Braz. j. . vol.81 número1

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Brazilian

Journal

of

OTORHINOLARYNGOLOGY

www.bjorl.org

ORIGINAL

ARTICLE

Cephalometric

and

anthropometric

data

of

obstructive

apnea

in

different

age

groups

夽

,

夽夽

Paulo

de

Tarso

Moura

Borges

a,∗

,

Benedito

Borges

da

Silva

a

,

José

Machado

Moita

Neto

a

_,

_Núbia

_Evangelista

_de

_Sá

_Borges

b

_,

_Li

_M.

_Li

c

a_Universidade_Federal_do_Piauí_(UFPI),_Teresina,_PI,_Brazil b_Clínica_Paulo_Borges,_Teresina,_PI,_Brazil

c_Universidade_Estadual_de_Campinas_(UNICAMP),_Campinas,_SP,_Brazil

Received2November2013;accepted18June2014 Availableonline20November2014

KEYWORDS Sleepapnea syndromes; Cephalometry; Bodymassindex; Anthropometry; Cervicalrib; Obesity

Abstract

Introduction:Patientswithobstructivesleepapneasyndromeusuallypresentwithchangesin upperairwaymorphology and/orbodyfatdistribution,whichmayoccurthroughoutlifeand increasetheseverityofobstructivesleepapneasyndromewithage.

Objective: Tocorrelate cephalometricandanthropometric measureswith obstructive sleep apneasyndromeseverityindifferentagegroups.

Methods:Aretrospectivestudyofcephalometricandanthropometricmeasuresof102patients with obstructivesleep apneasyndromewas analyzed.Patients weredividedinto threeage groups(≥20and<40years,≥40and<60years,and≥60years).Pearson’scorrelationwas per-formedforthesemeasureswiththeapnea---hypopneaindexinthefullsample,andsubsequently byagegroup.

Results:ThecephalometricmeasuresMP-H(distancebetweenthemandibularplaneandthe hyoid bone) andPNS-P(distance between theposterior nasal spineandthe tipofthe soft palate)andtheneckandwaistcircumferences showedastatisticallysignificant correlation withapnea---hypopneaindexinboththefullsampleandinthe≥40and<60yearsagegroup. Thesevariablesdidnotshowanysignificantcorrelationwiththeothertwoagegroups(<40and ≥60years).

夽 _Please_cite_this_article_as:_Borges_PT,_da_Silva_BB,_Moita_Neto_JM,_Borges_NE,_Li_LM._{Cephalometric}_and_{anthropometric}_data_of_obstructive apneaindifferentagegroups.BrazJOtorhinolaryngol.2015;81:79---84.

夽夽

Institution:UniversidadeFederaldoPiauí(UFPI),Teresina,PI,Brazil.

∗_{Corresponding}_author.

E-mail:ptborges@gmail.com(P.T.M.Borges). http://dx.doi.org/10.1016/j.bjorl.2014.06.001

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Conclusion:CephalometricmeasurementsMP-HandPNS-Pandcervicalandwaist circumfer-encescorrelatedwithobstructivesleepapneasyndromeseverityinpatientsinthe≥40and<60 agegroup.

PALAVRAS-CHAVE Apneiadosonotipo obstrutiva;

Circunferência craniana; Índicedemassa corporal; Antropometria; Costelacervical; Obesidade

Medidascefalométricaseantropométricasdoíndicedeapneiaehipopneiaem diferentesfaixasetárias

Resumo

Introdução:Pacientescomasíndromedaapneiahipopneiaobstrutivadosono(SAOS) geral-menteapresentamalteraçõesnamorfologiadasviasaéreassuperiorese/ounadistribuiçãoda gorduracorporal,quepodemocorrerduranteavidaeaumentaragravidadedaSAOScoma idade.

Objetivo:CorrelacionarmedidascefalométricaseantropométricascomagravidadedaSAOS emdiferentesfaixasetárias.

Método: Estudoretrospectivodemedidascefalométricaseantropométricasde102pacientes portadoresdeSAOS.Ospacientesforamdivididosemtrêsfaixasetárias(≥20e<40anos,≥40 e<60anos,e≥60anos).Foirealizadacorrelac¸ãodePearsondestasmedidascomoíndicede apneiahipopneia(IAH)naamostracompletaedepoisporfaixaetária.

