio, and superior, middle, and inferior adenoid-ICA distances were measured.

RESULTS

Adenoid thickness is significantly higher in the 10-to-15 years age group than in the 5-to-9 years age group (P < 0.05). Adenoid-ICA distance got lower from the superior to the inferior part in both age groups and in both sexes: inferior < middle < superior adenoid-ICA distance. In the 5-to-9 years age group, the minimum adenoid-ICA distances were 2.40 mmsuperior, 0.90 mmmiddle, and 1.20 mminferior. In 10-to-15 years age group, the minimum adenoid-ICA distances were 2.50 mmsuperior, 1.00 mmmiddle, and 0.90 mminferior. As adenoid thickness increased, the inferior adenoid-ICA distance decreased bilaterally (P < 0.05). As the age got older, adenoid thickness increased, and the left superior and middle adenoid ICA distances and bilateral inferior adenoid-ICA distances decreased (P < 0.05).

CONCLUSION

The distance between adenoid and ICA decreased from superior to inferior. In 10- to 15-year-old children, the distance between adenoid and ICA was determined as lower than in the 5- to 9-year-old children. The minimum distances between adenoid and ICA were found to be between 0.9 and 2.5 mm in the 10-to-15 age group and between 0.9 and 2.4 mm in the 5-to-9 age group. It should be remembered that ICA can be very close to the adenoid tissue. In addition, because thermal injury can cause deeper damage to the tissue, bipolar cautery should be used with caution in this area and unipolar cautery should not be used.

Gender Issues in Obstructive Sleep Apnea

Obstructive sleep apnea has historically been considered a male disease. Although most studies have shown male predominance, obstructive sleep apnea is highly prevalent in women, increasing with age and varying with physiologic status among other factors. Obstructive sleep apnea is associated with significant symptoms and health consequences in women yet remains underdiagnosed in women in part due to differences in presenting symptoms, differences in polysomnographic findings, and/or sociocultural factors. This review will discuss the epidemiology, pathophysiology, clinical presentation, diagnostic findings, and treatment of obstructive sleep apnea, focusing on sex and gender differences.

Acute Stroke Patients with Sleep Apnea Acording to the Disability and Incidence of Relapse

BACKGROUND

Sleep is a complex process involving the interactions of several brain regions, which play a key role in regulating the sleep process, particularly the brainstem, thalamus, and anterior basal brain regions. The process of sleep is accompanied by a change in body functions, as well as a change in cerebral electrical activity, which is under the control of the autonomic nervous system.

OBJECTIVE

The aim of the study was to analyze the frequency of stroke recurrence and disability of patients with stroke and apnea.

METHODS

It was analyzed 110 acute stroke patients with sleep apnea. All patients were evaluated with: Glasgow scale, The American National Institutes of Health Scale Assessment, Mini Mental Test, The Sleep and snoring Questionnaire Test, The Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale, and The general sleep questionnaire.

RESULTS

The largest number of patients with apnea on admission had a degree of disability of 4, and on discharge of 1. There was a statistically significant difference between the mean values of incapacity for admission and discharge. The student's t - test did not determine a statistically significant difference in disability according to the Rankin scale between patients with and without apnea at admission (t = 0.059, p = 0.95) and discharge (t = 0.71, p = 0.48). According to the NIHS scale, patients of both sexes with apnea had a neurological deficit of 7.55 ± 5.22 on admission and 7.1 ± 4.3 without apnea. Statistically significant difference was not found on the neurological deficit of both sexes, with and without apnea, at admission and discharge. With apnea, there were 13 relapses of stroke during one year, and without apnea in only 3 patients.

CONCLUSION

Patients with acute stroke have a significantly higher correlation rate according to sleep apnea. There is no significant correlation in the degree of disability between patients with and without apnea.

Evaluation of sex-based differences in airway size and the physiological implications

Recent evidence suggests healthy females have significantly smaller central conducting airways than males when matched for either height or lung volume during analysis. This anatomical sex-based difference could impact the integrative response to exercise. Our review critically evaluates the literature on direct and indirect techniques to measure central conducting airway size and their limitations. We present multiple sources highlighting the difference between male and female central conducting airway size in both pediatric and adult populations. Following the discussion of measurement techniques and results, we discuss the functional implications of these differences in central conducting airway size, including work of breathing, oxygen cost of breathing, and how these impacts will continue into elderly populations. We then discuss a range of topics for the future direction of airway differences and the benefits they could provide to both healthy and diseased populations. Specially, these sex-differences in central conducting airway size could result in different aerosol deposition or how lung disease manifests. Finally, we detail emerging techniques that uniquely allow for high-resolution imaging to be paired with detailed physiological measures.

