Clinical Characteristics Combined with Craniofacial Photographic Analysis in Children with Obstructive Sleep Apnea

Figures & data

Figure 1 Facial landmarks in frontal and profile views.

Note: (L) = left side of the participants, (R) = right side of the participants.

Abbreviations: Cl, calibration point (L); Cr, calibration point (R); Ns, nasion; Enl, endocanthion (L); Enr, endocanthion (R); Exl, exocanthion (L); Exr, exocanthion (R); T, tragion; Tl, tragion (L); Tr, tragion (R); Prn, prenasale, Sn, subnasion; Anl, ala nasi (L); Anr, ala nasi (R); Las, labrale superior; Lai, labrale inferior; Lal, labrale (L); Lar, labrale (R); Sto, stomion; Ul, upper lip protrusion; Ll, upper lip protrusion; Sl, sublabiale; Pog, pogonion; Me, mentum; Go, gonion; Stl, face point on stomion plane (L); Str, face point on stomion plane (R).

Table 1 Demographic and Respiratory Parameters Between the Participants

	Controls (n=30)	PS (n=62)	OSA (n=53)	p value
Age (years)	8.07±1.59	7.88±1.73	7.75±1.81	0.723
Gender (Male/%)	14, 46.7%	42, 66.7%	37, 69.8%	0.091
BMI (z score)	0.32±1.14	0.31±1.25	0.88±1.23^‡§	0.028
Neck circumference (cm)	26.05[25.40, 27.55]	26.56[24.88, 27.70]	26.70[25.90, 29.10]	0.169
Neck-to-height ratio (%)	20.52±1.29	20.49±1.42	21.11±1.86	0.084
Mouth breathing (n, %)	9/30.0%	21, 33.3%	21, 39.6%	0.656
AHI (/h)	0.30[0.10, 0.22]	0.66[0.24, 1.20]	5.00[3.04, 11.71]^‡§	<0.001
LSaO2 (%)	95.00[92.00, 97.00]	94.00[92.00, 96.00]	89.00[85.00, 92.00]^‡§	<0.001
ODI (/h)	0.10[0.00, 0.50]	0.20[0.00, 090]	4.70[1.90, 11.30]^‡§	<0.001

Notes: The bold text highlights the significant differences between the three groups. ^‡p<0.05 between OSA group and control group. ^§p<0.05 between OSA group and PS group.

Abbreviations: PS, primary snoring; BMI, body mass index; AHI, apnea-hypopnea index; LSaO₂, the lowest oxygen saturation; ODI, oxygen desaturation index.

Table 2 Comparison of the Score of OSA-18 and Pharyngeal Examination Between Groups

	Controls (n=30)	PS (n=62)	OSA (n=53)	p value
OSA-18 questionnaire
Sleep disturbance (Item1–4)	8.70±3.03	13.56±3.56^†	15.21±4.73^‡	<0.001
Physical suffering (Item5–8)	12.67±3.92	14.69±2.93^†	14.09±3.84	0.036
Emotional distress (Item9–11)	7.77±3.58	9.45±4.13	9.17±4.61	0.188
Daytime problems (Item12–14)	8.67±3.66	10.16±3.50	9.09±3.76	0.121
Caregiver concerns (Item15–18)	14.63±5.78	17.76±5.30^†	17.36±5.52	0.033
Total score	52.43±12.27	65.63±14.25^†	64.92±16.31^‡	<0.001
Friedman tongue position (n, %)				0.924
Grade 1	10, 33.3%	18, 29.0%	12, 22.6%
Grade 2	16, 53.3%	37, 59.6%	29, 54.7%
Grade 3	11, 36.7%	18, 29.0%	17, 32.1%
Grade 4	0, 0%	2, 3.2%	1, 1.9%
Pharyngeal grade (n, %)				0.028
Grade 1	2, 6.7%	4, 6.5%	0, 0%^§
Grade 2	9, 30.0%	19, 30.6%	8, 15.1%
Grade 3	12, 40.0%	29, 46.8%	24, 45.3%
Grade 4	7, 23.3%	10, 16.1%	21, 39.6%
Tonsil hypertrophy (n, %)	8, 26.7%	22, 35.5%	34, 64.2%^‡§	<0.001
Adenoid hypertrophy (n, %)	3, 10%	18, 29.0%	24, 45.3%^‡	0.003

Notes: The bold text highlights the significant differences between the three groups. ^†P<0.05 between PS group and control group. ^‡p<0.05 between OSA group and control group. ^§p<0.05 between OSA group and PS group.

