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Cephalometric Evaluation of Facial Pattern and Hyoid Bone Position in Children With Obstructive Sleep Apnea Syndrome

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International Journal of Pediatric Otorhinolaryngology 75 (2011) 383–386

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International Journal of Pediatric Otorhinolaryngology


journal homepage: www.elsevier.com/locate/ijporl

Cephalometric evaluation of facial pattern and hyoid bone position in children


with obstructive sleep apnea syndrome
Bruno B. Vieira a,*, Carla E. Itikawa a, Leila A. de Almeida b, Heidi S. Sander b, Regina M.F. Fernandes b,
Wilma T. Anselmo-Lima c, Fabiana C.P. Valera c
a
Division of Orthodontics, Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
b
Departmento of Neurology, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
c
Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To assess the development of face and hyoid bone in children with obstructive sleep apnea
Received 10 November 2010 syndrome (OSAS) through lateral cephalometries.
Received in revised form 6 December 2010 Materials and methods: Children aged 7–10 years with mixed dentition and with no previous
Accepted 9 December 2010
otorhinolaryngologic, orthodontic or speech therapy treatments were studied. Twenty nasal breathers
Available online 8 January 2011
were compared to 20 mouth breathing children diagnosed as OSAS patients. All children underwent
otorhinolaryngologic evaluation and cephalometries; children with OSAS also underwent nocturnal
Keywords:
polysomnography in a sleep laboratory.
OSAS
Cephalometry
Results: Children with OSAS presented increase in total and lower anterior heights of the face when
Hyoid bone compared to nasal breathers. In addition, children with OSAS presented a significantly more anterior and
Mouth breathing inferior position of the hyoid bone than nasal breathers. No significant differences in upper, anterior or
Children posterior heights of the face were observed between groups.
Growth and development Conclusion: The results suggest that there are evident and early changes in facial growth and
development among children with OSAS, characterized by increased total and inferior anterior heights of
the face, as well as more anterior and inferior position of the hyoid bone.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction higher distance between the hyoid bone to the mandibular base
present a poorer postoperative success [5].
Mouth breathing is one of the most frequent symptoms in Tonsils hypertrophy is the main cause of OSAS in children [6]. In
childhood, and rhinitis and tonsils hypertrophy are the most this age group, OSAS may be more subtle and silent, whereas this
frequent causes for it [1]. It influences the perioral muscles and soft characteristic does not prevent the development of serious
tissues, and thus affects the apposition of bone tissue during the neurobehavioral and cognitive impairment, as well as facial and
infant growth [2]. The severity of respiratory disorders may range occlusal changes.
from intermittent nasal obstruction to more exuberant symptoms The study of facial development and mainly of the hyoid
such as obstructive sleep apnea syndrome (OSAS) [3]. position in children precisely diagnosed with OSAS has been
It has been previously reported that adult patients with OSAS scarcely reported in the literature. The purpose of this study was to
present a more anterior and inferior hyoid bone position when evaluate children in scholar age, comparing children with OSAS
compared to controls, associated to lower position of the tongue. (group 1) to nasal breathers (group 2), in terms of skeletal facial
This is related to changes in geniohyoid muscle, which in turn and hyoid changes.
worsen apnea during sleep [4]. The position of the hyoid bone may
be also related to a poorer prognosis in surgeries for uvulopala-
topharyngoplasty (UPPP) for OSAS in adults, and patients with a 2. Materials and methods

Twenty patients with OSAS and 20 nasal breathing patients,


from 7 to 10 years, and with mixed dentition, were selected.
* Corresponding author at: Av. Monte Alegre, 3900–128 andar, Bairro: Monte Patients with systemic disorders and those with adjuvant
Alegre, CEP: 14049-900, Ribeirão Preto, São Paulo, Brazil. Tel.: +55 16 36235290;
fax: +55 16 36022860.
orthodontic, speech therapeutic and otorhinolaryngologic treat-
E-mail addresses: facpvalera@fmrp.usp.br, facpvalera@uol.com.br (B.B. Vieira). ment were excluded.

