Obstructive Sleep Apnea and the Use of Cone

Beam Computed Tomography in Airway

Imaging: A Review
John M. McCrillis, Jennifer Haskell, Bruce S. Haskell, Michelle Brammer,
Douglas Chenin, William C. Scarfe, and Allan G. Farman
The use of cone beam computed tomography to permit three-dimensional
visualization of the airway is described. Obstructive sleep apnea is dened in
relation to associated anatomy. Work in progress examining the visualiza-
tion of airway changes using one treatment modality, a mandibular ad-
vancement device, is discussed. (Semin Orthod 2009;15:63-69.) 2009
Elsevier Inc. All rights reserved.
O
bstructive sleep apnea (OSA) can be de-
ned as a cessation of breathing during
sleep because of a mechanical obstruction such
as a retropositioning of the tongue in the airway,
a large amount of tissue in the upper airway, or
even a partially collapsed trachea. OSA is a com-
mon respiratory sleep disorder characterized by
snoring and episodes of breathing cessation or
absence of respiratory airow (10 seconds)
during sleep and despite respiratory effort.
1
A
rising occurrence rate in the general population
rivaling that of asthma and diabetes has been
variously credited to increased awareness, better
diagnostics, and a pandemic of obesity.
2-4
Re-
gardless of etiology, identifying the area of air-
way obstruction has often proven challenging.
Factors bearing on this challenge include the
difculty in visualizing the airway in three di-
mensions, the difculty of visualizing the airway
through its entire length, and the inability to
visualize the anatomical changes of various treat-
ment methods.
Cone beam computed tomography (CBCT)
scanners have been available for craniofacial imag-
ing since 2001 in the United Sates. Their compact
size and relatively low radiation dosage make the
CBCT scan an imaging modality that helps address
the previously stated challenges effectively and ef-
ciently.
5
The resulting volume of digital data
can be manipulated to allow the clinician three-
dimensional (3D) images that can be rotated in
three axes, can be selectively contrasted, empha-
sized, or reduced to visualize certain anatomical
structures such as the airway, and can be shared
electronically among any number of remote
sites.
Obstructive Sleep Apnea
The upper airway has three major functions:
ventilation, swallowing, and speech. For ventila-
tion, the upper airway must remain patent, but
for the other functions, it must narrow or close.
In addition, ventilation must be maintained
when the nose is occluded or, alternatively,
when the mouth is closed. Integration of these
conicting functions in one anatomical region is
complicated, and it is not surprising that inter-
mittent failure of ventilation occurs.
6
Addition-
ally, the nose and mouth are the source of large
volumes of secretions that must be cleared via
the pharynx.
Private Practice, Louisville Dental Sleep Medicine, Louisville,
KY. Dental Student, School of Dentistry, The University of Louis-
ville, Louisville, KY. Graduate Orthodontics Student, School of
Dentistry, The University of Louisville, Louisville, KY. Anatomage,
In Vivo Dental, San Jose, CA. Department of Radiology, School of
Dentistry, University of Louisville, Louisville, KY.
Address correspondence to: John M. McCrillis, DMD, Louisville
Dental Sleep Medicine, 2902 Taylorsville Road, Louisville, KY
40205. Phone: 502-458-7476; E-mail: drmcf_jm@insightbb.com
2009 Elsevier Inc. All rights reserved.
1073-8746/09/1501-0$30.00/0
doi:10.1053/j.sodo.2008.09.008
63 Seminars in Orthodontics, Vol 15, No 1 (March), 2009: pp 63-69
Patency of the pharynx is vital to the ventila-
tion (respiratory) function. With the exception
of the two ends of the airway, that is, the nares
and the small intrapulmonary airways, the phar-
ynx is the only collapsible segment of the respi-
ratory tract. What became apparent only in the
1970s is that some individuals possess an ade-
quate pharyngeal lumen for all respiratory func-
tions while awake but have an obstructed lumen
during sleep.