Resultados: Asmedidas cefalométricas MP-H (distância entre o plano mandibular e o osso hioide)ePNS-P(distânciaentreaespinhanasalposterioreapontadopalatomole)eas cir-cunferênciascervicaleabdominalapresentaramcorrelac¸ãoestatisticamentesignificantecom oIAHtantonaamostratotalquantonafaixade<40e≥60anos.Estasvariáveisnãomostraram correlac¸ãosignificantecomasoutrasduasfaixasetárias(≤40e≥60anos).

Conclusão:AsmedidascefalométricasMP-HePNS-Peascircunferênciascervicaleabdominal apresentaramcorrelac¸ãocomagravidadedaSAOSempacientesnafaixaetáriade≥40e<60 anos.

Introduction

There is consensus in the medical literature that the severity of obstructive sleep apnea syndrome (OSAS) is related to age1---7_; _however, _there _have _been _few stud-iesevaluatingthe changes that mayoccur in craniofacial morphologyandanthropometricmeasuresinadultpatients

with respect to age, and there is no standardization of

criteriatodefine the age ranges for the groups of adults studied.5,8

Changes in upper airway morphology occur throughout

adulthoodandmaybeonefactorexplainingtheincreased prevalenceofOSASinolderages.9

CephalometricX-rayshavebeenusedtoinvestigatethe topographicdiagnosisofOSAS,10,11_as_they_are_useful_in_the assessmentofupperairwaymorphology,andaretoolowin costandreadily available in mosthospitals and radiology centers.2,12,13

Certainanthropometricfeaturesareassociatedwiththe prevalenceofOSAS.Thus,measurementsofbodymassindex (BMI),neckcircumference(NC),waistcircumference(WC), andpelviccircumference(PC)havebeen analyzedby sev-eralauthorsaspredictorsofOSASseverity,14---16_with_obesity consideredapredictivefactor.6

According to a study conducted by the World Health

Organization(WHO)17_on_the_nutritional_diagnosis_of_the pop-ulation,adulthoodisdividedintotwogroups:adult,from20 tolessthan60yearsofage,andtheelderly,over60yearsof age,eachwithdifferentBMIvalues.Thisdivisionwasbased onthefindingthatwithadvancingage,individualsshowa declineinheightandweightduetocompressionofthe inter-vertebraldiscs,lossofmuscletoneandmass,reductionof bodywater,andposturalalterations.

Becausetheliterature3,5,8_exhibited_very_few_studies

cor-relatinganthropometricand cephalometricmeasureswith

OSASseverity,andtherewasalackofstandardizationofage rangesforadultsubjectsinthesestudies,weproposedthis study withthe objectiveof correlatingcephalometricand anthropometricmeasureswithOSASseverityindifferentage ranges.

Methods

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this period was 208, but 106 were excluded because of incompletedata,priorsurgicaltreatmentforOSAS,theuse ofcontinuouspositiveairwaypressure(CPAP)equipmentor an intraoralappliance (IOA),theuseof sedativesor alco-holism.Thefinalsampleconsistedof102patients,57males and45females,aged20---70years.Thisstudywasapproved bytheEthicsCommitteeinResearch,No.248.678.

Polysomnography was carried out using a Somté

Compumedics®_device_with_all-night_domiciliary_monitoring,

usingthelevelIIparametersoftheAmericanSleepDisorders Association.18

PatientswereconsideredashavingOSASif,inaddition toclinical complaints,theyhadan apnea---hypopneaindex (AHI)≥5.19_Severity_was_measured_by_the_AHI._Cephalometry

wasperformedwiththeOrthophos3device,manufactured

bySirona,withmanualtracing.

The cephalometricmeasurements usedwere: PAS, the

space between the base of the tongue and the posterior

pharyngealwall;MP-H,thedistancebetweenthe mandibu-larplaneandthehyoidbone;SNA,theangleformedbythe unionoftheSpoint,whichisthemidpointofthesella tur-cica,withpointN,whichcorrespondstotheunionbetween thefrontalandnasalbones,andpointA,whichisthemost posteriorpointontheanteriorsurfaceofthemaxilla;SNB,

the angle formed by the union of the S point withthe N

point and the B point, which is the most posterior point of the anteriorsurface of the mandible; ANB, difference

