Automatic detection of adenoid

hypertrophy on cone-beam computed

tomography based on deep learning
Wenjie Dong,A Yaosen Chen,A Ankang Li,B Xiaoguang Mei,C and Yan Yanga
Wuhan, Hubei, China

Dr Muhammad Asif
INTRODUCTION

 Obstructive sleep apnea (OSA) is a breathing disorder during sleep because of

prolonged partial and/or intermittent complete upper airway obstruction that
disrupts normal ventilation during sleep.
INTRODUCTION

 Currently a lot of parents come to the orthodontists with complaints of

malocclusion in their kids’ teeth.
 The cause of these malocclusions is often adenoid hypertrophy and mouth
breathing.
 Thus, early, accurate screening of adenoid hypertrophy is necessary for the
dentist.
INTRODUCTION

 Recently, CBCT has been increasingly used in the formulation of orthodontic

diagnosis and treatment plans11 and research on upper airway morphology.12,13
INTRODUCTION

 Deep learning algorithms have been applied to orthodontic cephalometric

measurements.
 Some studies have provided skeletal classification systems and landmark system-
based convolutional neural networks (CNNs) with lateral cephalograms. 18,19
 Neural networks have recently been used to segment the sinonasal cavity and
upper airway on CBCT images,20,21 allowing a better understanding of the upper
airway.
INTRODUCTION

 However, no study has attempted the automatic classification of normal or

blocked upper airways with CBCT images based on deep learning.
INTRODUCTION

 Therefore, this study was designed to develop and search for a new deep
learning-based method for diagnosing abnormal upper airway morphologies on
CBCT.
 The proposed system consists of a neural network based on deep learning, which
segments the upper airway accurately in 3D space, and a classification model,
which judges whether the upper airway is abnormal according to its morphology.
INTRODUCTION

 Finally, we compared the performance of the proposed system with a set of

experienced orthodontics to test its accuracy.
MATERIAL AND METHODS

 Helsinki Declaration on medical protocols and ethics.

 Pre-operative CBCTs of 129 patients.
 Settings: 90 kV, 4.0 mA,
 Scan time of 11.3 seconds.
 Minimal resolution was 0.3 mm voxels,
 Field of view was at least 16 × 3 cm.
 All images were stored in digital imaging and communications in medicine
format.
MATERIAL AND METHODS

First, we evaluated adenoid enlargement on CBCT using a previously

established 4-grade scale on electronic nasopharyngoscopy.22,23
MATERIAL AND METHODS

 All CBCT images were annotated by 2 experienced orthodontists

MATERIAL AND METHODS
MATERIAL AND METHODS

 If 2 orthodontists disagreed, a third orthodontic specialist (Y.Y., with 30 years of

clinical experience) provided an opinion.
 If the third orthodontist was unsure of the diagnosis, the confusing CBCT image
was excluded.
 Among the 129 CBCT images, 87 were finally retained in our study, including 35
patients with adenoid enlargement and 52 with normal adenoids, after excluding
images of low quality and with controversial diagnoses.
MATERIAL AND METHODS

 Data augmentation techniques were applied to the original medical image dataset
to alleviate the problem of small data set.
 In our practice, the original dataset was augmented by performing 5 random
affine transformations and 4 random elastic transformations using the MONAI
medical image deep learning framework, producing 3D volumes from the
original dataset (n=870).
MATERIAL AND METHODS

 Existing deep learning-based adenoid hypertrophy diagnostic methods were

generally designed only for segmentation, not for classification tasks. 20,21
 Specifically, those studies only provided doctors with the segmentation result,
and the final decision still had to be made manually.
MATERIAL AND METHODS

 Unlike these methods, our proposed method involves 2 deep learning models that
not only segment the upper airway more accurately but also use the precise
segmentation results to determine whether the airway is blocked.
Hierarchical masks self-attention U-net
(HMSAU-Net)

 Despite the excellent performance of CNN-based methods in current medical

image segmentation tasks, they are not very suitable for upper airway
segmentation tasks.
 Compared with other organs, the upper airway contains more long-distance
semantic dependencies that are not easily captured by traditional CNN-based
structures.27
 Self-attention U-Net (SAU-Net) was used to capture those features that were
highly relevant to our task
Hierarchical masks self-attention U-net
(HMSAU-Net)

 SAU-Net replaces the traditional U-Net encoder path with a string of vision
transformer (ViT)28 encoders, thus obtaining the ability to capture long-distance
semantic dependencies.
 Hierarchical masks (HMs) were introduced to ensure that HMSAU-Net could
capture sufficient local semantic information because the global self-attention
mechanism of ViT weakens the local feature extraction ability.
ResNet classification model

 ResNet Classification model has demonstrated excellent performance on various

image classification tasks.
 ResNet possesses too many layers and thus was originally not suitable for our
task because our dataset was relatively small.
 To avoid overfitting, we implemented 3 modified ResNet models with fewer
layers (ResNet10, ResNet18, and ResNet34).
ResNet classification model

 The patients’ CBCT images were sent to the well-trained HMSAU-Net to obtain a
high-precision airway segmentation result.
 This result was automatically input to the well-trained 3D-ResNet to obtain an
adenoid hypertrophy diagnosis.
 Finally, the orthodontic doctors can use both results to make a final decision.
FLOW CHART OF THE PROPOSED
SYSTEM
STATISTICAL ANALYSIS

 All statistical analyses performed by Python programming language.