7,8
Anatomical Terms
Anatomical structures describing the various
portions of the pharyngeal airway, superiorly to
inferiorly, include:
Nasopharynx. The uppermost portion of the
airway, mainly the nose. It begins with the nares,
where air enters the nose, and extends back to
the hard palate at the superior portion of the
soft palate. This includes, then, the nasal septum
and the nasal turbinates.
Velopharynx (also known as the retropalatal
area). Extends from the hard palate to the infe-
rior tip of the soft palate. Includes the uvula and
the uppermost segment of the posterior pharyn-
geal wall. Major muscles include the tensor pala-
tini and levator pallatini, which elevate the soft
palate, and the musculous uvulae providing ele-
vation of the uvula.
Oropharynx (also known as the retroglossal
area). Includes the oral cavity, beginning with the
back portion of the mouth and extending rear-
ward to the base of the tongue. This segment of
the posterior pharyngeal wall includes the tonsils.
In this area are many muscles, both extrinsic and
intrinsic, that control tongue posture: genioglos-
sus, palatoglossus, and the superior longitudinal
and transverse muscles of the tongue as examples.
Hypopharynx. Extends from the tip of the epi-
glottis to the lowest portion of the airway at the
larynx. A large number of muscles affect this
portion of the airway, often acting in concert
with or opposition to other related muscles.
9
Sleep Apnea Events and Terms
OSA events are often described as follows:
Apnea (obstructive apnea), literally no bre-
ath. Cessation of airow for 10 or more sec-
onds.
Hypopnea (partial obstructive apnea), literally
low breath. Reduction of airow below 70%
for 10 seconds or longer with a 4% or greater
blood oxygen desaturation. Alternatively de-
ned as reduction of airow below 50% for 10
seconds or longer with a 3% desaturation, or the
event is associated with arousal.
10
Respiratory effort-related arousals (RERAs). An
arousal from sleep that follows a 10-second or
longer sequence of breaths that are character-
ized by increasing respiratory effort but which
does not meet criteria for an apnea or hypop-
nea.
11
Upper airway resistance syndrome (UARS). A form
of sleep disordered breathing (SDB) in which
repetitive increases in resistance to airow
within the upper airway lead to brief arousals
and daytime somnolence.
12
There may be few, if
any, obvious apneas or hypopneas with desatu-
ration, but snoring may be a very prominent
nding.
13
Apnea/hypopnea index (AHI). An index of the
severity of the OSA, the AHI is calculated by
adding the total number of apneas and hypop-
neas observed and dividing by the number of
hours observed.
14
Respiratory disturbance index (RDI). Many sleep
diagnostic centers use AHI and RDI inter-
changeably. While similar, the RDI also includes
respiratory events such as RERAs that do not
technically t the denitions of apnea or hypop-
nea but do disrupt sleep.
14
Mild, moderate, and severe OSA. Severity of OSA
is generally dened using the AHI/RDI (mild
5 to 15; moderate 16 to 25; severe 26 and
more). Exact boundaries are somewhat uid,
leading to terms such as mild to moderate and
so forth, to better describe clinical reality. Addi-
tionally, it should be noted that the level of
severe is quite open ended with AHI/RDIs
exceeding 100 being well known.
Pathophysiology
OSA events occur when the pharyngeal airway
narrows or closes with respiratory effort during
sleep. Several concepts, among them a balance
of pressures, a modication that adds transmu-
ral pressure, and a tube law have been de-
scribed in explanation of the many and varied
changes in the airway leading to these apneas
and hypopneas.
15,16
This challenging and often
incredibly detailed work permits a summary de-
scription as follows.
64 J.M. McCrillis et al.
The pharyngeal airway is unique in having no
rigid support, instead being muscle and liga-
ment formed and supported. During wakeful-
ness, muscle tensions keep the lumen patent.
During sleep, as the muscles relax, the pharyn-
geal walls become more exible and more col-
lapsible. In the reclined position, the effects of
gravity distort the pharyngeal walls, especially by
retropositioning the tongue mass when supine,
resulting in a narrowed lumen.
