Upper Airway Research Articles

Knowledge, Attitude, and Practice of the General Population toward Pediatric Obstructive Sleep Apnea in Al-Baha Region, Saudi Arabia: A Cross-sectional Study

Abstract Context: Obstructive sleep apnea syndrome in children is characterized by partial or complete upper airway obstruction during sleep, leading to disrupted breathing and altered sleep patterns. Prompt diagnosis and intervention are crucial for preventing severe health complications. Aim: The aim of the study was to evaluate the knowledge, attitudes, and practices related to pediatric OSA among residents of the Al-Baha region, Saudi Arabia, and explore associations with sociodemographic factors to improve the health outcomes and quality of life of the affected children. Settings and Design: The study design was an observational cross-sectional study. Subjects and Methods: From the general public in the Al-Baha region, 413 participants were recruited through an online self-administered questionnaire. Data were collected between May 4 and June 5, 2024. Statistical Analysis Used: Descriptive statistics, frequency distributions, and Chi-square test. Results: The majority of participants were predominantly female (66.3%) and aged 18–30 years (61%). Most participants were single and held a bachelor’s degree. An adequate level of knowledge about OSA was demonstrated by 64% of the participants, 78% exhibited a positive attitude, and 62% showed an adequate practice level. Young adults and females had the highest levels of knowledge and positive attitudes, with females also displaying better practice habits than males. Participants with 1–3 children demonstrated better practice levels than those with more children. Conclusion: Adequate awareness of pediatric OSA was demonstrated in the Al-Baha region, particularly among young adults and females. Positive attitudes and effective practices are influenced by education and profession. While current awareness efforts are effective, targeted interventions can further improve knowledge and practice.

The Inhibitory Effect of Hedera helix and Coptidis Rhizome Mixture in the Pathogenesis of Laryngopharyngeal Reflux: Cleavage of E-Cadherin in Acid-Exposed Primary Human Pharyngeal Epithelial Cells

Laryngopharyngeal reflux disease (LPRD) is a prevalent upper airway disorder characterized by inflammation and epithelial damage due to the backflow of gastric contents. Current treatments, primarily proton pump inhibitors (PPIs), often show variable efficacy, necessitating the exploration of alternative or adjunctive therapies. This study investigates the therapeutic potential of a mixture of Hedera helix and Coptidis rhizome (HHCR) in mitigating the pathophysiological mechanisms of LPRD. Using an in vitro model of human pharyngeal epithelial cells exposed to acidic conditions, we observed that acid exposure significantly increased the expression of adenosine A3 receptor (adenosine A3) and matrix metalloproteinase-7 (MMP-7), leading to E-cadherin cleavage and compromised epithelial integrity. Treatment with the HHCR mixture effectively suppressed adenosine A3 expression and MMP-7 activity, thereby reducing E-cadherin cleavage and preserving cellular cohesion. These results highlight the HHCR mixture’s ability to modulate the adenosine A3–MMP-7–E-cadherin pathway, suggesting its potential as a valuable adjunctive therapy for LPRD, particularly for patients unresponsive to conventional PPI treatment. This study provides new insights into the molecular interactions involved in LPRD and supports further clinical evaluation of HHCR as a complementary treatment option.

Relationship Between Obstructive Sleep Apnea and Sports—Systematic Review and Meta-Analysis

The primary objective of this research is to analyze and compare the effects of physical activity on patients diagnosed with obstructive sleep apnea (OSA), a condition characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep, leading to disrupted sleep and various health complications. Methods: A systematic and strategic search of 16 peer-reviewed articles was conducted to assess the impact of different types of physical exercise on the apnea–hypopnea index (AHI), a key metric used to quantify the severity of OSA. The selected studies focused on two main exercise modalities: aerobic exercise alone and a combination of aerobic and resistance training. These modalities were examined to determine their respective influences on the AHI among individuals with OSA. Results: The findings revealed that aerobic exercise alone did not significantly alter the apnea–hypopnea index (p = 0.15), suggesting limited effectiveness in reducing the severity of OSA when performed in isolation. However, in patients who engaged in combined physical activity—incorporating both aerobic and resistance exercises—a significant reduction in the AHI was observed (p < 0.01), indicating a more substantial therapeutic effect. Conclusions: This study concludes that a structured exercise program combining aerobic and resistance training produces a significant improvement in the apnea–hypopnea indices of patients with obstructive sleep apnea. These results highlight the potential of combined exercise regimens as a non-pharmacological intervention that could complement traditional OSA treatments, offering a viable approach to managing the condition and improving patient outcomes. Future research should aim to explore the optimal exercise intensity, duration, and frequency to maximize these benefits.

