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Hwang, Park, Kim, Lee, and Park: Usefulness of Measuring Airway Length with Cephalometry in Pediatric Subjects with Obstructive Sleep Apnea
Original Article

J Rhinol 2019;26(2):99-105.

Published online: 20 January 2019

DOI: https://doi.org/10.18787/jr.2019.26.2.99

Usefulness of Measuring Airway Length with Cephalometry in Pediatric Subjects with Obstructive Sleep Apnea

Jae Hyung Hwang, MD1, Dong Sun Park, MD, PhD2, In Hye Kim, MD1, Hyesook Lee, MD1, Chan-Soon Park, MD, PhD1,

1Department of Otolaryngology-Head and Neck Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea

2Ds Sleep Center, Seoul, Korea

Address for correspondence: Chan-Soon Park, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea Tel: +82-31-881-8968, Fax: +82-31-257-3752, E-mail: pcs0112@catholic.ac.kr

Received 16 November 2018       Revised 17 February 2019       Accepted 11 April 2019

Copyright © 2019 Journal of Rhinology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background and Objectives

This study was designed to analyze the relationship between measurement of airway length with cephalometry and AHI in children with OSA and to assess the correlations between cephalometric parameters and salivary cortisol level.

Subjects and Method

Three parameters of the upper airway were measured by cephalometry: distance from the posterior nasal spine to the hyoid bone (PHy), distance from the mandibular plane to the hyoid bone (MP-Hy), and distance from the pos-terior nasal spine to the mandibular plane (P-MP). Ratios for each segment were also determined.

Results

Subjects with OSAS had longer P-Hy and MP-Hy than the control group. In particular, MP-Hy was significantly lon-ger in the moderate-severe group than the other groups. In the OSAS group, there were significant correlations between MP-Hy, Ratio1, Ratio3 and m-Cor, s-Cor.

Conclusion

Length of upper airway and ratio parameters of cephalometry may be more useful indices in moderate-severe OSA than absolute distance parameters, and Ratio1 may be valuable for prediction of activating HPA axis.

Keywords: Sleep apnea, obstructive, Cephalometry, Child, Airway resistance

References

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Fig. 1.
Cephalometric landmarks and parameters. P: posterior nasal spine, MP: mandibular plane, Hy: the most anterior and su-perior point of hyoid bone.
jr-26-99f1.tif
Table 1.
Definition of the cephalometric parameters
Parameters Definition
P-Hy The distance from posterior nasal spine to hyoid bone
MP-Hy The distance from mandibular plane to hyoid bone
P-MP The distance from posterior nasal spine to madibular plane
Ratio 1 The ratio of M-H/H-P
Ratio 2 The ratio of P-M/H-P
Ratio 3 The ratio of M-H/P-M
Table 2.
The demographic data and PSG finding of studied patients
  Control AHI≤1 (n=18) OSAS AHI＞1 (n=21) p value
Gender      
Male 9 (50.0) 17 (80.9) 0.04
Female 9 (50.0) 4 (19.1)  
Age 7.2±1.9 5.9±2.2 0.06
BMI 16.9±2.3 16.6±2.3 0.58
AHI 0.2±0.3 11.1±9.8 ＜0.0001

Data are presented as mean± SD; as n (%). p value difference between control and OSAS by Chi-square test, Student t test and wilcoxon rank sum test

Table 3.
Comparison of physical and cephalometric parameters in patients with OSAS and control group
  Control AHI≤1 (n=18) OSAS AHI＞1 (n=21) p value∗ Adjusted OR (95%CI)/p value†
Tonsil 2.8±0.9 3.2±0.6 0.0954 2.017 (0.727–5.598)/0.1780
AN-r 0.6±0.1 0.6±0.1 0.0550 59.163 (0.014-inf)/0.3363
P-Hy 51.8±5.5 56.1±5.5 0.0217 1.334 (1.075–1.655)/0.0089
MP-Hy 6.7±3.2 10.4±5.5 0.0358 1.271 (1.021–1.581)/0.0316
P-MP 41.3±4.1 40±3.4 0.2827 0.976 (0.782–1.219)/0.8334
Ratio 1 0.1±0.1 0.2±0.1 0.0502 Inf (1.440-Inf)/0.0437
Ratio 2 0.8±0.1 0.7±0.1 0.0004 Inf (Inf-0.009)/0.0106
Ratio 3 0.2±0.1 0.3±0.1 0.0270 Inf (2.172-Inf)/0.0334

∗ : p values of significant difference between Control and OSAS, by Student t test and Wilcoxon rank sum test, †: p values of dif-ference between Control and OSAS by multivariable logistic regression (adjust: age and gender). Inf: infinity

Table 4.
The relationship between AHI and physical and cepha-lometric parameters in OSAS group
  AHI
r p value
Tonsil 0.0788 0.7342
AN-r 0.3437 0.1272
P-Hy 0.0249 0.9147
MP-Hy 0.3987 0.0734
P-MP 0.0085 0.9709
Ratio 1 0.4455 0.0430
Ratio 2 0.0104 0.9642
Ratio 3 0.3896 0.0808

