Indications of Risk For Obstructive Sleep-Disordered Breathing Seen On Cone Beam Computed Tomography - CAD-Ray

12/12/2017 Indications of risk for Obstructive Sleep-disordered breathing seen on Cone Beam Computed Tomography - CAD-Ray.
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SEPTEMBER 3, 2017 ARMEN MIRZAYAN APNEA, CT TECHNOLOGY
Indications of risk for Obstructive Sleep-

disordered breathing seen on Cone Beam
Computed Tomography
Patient information regarding the presence of sleep disordered breathing (apnea),

begins with thorough clinical evaluation. The patient/parent should be interviewed
regarding snoring, mouth breathing, medications, and visits to the ENT. An important
initial area of assessment includes facial profile (as Class II dolicofacial profiles tend to
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12/12/2017 Indications of risk for Obstructive Sleep-disordered breathing seen on Cone Beam Computed Tomography - CAD-Ray.com
have more airway problems than other facial types). Resting lip posture, droopy eyes,
and the presence of “shiners” (vascular congestion manifested as darkness under the
eyes) should be noted. Intraoral findings, such as high palatal vault, narrowed
transverse dimensions of the maxillary and/or mandibular dentition, anterior or
posterior crossbites with associated functional shifts can be related to airway
irregularities.
Once the above questions and clinical assessment are performed, and the findings
suggest presence of breathing disorder, imaging is useful to identify possible anatomic
and morphologic structures that contribute to risk for presence or development of
obstructive sleep-disordered breathing. While sleep apnea is not diagnosed with
imaging, cone beam computed tomography (CBCT) exams are valuable in providing
three-dimensional or multiplanar views that enable clear definition of irregularities that
may be creating obstruction or resistance to airflow through the nasal passages, the
nasopharynx, the oropharynx, and the hypopharynx. Some of these irregularities
include soft-tissue enlargements or aberrant morphology, bony structures, dental
findings, cephalometric measurements, and pathology. Examples in these categories
are depicted in images below.
Commonly seen irregularities that indicate risk for presence or development of obstructive
sleep-disordered breathing
Airflow into the patient’s airway begins at the external, then the internal, nasal valves.
These entrances are composed of cartilage, muscle, ligaments, and mucosal soft-
tissue, all of which can display irregularities of various etiologies, creating narrowing or
blockages. The image above depicts narrowed left internal nasal valve, and constricted
right internal nasal valve.
Deviation of the nasal septum is a frequent finding. A large range of variability is seen.
Some examples include minor deviation of the full septum, deviation of a small
segment, enlarged septal tubercle, formation of a septal spur, and S-shaped contour
that deviates both to the right and the left at different levels of the septum. The image
above shows right deviation near the level of the right middle meatus, with a bulbous
morphology of the septal tubercle contacting the right inferior concha. This can
introduce alteration to airflow pattern through the nasal passage.
Note: an anatomic variant of paradoxical turbinate (arrow) is present at the left middle
concha. This finding is often without clinical significance, but can create a blockage of
the ipsilateral ostiomeatal complex. In this case, the left ostiomeatal complex is patent.
The above image shows septal tubercle/spur formation to the left, where it contacts the
superior portion of the left inferior concha and the left middle concha. More superiorly,
the nasal septum displays a gradual curvature toward the right. Accompanying these
deviations is mild soft-tissue enlargement of the nasal septum as well as mucosal
thickening in the superior portion of the left maxillary sinus. The combination of these
features is forming obstruction to airflow through the nasal cavity and creating
obstruction of the left ostiomeatal complex.
Concha bullosa is an air cell which is most commonly seen occupying the middle
concha, either unilaterally or bilaterally. On occasion, smaller conchae bullosa are seen
at the superior conchae. They are frequently clinically insignificant, but can influence
deviation of the nasal septum and create narrowing or blockage of the ostiomeatal unit.
The image above shows an obstructed left ostiomeatal complex (red arrow).
Enlargement of the pharyngeal tonsils (adenoids) is commonly seen, most often in

children, which would be expected. If enlargement is seen in adults, more questions
regarding etiology are raised, as these tissues typically begin gradual regression after
the age of 12. This size enlargement creates significant blockage in the nasopharynx.
Note parted lips, even though the condition of deep anterior vertical overlap is present.
Thickened soft palate and uvula soft-tissue can narrow, and at times, constrict the
airway, even while the patient is in an upright position. The presence of obstructive
sleep-disordered breathing would be suspected with these patients in supine position.
Both sagittal and axial views show the significant narrowing that can be created by
swollen or enlarged uvula/soft palate.
Elongated uvula/soft palate is sometimes implicated in creating narrowing in the

oropharynx. Typical length of this soft-tissue complex is approximately 40 mm or less.
The image above shows a length that approaches the superior aspect of the epiglottis,
with associated airway narrowing.
Enlarged palatine tonsils are most commonly seen in children, and demonstrate
significant variety in size. The above image depicts considerable enlargement of the
palatine tonsils, which is creating blockage of the airway. Regression of the palatine
tonsils occurs gradually after the age of 12.
Enlargement of the lingual tonsils is less frequently seen than the pharyngeal or
palatine tonsils, but is nevertheless a common finding, and can create significant
narrowing of the inferior oropharynx, as shown above. Lordotic curvature of the cervical
spine in this instance it exacerbating the constriction.
Commonly seen, but less scrutinized findings relative to risk of sleep-disordered