Anesthesia in Obese Patients and Complications

Background: Almost all ages and socioeconomic categories are affected by the complex illness known as obesity, which has major social and psychological ramifications. Global obesity rates have reached epidemic proportions and obesity plays a significant role in the burden of chronic illnesses and disabilities worldwide. The aim of the study was to assess the Anesthesia in obese patient and its Complications in a tertiary care hospital. Materials and mathods: This cross-sectional observational study was carried out in the Department of Anesthesiology, Bangabandhu Memorial Hospital (BBMH) from July 2020 to June 2022.Total sample size was 200. Adult in-patients who had undergone non-cardiac surgery and were older than 18 with a BMI greater than 30 kg/m2 met the inclusion criteria. Pregnancy, ambulatory surgery and missing or insufficient data on the desired outcomes were the exclusion criteria. Results: Mean age ±SD was 32 ± 0.9 years. About 55% of the patients were female and 45% were male. Regarding ASA classification 53.5% had 2, 45.5% had 3 and 1.0% had 4 score. Regarding coexisting disease 42.5% had hypertension, 14% had dyslipidemia, 18% had DM type-2 and 7.5% had obstructive sleep apnea. Here, type of anesthesia was 55% general anesthesia, 6% normal mask ventilation, 25% regional anesthesia, 4% total intravenous anesthesia and 10% LMA (Laryngeal Mask Airway). Regarding complication 4.5% was Reintubation, 5.5 %Pneumonia, 7.5% Upper airway obstruction, 0.5% Delay emergence respectively. 2.5% Urinary retention, 5% Oliguria, 2% Wound infection. 0.5% myocardial infarction and 0.5% Cardiac arrest occurred and no death occur inpatient respectively. Conclusion: Obesity has long been seen from a surgical standpoint as a risk factor for unfavorable post-surgical outcomes. Patients who are morbidly obese may experience respiratory adverse effects following surgery as a result of physiological disruption. The undesirable effects range depending on the surgical population. IAHS Medical Journal Vol 7(1), June 2024; 97-101

The Impact of NO2 on Epithelial Barrier Integrity of a Primary Cell-Based Air-Liquid Interface Model of the Nasal Respiratory Epithelium.

Nitrogen dioxide (NO2) is a pervasive gaseous air pollutant with well-documented hazardous effects on health, necessitating precise toxicological characterization. While prior research has primarily focused on lower airway structures, the upper airways, serving as the first line of defense against airborne substances, remain understudied. This study aimed to investigate the functional effects of NO2 exposure alone or in combination with hypoxia as a secondary stimulus on nasal epithelium and elucidate its molecular mechanisms because hypoxia is considered a pathophysiological factor in the onset and persistence of chronic rhinosinusitis, a disease of the upper airways. Air-liquid interface cell cultures derived from primary nasal mucosa cells were utilized as an invitro model, offering a high invitro-in vivo correlation. Our findings demonstrate that NO2 exposure induces malfunction of the epithelial barrier, as evidenced by decreased transepithelial electrical resistance and increased fluorescein isothiocyanate (FITC)-dextran permeability. mRNA expression analysis revealed a significant increase in IL-6 and IL-8 expressions following NO2. Reduced mRNA expression of the tight junction component occludin was identified as a structural correlate of the damaged epithelial barrier. Notably, hypoxic conditions alone did not alter epithelial barrier integrity. These findings provide information on the harmful effects of NO2 exposure on the human nasal epithelium, including compromised barrier integrity and induction of inflammatory responses. Overall, this study contributes to our understanding of pathophysiological mechanisms underlying also upper airway respiratory diseases associated with air pollution exposure and emphasizes the importance of mitigating NO2 emissions to safeguard respiratory health.

