Primary site identification in children with OSA

Study Objectives: Obstructive sleep apnea (OSA) is a respiratory disorder caused by the obstruction of the upper airway during sleep. The identification of the primary site of OSA is essential to determine treatment strategy. This study aimed to establish computational fluid dynamics (CFD) analysis for determining the clinical severity of OSA and the primary site of OSA. Methods: Twenty children (mean age, 6 years) were divided into OSA and control groups according to their apnea hypopnea index. Three-dimensional airways were constructed from computed tomography data. The pharyngeal airway morphology and the pressure and velocity of the upper airway were evaluated using CFD analysis. Results: The maximum velocity and pressure of the upper airway in the OSA group were significantly correlated with the severity of OSA (rs = 0.741, P < 0.001; rs = 0.653, P = 0.002). A velocity higher than 12 m/s indicated the primary site of OSA. In addition, we found that the primary site of OSA is not necessarily the same as the collapsible conduit site. Conclusions: CFD analysis allows both the evaluation of the disease severity of OSA and the identification of the primary site of OSA in children. The primary site of OSA is not necessarily the same as the collapsible conduit site; therefore, CFD analysis can be used to identify the appropriate intervention for treating OSA

Evaluation of Pharyngeal Airway in Acromegaly

Objectives: Perioperative airway management may be particularly challenging in patients with acromegaly undergoing trans‐sphenoidal pituitary surgery (TSS). Management for airway obstruction is required prior to pituitary surgery to minimize perioperative hypoxia. The purpose of this retrospective study was to evaluate airway obstruction by simulation of computational fluid dynamics (CFD) using computed tomography (CT) images in patients who had undergone TSS. Methods: CT images of the nasopharyngeal airways of patients with acromegaly (n = 5) or nonfunctional pituitary adenoma (n = 6) undergoing TSS from April 2012 to January 2017 were used to construct these airways in three dimensions. Estimated airflow pressure and velocity in the retropalatal airway (RA), oropharyngeal airway (OA), and hypopharyngeal airway (HA) were simulated using CFD. Results: Estimated pharyngeal airflow pressure in the HA, OA, and RA was significantly greater in patients with acromegaly than in those with nonfunctional pituitary adenomas whereas the estimated pharyngeal airflow velocity was significantly impaired only in the RA of patients with acromegaly. Minimum postoperative SpO2 both within 3 hours and from 3 to 12 hours after the end of anesthesia was significantly lower in the patients with acromegaly. Additionally, estimated volume of tongue and pharyngeal airflow pressure in the HA, OA, and RA correlated with minimum postoperative SpO2. Conclusion: Pharyngeal airflow pressure estimated from CT images is high in patients with acromegaly, and these values correlate with postoperative minimum values for SpO2. Preoperative evaluation of CT images by CFD can predict difficulty in airway management and perioperative hypoxia

Evaluation of the effect of oral appliance treatment on upper-airway ventilation conditions in obstructive sleep apnea using computational fluid dynamics

Objective: To evaluate the effect of oral appliance (OA) treatment on upper-airway ventilation conditions in patients with obstructive sleep apnea (OSA) using computational fluid dynamics (CFD). Methods: Fifteen patients received OA treatment and underwent polysomnography (PSG) and computed tomography (CT). CT data were used to reconstruct three-dimensional models of nasal and pharyngeal airways. Airflow velocity and airway pressure measurements at inspiration were simulated using CFD. Results: The apnea–hypopnea index (AHI) improved from 23.1 to 10.1 events/h after OA treatment. On CFD analysis, airflow velocity decreased at the retropalatal and epiglottis-tip levels, while airway pressure decreased at the retropalatal, uvular- and epiglottis-tip levels. The AHI of patients with OSA before OA treatment was correlated with airway pressure at the epiglottis-tip level. Discussion: Treatment with OA improved the ventilation conditions of the pharyngeal airway and AHI. Results of CFD analysis of airway pressure and airflow velocity helped determine the severity and ventilatory impairment site of OSA, respectively

Effect of adenoids and tonsil tissue on pediatric obstructive sleep apnea severity determined by computational fluid dynamics