breathing
High palatal vault is suggestive of narrowed maxillary alveolar and dental arches,
which can result in unilateral or bilateral posterior crossbites, functional shifts, and
restriction in the freedom of anterior mandibular movement. It also creates a space for
the tongue to be positioned superiorly, which can lead to airway restriction at the
superior oropharynx.
Narrow dental arches often reduce the amount of available tongue space, and may
transversely constrict the tongue. This can lead to aberrant tongue shape and position,
and subsequent alteration of normal airway space. Rule of thumb: less than
approximately 44mm may indicate risk for development of breathing disorder. (Dr.
Sean Carlson)
An unusual finding of enlarged soft tissue in the hypopharynx, at the level of the larynx,
warrants evaluation medical ENT. The small hyperdensity is likely calcification of
arytenoid cartilage.
Narrowed airway dimensions are seen more frequently in cases of this facial growth
type than other growth patterns.
Less-commonly seen irregularities that indicate risk for presence or development of
obstructive sleep-disordered breathing
The left maxillary sinus in the image above is considerably smaller than the right, and
its lumen is opacified with mucosal thickening. This finding does not necessarily create
a condition of sleep-disordered breathing, but should raise suspicion and indicates the
need for further assessment.
Image from University of Washington Image from Radiopaedia contributed by Dr.

Roberto Schubert.
Pneumatized crista galli may communicate with the frontal recess and can potentially
obstruct the frontal sinus ostium.
These tissue enlargements are non-neoplastic, inflammatory swellings of sinonasal

mucosa that buckles to form “polyps”. Considerable resistance to airflow is created by
lesions this size.
Ossifying fibroma is an expansile benign fibro-osseous neoplasm which can create

significant airway blockage.
A schwannoma is a normally benign, neural sheet tumor, in this case creating blockage
in the right nasal cavity.
The preceding images represent some findings identified on CBCT exams that suggest
the possibility of presence or future development of obstructive sleep-disordered
breathing. Numerous additional abnormalities not included in this article can create
obstructions or disruptions of normal airflow. This flow of air from the environment into
the lungs must negotiate a course from the external nasal valves, through the nasal
fossa, the nasopharynx, oropharynx, and hypopharynx. Airflow dynamics through this
pathway are subject to laws of Poiseuille and Ohm, which show resistance to airflow
can create increases in the pressure gradient between the mouth/nose and the alveoli
(Hatcher, 2010). Anatomical structures along this pathway involve cartilage, bone,
muscles, and mucosa, which are dynamic and can change in dimension and shape in
response to normal physiological (swelling and shrinkage of nasal conchae), allergies,

infection, and abnormal tissue proliferation, such as polyps or neoplasm.
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12/12/2017 Indications of risk for Obstructive Sleep-disordered breathing seen on Cone Beam Computed Tomography - CAD-Ray.

SEPTEMBER 3, 2017 ARMEN MIRZAYAN APNEA, CT TECHNOLOGY

Indications of risk for Obstructive Sleep-

Patient information regarding the presence of sleep disordered breathing (apnea),

Enlargement of the pharyngeal tonsils (adenoids) is commonly seen, most often in

Elongated uvula/soft palate is sometimes implicated in creating narrowing in the

Commonly seen, but less scrutinized findings relative to risk of sleep-disordered

Less-commonly seen irregularities that indicate risk for presence or development of

obstructive sleep-disordered breathing

Image from University of Washington Image from Radiopaedia contributed by Dr.

These tissue enlargements are non-neoplastic, inflammatory swellings of sinonasal

Ossifying fibroma is an expansile benign fibro-osseous neoplasm which can create

response to normal physiological (swelling and shrinkage of nasal conchae), allergies,

Click here to submit your scan for an airway assessment

Please Share this:

Share 2 Share 6 Tweet Save  WhatsApp submit

 Telegram Share 0  Email  Print

You must be logged in to post a comment.

Powered by OneAll Social Login

← HAPPY PATIENT THAT IS FINALLY GETTING SOME SLEEP

PEDIATRIC AIRWAY DEVELOPMENT →

BlueSkyBio Level 2 Course with Dr. Cory Glenn

What you will learn:

*Mastering the Blue Sky Bio software

Apnea.Today Intro to Pediatric Airway Management (Dr. Tracey

Dr. Tracey Nguyen maintains a private private 30 minutes outside of

Recently she created the Northern Virginia Interdisciplinary Airway Group,

Dr. Armen Mirzayan

Course Description: Obstructive Sleep Apnea is chronic, sometimes life-

Participants will learn:

The impact of sleep apnea

What is needed to begin treating sleep apnea

Dr Umang Patel Course Testimonial

Testimonial Dr. Umang Patel

Dr. Jason Chen Testimonial

Dr. Ashish Vashi Testimonial

Apnea.Today Course Testimonial from Dr. Ashish Vashi

Introduction to Guided Surgery

Common Clinical Issues with Guided Surgery

Apple Heart Study Announcement with new Apple Watch Feature

OUR AFFILIATE CENTERS

Affiliated Centers Search

View CAD-Ray Imaging Affiliated Centers in a full screen map

PROUDLY POWERED BY WORDPRESS | THEME: IXION BY AUTOMATTIC.

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