The purpose of this research was to elucidate the relationship between tonsillar hypertrophy and Obstructive Sleep Apnea Syndrome (OSAS) in terms of cephalometric analysis, as well as to determine factors that affect OSAS severity. 25 patients were enrolled in this study. Lateral cephalograms of the subjects were taken. Disease severity was evaluated by the Apnea Hypopnea Index (AHI). Cephalometric measurements (angle between line S-N and line N-A (SNA), angle between line S-N and line N-B (SNB), distance between the Mandibular Plane and the Hyoid (MPH), posterior airway space, the width of the airway behind the base of tongue along the B-Go line (PAS), upper airway space, the distance parallel to long axis of the airway, between a horizontal plane tangent to the superior aspect of the hyoid and a horizontal plane tangent to the posterior palate (UAL), multiplication of PAS and UAL (PAS × UAL)) were analyzed and compared between the groups with and without tonsillar hypertrophy. PAS and PAS × UAL were lower in the no hypertrophy group. SNB was significantly lower in the severe apnea group than mild to moderate group in no hypertrophy group (p = 0.035). In conclusion, patients with tonsillar hypertrophy had severe obstruction, but they had a relatively larger pharyngeal space on cephalometric analysis. After exclusion of the tonsillar hypertrophy group, cephalometric analysis could be more effective for analyzing OSAS severity.
Obstructive Sleep Apnea Syndrome (OSAS) is a potentially life-threatening disorder caused by repetitive narrowing and occlusion of the upper airway during sleep, and it has been associated with loud snoring and apnea. OSAS is considered to be a risk factor for hypertension, ischemic myocardial diseases, and cerebral vascular diseases [
Especially in our company, which has many railway employees, if apnea symptoms were to happen during work hours, a serious disaster could occur.
Cephalometric analysis has been used by many authors to evaluate the severity of OSAS [
The aim of the present investigation is to study the relation between tonsillar hypertrophy and cephalometric analyses and efficacy of cephalometric analyses for OSAS severity.
1) Patients who were suspected to have obstructive sleep apnea syndrome (OSAS) based on a medical examination referring to International Classification of Sleep Disorders-Third Edition (ICSD-3) [
The OSAS examination included the Epworth sleepiness scale (ESS) [
And all patient’s background data including age, sex and mean AHI were recorded.
2) Cephalometric analyses
Lateral cephalograms of the subjects were taken with the Frankfort horizontal plane (FH plane) parallel to the floor and with the patient in centric occlusion. The cephalograms were traced to identify hard and soft tissue landmarks (
3) Statistical analysis
Patients’ background characteristics included age and BMI. Severity of disease was evaluated using the AHI from International Classification of Sleep Disorders-Third Edition (ICSD-3) as follows.
Mild: AHI 5 - 15.
Moderate: AHI 15 - 30.
Severe: AHI more than 30.
The SNA, SNB, MPH, PAS, UAL, and PAS × UAL values of cephalometric analysis were compared (
1) Overall analysis
The data of all 25 patients are shown in
The patients were divided into two groups based on the AHI score (<30 and ≥30). An AHI score of <30 indicates mild and moderate OSAS, while an AHI score of ≥30 indicates severe OSAS.
In terms of age, there is no difference between them.
BMI of AHI > 30 group is larger that of AHI < 30, but there is no difference.
SNB was lower and UAL was higher in the severe apnea group, but the differences were not significant.
There were no significant differences between the groups (
2) Comparison of the groups with and without tonsillar hypertrophy
Age and BMI are higher in no-hypertrophy group without difference.
PAS and PAS × UAL were significantly lower in the non-hypertrophy group, p values were 0.011 and 0.009
respectively (
3) Non-hypertrophy group analysis
Tonsillar hypertrophy patients were excluded, and only the remaining18 patients without hypertrophy were analyzed. The patients were divided into two groups based on the AHI score (<30 and ≥30).
Age is same in both group. BMI is higher in AHI > 30 group, but there is no difference.
SNB was significantly lower in the severe apnea group, and PAS and PAS × UAL were lower and MPH and UAL were higher in the severe apnea group, but the differences were not significant (
OSAS is a sleep disorder causing excessive daytime sleepiness due to fragmentation of sleep and a chronic shortage of sleep. Napping and carelessness resulting from OSAS increases the risk of accidents. Because of the seriousness of such potential accidents, railroad companies and public transportation facilities try to prevent those caused by OSAS.