betweenSNAandSNB;PNS-P,distancebetweenthe

poste-riornasal spine and the tipof the soft palate.10---12,20 _The followinganthropometricmeasureswereassessed:BMI,NC, WC, and PC. BMI is defined asthe ratio of the weightof theindividualinkgandthesquareofheightinmeters. Cer-vicalcircumference(CC)wasmeasuredatthelevelofthe

cricothyroidmembrane.WCwasmeasuredbetweenthelast

ribandtheiliac crest,while thePCwasmeasured at the largestcircumferenceatthelevelofthetrochanteredge.21 Duetothelackofstandardizationoftheagerange divi-sionin adultswithOSAS in thisstudy,the divisionbyage groupwasbasedonthatreportedbytheWHO,17_which_takes intoaccounttheevaluationofnutritionalstatusand consid-ersanadultasanindividualagedbetween20and60years, andaselderly,anindividualaged≥60years.However,asthe intervalbetween20and60yearsisbroadandallare consid-eredadultsinthisstudy,thisstudyuseda20-yearinterval, asfollows:

Group1:≥20and<40years; Group2:≥40and<60years; Group3:≥60years.

The data were entered into a database, using

SPSS software, release 16.0, which calculated the

sim-ple descriptive statistics such as percentage

distribu-tion, mean, and standard deviation. The normality test

(Kolmogorov---Smirnov)wasappliedandtheappropriatetest

for each type of variable (parametric or nonparametric)

waschosen.Pearson’scorrelationwasassessedbetweenAHI andthevariablesage,BMI,CC,WC,PC,andcephalometric measures(SNA,SNB,ANB,MP-H,PAS,andPNS-P).The differ-encesregardinggenderwerecomparedbyStudent’st-test. Thelevelofsignificancewassetatp<0.05.

Table 1 Mean and standard deviation of age, apnea---hypopnea index (AHI), and anthropometric and cephalometricvariablesof102patients.

Variables Minimum Maximum Mean SD

Age,years 20.0 70.0 46.75 15.41 BMI,kg/m2 _19.72 _40.18 _27.92 _3.93

NC,cm 30.0 47.0 38.47 3.86

WC,cm 57.0 125.0 97.57 10.94 PC,cm 87.0 131.0 104.37 7.62

SNA◦ _72.0 _92.0 _82.72 _4.01

SNB◦ _69.0 _92.0 _80.75 _4.30

ANB◦ ₋_13.0 _10.0 _1.96 _3.85

MP-H,mm 4.0 45.0 19.28 8.39

PAS,mm 3.0 20.0 9.88 3.66

PNS-P,mm 20.0 52.0 40.11 5.32 AHI,events/h 5.00 83.40 34.71 17.41

SD,standarddeviation;BMI,bodymassindex;NC,neck circum-ference; WC,waist circumference;PC,pelviccircumference; SNA,sella-nasion-Apointangle;SNB,sella-nasion-Bpointangle; ANB,differencebetweenSNAandSNB;MP-H,distancebetween themandibularplaneandthehyoidbone;PAS,spacebetween thebaseofthetongueandtheposteriorpharyngealwall; PNS-P,distancebetweentheposteriornasalspineandthetipofthe softpalate;AHI,apnea---hypopneaindex.

Results

Theageofpatientsrangedfrom20to70years,withamean of46.75±15.41years,andvariationwasobservedregarding themeansofthestudiedvariables(Table1).

Ofthe102patientsstudied,57(55.9%)weremalesand

45(44.1%)werefemales.Whencomparingageand

anthro-pometric and cephalometric measures between men and

womenusingStudent’st-test,astatisticallysignificant dif-ferencewasfoundfor age,for NC,andfor cephalometric MP-HandPNS-P(Table2).

When comparingage andanthropometric and

cephalo-metricmeasuresbetweenmenandwomenusingStudent’s

t-test,astatisticallysignificantdifferencewasobservedfor

age,NC,andthecephalometricmeasuresMP-HandPNS-P

(Table2).

Table 3 shows the analysis of Pearson’s correlation

betweenageandanthropometricandcephalometric

meas-ureswithAHI inthe fullsample. Therewasastatistically significantcorrelationwithage,withNCandWC,andwith thecephalometricmeasuresMP-HandPNS-P,i.e.,thehigher thevalueofthesevariables,thehighertheAHIvalue.There wasnosignificantcorrelationwithBMI.

Table 4 shows the analysis of Pearson’s correlation to assess the association, in the age range of ≥20 and <40 years,ofanthropometricandcephalometricmeasureswith AHI. There wasno significant correlation withany of the variables.