Effect of tube length on the buckling pressure of collapsible tubes

BACKGROUND

The higher incidence of obstructive sleep apnea (OSA) in men than in women has been attributed to the upper airway being longer in men. The Starling resistor is the paradigm biomechanical model of upper airway collapse in OSA where a collapsible tube (representing the pharynx) is located between two rigid tubes (representing the nasal cavity and trachea). While the Starling resistor has been extensively studied due to its relevance to many physiological phenomena, the effect of tube length on tube collapsibility has not been quantified yet.

METHODS

Finite element analysis of a 3-dimensional collapsible tube subjected to a transmural pressure was performed in ANSYS Workbench. The numerical methods were validated with in vitro experiments in a silicone tube whose modulus of elasticity (361 ± 28 kPa) and dimensions (length = 100 mm, diameter = 22.2 mm, and wall thickness = 1.59 mm) were selected so that tube compliance was similar to pharyngeal compliance in humans during sleep. The buckling pressure (transmural pressure at which the tube collapses) was quantified in tubes of three different diameters (10 mm, 16 mm, and 22.2 mm) and ten length-to-diameter ratios (L/D = 4 to 13), while keeping the wall-thickness-to-radius ratio constant at 0.143.

RESULTS

The absolute value of the buckling pressure decreased from 4.7 to 3.3 cmH₂O (461-324 Pa) when L/D increased from 4 to 13. The buckling pressure was nearly independent from tube length for L/D >10.

CONCLUSIONS

Our finding that longer tubes are more collapsible than shorter tubes is consistent with the higher incidence of obstructive sleep apnea in males than females.

Pharyngeal airway space changes and stability following an extended LeFort-I osteotomy advancement in cleft lip and palate and non-cleft lip and palate patients: A long term comparison study

PURPOSE

The aim of this study was to evaluate effects of extended maxillary advancement osteotomy on pharyngeal airway space (PAS) in mid-facial deficient cleft lip and palate (CLP) patients and mid-facial deficient non-CLP patients.

METHODS

Pharyngeal airway space (PAS) of 10 CLP and 10 non-CLP patients with the mean age of 19 years 10 months was measured on digitized lateral cephalograms taken shortly before maxillary advancement operation with Quadrangular Le Fort I osteotomy (QLF-I) (T0), early post-operative, (T1) and long term post-operative (T2). Two way repeated analysis of variance, independent samples t-test and correlations tests were used for statistical analysis of airway and skeletal changes.

RESULTS

Total PAS depth and area was significantly increased after the advancement and was stable in long term post-operative period for CLP and non-CLP patients. Nasopharyngeal and velopharyngeal airway space depth and area was statistically increased at T1 and T2 for both groups. Oropharyngeal airway depth and area showed no significant statistical difference at any of the time points. The effect of QLF-I osteotomy on (PAS) was similar in both CLP and non-CLP patients.

CONCLUSIONS

Nasopharyngeal, velopharyngeal, and total pharyngeal airway space depth and area increased after maxillary advancement with the QLF-I osteotomy; this increase was stable in long term follow up. Maxillary advancement with the QLF-I technique had no significant effect on oropharyngeal airway space depth and area in both CLP and non-cleft patients.

Perinatal antecedents of sleep disturbances in schoolchildren

STUDY OBJECTIVES

Prematurity has been associated with an increased risk for sleep apnea. However, sleep disturbances in children born preterm have not been extensively investigated. Considering that determinants of sleep may originate early in life, the potential impact of prematurity on sleep disturbances later in life could be important. To establish the role of prematurity on sleep disturbances in a cohort of schoolchildren that were born preterm and compare them with healthy controls.

METHODS

A cohort of 147 schoolchildren, 45 born at term (≥37 weeks) and 102 very preterm (<32 weeks), was recruited and evaluated at school age (5-9 years). The Pediatric Sleep Questionnaire (PSQ) and the Sleep Disturbance Scale for Children (SDSC) were used to assess sleep disturbances in different domains.

RESULTS

PSQ score was significantly higher in former preterm children (0.26 ± 0.18 vs. 0.18 ± 0.14 in controls; p = 0.004), and SDSC total score was also significantly different among groups (21.7 ± 11.6 vs. 14.1 ± 12.6; p < 0.001). Regression models showed significant mean differences in PSQ score, total SDSC score, and two SDSC subscale scores (i.e. sleep-wake transition disorders, sleep-breathing disorders, and sleep hyperhidrosis) even after adjustment for confounders. Maternal age and type of delivery were not significantly associated with total PSQ scores.