 Dice coefficient was used to evaluate the performance of the trained model
segmentation of the upper airway.
 Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV),
negative predictive value (NPV), F1 score, the receiver operating characteristic
curve, and the area under the curve (AUC) were used to assess the performance
of the 3D-ResNet mode
STATISTICAL ANALYSIS

 The intraclass correlation coefficient (ICC) 30 was used to test intraevaluator and
interevaluator agreement regarding the segmentation by comparing the manually
segmented volumes of the upper airway.
 Cohen’s kappa31 and Fleiss’s kappa32 were applied to assess the intra- and
interobserver agreement.
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS

 The proposed system was also fast in delivering a diagnosis.

 The 3D-ResNet10 model took the least time (2.61 min) to diagnose all 170 CBCT
images.
 The average speed required to analyze a CBCT image was 0.92 seconds, whereas
a human expert needed an average of 9.8 seconds to diagnose 1 CBCT image.
DISCUSSION

 Our results showed that our model performance was very close to the
performance of human experts while only requiring one-tenth of their time.
DISCUSSION

 In our study, we not only proposed a segmentation model for the upper airway on
the basis of a deep neural network but also obtained a diagnosis of adenoid
hypertrophy by evaluating the morphology of the segmented airway through a
second neural network.
 The average Dice value of upper airway segmentation in our model was 0.960,
which is higher than that of other organs.17
DISCUSSION

 Some commercial software programs have been published that can segment the
upper airway, but first requires setting a manual point, framing the range of the
upper airway, and then forming the 3D structure of the airway.
 Establishing landmarks produces errors that affect the final diagnosis and
consume more time.
DISCUSSION

 These commercial software programs are partly based on semiautomatic

segmentation, whose segmentation accuracy relies on the gray value and
threshold value defined by the operator.
 There is no significant gray gradient between the upper airway and surrounding
tissues on CBCT images.
DISCUSSION

 After commercial software segments the upper airway, the edge morphology
must be manually adjusted, which is time-consuming and complex.
 Therefore, our study applies the end-to-end characteristics of deep learning and
directly obtains diagnostic results by inputting a CBCT image, eliminating the
process of locating landmarks and reducing the doctor’s workload.
DISCUSSION

 As a screening tool, our deep learning-based diagnosis system demonstrates good

sensitivity (0.976), reflecting the ability to detect disease, and good specificity
(0.867), reflecting the ability to rule out normal adenoids.
 This diagnostic system can help dentists detect adenoid hypertrophy in children at
an early stage to avoid irreversible damage to their physical and mental health.
 We expect this auxiliary diagnostic technique to be accepted and promoted in
clinical work because of its rapid monitoring ability and minimal invasiveness
LIMITATIONS

 Our dataset consists only of data from our hospital.

 Although our model was tested on a public dataset, the result was not as good as
that with our dataset, probably because the public dataset was derived to solve a
multiclassification problem.
 In future steps, it will be necessary to train our model by collecting images from
various patients from more clinical centers to increase its generalizability
LIMITATIONS

 Second, a variety of factors often must be taken into consideration in the

diagnosis and treatment of OSA.
 Compared with human experts, our deep learning model only considers 1 factor
because of the limitations of technology and the datasets, which may lead to
misjudgment.
 We expect to add text information and image information extractors in future
versions of the model to fuse different extracted features and finally form a
multimodal diagnostic system to provide clinicians with efficient and convenient
services.
LIMITATIONS

 Third, the HMSAU-Net model does not perform as well as 3DU-Net in capturing
local information.
 Even if we add extra 4-layer supervision information to our task, the essence of
those network structures is not changed, so their generalization is still
questionable
CONCLUSIONS

 We achieved the automatic diagnosis of adenoid hypertrophy on CBCT based on

deep learning for screening OSA in children.
 The HMSAU-Net model showed good performance in segmenting the upper
airway on CBCT, and 3D-ResNet10 demonstrated sensitivity and specificity
similar to that of human experts in diagnosing adenoid hypertrophy at one-tenth
of their speed.
 The diagnostic system can assist dentists in the early screening of OSA children
and in making treatment plans.
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THANKS