Statistics were carried out using Pearson's and Spearman's cor-relation analysis

Table 5.
Comparison of the physical and cephalometric parameters according to the OSA severity
  Control AHI≤1 (n=18) Mild 1＜AHI≤5 (n=7) M Moderate-severe 5＜AHI (n=14) p value∗ Event= moderate severe
        Control OR (95%CI)/p value† Mild OR (95%CI)/p value†
Tonsil 2.8±0.9 3.1±0.7 3.3±0.6 0.2196 2.333 (0.740–7.355)/0.1481 1.592 (0.366–6.913)/0.5350
AN-r 0.6±0.1 0.6±0.1 0.7±0.1 0.1340 343.512 (0.039-Inf)/0.2080 295.429 (0.005-Inf)/0.3077
P-Hy 51.8±5.5 53.6±3.8 57.3±6 0.0273 1.413 (1.108–1.803)/0.0054 1.158 (0.931–1.441)/0.1883
MP-Hy 6.7±3.2 6.9±3.5 12.2±5.6 0.0089 1.413 (1.086–1.838)/0.0101 1.328 (1.006–1.753)/0.0453
P-MP 41.3±4.1 40.6±1.8 39.7±4 0.4829 0.932 (0.733–1.186)/0.5691 0.846 (0.610–1.175)/0.3185
Ratio 1 0.1±0.1 0.1±0.1 0.2±0.1 0.0126 Inf (75.773-Inf)/0.0122 Inf (3.127-Inf)/0.0364
Ratio 2 0.8±0.1 0.8±0.1 0.7±0.1 0.0002 Inf/0.0046 Inf (Inf-4.014)/0.0719
Ratio 3 0.2±0.1 0.2±0.1 0.3±0.1 0.0074 Inf (26.861-Inf)/0.0114 Inf (1.122-Inf)/0.0478

∗ : p value difference between Control, Mild and Moderate-Severe by ANOVA and Kruskal-Wallis test, followed by post hoc schef-fe and Dunn's test, †: p values of difference between Control, Mild and Moderate-Severe by multivariable logistic regression (ad-just: age and gender)

Table 6.
The evaluation of the effective screening measurements to identify the moderate-severe OSAS group in all patients
  Cut-off value Sen (95%CI) Spe (95%CI) AUC (95%CI) p value
Tonsil ＞2 92.86 (66.1–99.8) 24.00 (9.4–45.1) 0.630 (0.461–0.779) 0.1109
AN-r ＞0.6 78.57 (49.2–95.3) 68.00 (46.5–85.1) 0.683 (0.514–0.822) 0.0381
P-Hy ＞52.69 78.57 (49.2–95.3) 64.00 (42.5–82.0) 0.720 (0.553–0.852) 0.0088
MP-Hy ＞8.91 78.57 (49.2–95.3) 72.00 (50.6–87.9) 0.800 (0.641–0.911) 0.0001
P-MP ≤36.75 35.71 (12.8–64.9) 92.00 (74.0–99.0) 0.637 (0.468–0.785) 0.1718
Ratio 1 ＞0.2108 50.00 (23.0–77.0) 100.00 (86.3–100.0) 0.789 (0.628–0.903) 0.0003
Ratio 2 ≤0.7158 64.29 (35.1–87.2) 92.00 (74.0–99.0) 0.840 (0.687–0.937) ＜0.0001
Ratio 3 ＞0.2771 57.14 (28.9–82.3) 96.00 (79.6–99.9) 0.806 (0.648–0.915) ＜0.0001

Area under the ROC curve using to determine cut-off point of factor's in OSAS. Sen: Sensitivity, Spe: Specificity, AUC: area under the curve

Table 7.
The univariable logistic regression analysis of each variable
    AHI≤5 (n=25, 64.1%) AHI＞5 (n=14, 35.9%) Odds ratio (95%CI) p value
Gender Male 15 (60.0) 11 (78.6) 2.444 (0.542–11.028) 0.2449
Age ＜6 6 (24.0) 6 (42.9) 2.375 (0.585–9.640) 0.2263
Tonsil ＞2 19 (76.0) 13 (92.9) 4.104 (0.441–38.221) 0.2148
AN-r ＞0.6 8 (32.0) 11 (78.6) 7.791 (1.690–35.918) 0.0085
P-HY ＞52.69 9 (36.0) 11 (78.6) 6.518 (1.432–29.666) 0.0153
Mp-HY ＞8.91 7 (28.0) 11 (78.6) 9.427 (2.008–44.259) 0.0045
P-MP ≤36.75 2 (8.0) 5 (35.7) 6.389 (1.044–39.112) 0.0448
Ratio 1 ＞0.2108 1 (4.0) 7 (50.0) 23.994 (2.509–229.458) 0.0058
Ratio 2 ≤0.7158 2 (8.0) 9 (64.3) 20.700 (3.381–126.720) 0.0010
Ratio 3 ＞0.2771 1 (4.0) 8 (57.14) 32.000 (3.329–307.633) 0.0027

Statistics were carried out using logistic regression

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