In our company, OSAS screening is performed. As part of examinations for OSAS, cephalometric analyses are often used and reported [
In our overall analysis (
Case | Tonsil hypertrophy | Age year old | AHI | BMI | SNA | SNB | PAS | MPH | UAL | PAS × UAL |
---|---|---|---|---|---|---|---|---|---|---|
1 | - | 53 | 70.7 | 23.5 | 84.5 | 82.3 | 9.1 | 10.6 | 75.8 | 689.8 |
2 | - | 67 | 77.3 | 24.0 | 73.1 | 71.8 | 7.1 | 21.4 | 87.1 | 618.4 |
3 | - | 32 | 69.2 | 28.1 | 82.7 | 76.6 | 10.7 | 22.9 | 81.4 | 871.0 |
4 | - | 49 | 77.5 | 27.7 | 81.2 | 75.9 | 7.9 | 28.6 | 85.7 | 677.0 |
5 | - | 31 | 16.2 | 20.3 | 83.5 | 80.2 | 9.5 | 20.3 | 82.4 | 782.8 |
6 | - | 52 | 71.4 | 23.9 | 77.5 | 73.9 | 9.7 | 18.1 | 88.9 | 862.3 |
7 | - | 49 | 20.4 | 18.8 | 77.7 | 79.5 | 13.5 | 8.1 | 81.1 | 1094.9 |
8 | - | 27 | 57.6 | 37.2 | 80.5 | 76.8 | 19.1 | 16.2 | 79.4 | 1516.5 |
9 | - | 33 | 51.6 | 33.1 | 75.7 | 73.2 | 7.6 | 15.2 | 72.7 | 552.5 |
10 | - | 28 | 45.4 | 31.7 | 80.9 | 74.8 | 12.5 | 23.4 | 89.1 | 1113.8 |
11 | - | 64 | 78.9 | 22.0 | 86.5 | 79.3 | 9.1 | 16.7 | 81.8 | 744.4 |
12 | - | 68 | 55.6 | 25.7 | 78.8 | 79.8 | 13.2 | 27.9 | 88.2 | 1164.2 |
13 | - | 53 | 64.1 | 25.3 | 78.3 | 73.4 | 7.7 | 24.3 | 90.8 | 699.2 |
14 | - | 54 | 27.7 | 24.6 | 85.3 | 85.1 | 7.6 | 21.2 | 72.7 | 552.5 |
15 | - | 74 | 25.8 | 18.1 | 80.6 | 76.8 | 23.0 | 14.9 | 74.3 | 1708.9 |
16 | - | 44 | 28.0 | 37.2 | 78.1 | 77.2 | 16.4 | 24.7 | 86.3 | 1415.3 |
17 | - | 75 | 63.0 | 23.5 | 85.3 | 79.8 | 10.3 | 28.8 | 87.9 | 905.4 |
18 | - | 48 | 23.2 | 28.4 | 86.3 | 80.2 | 10.2 | 8.5 | 74.6 | 760.9 |
19 | + | 37 | 55.4 | 22.1 | 83.1 | 78.2 | 11.4 | 18.6 | 80.0 | 912.0 |
20 | + | 34 | 94.5 | 28.7 | 88.7 | 83.4 | 27.9 | 19.1 | 77.9 | 2173.4 |
21 | + | 28 | 68.2 | 25.1 | 85.3 | 85.6 | 17.8 | 27.4 | 89.0 | 1584.2 |
22 | + | 36 | 68.9 | 34.9 | 79.9 | 77.7 | 22.4 | 29.3 | 94.8 | 2123.5 |
23 | + | 29 | 24.3 | 21.0 | 79.5 | 79.5 | 15.4 | 15.4 | 84.6 | 1302.8 |
24 | + | 35 | 40.1 | 28.1 | 78.0 | 76.5 | 14.8 | 7.4 | 92.6 | 1370.5 |
25 | + | 54 | 35.9 | 20.8 | 84.0 | 77.4 | 11.3 | 3.8 | 77.4 | 874.6 |
<30 | (7 cases) | ≥30 | (18 cases) | p value | |
---|---|---|---|---|---|
mean | SD | mean | SD | ||
age | 47.0 | 14.0 | 45.8 | 15.1 | 0.952 |
BMI | 24.1 | 6.3 | 27.0 | 4.5 | 0.146 |
SNA | 81.6 | 3.2 | 81.3 | 3.9 | 0.952 |
SNB | 79.8 | 2.5 | 77.6 | 3.6 | 0.096 |
PAS | 13.7 | 4.8 | 12.8 | 5.5 | 0.565 |
MPH | 16.2 | 5.9 | 20.0 | 7.3 | 0.204 |
UAL | 79.4 | 5.1 | 84.5 | 6.1 | 0.074 |
PAS × UAL | 1088.3 | 382.8 | 1080.7 | 475.9 | 0.832 |
Hyper | (7 cases) | Non-hyper (18 cases) | p value | |||
---|---|---|---|---|---|---|
Mean | SD | Mean | SD | |||
Age | 36.1 | 8.0 | 48.6 | 15.0 | 0.102 | |
AHI | 55.3 | 22.2 | 52.3 | 21.5 | 0.904 | |
BMI | 25.8 | 4.8 | 26.3 | 5.4 | 0.904 | |
SNA | 82.6 | 3.5 | 80.3 | 3.7 | 0.431 | |
SNB | 79.8 | 3.2 | 77.3 | 3.4 | 0.238 | |