CONCLUSIONS

Sleep disturbances may originate early in life since children born preterm exhibit an increased risk for developing long-term sleep problems. These findings may have important implications for management of preterm children and for implementation of early interventions focused on optimizing sleep habits.

Quality-of-life but not behavior improves 48-months post-adenotonsillectomy in children with SDB

BACKGROUND

Long term follow-up studies (>12 mths) of changes in behavior and quality-of-life (QoL) in children with sleep disordered breathing (SDB) post-adenotonsillectomy are limited and there is a lack of consensus in the reported findings. The aim of this study was to evaluate children's sleep, QoL and behavior at baseline and 6 mths and 48 mths post-adenotonsillectomy for clinically diagnosed SDB.

METHODS

This prospective longitudinal study of children aged 3-12 y recruited from a Children's Hospital otolaryngology clinic compared polysomnographic parameters, behavior (Child Behavior Checklist; CBCL) and QoL (OSA-18) at baseline, 6mths and 48mths post-adenotonsillectomy and compared these parameters to healthy non-snoring controls recruited from the general community at the same time points.

RESULTS

Sixty-four children completed sleep, behavior and QoL assessments (SDB = 20M/9F, Controls = 18M/17F) at all three time points. Sleep and ventilatory parameters significantly improved in children with SDB with minimal residual obstruction evident at 48 mths post-adenotonsillectomy. Compared to baseline, OSA-18 scores significantly improved post-adenotonsillectomy in children with SDB and were equivalent to the scores of controls at 6 mths and 48 mths post-AT. No significant improvement was observed in behavior in children with SDB post-adenotonsillectomy over the same time period.

CONCLUSION

Baseline deficits in sleep and QoL in children with SDB were normalized at 6 mths post-adenotonsillectomy and gains were maintained at 48 mths post-adenotonsillectomy. Children with SDB did not show significant gains in behavior either at 6 mths or 48 mths post-adenotonsillectomy.

Nasopharyngeal structure development in patients with cleft palate who underwent repair surgery

OBJECTIVE

This study aimed to compare the developmental characteristics of bony nasopharyngeal (NP) in children with cleft palate (CP) and non-cleft subjects.

METHODS

This study was conducted on 64 non-syndromic CP patients who underwent repair surgery and 23 non-cleft subjects as controls. Lateral cephalograms were performed on participants at rest in the natural head position. The X-coordinate and the Y-coordinate of three points on cephalograms were determined as Hormion (Ho), posterior maxillary point (PMP) and anterior point of the atlas (At) representing the anterior-posterior (AP) and vertical dimension of the NP. The linear dimension of the NP (i.e. Ho-At, Ho-PMP, At-PMP) and its area was also calculated.

RESULTS

The bony structures of NP in the clef-affected subjects in isolated CP subgroup, had a significantly greater downward development in the maxillary region (PMP) (both with p = 0.001), more linear growth in cranial-maxillary (Ho-PMP) dimension (p = 0.017 and 0.004, respectively), and larger area (p = 0.017 and <0.001, respectively), when compared to normal subjects. There was no significant difference between either the unilateral cleft lip and palate (CLP) or bilateral CLP group with the control group regarding AP, vertical, and linear growth of the NP and its area (P > 0.05).

CONCLUSIONS

Patients with repaired CP had downward deviated posterior maxilla, more linear growth in cranial-maxillary dimension and larger area compared to normal subjects. Among CP subtypes, a balanced growth was observed among repaired UCLP and BCLP patients, suggesting that with appropriate repaired surgery, normal development of the NP region could be expected in these subtypes.

Three-dimensional assessment of pharyngeal volume and cross-sectional area in Chinese infants and preschool children

OBJECTIVE

The cross-sectional area (CSA) and the volume of the pharyngeal airway normative reference data aren't established, although they are closely associated with the pathogenesis of obstructive sleep apnea syndrome (OSAS) in infants and preschool children. Our objective is to measure the cross-sectional area (CSA) and volume of pharyngeal airway subregions and investigate the effects of age and sex in infants and preschool children using computerized tomography (CT).

METHODS

After applying strict inclusion criteria, 57 infants and preschool children (27 females, 30 males) aged from 1 day to 72 months who underwent maxillofacial CT scans due to trauma were selected. The sample was stratified into three age groups (1 day-24 months, 25-48 months, and 49-72 months). The CSA and the volume of the naso-, palato-, glosso-, and laryngopharyngeal airway were calculated using a 3-dimensional image processing software. Linear regression analysis was performed to express the effect of age, height, and weight. One-way analysis of covariance with height as a covariate was used to analyze the statistical significance of the difference between males and females within each age group.

