Postural Mechanisms That Maintain Airway Adequacy In Obstructive Sleep Apnoea As Determined By Magnetic Resonance Imaging

Objective: This magnetic resonance imaging (MRI) study aimed to explored associations between neutral head posture, size, and shape of the pharyngeal airway and the severity of obstructive sleep apnoea (OSA). Methods: A retrospective methodology was used to study 90 male patients who had already undergone overnight polysomnography and cervical MRI. 60 cases of OSA were compared with a control group of 30 mild OSA (or straightforward snoring) cases in terms of MRI, with the aim to examine how neutral head posture, the pharynx and the adjacent anatomical structures interact. MRI was performed in all cases with the patient supine and head held in neutral position. Measurements were taken of the Craniocervical extension (CCE) and epiglot angle, length of the tongue root, distance between the hyoid and the plane of the mandible (MP-H distance), and the diameter of the pharyngeal airway at seven points were measured. Results: Differences in shape were more perceptible at the caudal levels. In the OSA group, the shapes were more oblique. The retroglossal level was where the largest shape difference was apparent. After adjusting for body mass index and age, neutral head posture was correlated with OSA severity. There was a correlation between CCE and lengthening of the tongue root, MP-H distance, epiglot angle, and the two most caudal airway areas. Conclusions: Overall, increased length of the root of the tongue, MP-H distance, and epiglot angle are associated with CCE in OSA patients and resulted in a larger and more oblique airway in the majority of caudal planes. Such an alteration may be viewed as an adaptation in posture designed to keep the airway sufficiently open in patients suffering from OSA.

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1. Prisant LM, Dillard TA, Blanchard AR. Obstructive sleep apnea syndrome. J Clin Hypertens. 2006;8:746-50.

2. Guilleminault C, Tilkian A, Dement WC. The sleep apnea syndromes. Annu Rev Med. 1976;27:465-84.

3. Ciscar MA, Juan G, Martínez V, Ramón M, Lloret T, Mínguez J, Armengot M, Marín J, Basterra J. Magnetic resonance imaging of the pharynx in OSA patients and healthy subjects. Eur Respir J. 2001;17(1):79-86.

4. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis. 1993;148(5):1385- 400.

5. Suratt PM, Dee P, Atkinson RL, Armstrong P, Wilhoit SC. Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis. 1983;127:487-92.

6. Lenza MG (1), Lenza MM, Dalstra M, Melsen B, Cattaneo PM. An analysis of different approaches to the assessment of upper airway morphology: a CBCT study. Orthod Craniofac Res. 2010;13(2):96-105. doi:10.1111/ j.1601-6343.2010.01482.x.

7. Abbott MB, Donnelly LF, Dardzinski BJ, Poe SA, Chini BA, Amin RS. Obstructive sleep apnea: MR imaging volume segmentation analysis. Radiology. 2004;232:889-95.

8. Schwab RJ. Upper airway imaging. Clin Chest Med. 1998;19:33-54.

9. Di Carlo G (1), Polimeni A, Melsen B, Cattaneo PM. The relationship between upper airways and craniofacial morphology studied in 3D. A CBCT study. Orthod Craniofac Res. 2015;18:1-11. doi: 10.1111/ocr.12053.

10. Solow B, Skov S, Ovesen J, Norup PW, Wildschiødtz G. Airway dimensions and head posture in obstructive sleep apnoea. Eur J Orthod. 1996;18:571-9.

11. Sonnesen L, Petersson A, Berg S, Svanholt P. Pharyngeal airway dimensions and head posture in obstructive sleep apnea patients with and without morphological deviations in the upper cervical spine. J Oral Maxillofac Res. 2017;30;8:e4. doi: 10.5037/jomr.2017.8304.

12. Ozbek MM, Miyamoto K, Lowe AA, Fleetham JA. Natural head posture, upper airway morphology and obstructive sleep apnoea severity in adults. Eur J Orthod. 1998;20:133-43.

13. Iber C, Ancoli-Israel S, Chesson A, Quan S (2007) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. American Academy of Sleep Medicine, Westchester

14. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Ward SLD, Tangredi MM (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med 8:597–619. https:// doi.org/10.5664/jcsm.2172

15. Ono T, Otsuka R, Kuroda T, Honda E, Sasaki T.J Dent Res. Effects of head and body position on two- and three-dimensional configurations of the upper airway. 2000;79:1879-84.

16. Pirilä-Parkkinen K(1), Pirttiniemi P, Pääkkö E, Tolonen U, Nieminen P, Löppönen H. Pharyngeal airway in children with sleep-disordered breathing in relation to head posture. Sleep Breath. 2012;16:737-46. doi:10.1007/ s11325-011-0569-y.

17. Zhang W (1), Song X, Masumi SI, Tanaka T, Zhu Q. Effects of head and body positions on 2- and 3-dimensional configuration of the oropharynx with jaw protruded: A magnetic resonance imaging study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111:778-84. doi:10.1016/j.tripleo.2011.02.019.

18. Gurani SF, Di Carlo G, Cattaneo PM, Thorn JJ, Pinholt EM. Effect of head and tongue posture on the pharyngeal airway dimensions and morphology in three-dimensional imaging: A systematic review. J Oral Maxillofac Res. 2016;31;7:e1. doi: 10.5037/jomr.2016.7101.

19. Solow B, Ovesen J, Nielsen PW, Wildschiødtz G, Tallgren A. Head posture in obstructive sleep apnoea. Eur J Orthod. 1993;15:107-14.

20. Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. Obstructive sleep apnoea: a cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Eur J Orthod. 1995;17:45-56.

21. Polo OJ, Tafti M, Fraga J, Porkka KV, Déjean Y, Billiard M. Why don’t all heavy snorers have obstructive sleep apnea? Am Rev Respir Dis. 1991;143:1288-93.

22. Koski K, Lähdemäki P. Adaptation of the mandible in children with adenoids. Am J Orthod. 1975 Dec;68(6):660-5.

23. Ünlü M, İriz A, Doğan BA, Dinç ASK, Dursun E, Eryılmaz A , Acar A. Relationship between obesity with symptoms and findings of obstructive sleep apnea syndrome. J Med Updates 2014;4:11-15 doi:10.2399/ jmu.2014001003

24. Safiruddin F, Vanderveken OM, de Vries N, Maurer JT, Lee K, Ni Q, Strohl KP (2015) Effect of upper-airway stimulation for obstructive sleep apnea on airway dimensions. Eur Respir J 45:129–138. https://doi. org/10.1183/09031936.00059414