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Table2 Comparisonbetween malesandfemalesofage, anthropometricandcephalometricmeasurements,andAHI.

Females(n=45) Males(n=57) p-Value

Age,years 50.29±13.72 43.95±15.13 p<0.05 BMI,kg/m2 _27.92_±_4.75 _27.91_±_3.19 _p_>0.05

CC,cm 35.44±2.40 40.86±3.02 p<0.01 WC,cm 95.73±11.37 99.02±10.46 p>0.05 PC,cm 103.51±8.94 105.05±6.38 p>0.05 SNA◦ _82.62_±_3.35 _82.79_±_4.49 _p_>0.05

SNB◦ _80.13_±_4.21 _81.35_±_4.44 _p_>0.05

ANB◦ _2.49_±_3.86 _1.54_±_3.83 _p_>0.05

MP-H,mm 15.41±7.22 22.33±8.03 p<0.01 PAS,mm 9.18±3.26 10.44±3.88 p>0.05 PNS-P,mm 38.24±5.02 41.58±5.13 p<0.01 AHI,events/h 31.11±15.14 37.55±18.66 p>0.05

BMI,bodymassindex; CC,cervical circumference;WC,waist circumference;PC, pelviccircumference;SNA, sella-nasion-A pointangle; SNB,sella-nasion-Bpoint angle;ANB, difference betweenSNAandSNB;MP-H,distancebetweenthe mandibu-larplaneandthehyoidbone;PAS,spacebetweenthebaseof thetongueandtheposteriorpharyngealwall;PNS-P,distance betweentheposteriornasalspineandthetipofthesoftpalate.

Table 6 shows the analysis of Pearson’s correlation to assesstheassociation,intheagerange≥60years,of

anthro-pometricandcephalometricmeasureswithAHI.Therewas

nosignificantcorrelationwithanyofthevariables.

Discussion

Several factors can increase OSAS predisposition, such as obesity,whichcancausefatdepositioninupperairway tis-sues,reducingthenasopharyngealcaliberand/orleadingto hypoventilation.6,22 _Assessment_of_craniofacial_morphology isfrequentlyperformedinstudieswiththesepatients,not onlytoidentifythemorphological alterations,but alsoto

identifythesiteoftheobstructionthatcanaidinselecting theappropriatetreatment.13,23

There are several studies in the literature

correlat-ing age with the severity of OSAS1---7 _and _it _is _known

that upper airway morphology alterations occur

through-out adulthood,3,5,8,9,24,25 _as _well _as _in _{anthropometric} measures,14---16 _but_most_studies_do_not_stratify_patients_by agegroups,andinthosethatdoso,thereisno standardiza-tionofcriteriaforthisdivision.3,5,8,26

Inthepresentstudy,whenthefullcohortofpatientswas evaluatedtogetherwithoutdivisionbyagerange,a

signif-icant correlation wasobservedbetween AHIwithage and

withNC,inagreementwithother studies2,3,5,15,16,27---32_;_the same significant correlation was noted for WC.2,4,5,15,28---30

There was no correlation with BMI, as reported in most

studies,1---4,6---8,15,29---34 _although _some _studies _have demon-stratedresultssimilartoours.5,27

There was also a significant correlation with

cephalo-metric measures MP-Hand PNS-P with AHI, in agreement

with other studies, meaning that these patients have an

increasedlengthofthesoftpalateandincreaseddistance from the hyoid bone to the mandible.2,8,24,35,36 _The

posi-tion of the hyoid bone has an impact on the shape and

position of the tongue and affects the patency of the

hypopharyngeal airway27_; _it _is _also _used _as _a _predictor of therapeutic efficacyof mandibular advancement

appli-ance (MAA) in patients with mild to moderate OSAS.37

Approximately80%ofpatientswithOSAShaveretropalatal obstruction38_and_it_is_known_that_when_the_PNS-P measure-mentisincreased,itisusedtopredict apositiveresponse touvulopalatopharyngoplasty.39

Whenpatientsweredividedbyagerange,thoseaged≥20 <40yearsand≥60yearsshowednosignificantcorrelation

of cephalometric and anthropometric measures withAHI.

However,asignificantcorrelationwasobservedbetweenAHI withageandwithNCintheagegroupof≥40and<60years whichalsohadbeenobservedinthesampleasawhole.