Obstructive Sleep Apnea in Pediatrics and Adolescent Women: A Systematic Review of Sex-Based Differences Between Girls and Boys

Background/Objectives: Obstructive sleep apnea (OSA) is marked by repetitive occurrences of upper airway (UA) obstruction during sleep. Morbidities impacting the metabolic, cardiovascular (CV) and neurological systems are correlated with OSA. Only a few studies have described the existence of different characteristics depending on sex and, to date, the girl phenotype in OSA pediatrics is not well known. The objective of this systematic review is to identify the specific phenotype of OSA in pediatric and adolescent females compared to males. Methods: A systematic review was performed. The terms “pediatric sleep apnea” and “sex differences” were used to look for publications using PubMed, the Cochrane Library and Web of Science. Inclusion criteria: (1) peer-reviewed journal articles written in English; (2) investigations conducted on individuals diagnosed with OSA; and (3) investigations providing information about sex differences. Exclusion criteria: (1) studies carried out with individuals aged 18 years and older; (2) studies involving a sample size of fewer than 10 patients; and (3) editorials, letters and case reports. Results: Fifteen studies were included and classified in sections related to sex-based differences. Conclusions: Limited information related to sex-based OSA differences in the pediatric population exists. These differences are conditioned by hormonal status, and are minimal in the premenarcheal period. Moreover, adolescent women present a lower prevalence of obesity and craniofacial alterations, lower OSA severity related to higher UA area and earlier tonsil regression. Hyperactivity is more frequent in boys. Some studies pointed to a higher risk of high diastolic blood pressure in girls than in boys.

Hyoid Bone Position and Upper Airway Morphology of Children With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

The objective of this systematic review was to summarise the existing evidence regarding hyoid bone position and upper airway morphology of children with obstructive sleep apnea (OSA). Electronic searches were carried out in PubMed, Embase, Web of Science, CINAHL and WorldCat databases without any restrictions on language from inception to March 2024. The studies which compared the hyoid bone position and upper airway morphology using lateral cephalograms between children with and without OSA will be included. The methodological quality of the included studies was assessed using Newcastle-Ottawa Scale, and the meta-analysis was conducted utilising random-effects model. Twelve cross-sectional studies and one case-control study were included. One study was rated as low quality, three as medium quality, five as high quality, and four as very high quality. Meta-analysis showed that compared to healthy children, children with OSA tended to have increased distance between hyoid bone and mandibular plane (Hy-MP, MD: 3.33, 95% CI: 1.90 to 4.77, p < 0.00001, I2 = 72%), increased distance between hyoid bone and cervical vertebra (Hy-C3, MD: 1.54, 95% CI: 0.62 to 2.46, p = 0.001, I2 = 68%), and a smaller airway space behind the soft palate (U-MPW, MD: -3.07, 95% CI: -4.76 to -1.38, p = 0.0004, I2 = 68%). Whereas there was no significant difference in inferior posterior airway space between children with OSA and healthy controls (IPAS, MD: -1.51, 95% CI: -3.37 to 0.35, p = 0.11, I2 = 71%). In children with OSA, the hyoid bone may exhibit a more anterior and inferior position and the airway posterior to the soft palate demonstrated a narrower dimension. Registration: PROSPERO (CRD42024528171).

