"Relationship between craniofacial photographicanalysis and severity of obstructive sleep apnea/ hypopnea syndrome in Iranian patients rticle a 1 2 2 3 4 5 Babak Amra, Alireza Peimanfar , Elham Abdi , Mojtaba Akbari , Thomas Penzel , Ingo Fietze , Mohammad Golshan 1 Department of Medicine, Bamdad Respiratory Research Center, Isfahan University of Medical Sciences, Isfahan, Department of Internal2 3 Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran, Departments of5 Cardiology and Pulmology, Center of Sleep Medicine, Charité — Universitätsmedizin Berlin, Germany, Bamdad Respiratory Research Center,Isfahan, Iran Background: Considering the efectiveness of craniofacial photographic analysis for diagnosis and management of obstructive sleepriginal apnea-hypopnea syndrome (OSAHS) as well as ethnic diferences in indexes measured by this method, this study designed to comparethe surface facial dimensions, including nose width, intercanthal width and mandibular width of Iranian patients with mild, moderateand severe OSAHS. Materials and Methods: In this cross sectional study subjects with mild, moderate and severe OSAHS basedon apnea-hypopnea index, were studied. To determine cephalometric measurements, face and neck digital photographs were takenfrom participants following a standardized procedure. Cephalometric measurements including face, intercanthal and mandibularwidths were compared between studied groups. Results: In this study, 100 participants enrolled. From which 20 (20.8%), 35 (36.45%)and 41 (42.7%) of them had mild, moderate and severe OSAHS, respectively. Mean of nose, intercanthal and mandibular width weresignifcantly higher in patients with severe OSAHS than those with mild or moderate OSAHS (P < 0.05).In both genders, mandibularwidth were higher in severe forms of OSAHS. Disease severity was signifcantly associated with increased age and mandibular width(P < 0.05). Conclusion: Mandibular width was the most important index, which had a signifcant association with the disease severity.It seems that our results could be used both for diagnosis and follow-up of OSAHS management. Tey could be used as baselineinformation as well as a clinical and research tool in the feld of OSAHS. Key words: Intercanthal, mandible, nose, obstructive sleep apnea hypopnea syndrome, severity How to cite this article: Amra B, Peimanfar A, Abdi E, Akbari M, Penzel T, Fietze I, Golshan M. Relationship between craniofacial photographic analysisand severity of obstructive sleep apnea/hypopnea syndrome in Iranian patients. J Res Med Sci 2015;20:62-5. Computed tomography, magnetic resonance imagingINTRODUCTION (MRI) and cephalometry are the most accurate diagnostictools, which provide details of bony and sof tissueObstructive sleep apnea-hypopnea syndrome (OSAHS)structures properly. These methods commonly used foris characterized by coexistence of daytime sleepinessresearch applications due to their higher cost, radiation[1] with at least fve apnea or hypopnea per hour of sleep.exposure and time-consuming analysis. Thus, the useThis condition occurs in around 1-4% of middle-agedof some noninvasive alternative methods including[2-4] males. craniofacial anthropometry and photogrammetryhas been developed recently. Accordingly the laterIn patients with OSAHS, airway narrowing and decreasemethods have not the limitation of previous methods.[1] in its muscle tone lead to airway obstruction. InRecently photogrammetry has become as one of theaddition, the patients are at increased of hypertension,favorable methods due to its noninvasively and readilydiabetes mellitus, hepatic dysfunction, somnolence,[9,10] accessibility. [5] nocturia and nocturnal choking. Several investigations revealed signifcant diferences inThough the most important risk factor in the pathogenesiscraniofacial morphological parameters of subjects with[11] of OSAHS is obesity, but there are growing the body ofand without OSAHS. evidences that indicated that craniofacial morphologyalso considered