Table3 CorrelationofageandanthropometricandcephalometricmeasurementswiththeAHIinthefullsample(n=102).

Age BMI NC WC PC SNA SNB ANB MP-H PAS PNS-P

Pearson’scorrelation 0.254 0.155 0.355 0.337 0.100 −0.035 0.036 −0.076 0.251 −0.118 0.304 p 0.010 0.120 0.000 0.011 0.318 0.726 0.722 0.466 0.011 0.236 0.002

BMI,bodymassindex;NC,neckcircumference;WC,waistcircumference;PC,pelviccircumference;SNA,sella-nasion-Apointangle; SNB,sella-nasion-Bpointangle;ANB,differencebetweenSNAandSNB;MP-H,distancebetweenthemandibularplaneandthehyoid bone;PAS,spacebetweenthebaseofthetongueandtheposteriorpharyngealwall;PNS-P,distancebetweentheposteriornasalspine andthetipofthesoftpalate.

Table4 Correlationintheagerange≥20and<40yearsofanthropometricandcephalometricmeasurementswithAHI(n=37).

BMI NC WC PC SNA SNB ANB MP-H PAS PNS-P

Pearson’scorrelation −0.104 0.186 0.068 −0.062 −0.068 0.006 −0.107 0.315 −0.032 0.226 p 0.540 0.269 0.689 0.717 0.690 0.970 0.527 0.058 0.850 0.179

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Table5 Correlationintheagerange≥40and<60yearsofanthropometricandcephalometricmeasurementswithAHI(n=39).

Pearson’scorrelation 0.290 0.574 0.492 0.338 −0.083 0.118 −0.042 0.380 −0.021 0.379 p 0.073 0.000 0.001 0.035 0.597 0.473 0.801 0.017 0.900 0.017

Table6 Correlationintheagerange≥60yearsofanthropometricandcephalometricmeasureswithAHI(n=26).

Pearson’scorrelation 0.119 0.373 0.167 0.026 0.098 0.056 0.037 0.091 −0.352 0.363 p 0.561 0.060 0.414 0.900 0.635 0.787 0.859 0.660 0.077 0.068

Whencomparingthefullsamplebygender,asignificant correlation withNC wasobservedin males, in agreement with other studies,7,15,26,27,40 _while _BMI _and _WC _did _not

differ between the genders, in agreement with another

study.40 _The_{cephalometric}_measures_MP-H_and_PNS-P_were

higher in male patients, in agreement with the assessed

literature.7,27

Inastudyinvolving60menand54healthywomenranging inagefrom16to74years,withameanof35years,itwas observedthattherewasadecreaseinthedimensionsofthe upperairwayswithincreasingageinbothgenders,except intheoropharyngealjunction;however,therewasgreater upperairwaycollapseintheoropharyngealjunctioninthe malegender.26

The pharynx was evaluated by cephalometry in young

adults. After 32 years, the individuals were reassessed,

which disclosed a reduction in the oropharyngeal airway

caused by the increase of the soft palate (PNS-P), a

fact that would justify the increased prevalence of OSAS with age.9 _Maltais _et _al.24 _also _observed _{abnormalities} in older patients, with increased MP-H distance in older patients.

When analyzingpatientsatdifferentagegroups,Mayer etal.8_observed_upper_airway_alterations._They_found_that inyoungerandslimmerpatients,upperairway abnormali-tiesexplainedmostAHIvariance.Inmoreobeseandolder

patients that did not have upper airway abnormalities,

but had OSAS, theysuggest that other physiopathological

mechanisms are responsible, such as primary respiratory

conditionsandunstableneurologicalmechanisms.

Whenanalyzing433patientswithOSASbyagerange(<43, 43---52,and>52years),Montoyaetal.3_found_that_patients aged >52 years were 3.8 times more likely tohave OSAS thanyoungerindividuals(<43years),whichwasstatistically significant.

Anotherstudyevaluated163normalmalesubjectsaged

30---72years.Theywerereassessedaftertenyearsanditwas foundthatthepositionofthehyoidbonechangedwithage, withasignificantincreaseindolichofacialindividuals.25

Conclusion

ThecephalometricmeasuresMP-HandPNS-Pand

anthropo-metricmeasuresNCandWCcorrelatedwithOSASseverity

inpatientsaged≥40and<60years.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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