Relationship between plasma fibrinogen level and obstructive sleep apnea

Abstract Background Obstructive sleep apnea (OSA), which causes recurring hypoxemia owing to upper airway closure, is one of the most frequent sleep disorders. OSA patients are more prone to suffer cardiovascular disease (CVD) and stroke. One primary mechanism connecting OSA with cardiovascular problems is the prothrombotic state. Our goal in this research is to confirm the relationship between plasma fibrinogen levels and OSA. Results A case–control study involved 20 adults, non-obese participants who had been recently diagnosed with OSA, had never been treated for OSA before, and did not have any other preexisting conditions, and 20 controls underwent measurement of plasma fibrinogen levels following whole night polysomnography. The patient's plasma fibrinogen levels were substantially more significant than the controls' (399.8 ± 54.7 versus 309.8 ± 26.7 mg/dL, respectively), with a p-value of less than 0.001. Plasma fibrinogen levels in moderate and severe OSA (383.6 ± 20.6 mg/dL and 454.4 ± 25.6 mg/dL, respectively) were significantly higher than in controls (309.8 ± 26.7 mg/dL) (p &lt; 0.001 and p &lt; 0.001) and mild OSA patients (335 ± 27.8 mg/dL) (p = 0.013 and p &lt; 0.001). Plasma fibrinogen levels were not significantly different between the controls and patients with mild OSA (p = 0.219). Apnea–hypopnea index, arousal index, and oxygen desaturation index showed positive correlations with plasma fibrinogen (r = 0.953, 0.888, and 0.894, p = &lt; 0.001, &lt; 0.001, and &lt; 0.001, respectively). The total sleep time, sleep efficiency, N3%, REM%, and lowest oxygen saturation showed negative correlations (r = − 0.860, − 0.877, − 0.611, − 0.844, and − 0.745, p = &lt; 0.001, &lt; 0.001, &lt; 0.001, and &lt; 0.001, respectively). Conclusion Elevated levels of plasma fibrinogen in individuals with moderate-to-severe OSA may be attributed to sleep apnea and these increased levels could serve as a significant risk factor that establishes a connection between OSA and pathology of the cardiovascular and cerebrovascular systems. These results could significantly affect OSA diagnosis, therapy monitoring, and outcome.

Erratum to “Study of the tumor effect on airflow in human upper airway exhalation using fluid–structure interaction method”

Erratum to “Study of the tumor effect on airflow in human upper airway exhalation using fluid–structure interaction method”

The hyoid bone position and upper airway morphology among children with and without adenotonsillar hypertrophy: a cross-sectional study

BackgroundAdenotonsillar hypertrophy (ATH) is a major cause of pediatric obstructive sleep apnea (OSA), potentially impacting craniofacial growth and development. Currently, whether children with ATH exhibit distinctive hyoid bone position and upper airway morphology remains uncertain. This research aimed to compare the hyoid bone position and upper airway morphology of children with and without ATH.MethodsA total of 199 children aged 6–8 years were recruited for the study, and their pre-treatment lateral cephalograms were obtained. The size of the adenoids and tonsils on the lateral cephalogram was assessed based on Fujioka’s and Baroni’s methods for classification into groups: adenoid hypertrophy only (AHO) group, tonsillar hypertrophy only (THO) group, adenoid and tonsillar hypertrophy (AH + TH) group, and control group (CG). The position of the hyoid bone and upper airway morphology was analyzed using Dolphin Image Software.ResultsThe distance between the hyoid bone and mentum was greater in the THO group compared to the AHO group (P = 0.005). Children in the AHO group exhibited a longer soft palate (SPL) compared to the THO group (P = 0.014), whereas the THO group displayed a reduced SPL in comparison to healthy controls (P = 0.008). The THO group showed a more inferior tongue position compared to children in the AHO group (P = 0.004). Subjects in the THO group exhibited significantly wider inferior airway space compared to healthy children (P < 0.001).ConclusionsAdenotonsillar hypertrophy may be associated with hyoid bone position and upper airway morphology in children seeking for orthodontic treatment. In children with enlarged tonsils, the hyoid bone was positioned farther from the mentum than in those with enlarged adenoids. Conversely, children with enlarged adenoids had a longer soft palate compared to those with enlarged tonsils.

Differential Inflammatory and Immune Response to Viral Infection in the Upper-Airway and Peripheral Blood of Mild COVID-19 Cases

Background/Objectives: COVID-19 is characterised by a wide variety of clinical manifestations, and clinical tests and genetic analysis might help to predict patient outcomes. Methods: In the current study, the expression of genes related to immune response (CCL5, IFI6, OAS1, IRF9, IL1B, and TGFB1) was analysed in the upper airway and paired-blood samples from 25 subjects infected with SARS-CoV-2. Relative gene expression was determined by RT-qPCR. Results: CCL5 expression was higher in the blood than in the upper airway (p &lt; 0.001). In addition, a negative correlation was found between IFI6 and viral load (p = 0.033) in the upper airway, suggesting that the IFI6 expression inhibits the viral infection. Concerning sex, women expressed IL1B and IRF9 in a higher proportion than men at a systemic level (p = 0.008 and p = 0.049, respectively). However, an increased expression of IRF9 was found in men compared to women in the upper airway (p = 0.046), which could be due to the protective effect of IRF9, especially in men. Conclusions: The higher expression of CCL5 in blood might be due to the key role of this gene in the migration and recruitment of immune cells from the systemic circulation to the lungs. Our findings confirm the existence of sex differences in the immune response to early stages of the infection. Further studies in a larger cohort are necessary to corroborate the current findings.