RESULTS

The CSA and volume of all pharyngeal airway subregions increased with age, height, and weight (P < 0.05) in children under 6 years old. Multiple linear regression analysis showed an age effect, identified in all measurements (P < 0.001), whereas no height or weight effect were found. There were no differences in any measurements between males and females within each age group.

CONCLUSION

The normative reference data of CSA and volume of pharyngeal airway subregions were established after applying strict inclusion and exclusion criteria in infants and preschool children. Results may be useful in screening and assist in the timely diagnosis and management of pediatric OSAS.

Prevalence of malocclusions and oral dysfunctions in children with persistent sleep-disordered breathing after adenotonsillectomy in the long term

STUDY OBJECTIVES

To evaluate the prevalence of craniofacial/orthodontic abnormalities and oral dysfunctions in a population of children with persistent sleep-disordered breathing despite adenotonsillectomy.

METHODS

Medical charts of 4,000 children with sleep-disordered breathing operated on in a tertiary hospital were retrospectively reviewed. Patients reporting persistent sleep-disordered breathing symptoms were invited to an orthodontic/myofunctional evaluation following the Sleep Clinical Score), followed by a 1-night ambulatory type III sleep study.

RESULTS

One hundred nonsyndromic symptomatic patients were examined (mean age 8.8 ± 3.5 years), from 1 to 12 years after surgery (mean 4.6 ± 3.1 years); 24% were overweight/obese; 69 had a sleep study. Although prevalent, oronasal abnormalities and malocclusions were not specifically associated with pathological sleep parameters (cartilage hypotonia 18%, septal deviation 5%, short lingual frenulum 40%). Malocclusions were associated with a higher respiratory event index in children under 8 years only, whereas an impaired nasal dilator reflex and tongue immaturity were associated with an increased obstructive respiratory event index in all patients (1.72 ± 2.29 vs 0.72 ± 1.22 events/h, P = .011) and Respiratory Event Index, respectively (3.63 ± 3.63 vs 1.19 ± 1.19 events/h). Male sex, phenotype, nasal obstruction, oral breathing, and young age at surgery (< 3 years) were significantly related to higher respiratory event index. Using the Sleep Clinical Score > 6.5 cut-off, patients with persistent sleep apnea were significantly distinct from chronic snoring (2.72 ± 2.67 vs 0.58 ± 0.55, P < .01).

CONCLUSIONS

Oronasal anatomical and functional abnormalities were quite prevalent and various in persistent sleep-disordered breathing after adenotonsillectomy. Nasal disuse and tongue motor immaturity were associated with a higher obstructive respiratory event index in the long term, whereas craniofacial risk factors might have a more pronounced impact at younger age.

Pharyngomalacia in Neonates: The Missed Issue

Background: Airway malacia (AM) is a weakness of the airway's frameworks making them collapsible during the respiratory phases. Although the larynx, trachea, and bronchus are the usual sites for malacia to occur, there is another important type of malacia that involves the pharynx. Pharyngomalacia (PM) or concentric pharyngeal wall inspiratory collapse (PWIC) is mostly missed during bronchoscopic evaluations in the neonates with noisy breathing because people are not aware of this condition. Methods: This study aimed to evaluate the nasopharyngeal investigation among neonates suffering from noisy breathing. The retrospective study was undertaken to assess the frequency of PM and to propose indications for intervention in 100 neonates with noisy breathing. A thin fiberoptic bronchoscope was used to evaluate the upper airways under conscious status without any sedation in the neonates. Results: A total of 100 neonates with noisy breathing from September 2015 to October 2018 were retrospectively analyzed. The most common presenting symptom was inspiratory stridor which was observed in 35 (92.1%) of cases. PM was diagnosed in 38 neonates (38%) including 27 (71%) males and 13 (29%) females. Seventeen (44.7%) cases had mild, 11 (28.9%) cases had moderate, and 10 (26.4%) cases had a severe type of PM. PM was more prominent at the velopharynx level in 15 (39.4%) cases, and it was accompanied by up to six synchronous airway abnormalities. The most frequent synchronous airway abnormality was laryngomalacia in 13 (34.3%). Conclusion: PM is one of the causes of noisy breathing in infants. Since PM can be accompanied by the presence of other types of airway malacia, the issue becomes more complicated. On the other hand, lack of experience and facilities are two main causes for the accurate diagnosis and effective management among neonates. This study indicates that the investigation of pharynx is a missed part of the many workups that are used to diagnose the site of involvement in neonates with noisy breathing.