as an important interacting factor in It is recognized from these studies that the correlation[6-8] this regard. between the number of surface facial dimensions andAddress for correspondence: Dr. Alireza Peimanfar, Department of Internal Medicine, Schoolof Medicine, Isfahan University of Medical Sciences,Isfahan, Iran. E-mail: [email protected] Received: 20-08-2014; Revised: 04-10-2014; Accepted: 01-12-2014 Journal of Research in Medical Sciences | January 2015 | 62 O Amra, et al.: Craniofacial photographic analysis in sleep apnea upper airway structures and craniofacial morphology Canon, Japan). Bony landmarks were preidentifed in the[12,13] appear useful for prediction of OSAHS. Moreover, these patients by palpation and marked with red tapes. Pixel[14,15] craniofacial features difer between ethnic populations. measurements were converted to metric dimensions usingimage analysis sofware (image J1, 44p; java1.6.0-20 [32-bit],Hence, considering the efectiveness of mentioned assay 41scommands; 58 macros). for diagnosis and management of the disease as well asethnic diferences in indexes measured by this method, this These measurements represented mandibular widthstudy designed to compare the surface facial dimensions, (distance between right mandibular angle and leftincluding nose width, intercanthal width and mandibular mandibular angle), intercanthal width and nose width. width of Iranian patients with mild, moderate and severeOSAHS. Statistical analysis Data analyzed using SPSS version 20 (SPSS Inc., Chicago, IL,MATERIALS AND METHODS USA) sofware. Continuous and categorical variables wereth presented as mean (standard deviation) or median (25 andth In this cross sectional study, subjects complaining of 75 percentiles) and number (%), respectively. Shapiro– snoring, daytime sleepiness and dyspnea referred to a Wilk test was used to determine the normal distributionprivate sleep disorder clinic for polysomnography fromof studied variables. Continuous and categorical variablesJanuary 2013 to December 2013 were enrolled. in studied groups were compared using Kruskal–Wallisand Chi-square tests, respectively value <0.05 consideredThe protocol of the study was approved by the Regionalstatistically signifcant. Ethics Commitee of the Isfahan University of MedicalSciences (research project number: 392294). RESULTS From selected subjects those with craniofacial anomaliesTotally 100 participants were enrolled in this study.associated with syndromes (such as apert and crouzon), According to the fndings of polysomnograghy 4 of themexcessive facial hair, previous facial trauma which afected were cases of simple snorers, and they had <5 episodes offacial landmarks, systemic disease (such as renal failure,apnea/hypopnea per hour while the other 96 patients werethyroid dysfunction) and psychiatric disorders were diagnosed with OSAHS. Mean age of patients with OSAHSexcluded from the study. From which those with apnea/ was 48.6 ± 12.3 with a male:female ratio of 2:1. From studiedhypopnea index (AHI) values >5 diagnosed as those withpopulation 20 (20.8%), 35 (36.45%) and 41 (42.7%) of themOSAHS were selected fnally. Selected patients underwent had mild, moderate and severe OSAHS, respectively. full overnight polysomnography and based on the AHIthey classifed in three groups of severity of the disease Demographic characteristics and cephalometricas follows; mild (5= AHI <15), moderate (15= AHI <30) measurements of studied population in three subgroups[16] and severe (30= AHI). To determine cephalometric of OSAHS are presented in Table 1. Accordingly patientsmeasurements, face and neck digital photographs with moderate to severe OSAHS were significantlywere taken from participants following a standardized older than milder ones. Mean of nose, intercanthal andprocedure on the same day as the polysomnography. mandibular width were signifcantly higher in patientsCephalometric measurements were compared between with severe OSAHS than those with mild or