As the desired volume exchange of air re-
mains the same, a higher velocity is required
through the smaller passageway. This ow is tur-
bulent
17
and tends to produce vibration and
utter of the exible walls and soft palate, pro-
ducing (often loud) snoring.
The narrower the lumen, the faster the veloc-
ity and the lower the pressure.
18
At some critical
point, this combination of physical conditions
will result in an occluded airway (sucked shut).
Although breathing effort will continue, with
the diaphragm contracting downward forcefully
enough that the chest walls may be drawn in-
ward, no air will be exchanged until there is
sufcient arousal (lighter level of sleep) to re-
gain some muscle tension and reopen the pha-
ryngeal airway.
This sequence of loud snoring, sudden si-
lence, and loud resuscitative snort is not only
virtually pathognomonic for OSA, but is fre-
quently the last straw that drives the offenders
family to force the individual to seek care.
Symptoms and Consequences
Symptoms
1. Loud irregular snoring
2. Snorts, gasps, and other unusual breathing
sounds during sleep
3. Long pauses in breathing during sleep
4. Excessive daytime sleepiness
5. Fatigue
6. Obesity
7. Changes in cognitive functions such as alert-
ness, memory, personality, or behavior
8. Impotence
9. Morning headaches
19
Consequences
Cardiovascular.
1. Systemic hypertension
2. Coronary heart disease
3. Cardiac arrythmias
4. Sudden nocturnal death
5. Other (stroke, pulmonary hypertension)
Social/behavioral.
1. Drowsy driving/accidents
2. Decreased work performance
3. Poor quality of life
19
4. Increased mortality
20-22
Use of CBCT in Airway Imaging
Technology
CBCT provides, in a single rotation much like a
dental panoramic radiograph unit, precise, es-
sentially immediate, accurate 3D radiographic
images (Figs 1 and 2). Collimation of the CBCT
primary x-ray beam allows limitation of exposure
to the region of interest or eld of view (FOV).
By using megapixel solid state detection devices,
minimal voxel (3D pixel) sizes of 0.09 mm
0.25 mm are achieved, exceeding the highest
grade multislice CT in terms of spatial resolu-
tion. Reconstruction of the digital data for view-
ing is accomplished on a PC in close to real time.
Standard viewing layouts include the display of
coronal, sagittal, and axial data sets concur-
rently. The views can be rotated on all three
Figure 1. Segmentation of airway in relation to hard
tissue using midline cone beam computed tomogra-
phy ray-sum volume of Digital Imaging and Commu-
nications in Medicine data set and Anatomage InVi-
voDental software (San Jose, CA). (Color version of
gure is available online.)
65 CBCT in Airway Imaging
axes. Cursor-driven measurement algorithms
provide the clinician with an interactive capabil-
ity for real-time dimensional assessment.
23
Dosimetry
CBCT provides a lower dose, lower cost alterna-
tive when compared with conventional medical
CT scans although somewhat more than typical
dental panoramic exposures.
24
As noted by
Farman, ALARA (as low as reasonably achiev-
able) still applies.
25
Ludlow and coworkers looked at dosimetry of
3 CBCT devices for oral and maxillofacial radi-
ology: CB Mercuray (Hitachi Medical Systems
America, Twinsburg, OH), NewTom 3G (QR,
Verona, Italy), and i-CAT (Imaging Sciences In-
ternational, Harteld, PA).
Utilizing thermoluminescent dosimeter chips
(TLDs) in a tissue-equivalent phantom (RANDO-
radiation analog dosimetry system; Nuclear Asso-
ciates, Hicksville, NY), Ludlow and coworkers re-
ported widely varying exposure levels depending
on not only the exposure settings but also the eld
of view (FOV), which can range from 6 to 12.
Dose levels reported were 4 to 77 times greater
than comparable panoramic examination doses.
Reductions in dose were seen with reduction in
eld size and with mA and kV technique factors.