TAp73 regulates mitochondrial dynamics and multiciliated cell homeostasis through an OPA1 axis

Dysregulated mitochondrial fusion and fission has been implicated in the pathogenesis of numerous diseases. We have identified a novel function of the p53 family protein TAp73 in regulating mitochondrial dynamics. TAp73 regulates the expression of Optic Atrophy 1 (OPA1), a protein responsible for controlling mitochondrial fusion, cristae biogenesis and electron transport chain function. Disruption of this axis results in a fragmented mitochondrial network and an impaired capacity for energy production via oxidative phosphorylation. Owing to the role of OPA1 in modulating cytochrome c release, TAp73−/− cells display an increased sensitivity to apoptotic cell death, e.g., via BH3-mimetics. We additionally show that the TAp73/OPA1 axis has functional relevance in the upper airway, where TAp73 expression is essential for multiciliated cell differentiation and function. Consistently, ciliated epithelial cells of Trp73−/− (global p73 knock-out) mice display decreased expression of OPA1 and perturbations of the mitochondrial network, which may drive multiciliated cell loss. In support of this, Trp73 and OPA1 gene expression is decreased in chronic obstructive pulmonary disease (COPD) patients, a disease characterised by alterations in mitochondrial dynamics. We therefore highlight a potential mechanism involving the loss of p73 in COPD pathogenesis. Our findings also add to the growing body of evidence for growth-promoting roles of TAp73 isoforms.

Cognitive and Behavioral Outcomes of Snoring Among Adolescents

Snoring is central to sleep-disordered breathing (SDB), which arises from nocturnal upper airway resistance. Habitual snoring is associated with cognitive and behavioral problems in young children, but less is known about these associations in adolescents. To assess the longitudinal associations of snoring with cognition and problem behaviors among adolescents. This cohort study was a secondary analysis of the Adolescent Brain Cognitive Development (ABCD) Study dataset (release 5.0), which enrolled 11 875 children and a parent or caregiver from June 1, 2016, to October 15, 2018, at 21 participating US research institutions and followed-up for 5 years. The analysis was performed between December 2023 and April 2024. Parent-reported snoring categorized as none, nonhabitual (<3 nights/week), and habitual (≥3 times/week). Cognition was assessed using 5 measures from the National Institutes of Health Toolbox (NIH-TB), and caregiver-reported problem behaviors were assessed using the Child Behavior Checklist (CBCL), including Total Problems, Internalizing Problems, and Externalizing Problems. Longitudinal associations of snoring with these assessment measures were analyzed using linear mixed-effects models stratified by obesity. Model fits were assessed after including the fixed-effects of age, sex at birth, race, family income, follow-up time, visit type, and the random-effects of site and identification number. The study included data from 11 862 children at year 1 (mean age, 119.0 months [95% CI, 118.8 to 119.1 months]; 6164 male [52.2%]) and 11 198, 10 870, 10 064, and 4668 children at years 2 to 5, respectively. The proportion of habitual snorers decreased from 811 participants (6.8%) in year 1 to 150 participants (3.2%) in year 5. Snoring was not associated with any of the NIH-TB scores. A statistically significant association of snoring was identified with all CBCL scales. The largest-magnitude association was of snoring with the CBCL Total Problems scale among adolescents with obesity (β = 3.18; 95% CI, 2.59-3.77). In this cohort study analyzing associations of snoring with cognitive test scores and problem behaviors based on the ABCD dataset, the prevalence of snoring declined over time; snoring in adolescents was associated with problem behaviors but not cognitive deficits. These findings may aid shared decision-making regarding treatment options such as adenotonsillectomy for adolescents with SDB.

Influence of natural hyoid bone position and surgical repositioning on upper airway patency: A computational finite element modeling study.