moderatestudied groups. OSAHS (P < 0.05). Cephalometric measurements Cephalometric measurements of studied population in threePhotographs obtained with the patients seated upright in subgroups of OSAHS according to sex groups are presenteda straight ahead and in the extended head position using a in Table 2. In both genders, mandibular width were highersingle lens refex digital camera (SX 220 HS 50-70 mm lens; in severe forms of OSAHS. Table 1: Demographics characteristics and cephalometric measurements of patients with mild, moderate and severe OSAHS Characteristic Mild OSAHS (n = 20) Moderate OSAHS (n = 35) Severe OSAHS (n = 41) Total (n = 96) P Age (year) 41.1±11.9 51.2±11.7 50.2±11.8 48.69±12.31 0.007 Gender (female/male) 9/11 13/22 9/32 31/65 0.145 Nose width (mm) 42.03±4.11 41.43±4.60 44.32±5.6 42.39±5.26 0.009 Intercanthal width (mm) 39.35±4.14 38.82±3.9 40.69±3.87 39.32±4.12 0.011 Mandibular width (mm) 105.86±8.00 110.24±9.86 124.47±10.58 113.96±11.65 <0.0001 OSAHS = Obstructive sleep apnea hypopnea syndrome Journal of Research in Medical Sciences 63 | January 2015 |Amra, et al.: Craniofacial photographic analysis in sleep apnea The relation between studied cephalometric measurements that the Chinese had more craniofacial bony restriction than[19] and severity of OSAHS using logistic regression are Caucasian in the same degree of OSAHS severity. presented in Table 3. Accordingly disease severity wasMost reported studies in this field have comparedassociated with increased age and mandibular width. phenotypical craniofacial indexes among patients withOSAHS and a group of healthy subjects. There were fewDISCUSSION studies regarding the association of the indexes and OSAHAaccording to the disease severity. Previous researchesIn this study, diferences between phenotypic craniofacialindexes performed using craniofacial photogrammetry that indicated the relationship between craniofacialmeasurements and OSAHS severity mostly used the necktechnique among patients with different degree ofmeasurements. They suggested that from craniofacialOSAHS. The results demonstrated increased value of nose,measurements face and mandibular width may be usefulintercanthal and mandibular width in patients with severe[20] for evaluating OSAHS severity. OSAHS. Severity of the disease was signifcantly associatedwith increased age and mandibular width. In this study, we compare the indexes in patients withdiferent degree of OSAHS. The implication of our resultsIn this study, we used craniofacial photogrammetry methodcould be used for diagnosis, treatment and follow-up ofamong Iranian population. patients with OSAHS. In our study though mean of nose,intercanthal and mandibular width in patients with severeThough the method which is used in this study is notOSAHS were signifcantly higher than moderate and mildthe gold standard diagnostic tool in this regard, butform of the disease, but logistic regression showed that fromsome of its advantages including its availability, safety,mentioned indexes only mandibular width had signifcantinexpensiveness and quick made results made it as a feasibleassociation with severity of the disease. The importance oftechnique. Moreover, evidences confrmed that it capturesmandibular index measured both by MRI and phenotypicalboth skeletal anatomy and sof tissues and diferent indexescraniofacial measurements in patients with OSAHS havemeasured by this method allow quantifcation of the surface[20,21] [17] been reported in many studies. morphology. These mentioned advantages could notassess by other imaging techniques. The method was frst described by Lee et al. In a case-controlstudy, they have investigated the craniofacial morphologicalSeveral researches worldwide showed that the measuresphenotype of patients with OSAHS and a control group. In[18,19] are diferent in various ethnic groups. Lee et al. reportedtheir primary analysis, patients have higher measurementsof mandible (13.0 ± 0.11 vs. 12.3 ± 0.12), intercanthalTable 2: Cephalometric