0165-5876/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2010.12.010
384 B.B. Vieira et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 383–386

Group 1 patients (OSAS) were selected at the Mouth Breathing HyS: linear vertical distance from Hy (uppermost point of the
Center of the School of Medicine of Ribeirão Preto, University of São hyoid) to S
Paulo, and group 2 patients (nasal breathers) were selected at the vert.dH: linear vertical distance from H (most anterior point of
Pediatric Clinic of the Dental School of Ribeirão Preto, University of the hyoid) to the palatal plane
São Paulo. All childrens’ parents gave informed consent prior the HyMP: vertical distance from Hy to the mandibular plane
evaluations, and the patient was included in the study only if their horiz.dH: linear horizontal distance from H to the posterior wall
parents agreed to perform the whole study. of the hypopharynx
Otorhinolaryngologic evaluation was performed in each patient C3–H: linear measure from the H to the most anterior and
to confirm the breathing pattern. This evaluation included a inferior point of C3.
questionnaire about the intensity and frequency of respiratory
symptoms and a specific otorhinolaryngologic examination. The The study was approved by the Research Ethics Committee of
palatine tonsils were graded according to Brodsky [7] and the University Hospital, School of Medicine of Ribeirão Preto,
percentage of adenoid obstruction on choanal area was graded University of São Paulo (protocol no. 4212/2009).
by nasoendoscopy.
Mouth breathing group also underwent to nocturnal diagnostic 2.1. Statistical analysis
polysomnographic examination, according to the 2007 criteria of
the AASM [8]. Only children with an apnea-hypopnea index higher Otorhinolaryngologic evaluation and polysomnography were
than 1 and symptoms of OSAS were included in this group. For used to stratify the patients into the different groups and no
ethical reasons, the control group was not submitted to statistical analysis was applied to these data. The orthodontic
polysomnography. measures were compared statistically by unpaired parametric
After the inclusion in each group, a complete orthodontic tests, through ANOVA. The GraphPad Instat 3.0 software was used
evaluation and documentation was performed in each child, for the analyses.
including lateral cephalometric radiograph. Based on this exam,
the following linear measurements were obtained (Fig. 1): 3. Results

N–Me: linear distance from N (nasion) to Me (menton); A total of 40 non-obese children were selected, from which 20
represents the total anterior facial height belonged to the group of nasal breathers (mean age 7.35 years) and
N–ANS: linear distance from N to ANS (anterior nasal spine); 20 were from OSAS group (mean age 7.85 years).
represents the upper anterior height of the face
ANS–Me: linear distance from ANS to Me; represents the lower 3.1. Otolorayngologic and polysomnographic exams
anterior height of the face
S–Go: linear distance from S (sella) to Go (gonion); represents All patients in the OSAS group presented a history of snoring
the total posterior facial height and apnea witnessed by their parents. In addition, these children
[()TD$FIG] had obstructive adenoids (more than 70% of the choana) and/or
grade III or IV palatine tonsils. The polysomnographic diagnosis
showed that OSAS was mild in 10 children, moderate in 6 and
severe in 4.
In contrast, nasal breathing group did not present obstructive
respiratory symptoms for more than 15 consecutive days. ENT
exams revealed that adenoids obstructed less than 50% of the
choana and palatine tonsils were grade I or II in all patients.

3.2. Orthodontic exam

The cephalometric facial measures demonstrated a significant


increase of the total anterior facial height (N–Me, 109.9  5.0 for
OSAS vs. 106.1  5.6 for controls, P < 0.05), due to a significant
increase of the lower anterior facial height (ANS–Me, 65.9  4.6 for
OSAS vs. 62.3  4.3 for controls, P < 0.05). No significant difference
was observed in upper anterior height (N–ANS) or the posterior
height (S–Go) of the face (Table 1).
Hyoid bone measures revealed a significant lower position in
relation to the skull base (HyS, 98.7  8.6 for OSAS vs. 88.9  5.9 for
controls, P < 0.0005), to the palatal plane (vert.dH, 56.9  6.9 for
OSAS vs. 47.6  3.7 for controls, P < 0.0001) and to the mandibular
plane (HyMP, 16.4  6.5 for OSAS vs. 8.1  4.8 for controls,