24
Application
In a review of medical therapy for OSA, Veasey
and coworkers state: OSA is a highly prevalent
syndrome that is associated with substantial mor-
bidity and increased mortality. Positive air pres-
sure (PAP) is the most uniformly effective ther-
apy . . . However, approximately 25-50% of
patients with OSA will either refuse the offer of
PAP therapy, or will not tolerate it. Oral appli-
ances and surgical procedures to improve upper
airway patency are successful in certain subsets
of patients, but a notable proportion of patients
do not receive adequate clinical benet from
these approaches.
26
Any technology that would enhance clini-
cians ability to visualize where in the airway
obstruction occurs would help identify those
subsets of patients who may or may not benet
from a choice of treatment modalities. CBCT,
with its 3D presentation of the airway and its
surrounding structures, offers this increased vi-
sualization of both untreated obstruction ten-
dencies and potentially of changes in the airway
by treatment modality.
Ogawa and coworkers demonstrated the util-
ity of diagnosis of anatomy with the 3D airway
imaging with CBCT. They noted the ability to
describe signicant group differences in total
airway volume and the anteroposterior dimen-
sion of the oropharyngeal airway between OSA
and gender-matched controls.
27
The same group published additional nd-
ings notable in the use of a CBCT capable of
supine position imaging (Newtom QR DVT
9000; QA sri, Via Silvestrini 20, 37,135 Verona,
Italy). In this study of 10 OSA and 10 non-OSA
patients, statistically signicant differences
were reported in: the anterior-posterior di-
mension of the minimum cross-section seg-
ment; the minimum cross-section area; and in
the percentage incidence of location of the
minimum cross-section above or below the oc-
clusal plane. The OSA group presented a con-
cave or elliptic shaped airway and the non-
OSA group presented a concave, round, or
square-shaped airway.
28
Shi and coworkers utilized anonymous
CBCT data sets from subjects imaged for con-
ditions unrelated to the airway to evaluate
both a manual segmentation and an auto-
mated segmentation algorithm in measuring
Figure 2. Airway and facial soft tissue surface seg-
mented from 3D volume (Anatomage InVivoDental
software, San Jose, CA). (Color version of gure is
available online.)
66 J.M. McCrillis et al.
certain airway dimensions and airway volume.
They found no clinical signicant difference
in the manual versus automated algorithms,
opening the door to further automated analy-
sis of CBCT data sets.
29
In a follow-up article, Farman and coworkers
demonstrated the immense exibility of CBCT
in a highly visible Education in the Round
setting at the 148th American Dental Association
(ADA) Annual Session in San Francisco, Sep-
tember 26-30, 2007. Image production, process-
ing, and export to third-party software was per-
formed in real time. Multiple add-on services,
including model and positioning stent prepara-
tion from CBCT data sets, and 3-D photograph
production (3dMD, Atlanta, GA) were also
shown.
30
In work in progress, Farman and coworkers
examine the possibilities of using different soft-
ware packages to analyze changes in the upper
airway with and without placement of a mandib-
ular advancement device (MAD). Image J, a
noncommercial software (National Institutes of
Health, Bethesda, MD), was used to look at hor-
izontal plane le sets for cross-sectional area
changes. Anatomage (InVivoDental, San Jose,
CA) used the entire Digital Imaging and Com-
munications in Medicine (DICOM) multile
data sets to produce a color-contrasted blended
view of the airway changes with and without the
MAD in place (Figs 3 and 4). Excellent segmen-
tation was achieved and it was possible to make
airway minimum cross-sectional area and volu-
metric assessment.
31
Figure 3. Subtraction radiography using Anatomage InVivoDental software (San Jose, CA) to demonstrate
improvement in airway patency following placement of a mandibular advancement device. (Color version of
gure is available online.)
67 CBCT in Airway Imaging
Summary
CBCT technology provides 3D images that pro-
vide the third dimension in dental/airway imag-
ing. The rapid growth in numbers of new CBCT
imaging units being readied for the marketplace
evidences the interest of industry in this sector of
medical imaging.
32
Further studies are required
to correlate the visualized airway characteristics
with clinical outcomes by treatment modality,
hence then to the possibility of treatment mo-
dality choice based on predictable outcomes.
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