Study objective: Obstructive sleep apnea (OSA) is a respiratory disorder caused by the obstruction of the upper airway during sleep. The most common cause of pediatric OSA is adenotonsillar hypertrophy. Adenotonsillectomy is the first-line treatment for pediatric OSA; however, OSA persists in a significant number of patients due, in part, to the method of evaluating enlarged adenoids and tonsil tissue (AT). The reason for these effects on OSA severity is not clear. This study aimed to establish a method to diagnose the need for adenoidectomy or tonsillectomy. Methods: Twenty-seven Japanese children (mean age 6.6 years) participated in this study, undergoing polysomnography and computed tomography examination. Pharyngeal airway morphology (AT size, volume, and cross-sectional area [CSA]) and pressure on the upper airway were evaluated at each site using computational fluid dynamic analysis. Results: Apnea hypopnea index (AHI) showed a strong linear association with maximum negative pressure (Pmax) (AHI = -0.055* Pmax -1.326, R2 = 0.805). The relationship between minimum CSA (CSAmin) and Pmax was represented by an inversely proportional fitted curve (Pmax = -4797/ CSAmin -5.1, R2 = 0.507). The relationship between CSAmin and AHI was also represented by an inversely proportional fitted curve (AHI = 301.6/ CSAmin 1.22, R2 = 0.680). Pmax greatly increased if CSAmin became ≤ 30 mm2. The negative pressure of each site increased when CSA measured ≤ 50 mm2. Conclusions: In children, when the CSA for each site is ≤ 50 mm2, AHI is likely to be elevated, and the patient may require tonsillectomy or adenoidectomy

Detailed evaluation of the upper airway in the Dp(16)1Yey mouse model of Down syndrome

A high prevalence of obstructive sleep apnea (OSA) has been reported in Down syndrome (DS) owing to the coexistence of multiple predisposing factors related to its genetic abnormality, posing a challenge for the management of OSA. We hypothesized that DS mice recapitulate craniofacial abnormalities and upper airway obstruction of human DS and can serve as an experimental platform for OSA research. This study, thus, aimed to quantitatively characterize the upper airway as well as craniofacial abnormalities in Dp(16)1Yey (Dp16) mice. Dp16 mice demonstrated craniofacial hypoplasia, especially in the ventral part of the skull and the mandible, and rostrally positioned hyoid. These changes were accompanied with a shorter length and smaller cross-sectional area of the upper airway, resulting in a significantly reduced upper airway volume in Dp16 mice. Our non-invasive approach, a combination of computational fluid dynamics and high-resolution micro-CT imaging, revealed a higher negative pressure inside the airway of Dp16 mice compared to wild-type littermates, showing the potential risk of upper airway collapse. Our study indicated that Dp16 mice can be a useful model to examine the pathophysiology of increased upper airway collapsibility of DS and to evaluate the efficacy of therapeutic interventions for breathing and sleep anomalies

Fluid dynamics in patients with nasal disease

Computational fluid dynamics （CFD） analysis is useful for quantitative assessment in patients with upper airway obstructions. We compared CFD analysis with rhinomanometry （RM） and acoustic rhinometry （AR）. Twenty patients with nasal and paranasal diseases who required computed tomography assessment underwent RM and AR. We measured the pressure and velocity at four parts of the upper airway using CFD analysis. Then we evaluated the correlation among CFD analysis, RM, and AR. CFD analysis detected obstruction sites in the nasal airway and pharynx in 14 and 2patients, respectively. High negative pressure accompanied the nasal obstruction, even behind the nasal cavity. Nasal airway pressure measured using CFD analysis strongly correlated with nasal resistance in RM （Spearman correlation coefficient＝0.853）. CFD analysis’s sensitivity and specificity to detect the obstruction were 84.6％ and 57.1％, respectively （compared to those of RM） and 83.3％ and 50.0％, respectively （compared to those of AR）. The CFD analysis’s ability to detect obstruction was comparable to that of RM and AR; therefore, it may help evaluate the upper airways in patients with nasal and paranasal diseases. We found impaired nasal ventilation also affected other parts of the upper airway. Further studies with a larger sample size are required to validate the use of CFD analysis for assessing the degree of upper airway ventilation disorders

Simultaneous Evaluation of Three-Dimensional Lip Kinetics and Tongue Pressure during Swallowing

Objectives: The purpose of this study was to evaluate the amount of lip movement and simultaneous tongue pressure changes on an artificial palatal plate during swallowing. Methods: Subjects were 9 healthy males (25.4 ± 2.1 years of age). Three-dimensional lip movement was measured by a wireless optoelectronic system, and tongue pressure was simultaneously recorded by a sensor sheet attached to the incisive papilla of an artificial palatal plate. Reflective markers were attached to the right and left corners of the mouth to measure the distance between them. All subjects were instructed to swallow 5 mL and 20 mL samples of water at will. The maximum change of distance between the corners of mouth, the maximum tongue pressure, and the time interval between the two maxima (lip-tongue interval) were calculated. Wilcoxon’s test was used to detect significant differences in these measurements between the two volumes. Results: Maximum tongue pressure did not differ significantly between swallowed volumes. The maximum change of distance between the corners of mouth was larger and the lip-tongue interval was significantly shorter with the larger volume. Conclusions: We suggest that swallowing a larger volume is accomplished by larger lip movement rather than larger tongue movement. These results indicate that lip movement during swallowing can be evaluated objectively