A validated finite element model of the rabbit UA was advanced and used to simulate changes in BHP and SHR, alone and in combination. The hyoid was displaced in cranial, caudal, anterior, anterior-cranial and anterior-caudal directions from 1-4mm. Model outcomes included UA collapsibility, measured using closing pressure (Pclose), cross-sectional area (CSA) and soft tissue mechanics (displacement, stress and strain). Graded BHP increments increased Pclose for all directions, and up to 29-43% at 4mm (relative to the original BHP). Anterior-based SHR decreased Pclose (~-115% at 4mm) and increased ΔCSA (~+35% at 4mm). Cranial SHR decreased ΔPclose (-29%), minimally affecting CSA. Caudal SHR increased ΔPclose (+27%) and decreased ΔCSA (-7%). Anterior-cranial and anterior-caudal SHR produced the highest stresses and strains. SHR effects on UA outcomes were dependent on BHP, with more caudal BHPs leading to less effective surgeries. BHP (phenotype) and SHR both alter UA outcomes, with effects dependent on hyoid displacement direction and magnitude. BHP influences the effectiveness of SHR in reducing UA collapsibility. These findings provide further insights into the hyoid's role in UA patency and suggest that considering the hyoid's baseline position and surgical repositioning direction/increment may help improve hyoid surgeries for OSA treatment.

Upper Airway Block Using Lidocaine Nebulisation Versus Targeted Nerve Block for Awake Fibre-Optic Intubation in Patients with Head and Neck Burns: A Randomised Controlled Trial

Background: A difficult airway is a scenario in which an adequately trained anesthesiologist faces challenges with mask ventilation, endotracheal intubation, or both. Various anesthetic techniques have been proposed to prepare adequately for awake flexible fiber-optic intubation (AFOI), including nerve blocks for the upper airway, topical anesthesia via a specialized cannula, and lidocaine nebulization (LN). Proper anesthesia of the upper airway is crucial for successful AFOI. Objectives: This study aimed to evaluate the efficacy of airway block (AB) by LN compared to traditional upper AB techniques. Methods: This prospective, randomized, single-blinded study was conducted on 100 patients with head and neck burns scheduled for reconstructive surgery. Participants were randomly assigned to two groups of 50 patients each. In the AB group, AFOI was performed following an AB, while in the LN group, AFOI was performed 30 minutes after LN. The primary outcome measured was the time to successful awake nasal fiber-optic intubation. Secondary outcomes included the number of failed attempts and the revised nonverbal pain scale score. The time to successful awake nasal fiber-optic intubation showed no significant difference between the two groups. Results: Although the AB group had a higher number of failed attempts compared to the LN group, statistical analysis revealed no significant difference. Additionally, there was no significant difference in hemodynamic parameters between the groups. Conclusions: Both AB and LN are effective for awake nasal fiber-optic intubation, with comparable intubation times. However, LN offers a less invasive alternative.

Role of Nasopharyngeal Airway in Management of Craniofacial Syndrome-Associated Upper Airway Obstruction in Children.

Upper airway obstruction (UAO) management in children, particularly those with associated anatomical mid-face structural differences, poses a significant challenge. This study describes using a nasopharyngeal airway (NPA) in managing infants with severe upper airway obstruction. Infants discharged home from Queensland Children's Hospital with an NPA insitu for the management of upper airway obstruction were retrospectively evaluated for clinical and demographic parameters, underlying diagnoses and respiratory support, including NPA insertion details and comorbidities. Sixty-seven children (24 male) were included with a median age at NPA insertion of 24 (IQR 7-59) days and a median duration of NPA use of 229.1 (IQR 151.50-297.75) days. Fifty-two (77.6%) had Pierre Robin sequence. Other diagnoses included CHARGE syndrome, Treacher Collins syndrome, Stickler syndrome, Crouzon syndrome, Bohring-Opitz syndrome, isolated cleft palate, Beckwith-Wiedemann syndrome, Chromosome 3 deletion and VACTERL association. Four infants required tracheostomy, and no complications related to NPA use were reported. Those with oximetry and polysomnography data showed improving indices following NPA insertion [pre NPA median (IQR) SpO2: 95.9% (94.73-97.73), AHI: 51.40 (44.50-69.45), OAHI 65.9 (56.45-73.35) and TcCO2 (mmHg) 65.70 (61.95-67.30) vs. post-NPA median (IQR) SpO2: 97.1% (96.19-97.9), AHI: 12.20 (11.25-24.35), OAHI 10.20 (6.12-5.62) and TcCO2 (mmHg) 52.40 (47.90-58.40)]. Our findings highlight the effectiveness and safety of NPA as a noninvasive management option for severe upper airway obstruction in children, particularly in those with anatomical midface structural differences. Further research and larger studies are warranted to confirm these findings and optimise management strategies for these patients.