Associations among sleep symptoms, physical examination, and polysomnographic findings in children with obstructive sleep apnea

PURPOSE

The relationships among PSG findings, OSA symptoms, and tonsil and adenoid size are not clear. In this study, we aimed to investigate the associations between pediatric OSA and tonsil and adenoid size using subjective (OSA-18 questionnaire) and objective (PSG) measurements.

METHODS

101 consecutive patients aged from 2 to 12 years (mean age, 5.4 ± 2.2 years; boys, 72.3%) diagnosed with OSA were enrolled in two age groups (2-6 years group and 7-12 years group) and underwent PSG and lateral cephalometric radiography. Tonsil size and the adenoid-nasopharyngeal (A/N) ratio were determined. Quality of life and sleep symptoms were measured using the Chinese version OSA-18 questionnaire. Demographic and clinical data were obtained.

RESULTS

75 and 26 patients were separately enrolled in 2-6 years group and 7-12 years group. In 2-6 years group, the multiple linear regression revealed that tonsil size and A/N ratio were associated with log apnea-hypopnea index (AHI), and the Spearman's rank correlation reflected a positive correlation between log AHI and the OSA-18 sleep disturbance score (r = 0.362, P = 0.001). Log OSA-18 score was correlated with tonsil size (r = 0.349, P = 0.002) but not the A/N ratio in 2-6 years group. Finally, no significant associations were observed between log OSA-18 scores and log AHI in all patients.

CONCLUSION

As PSG stays the golden standard for diagnoses of pediatric OSA, physical examinations and quality-of-life assessments are needed to fully assess the impact of OSA on children.

Diagnostic Test Value of Assessment Adenoid Enlargement with and Without Airway Obstruction Using Lateral Soft Tissues X-ray Compared to Nasoendoscopy

Adenoid hypertrophy is one of the most important causes of airway obstruction. Skull lateral soft tissues X ray are reliable diagnostic tools for detection adenoid enlargement with or without airway obstruction. Compared to nasoendoscopy that invasive and not available in all hospital. The aim of this study is to evaluate the diagnostic value of Skull lateral soft tissues X ray for assessment adenoid enlargement using Kurien, Cohen and Konak, Fujioka and McNamara methods compared with nasoendoscopy. Analytic observational with cross sectional study. 24 patients suspected adenoid enlargement was performed Skull lateral soft tissues X ray and measured the enlargement with Kurien, Cohen and Konak, Fujioka and McNamara methods. After performed X-ray these patients was been nasoendoscopy. Diagnostic value of Skull lateral soft tissues X ray Kurien methods show sensitivity was 73.6%, specificity 100%, positive predictive value 100%, negative predictive value 50% and accuracy 79.1%. Diagnostic value of Skull lateral soft tissues X ray Cohen and Konak methods show sensitivity was 94.7%, specificity 100%, positive predictive value 100%, negative predictive value 83.3% and accuracy 95.8%. Diagnostic value of Skull lateral soft tissues X ray Fujioka methods show sensitivity was 10.5%, specificity 100%, positive predictive value 100%, negative predictive value 22.7% and accuracy 29.1%. Diagnostic value of Skull lateral soft tissues X ray McNamara methods show sensitivity was 68.4%, specificity 100%, positive predictive value 100%, negative predictive value 45.4% and accuracy 75%. Adenoid enlargement can be measure with Skull lateral soft tissues X ray using Cohen and Konak method that has the highest sensitivity, specificity, and accuration compare another methods and using McNamara methods can predict the airway obstruction.

Hospitalizations for infections by age and sex: register-based study of Danish children 1977-2014

Background: Infectious diseases are a major cause of hospitalizations in children and there is increasing interest in sex differences in immunity during childhood. Therefore, we examined hospital admission rates for infectious diseases in Danish children by age and sex.Methods: Register-based cohort study of all Danish residents aged 0-14 years from 1977 to 2014. We examined total admission rate for infections and rates of admission by types of infection.Results: This study included 3,689,999 children and 1,080,750 admissions for infections. The admission rates peaked at age 0 months (boys, 197.9 admissions per 1000 person-years; girls, 160.9) and age 11 months (boys, 155.5; girls, 113.9). The male-female ratio of admissions was 1.25 for children aged 0-14 years, but varied by age and type of infection. Boys had the highest admission rate for any infection until 9 years of age after which girls had a higher rate. Boys had higher admission rates for gastrointestinal infections and lower respiratory tract infections than girls at all ages. The admission rates for upper respiratory tract infections and 'Other infections' for girls were higher than the rates for boys at age 10 and 4 years, respectively.Conclusions: Overall, boys had around 25% higher admission rates for infections than girls, with some variation according to age and type of infection.