measurements of studied(3.50 ± 0.04 vs. 3.27 ± 0.05) and nose (3.97 ± 0.04 vs. 3.72 ±population in three subgroups of OSAHS according[20] 0.05) width than control group. to sex groups Characteristic Mild OSAHS Moderate Severe P Comparing their measurements with ours, it seems thatOSAHS OSAHS Iranian patients with OSAHS had lower mandibular widthMale Nose width 40.23±4.9 43.05±4.5 44.55±6.15 0.08 and higher nose and intercanthal width than AustralianIntercanthal width 37.58±5.19 40.20±3.68 41.09±3.90 0.05 population. Iranian patients with moderate to severeMandibular width 104.87±10.06 112.25±10.62 122.68±11.10 0.000 OSAHS had increased value of mentioned measurementsFemale than those with a mild form of the disease. Nose width 39.94±3.11 38.70±3.34 43.51±3.71 0.01 Intercanthal width 37.22±2.6 36.47±3.34 39.26±3.6 0.15 Albajalan et al. have indicated that Malay subjects with moderate- Mandibular width 107.07±4.72 106.85±7.63 115.64±6.22 0.008 severe OSAHS had a shorter maxillary and mandibular lengthOSAHS = Obstructive sleep apnea hypopnea syndrome [22] when compared with a mild OSAHS sample. Table 3: The relation between studied cephalometricmeasurements and severity of OSAHS Regarding sex diferences the results of the current studyVariable OR (95% CI) P showed that the mandibular width was higher in severeAge 7.38 (1.02–1.15) 0.007 forms of the disease both in male and female, but reminderSex 1.19 (0.13–1.77) 0.27 indexes were not similar in both genders. It seems that theNose width 0.47 (0.86–1.36) 0.49 results would be more accurate with larger sample size. Intercanthal width 0.01 (0.79–1.30) 0.9 Mandibular width 6.47 (1.02–1.17) 0.01 In this study, there was a signifcant association betweenOSAHS = Obstructive sleep apnea hypopnea syndrome; OR = Odds ratio;CI = Confdence interval increasing age and severity of OSAHS. Lam et al. in CanadaJournal of Research in Medical Sciences | January 2015 | 64Amra, et al.: Craniofacial photographic analysis in sleep apnea tissue by MRI of patients with obstructive sleep apnea hypopneaalso have indicated that patients with obstructive sleep[23] syndrome. Sleep 2006;29:909-15. apnea were older than healthy subjects. 7. Miles PG, Vig PS, Weyant RJ, Forrest TD, Rockette HE Jr.Craniofacial structure and obstructive sleep apnea syndrome –The limitations of this study were small sample size, lack ofa qualitative analysis and meta-analysis of the literature. Am Ja control group and lack of lateral dimensions of craniofacialOrthod Dentofacial Orthop 1996;109:163-72. 8. Lowe AA, Fleetham JA, Adachi S, Ryan CF. Cephalometric andstructures. computed tomographic predictors of obstructive sleep apneaseverity. Am J Orthod Dentofacial Orthop 1995;107:589-95. In sum, the findings of the current study indicated the9. Todd ES, Weinberg SM, Berry-Kravis EM, Silvestri JM, Kenny AS,phenotypic craniofacial differences among patients withRand CM, et al. Facial phenotype in children and young adults withdifferent severity of OSAHS using the novel method ofPHOX2B-determined congenital central hypoventilation syndrome:Quantitative patern of dysmorphology. Pediatr Res 2006;59:39-45. craniofacial photographic analysis. Mandibular width was10. Kitano I, Park S, Kato K, Nita N, Takato T, Susami T. Craniofacialthe most important index which had a signifcant associationmorphology of conotruncal anomaly face syndrome. Clef Palatewith the disease severity. It seems that our results could be usedCraniofac J 1997;34:425-9. both for diagnosis and follow-up of OSAHS management. Our11. Hui DS. Craniofacial profle assessment in patients with obstructiveresults could be used as baseline information as well as a clinicalsleep apnea. Sleep 2009;32:11-2. and research tool in the feld of OSAHS. It is recommended 12. Benumof JL. Obstructive sleep apnea in the adult obese patient:Implications for airway management. J Clin Anesth 2001;13:144-56. to design further studies with consideration of mentioned13. Sforza E, Bacon W, Weiss T, Thibault