Changes in Upper Airway Space in a Patient with Pycnodysostosis Following Primary Surgery and Orthodontic Treatment: A 12-Year Follow-Up Case Report

Pycnodysostosis (PDS) is an autosomal recessive form of osteosclerotic skeletal dysplasia characterized by craniofacial anomalies, a high-arched palate, and a narrowed pharyngeal space due to mandibular and maxillary deficiencies. These structural anomalies in the upper airway predispose PDS patients to obstructive sleep apnea (OSA). OSA can be managed in PDS patients using either a conservative (non-surgical and multidisciplinary) approach or surgical interventions. Given the craniofacial anomalies associated with PDS, orthodontic treatment aims to address the maxillary transverse deficit and retrognathia. Currently, there is no evidence regarding the impact of orthodontic therapy on OSA levels among PDS patients. This study reports the long-term morphological and functional changes in the upper airway of a PDS patient following adenotonsillectomy and uvulopalatoplasty at an early age (3.6 years) and orthodontic camouflage in late mixed dentition (10 years). Polysomnographies (PSGs), nuclear magnetic resonance (NMR), and lateral cephalograms taken before and after ENT surgery and orthodontic treatment were analyzed. Lateral X-rays were evaluated for changes in the posterior airway space (PAS), while polysomnographies provided the apnea–hypopnea index (AHI). The NMR scans were segmented to measure the perimeter and radius of the upper airway. The findings of this study indicate that improvements following uvulopalatoplasty (UPP) were partial and temporary. Nonetheless, orthodontic therapy and the use of elastics did not appear to influence the PAS or AHI. Future studies with larger cohorts are needed to evaluate the long-term effectiveness of the UPP procedure. This study was conducted in accordance with the CARE guidelines.

Treatment Outcomes in Awake Endoscopy With Advanced Programming in Hypoglossal Nerve Stimulation.

Hypoglossal nerve stimulation (HNS) is a treatment option for patients with moderate-to-severe obstructive sleep apnea. In the post-implant period, awake endoscopy with advanced programming (AEAP) can be employed to improve apnea hypopnea index (AHI) reduction and/or patient comfort. This study describes response patterns to HNS after AEAP as well as patient-specific patterns in our patient population. Retrospective evaluation of 17 consecutive patients who underwent AEAP between June 2019 and December 2022. Post-AEAP AHIs were used to create 2 response groups, which facilitated analysis of patient-based characteristics. AHI reporting, deemed non-titration AHI (NT-AHI), is the whole-night AHI resulting from non-titration studies. Chi-squared, Pearson correlation coefficient, and independent samples t-test were used to determine significance deemed as P < .05. Fifteen of 17 patients (88.2%) presented for failed NT-AHI reduction, and 2/17 (11.8%) presented for comfort measures. Eleven patients (65%) showed an improvement in post-AEAP NT-AHI; 6 (35%) patients failed to improve. Four patients with either lateral wall collapse or concentric wall collapse at the tongue base failed to improve NT-AHI compared to a single patient who showed an improved NT-AHI (P = .017). Of the 2 patients who presented with discomfort, patient 1/2 demonstrated improvement in device usage, and patient 2/2 reported improved comfort while maintaining average device usage. AEAP is a powerful tool that offers the ability to identify settings conducive to increased therapy efficacy and improved treatment tolerability. Airway phenotypes are closely correlated with treatment efficacy, and as such, careful anatomical consideration of the upper airway must be performed when titrating therapy. Amongst the different treatment options for obstructive sleep apnea, hypoglossal nerve stimulation has been shown to be effective in positive-airway-pressure intolerant patients. This article explores response patterns to AEAP and highlights the importance of careful anatomical considerations of the upper airway. Level 3.