The Effects of Transgender Hormone Therapy on Sleep and Breathing: A Case Series

None

The effect of hormone therapy on sleep-disordered breathing in transgender patients has not been described. We present three cases of patients undergoing gender reassignment and treated with hormone replacement. The first case was a transgender woman (assigned male at birth) with a prolonged history of severe obstructive sleep apnea (OSA) that resolved following initiation of female sex hormones. The second and third cases both address transgender males (assigned female at birth) in whom OSA developed following initiation of male sex hormones (with pretreatment polysomnography documenting absence of OSA). The growing interest in transgender health warrants further evaluation of the effects of related therapies on sleep and sleep-disordered breathing.

Is Tube Thermosoftening Helpful for Videolaryngoscope-Guided Nasotracheal Intubation?: A Randomized Controlled Trial

BACKGROUND

Thermosoftening of the endotracheal tube (ETT) and telescoping the ETT into a rubber catheter have been suggested as a method for reducing epistaxis during nasotracheal intubation (NTI). However, thermosoftening technique is known to make it difficult to navigate the ETT into trachea without the use of Magill forceps during NTI. The cuff inflation technique has been suggested as an effective alternative to the use of Magill forceps to improve the oropharyngeal navigation of the ETT, irrespective of their stiffness, during direct laryngoscope-guided NTI. We evaluated whether thermosoftening of the ETT telescoped into rubber catheters has an additional benefit in reducing nasal injury. Simultaneously, we also evaluated whether thermosoftening of the ETT worsened orotracheal navigability during cuff inflation-supplemented videolaryngoscope-guided NTI.

METHODS

One hundred forty patients were randomly assigned to 1 of the 2 groups depending on whether the ETT was softened by warming or not. The primary outcome was the incidence of epistaxis during NTI. The secondary outcome was nasotracheal navigability of the ETT, assessed by navigation grade and time required for insertion of ETT in each phase (from nose to oropharynx, from oropharynx to glottic inlet aided by cuff inflation if needed, and from glottic inlet to trachea).

RESULTS

The ETTs were successfully inserted through the selected nostril of all 140 patients. In the thermosoftening group, the incidence and severity of epistaxis was significantly lower (7% vs 51%; difference of 44.2%; 95% confidence interval, 29.9%-56.2%; P < .001), and the ETT passed through the nasal cavity with lower resistance (P = .001) and less time (P < .001) when compared to the control group. No difference was found in the ease of ETT insertion (navigation grade and time required) from the oropharynx to the glottic inlet (P > .99 and P = .054, respectively) and from the glottic inlet to the trachea (P > .99 and P = .750, respectively) between the 2 groups. In both groups, all ETTs could be navigated into the trachea without the use of Magill forceps.

CONCLUSIONS

Supplemented with cuff inflation during videolaryngoscope-guided NTI, thermosoftening of the ETT telescoped into rubber catheters has a substantial benefit because it significantly reduces the incidence of epistaxis without worsening the oropharyngeal navigability of the ETT.

Correlations between obstructive sleep apnea and adenotonsillar hypertrophy in children of different weight status

The present study aimed to evaluate the relationship between OSA and adenotonsillar size in children of different weight status. A total of 451 patients aged 2–13 years with suspected OSA were retrospectively enrolled in the study. Correlations between the apnea-hypopnea index (AHI) and adenotonsillar size in different weight status were investigated. The adenoidal/nasopharyngeal (A/N) ratio of underweight children was significantly higher than that of normal-weight children (P = 0.027). Both adenoid and tonsil size were positively correlated with logAHI in children of normal weight (r = 0.210, P = 0.001; and r = 0.212, P = 0.001) but uncorrelated in the other groups. Gender (OR = 1.49, 95% CI: 1.01–2.20, P = 0.043), obese (OR = 1.93, 95% CI: 1.10–3.40, P = 0.012), A/N ratio (OR = 1.55, 95% CI: 1.28–1.88, P < 0.001) and tonsil size (OR = 1.36, 95% CI: 1.18–1.57, P < 0.001) were all associated with the severity of OSA. Adenotonsillar hypertrophy contributed to OSA in normal-weight children. In children of abnormal weight, instead of treatment for adenotonsillar hypertrophy, appropriate treatments for other factors are required.

The Effect of Obesity on Transnasal Flexible Laryngoscopy

OBJECTIVE

Transnasal flexible laryngoscopy (TFL) is a practical and cost-effective procedure, allowing excellent evaluation of the upper airway with minimal risk of complications. The effect of obesity on endoscopic examination still remains unclear. The aim of this study was to determine if obesity has an effect on TFL.