A, Petiau C, Krieger J. Upperlimitation for obtaining more conclusive results in this regard. airway collapsibility and cephalometric variables in patients withobstructive sleep apnea. Am J Respir Crit Care Med 2000;161: 347-52. ACKNOWLEDGMENTS 14. Wong ML, Sandham A, Ang PK, Wong DC, Tan WC, Huggare J.Craniofacial morphology, head posture, and nasal respiratoryWe thank the University authorities who offered critical resistance in obstructive sleep apnoea: An inter-ethnic comparison.Eur J Orthod 2005;27:91-7. administrative support and managerial services in carrying15. Cakirer B, Hans MG, Graham G, Aylor J, Tishler PV, Redline S.out the study, and also all of the researchers for their help andThe relationship between craniofacial morphology and obstructivesupport. This paper was derived from a research project (researchsleep apnea in whites and in African-Americans. Am J Respir Critproject number; 392294) approved by School of Medicine, IsfahanCare Med 2001;163:947-50. University of Medical Sciences. 16. Sleep-related breathing disorders in adults: Recommendationsfor syndrome defnition and measurement techniques in clinicalAUTHOR’S CONTRIBUTION research. The Report of an American Academy of Sleep MedicineTask Force. Sleep 1999;22:667-89. 17. Lee RW, Sutherland K, Chan AS, Zeng B, Grunstein RR,BA, AP, EA, TP,IF and MG contributed to the design ofDarendeliler MA, et al. Relationship between surface facialthe work. MA analyzed data and interpreted the work.dimensions and upper airway structures in obstructive sleepAP and EA drafed the work. BA, AP, EA, MA, and TPapnea. Sleep 2010;33:1249-54. were involved in revising article. All authors approved the18. Hui DS, Ko FW, Chu AS, Fok JP, Chan MC, Li TS, et al.version to be published and agreed to be accountable forCephalometric assessment of craniofacial morphology in Chinesepatients with obstructive sleep apnoea. Respir Med 2003;97:640-6. all aspects of the work. 19. Lee RW, Vasudavan S, Hui DS, Prvan T, Petocz P, Darendeliler MA,et al. Diferences in craniofacial structures and obesity in CaucasianREFERENCES and Chinese patients with obstructive sleep apnea. Sleep2010;33:1075-80. 1. Fogel RB, Malhotra A, Dalagiorgou G, Robinson MK, Jakab M,20. Lee RW, Chan AS, Grunstein RR, Cistulli PA. CraniofacialKikinis R, et al. Anatomic and physiologic predictors of apneaphenotyping in obstructive sleep apnea – a novel quantitativeseverity in morbidly obese subjects. Sleep 2003;26:150-5. photographic approach. Sleep 2009;32:37-45. 2. Hui DS, Ko FW, Chan JK, To KW, Fok JP, Ngai JC, et al. Sleep- 21. Sutherland K, Schwab RJ, Maislin G, Lee RW, Benedikstdsotir B,disordered breathing and continuous positive airway pressurePack AI, et al. Facial phenotyping by quantitative photographycompliance in a group of commercial bus drivers in Hong Kong.reflects craniofacial morphology measured on magneticRespirology 2006;11:723-30. resonance imaging in Icelandic sleep apnea patients. Sleep3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The2014;37:959-68. occurrence of sleep-disordered breathing among middle-aged22. Albajalan OB, Samsudin AR, Hassan R. Craniofacial morphologyadults. N Engl J Med 1993;328:1230-5. of Malay patients with obstructive sleep apnoea. Eur J Orthod4. Kim J, In K, Kim J, You S, Kang K, Shim J, et al. Prevalence of sleep- 2011;33:509-14. disordered breathing in middle-aged Korean men and women.23. Lam B, Ip MS, Tench E, Ryan CF. Craniofacial profle in Asian andAm J Respir Crit Care Med 2004;170:1108-13. white subjects with obstructive sleep apnoea. Thorax 2005;60:504-10. 5. Young T, Peppard PE, Taheri S. Excess weight and sleep-disorderedbreathing. J Appl Physiol (1985) 2005;99:1592-9. Source of Support: Isfahan University of Medical Sciences (research project6. Okubo M, Suzuki M, Horiuchi A, Okabe S, Ikeda K, Higano S,number: 392294). Confict of Interest: None declared. et al. Morphologic analyses of mandible and upper airway sofJournal of Research in Medical Sciences 65 | January 2015 |"