Table 3 Craniofacial Photogrammetry - Primary Analysis

Craniofacial Parameters	Facial Landmarks	Unadjusted (M±SD)			p value	Adjusted for Age, Gender, BMI (z Score)(M±SE)			p value
		Controls	PS	OSA		Control	PS	OSA
Face
Upper face width (UFW)	Tl-Tr	12.18±0.84	12.16±0.90	12.58±0.75^§	0.017	12.25±0.12	12.21±0.08	12.48±0.09	0.085
Lower face width (LFW)	Stl-Str	9.75±0.99	10.05±1.25	10.72±1.22^‡§	<0.001	9.85±0.17	10.14±0.12	10.57±0.13^‡§	0.003
Upper face height (UFH)	Ns-Sn	6.32±0.73	6.16±0.64	5.97±0.60	0.429	5.37±0.07	5.49±0.05	5.53±0.05	0.189
Lower face height (LFH)	Sn-Me	5.39±0.39	5.49±0.44	5.51±0.44^‡	0.018	5.39±0.11	5.66±0.08	5.80±0.08^‡	0.017
Face height (FH)	Ns-Me	10.75±0.80	11.13±1.02	11.35±0.95^‡	0.025	10.76±0.14	11.15±0.09	11.32±0.10^‡	0.005
Upper part of LFH (ULFH)	Sn-Sto	2.06±0.26	2.15±0.26	2.14±0.21	0.226	2.06±0.04	2.15±0.03	2.13±0.03	0.185
Lower part of LFH (LLFH)	Sto-Me	3.31±0.44	3.48±0.60	3.70±0.58^‡§	0.008	3.33±0.09	3.51±0.06	3.66±0.07^‡	0.014
UFW/FH	Ns-Me/Tl-Tr	1.14±0.08	1.10±0.06^†	1.11±0.07	0.034	1.15±0.01	1.10±0.01^†	1.11±0.01^‡	0.009
LFW/FH	Ns-Me/Stl-Str	0.91±0.06	0.90±0.06	0.94±0.07^‡§	0.003	0.92±0.01	0.91±0.01	0.93±0.01	0.085
UFH/LFH	Ns-Sn/Sn-Me	1.02±0.13	0.99±0.12	0.96±0.12	0.093	1.01±0.02	0.98±0.02	0.97±0.02	0.304
ULFH/LLFH	Sn-Sto/Sto-Me	0.63±0.08	0.63±0.09	0.59±0.09	0.038	0.63±0.02	0.62±0.01	0.60±0.01	0.167
Facial convexity angle	Ns-Sn-Sl	164.77±5.53	161.78±5.19^†	164.46±5.09^§	0.007	164.68±0.95	162.00±0.66	164.24±0.72	0.023
Eyes and Nose
Inner-canthus width	Enl-Enr	3.36±0.40	3.47±0.28	3.53±0.32	0.085	3.37±0.05	3.48±0.04	3.51±0.04	0.127
Lateral-canthus width	Exl-Exr	8.36±0.47	8.38±0.56	8.55±0.60	0.173	8.39±0.08	8.40±0.06	8.52±0.06	0.275
Nose width	Anl-Anr	3.33±0.25	3.39±0.24	3.47±0.30	0.055	3.34±0.04	3.39±0.03	3.47±0.03^‡	0.019
Nasal convexity angle	Pm-Ns-Sn	20.94±2.43	20.41±2.17	20.98±2.01	0.308	21.17±0.40	20.42±0.27	20.83±0.30	0.273
Mouth
Lip width	Lal-Lar	3.72±0.39	3.84±0.40	3.94±0.49	0.082	3.72±0.07	3.84±0.05	3.95±0.05^‡	0.023
Lip height	Las-Lai	1.63±0.23	1.60±0.33	1.66±0.30	0.627	1.61±0.05	1.61±0.03	1.66±0.04	0.602
Nasal-upper lip relationship angle	Pm-Sn-Ul	122.12±7.96	126.11±8.54	125.33±8.07	0.093	122.19±1.51	125.94±1.03	125.49±1.14	0.110
Lips relationship angle	Ul-Sto-Ll	118.96±11.38	114.52±9.33	114.36±15.03	0.194	118.79±2.25	114.32±1.55	114.69±1.70	0.237
Lower lips-mandibular convexity angle	Ll-Sl-Pog	151.71±10.87	146.54±12.61	146.03±13.06	0.107	152.03±2.23	146.42±1.54	145.98±1.68	0.072
Mandible and Maxilla
Maxillary length	T-Sn	9.03±1.19	9.04±1.02	9.02±0.91	0.991	9.09±0.17	9.11±0.12	8.91±0.13	0.516
Mandibular length 1	T-Sl	9.53±1.32	9.53±1.13	9.60±1.05	0.938	9.56±0.19	9.61±0.13	9.49±0.14	0.814
Mandibular length 2	Go-Me	5.58±1.07	5.66±0.90	5.87±1.01	0.376	5.63±0.16	5.72±0.11	5.77±0.12	0.795
Mandibular length 3	Go-Pog	6.57±1.12	6.60±1.02	6.87±1.12	0.313	6.64±0.17	6.68±0.12	6.74±0.13	0.894
Posterior mandibular height	T-Go	4.63±0.83	4.70±0.62	4.73±0.63	0.788	4.63±0.12	4.74±0.08	4.66±0.09	0.742
Maxillary depth angle (SNA)	T-Ns-Sn	80.91±5.35	82.40±6.14	82.45±6.18	0.472	80.88±1.07	82.62±0.74	82.21±0.81	0.409
Mandibular depth angle (SNB)	T-Ns-Sl	73.72±5.68	73.87±5.98	75.12±6.48	0.468	73.61±1.07	74.19±0.74	74.82±0.81	0.658
Maxillary-mandibular relationship angle (ANB)	Sn-Ns-Sl	7.19±2.72	8.53±2.44^†	7.33±2.47^§	0.014	7.28±0.46	8.44±0.32	7.39±0.35	0.037
Mandibular angle	T-Go-Me	136.14±7.88	137.5±7.77	134.98±10.42	0.313	135.29±1.59	137.30±1.09	135.72±1.20	0.477