METHODS

Demographic data including age and gender, and physical and endoscopic examinations including body mass index (BMI), neck circumference, and grade of the laryngeal view according to Tasli classification (TC), Mallampati classification (MC), Friedman classification, and Moore tongue base classification (MTC) scores of 200 patients were evaluated. The patients were divided into two categories as obese and nonobese, and the scores of patients were compared.

RESULTS

Evaluation was made of 99 (50.5%) obese and 97 (49.5%) nonobese patients ranging in age from 18 to 65 years (mean age: 37.89 ± 13.55 years). Of the 196 patients in this study, 101 (51.5%) were male, and 95 (48.5%) were female. The mean BMI of the obese and nonobese patients was 33.18 ± 5.18 (min: 25, max: 45) and 22.48 ± 1.5 (min: 19, max: 24), respectively. According to cutoff points, 27 patients (27.3%) were classified as overweight, 30 (30.3%) as obese, and 42 (42.4%) as morbidly obese. According to TC, there was no statistically significant difference between the obese and nonobese groups (mean difference 0.12, P: 0.39). In Pearson correlation analysis, the scores for a correlation between TC, and MC and MTC were 0.206 (very weak) and 0.653 (strong), respectively, which were statistically significant (P < 0.05). There was no correlation between TC and BMI values (r = -0.051; P: 0.48).

CONCLUSION

The results of this study demonstrated that obesity influences the scores of MC, Friedman classification, and MTC, but does not affect the laryngeal view on TFL.

Sex Differences in the Association Between Smoking and Sleep-Disordered Breathing in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Results of previous studies examining associations between cigarette smoking and sleep-disordered breathing (SDB) are inconsistent. We therefore investigated this association in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

METHODS

A total of 13,863 US Hispanic/Latino subjects, 18 to 76 years old, provided smoking histories and underwent home SDB testing. Logistic regression analyses were conducted to assess the independent association of smoking and SDB with covariate adjustment. Sex- and age-stratified analyses were performed.

RESULTS

The weighted prevalence of moderate to severe SDB was 9.7% (95% CI, 9.0-10.5). No independent and statistically significant association was observed between ever smoking (defined as minimum lifetime cigarette use of 100) and moderate to severe SDB (defined as an apnea-hypopnea index ≥ 15 events per hour) (OR, 1.02; 95% CI, 0.85-1.22; P = .85). Sex and age were effect modifiers of the aforementioned association. Stratification according to age and sex revealed that younger (aged 35-54 years) female smokers had 83% higher odds of SDB compared with younger female never smokers (OR, 1.83; 95% CI, 1.19-2.81; P = .01). A significant dose-response relation was noted between smoking intensity and SDB in younger female smokers (P < .01). Lastly, use of ≥ 10 cigarettes per day was associated with a nearly threefold increase in SDB odds in younger female ever smokers. These associations were not observed in younger male subjects.

CONCLUSIONS

In the HCHS/SOL, no independent and statistically significant association was found between smoking and SDB. Sex and age stratification revealed a novel statistically significant association between smoking and SDB in younger (35-54 years old) female smokers. Our findings highlight the importance of investigating sex- and age-specific associations of SDB risk factors.

Three-dimensional assessment of the pharyngeal airway in Japanese preschoolers with orofacial clefts

OBJECTIVES/HYPOTHESIS

Individuals with orofacial clefts often experience respiratory problems because of nasopharyngeal abnormalities. Pharyngeal airway morphology is thought to differ among the various cleft types. We measured three-dimensional (3D) airway volume using cone-beam computed tomography (CBCT) analysis to evaluate and compare pharyngeal airways in Japanese preschoolers with and without orofacial clefts.

STUDY DESIGN

Retrospective case-control study.

METHODS

We enrolled 83 subjects (37 boys, 46 girls; mean age = 4.66 ± 0.56 years) with nonsyndromic orofacial clefts and 16 noncleft healthy subjects (seven boys, nine girls; mean age = 5.30 ± 0.52 years) as controls. The subjects were divided into five groups. Four groups were based on the cleft type: isolated cleft palate, unilateral cleft lip and alveolus), unilateral cleft lip and palate, and bilateral cleft lip and palate. The fifth group included the noncleft controls. All subjects were examined with CBCT, and the 3D airway volume was measured. We analyzed group differences statistically using analysis of covariance with the Bonferroni post hoc pairwise comparison tests for the corrected means.

RESULTS

Compared with the noncleft group, each cleft group exhibited significantly decreased total and nasal airway volumes and increased superior and inferior pharyngeal airway volumes. The differences were all statistically significant.