PAS | 17.3 | 5.6 | 11.5 | 4.2 | 0.011 | * |
MPH | 17.3 | 8.7 | 19.7 | 6.3 | 0.586 | |
UAL | 85.2 | 6.6 | 82.4 | 6.0 | 0.364 | |
PAS × UAL | 1477.3 | 483.8 | 941.5 | 329.4 | 0.009 | * |
<30 | (6 case) | ≥30 | (12 case) | p value | ||
---|---|---|---|---|---|---|
Mean | SD | Mean | SD | |||
Age | 50.0 | 12.9 | 50.1 | 16.0 | 0.815 | |
BMI | 23.6 | 6.7 | 27.1 | 4.4 | 0.325 | |
SNA | 81.9 | 3.3 | 80.4 | 3.8 | 0.542 | |
SNB | 79.8 | 2.7 | 76.5 | 3.1 | 0.035 | * |
PAS | 13.4 | 5.2 | 10.3 | 3.2 | 0.241 | |
MPH | 16.3 | 6.3 | 21.2 | 5.6 | 0.134 | |
UAL | 78.6 | 5.0 | 84.1 | 5.5 | 0.068 | |
PAS × UAL | 1052.6 | 402.5 | 867.9 | 265.2 | 0.426 |
This means that subjects with tonsillar hypertrophy had severe obstruction, even though they had a relatively large pharyngeal space on cephalometric analysis. Thus, evaluation of tonsillar condition is worthwhile, since tonsillectomy may offer a cure for OSAS.
In next step, in non-hypertrophy group, influencing factor were analyzed (
In the study, PAS was lower and MPH was higher in the severe OSAS group, however the differences were not significant. Only SNB was significantly lower in severe OSAS group.
This phenomenon is clear and reasonable, since retrognathia causes a small pharyngeal space. Although in this study we evaluated only small cases, our study could serve for future studies.
In the present study, after exclusion of subjects with tonsillar hypertrophy, cephalometric analysis became more effective. With careful evaluation of oropharyngeal findings, cephalometric analysis could be an important tool for evaluating OSAS severity.
Patients with tonsillar hypertrophy had severe obstruction, but they had a relatively larger pharyngeal space on cephalometric analysis. After exclusion of the tonsillar hypertrophy group, cephalometric analysis could be more effective for analyzing OSAS severity.
The study was compiled with the rules laid down by the Declaration of Helsinki. It was explained to the patients that inclusion of their data in the study was voluntary and that confidentiality and anonymity were guaranteed. They were also able to withdraw from the study at any time before publication without needing to give any reason. Written informed consent was obtained from all of the participants.
The authors declare that they have no competing interests.
TN treated all case and have full responsibility in this paper.
ST and TT co-operated the cases and cheeked the all literature.
SI is a chief of the Department of Otolaryngology and has a responsibility of all patients’ outcome and paper publication.
Tsutomu Nomura,Satoshi Takeuchi,Taro Takanami,Shinichi Ishimoto, (2016) Evaluation of the Role of Palatal Tonsil Hypertrophy in Sleep Apnea Patients: Cephalometric Analysis. Open Journal of Stomatology,06,164-169. doi: 10.4236/ojst.2016.66021