Notes: The bold text highlights the significant differences between the three groups. ^†P<0.05 between PS group and control group. ^‡p<0.05 between OSA group and control group. ^§p<0.05 between OSA group and PS group. Linear measurements are in cm, angles in degrees.

Table 4 The Logistic Regression Model for Predicting Children with Obstructive Sleep Apnea

	Variables	Beta Estimate (SE)	OR [95% CI]	p value	AUC[95% CI]	Youden Index	Accuracy	Sensitivity	Specificity
Model 1	OSA-18 questionnaire (Item 1–4)	0.171	1.187[1.087, 1.295]	<0.001	0.707[0.617, 0.796]	0.334	0.703	0.660	0.674
	Constant	−2.868		<0.001
Model 2	BMI (z score)	0.405	1.500[1.096, 2.054]	0.011	0.750[0.668, 0.832]	0.455	0.690	0.792	0.663
	Tonsil hypertrophy	1.364	3.911[1.840, 8.313]	<0.001
	Adenoid hypertrophy	1.006	2.734[1.242, 6.022]	0.013
	Constant	−5.518		<0.001
Model 3	Lower face width	0.532	1.703[1.255, 2.310]	<0.001	0.691[0.601, 0.781]	0.343	0.697	0.604	0.739
	Constant	−6.046		<0.001
Model 4	OSA-18 questionnaire (Item 1–4)	0.125	1.133[1.030, 1.247]	0.010	0.810[0.735, 0.984]	0.533	0.793	0.642	0.891
	Adenoid hypertrophy	1.038	2.824[1.152, 6.925]	0.023
	Pharyngeal grade	0.935	2.548[1.468, 4.424]	<0.001
	Lower face width	0.543	1.721[1.220, 2.428]	0.002
	Constant	−11.027		<0.001

Notes: Model 1, the prediction model of subjective symptoms; Model 2, the prediction model of physical examinations; Model 3, the prediction model of craniofacial measurement; Model 4, the ensemble prediction model.

Figure 2 ROC curves for predictive model.

Notes: Model 1: OSA-18 questionnaire (Item 1–4); Model 2: BMI (z score), tonsil hypertrophy, adenoid hypertrophy; Model 3: Lower face width; Model 4: OSA-18 questionnaire (Item 1–4), pharyngeal grade, adenoid hypertrophy, lower face width.