CONCLUSIONS

Our findings suggest that anatomical differences exist in pharyngeal airway volumes among various cleft groups and in those without a cleft.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:533-540, 2020.

Effects of rapid maxillary expansion on upper airway volume: A three-dimensional cone-beam computed tomography study

OBJECTIVE

To compare changes in pharyngeal airway volume and minimal cross-sectional area (MCA) between patients undergoing rapid maxillary expansion (RME) and a matched control group and to identify markers for predicting airway changes using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Pre- and posttreatment CBCT scans were selected of children who had RME (14 girls and 12 boys; mean age, 12.4 years) along with scans of a control group (matched for chronological age, skeletal age, gender, mandibular inclination) who underwent orthodontic treatment for minor malocclusions without RME. Changes in airway volume and MCA were evaluated using a standardized, previously validated method and analyzed by a mixed-effects linear regression model.

RESULTS

Upper airway volume and MCA increased significantly over time for both the RME and matched control groups (P < .01 and P = .05, respectively). Although the RME group showed a greater increase when compared with the matched controls, this difference was not statistically significant. A reduced skeletal age before treatment was a significant marker for a positive effect on the upper airway volume and MCA changes (P < .01).

CONCLUSIONS

Tooth-borne RME is not associated with a significant change in upper airway volume or MCA in children when compared with controls. The younger the skeletal age before treatment, the more positive the effect on the upper airway changes. The results may prove valuable, especially in RME of young children.

How OSA Evolves From Childhood to Young Adulthood: Natural History From a 10-Year Follow-up Study

BACKGROUND

Understanding the natural history of childhood OSA can help to determine disease prognosis and to guide risk stratification and management strategies.

METHODS

To evaluate the natural history of childhood OSA and factors associated with spontaneous remission and persistent and incident OSA from childhood to late adolescence/early adulthood, a longitudinal analysis of a prospective community-based cohort was designed. Subjects from a cohort established for an OSA prevalence study were invited to participate in this 10-year follow-up study.

RESULTS

Two hundred and forty-three participants (59% male) took part, and their mean age was 9.8 (SD, ± 1.8) and 20.2 (SD, ± 1.9) years at baseline and follow-up, respectively. The mean follow-up duration was 10.4 (SD, ± 1.1) years. Associations between baseline and follow-up log-transformed obstructive apnea-hypopnea index (OAHI) differed by age; a significant positive association was observed only among participants aged 10 years or older at baseline. Overall polysomnographic remission rate (with OAHI < 1 event/h at follow-up) of childhood OSA was 30%, and 69% had an OAHI < 5 events/h at follow-up. Complete remission of OSA was associated with female sex. Incidence of adolescent/adult OSA with an OAHI ≥ 5 events/h at follow-up was 22%. Male sex and higher baseline BMI z score were associated with incident OSA.

CONCLUSIONS

A proportion of children with OSA, particularly female children, had complete resolution during transition to late adolescence or early adulthood. Childhood and adolescent OSA are distinct entities, with the latter more likely to persist into adulthood. Obesity and male sex are consistent key risk factors for incident OSA.

Upper airway features of unilateral cleft lip and palate patients in different growth stages

OBJECTIVES

To compare growth-related changes of skeletal and upper airway features of unilateral cleft lip and palate subjects (UCLP) with non-cleft control (NCC) subjects by using lateral cephalograms.

MATERIALS AND METHODS

The sample comprised 238 subjects, collected cross-sectionally, divided into 2 groups: 94 with UCLP, and 144 NCC, subdivided into 4 groups according to their growth stages by using cervical vertebral maturation stage (CVMS). The subgroups were defined as early childhood (stage 1), prepubertal (stage 2: CVMS I and II), pubertal (stage 3: CVMS III and IV), and postpubertal (stage 4: CVMS V and VI).

RESULTS

The maxilla was more retrognathic at stages 2, 3, and 4 in females with UCLP. The mandible was more retrognathic in UCLP at stage 1 in males, and stages 2 and 3 in females. ANB (angle between NA plane and NB plane) was significantly smaller in UCLP subjects at stage 4 for both sexes. A vertical growth pattern was seen in UCLP subjects except males at stages 2 and 3, and females at stage 2. Posterior airway space was significantly narrower at all stages in males and after stage 1 in females. Middle airway space was significantly wider at all stages in females and after stage 1 in males. Epiglottic airway space was significantly narrower in males at stage 3.

CONCLUSIONS

Age- and sex-dependent differences in skeletal morphology and upper-airway widths of the UCLP subjects were identified when compared with controls.