Phenotyping Using Polysomnography Attributes Reduced Respiratory Events after CPAP Therapy to Improved Upper Airway Collapsibility.

Rationale: In patients with obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP), the apnea hypopnea index (AHI) measured off CPAP may be decreased relative to baseline AHI preceding CPAP treatment. Semi-invasive "endo-phenotyping" sleep studies attribute this fall in AHI primarily to improved ventilatory control stability. Phenotyping Using Polysomnography (PUP) attempts to reproduce these studies using routine polysomnography (PSG). Objectives: To determine whether changes in AHI following CPAP associate primarily with changes in PUP-estimated ventilatory control stability (loop gain, LG1) or with changes in other PUP-estimated pathophysiologic mechanisms. Methods: PUP analyses were performed on existing PSGs in research participants who underwent baseline PSG, 4.4±2.2 months CPAP therapy, and CPAP withdrawal with repeat PSG on night 2 of withdrawal. Pre-CPAP PUP-estimated LG1, arousal threshold (ArTH), and upper airway collapsibility (Vpassive) and compensation (Vcomp) were compared to corresponding values during CPAP withdrawal. Mixed effects models were constructed to determine which PUP estimate best explained changes in AHI. Results: PSG data were available for 35 participants (age 47±10.8 years; 12 female; BMI 38.5±8.6 kg/m2, AHI3A 58.8±33.1 events/hr, 9 mild/moderate OSA, 26 severe OSA). Following CPAP, AHI decreased, but the change was not statistically significant. However, a significant decrease was observed in those with severe OSA (pre-CPAP 68.2 [32.6-86.3] versus CPAP withdrawal 49.0 [36.1-74.4] events/hr). Across all participants, changes in PUP estimates did not exceed test-retest agreement limits. For those with severe OSA, decrease in LG1 (0.86 [0.61-1.13] pre-CPAP versus 0.71 [0.61-0.99] on CPAP withdrawal) and increase in Vpassive (64.8 [5.4-88.4] %Veupnea pre-CPAP versus 76.4 [20.7-92.7] %Veupnea on CPAP withdrawal) exceeded test-retest agreement limits. Increased Vpassive, decreased LG1, and decreased ArTH were predictors of decreased AHI in mixed effects models. Vpassive had the greatest estimated effect on AHI. After accounting for Vpassive, additional estimates did not improve model performance. However, Vpassive and LG1 were correlated, and post hoc analyses suggest these estimates may be influenced by both upper airway collapsibility and ventilatory control. Conclusions: According to PUP physiologic estimates, decreases in AHI following several months of CPAP therapy are primarily attributable to improved upper airway collapsibility.

Feasibility of Acoustic Features of Vowel Sounds in Estimating the Upper Airway Cross Sectional Area during Wakefulness: A Pilot Study

Assessment of upper airway dimensions has shown great promise in understanding the pathogenesis of obstructive sleep apnea (OSA). However, the current screening system for OSA does not have an objective assessment of the upper airway. The assessment of the upper airway can accurately be performed by MRI or CT scans, which are costly and not easily accessible. Acoustic pharyngometry or Ultrasonography could be less expensive technologies, but these require trained personnel which makes these technologies not easily accessible, especially when assessing the upper airway in a clinic environment or before surgery. In this study, we aimed to investigate the utility of vowel articulation in assessing the upper airway dimension during normal breathing. To accomplish that, we measured the upper airway cross-sectional area (UA-XSA) by acoustic pharyngometry and then asked the participants to produce 5 vowels for 3 seconds and recorded them with a microphone. We extracted 710 acoustic features from all vowels and compared these features with UA-XSA and developed regression models to estimate the UA-XSA. Our results showed that Mel frequency cepstral coefficients (MFCC) were the most dominant features of vowels, as 7 out of 9 features were from MFCC in the main feature set. The multiple regression analysis showed that the combination of the acoustic features with the anthropometric features achieved an R2 of 0.80 in estimating UA-XSA. The important advantage of acoustic analysis of vowel sounds is that it is simple and can be easily implemented in wearable devices or mobile applications. Such acoustic-based technologies can be accessible in different clinical settings such as the intensive care unit and can be used in remote areas. Thus, these results could be used to develop user-friendly applications to use the acoustic features and demographical information to estimate the UA-XSA.