Table 1
Comparison of cephalometric facial data between the OSAS and nasal breathing
groups.
Fig. 1. Cephalometric tracing illustrating the points and linear measurements
employed in this study: N–Me: total anterior facial height; N–ANS: upper anterior Nasal breathing OSAS P
height of the face; ANS–Me: lower anterior height of the face; S–Go: total posterior
N.Me 106.0  5.6 109.9  5.0 0.024
height of the face; HyS: vertical distance from Hy to sella; vert.dH: vertical distance
N.ANS 46.7  3.1 48.4  2.3 0.065
from H to the palatal plane; HyMP: vertical distance from Hy to the mandibular
ANS.Me 62.3  4.3 65.8  4.6 0.017
plane; horiz.dH: horizontal distance from H to the posterior wall of the
S.Go 65.5  4.3 67.5  4.0 0.144
hipopharynx; C3–H: linear measure from H to the most anterior point of C3.
B.B. Vieira et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 383–386 385

Table 2 The specific position of the hyoid bone in children with OSAS
Comparison of the cephalometric data regarding hyoid position between OSAS and
has been little explored in the literature, and controversial results
nasal breathing groups.
have been reported. Also, the available studies usually evaluate
Nasal breathing OSAS P mouth breathing children without a polysomnographic character-
HyS 88.9  5.9 98.6  8.6 0.0002 ization of the respiratory disorder.
HyMP 8.1  4.8 16.4  6.5 <0.0001 In agreement with the present results, Juliano et al. [15]
Dh.H 25.5  2.8 27.4  2.5 0.031 observed that the C3–H measure was increased in mouth breathing
Dv.H 47.6  3.7 56.9  6.9 <0.0001
children. According to the authors, this finding could occur because
C3–H 30.2  3.1 33.4  2.9 0.002
these patients extend their head in an attempt to improve their
new respiratory pattern, through mouth.
However, different results have also been reported in the
literature. Ferraz et al. [18] concluded that the hyoid bone
P < 0.0001), in addition to an anterior position in relation to the maintains a stable position independent of the respiratory pattern,
posterior wall of the nasopharynx (horiz.dH, 27.4  2.5 for OSAS vs. whereas Janicka et al. [19], studying adults and children (9–35
25.5  2.8 for control, P < 0.05) and to C3 (C3–H, 33.4  2.9 for OSAS years of age), detected a more inferior but also posterior hyoid
vs. 30.2  3.1 for controls, P < 0.005) (Table 2). position in patients with respiratory disorders.
Thus, we observed that the facial and hyoid bone morphological
pattern of adult individuals with OSAS are already present in
4. Discussion school-age children, probably as a mechanism of physiological
adaptation. These facial skeletal characteristics, in turn, lead to a
OSAS in children has been extensively related to syndromic more likely prognosis of future development of OSAS. However, in
craniofacial changes, especially those in the middle and lower view of the scarce literature available, further studies on well-
thirds of the face. However, the relation between non-syndromic defined groups of children with OSAS are needed for the
craniofacial changes and OSAS in children is not definitive, and few determination of the specific position of the hyoid bone.
cephalometric investigations are available in the literature for this
group [8–10]. 5. Conclusion
It is known that children with OSAS, in a mouth-breathing
adaptation, change the posture of the head and the mandible, as Based on the present study, we may conclude that there is an
well as the tonicity of the tongue and orofacial muscles [11]. When important change in facial growth and development in children
persistent, this adaptation changes the equilibrium of muscle with OSAS, with a significant increase in the total and lower
pressure on the facial bones and on teeth, influencing facial growth anterior heights of the face.
[12,13]. The hyoid bone was found to be in a more anterior and inferior
In the present study, we observed that children with OSAS position in children with OSAS, with extremely significant
presented a significant increase of total anterior facial height (N– statistical results compared to nasal breathing children.
Me) compared to control group. This increase was due to the
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