International Journal of Pediatric Otorhinolaryngology 78 (2014) 588–592

Craniofacial modifications in Ivorian melanoderm children withchronic retronasal obstruction

Marie-Josee Tanon-Anoh a,*, Yao Mathurin Kouassi a, Moussa Yoda a, Esther K. Badou a,Nidam Hoballah a, Jean-Baptiste Beugre c, Roger N’Gbesso b, Bertin Kouassi a

a Yopougon University Hospital, Department of ENT, Head and Neck Surgery, Abidjan, Cote d’Ivoireb Yopougon University Hospital, Department of Radiology, Abidjan, Cote d’Ivoirec RFU of Odonto-Stomatology, Department of Dento-Facial Orthopedic, Abidjan, Cote d’Ivoire

A R T I C L E I N F O

Article history:

Received 2 December 2013

Received in revised form 30 December 2013

Accepted 4 January 2014

Available online 13 January 2014

Keywords:

Chronic retronasal obstruction

Craniofacial modifications

Melanoderm children

A B S T R A C T

Objective: To determine the influence of the chronic retro nasal airway obstruction on craniofacial

morphology.

Methods: It was a case–control study which included fifty-eight melanoderm children aged from 3 to 6

years (31 males and 27 females), divided in 2 samples. A studied group of 29 habitual snorers presenting

chronic retro nasal obstruction due to enlarged adenoid and a control group of 29 age matched children

selected among patients consulting for routine evaluation. Patients who had used topical or systemic

medication for the nose, as well as those who had undergone adenoidectomy were excluded from the

study.

Children were submitted to history taking then ENT and orthodontic examination. Linear and angular

cephalometric measurements were used for craniofacial features evaluation.

Results: Significant craniofacial anomalies were found in patients presenting chronic retro nasal

obstruction: shortened cranial base and mandibular plane length, widened cranio-cervical flexure,

forwardness of hyoid bone, reduced nasopharyngeal airway space, widened of oropharyngeal and

hypopharyngeal airway space.

Conclusions: Our study suggests that craniofacial modifications due to chronic retro nasal obstruction

lead to pharyngeal airway readjustment. Persistent retro nasal obstruction should be corrected early in

life in order to avoid skeletal modifications appearance.

� 2014 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology

jo ur n al ho m ep ag e: ww w.els evier . c om / lo cat e/ i jp o r l

1. Introduction

Epidemiologic studies of habitual snoring in children suggest aprevalence of 7–12%. Snoring in children is frequently associatedwith adenotonsillar hypertrophy [1]. In the majority of childrenwithout evident craniofacial morphological abnormalities, habit-ual snoring and/or obstructive sleep apnoea are frequent between3 and 6 years [1]. Several studies have used cephalometrics toexamine for anatomic differences in snoring or apneic and non-snoring subjects [2,3]. Most of studies concerned adults and only afew studies have investigated differences in cephalometric factorsin children. However, it is apparent that Caucasian norms areinappropriate for application to different ethnic groups, as racialcharacteristics lead to important cephalometric variations [4,5].

* Corresponding author at: BP 725 cidex 3 Abidjan Riviera, Cote d’Ivoire.

Tel.: +225 07 09 92 92; fax: +225 22 47 01 84.

E-mail addresses: anohjose@ymail.com, anohjose@aviso.ci (M.-J. Tanon-Anoh).

0165-5876/$ – see front matter � 2014 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijporl.2014.01.004

The aim of this study was to determine the influence of thechronic retro nasal airway obstruction on skeletal craniofacial inmelanoderm child.

2. Patients and methods

2.1. Patients

The present prospective study was conducting after informedconsent had been obtained from the parents.

The sample consisted of 58 Ivorian melanoderm children, girlsand boys, aged from 3 to 6 years. Subjects that had used eithertopical or systemic medication for the nose were excluded from thestudy, as well as those who had undergone adenoidectomy or otherENT surgery. The studied group represented a sample of 29habitual snoring children due to enlarged adenoids with chronicretro nasal obstruction (n = 29). The control group consisted of29 age-matched children selected from patients referred in theENT consultation for routine evaluation, without craniofacial or

Fig. 1. Cephalometric landmarks. S (sella): center of the sella turcica; Ba: basion; Na:

nasion; PMm: the most posterior–superior point of the soft palate; PMi: the most

inferior tip of the soft palate; ANS: anterior nasal spine; PNS: posterior nasal spine;

Go: gonion; Gn: gnathion; C2: second cervical vertebra; C3: third cervical vertebra;

Hy: hyoid bone; Epigl: base of the epiglottis.

Fig. 2. Linear and angle measurements. (A) 1: S-Go: posterior face height; 2: Go-Gn: the le

ANS: upper anterior face height; 5: ANS-PNS: maxillary length; 6: S-Ba: posterior crania

angulation. (B) 1: Ba-S-N: cranial base flexure; representing the cranial base angle; 2:

posterior cranial base; 4: Co-Gn: the length of the mandible; 5: angle Co-Go-Gn: angulat

from Ba; 4: PMp-NL: distance between soft palate point and NL; 7: NPh/?Ba: distance bet

posterior side of nasopharynx; 9: PMm- NPh: distance from soft palate to posterior side o

12: OPha-OPhp: distance separating anterior side from posterior side of oropharynx; 13:

distance between anterior side and posterior side of hypopharynx; 15: HPhp-C3: dista

M.-J. Tanon-Anoh et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 588–592 589

orthodontics abnormalities and a negative history of chronicsnoring.

2.2. Methods

Clinical evaluation: children were submitted to history takingand clinical examination. This clinical examination includes ENTand orthodontic examinations.

Cephalometric evaluation: cases and controls were evaluatedwith standard lateral cephalometric radiographs. The sametechnician using the same device performed the exam, understandardized technique. The radiographs were taken with thechild’s head immobilized in a wall-mounted cephalostat andoriented to the Frankfort horizontal plane. The head was fixed sothat the median plane was parallel to the film. All linear andangular cephalometric measurements were performed by thesame operator.

The studied cephalometric reference points marked in cepha-lograms were as follows (Fig. 1):

- S (sella): center of the sella turcica- Ba: basion- Na: nasion- PMm: the most posterior–superior point of the soft palate- PMi: the most inferior tip of the soft palate- ANS: anterior nasal spine- PNS: posterior nasal spine- Go: gonion

ngth of the mandibular plane; 3: S-Na: anterior cranial base linear dimension; 4: Na-

l base linear dimension; 7: Co-Go: ramus length; 8: angle C2C3/SN: cervico-cranial

N-Ba: the length of the cranial base; 3: PNS?BaS: distance between PNS and the

ion (flexure) of the mandibular angle. (C) 1: NL (nasal line): distance separating ANS

ween Ba and posterior side of nasopharynx; 8: PNS-NPhp: distance between PNS and

f nasopharynx; 10: PMi-PNS-ANS: inferior angle formed by PMp-PNS and PNS-ANS;

OPhp-C2: distance separating posterior side of oropharynx from C2; 14: HPha-HPh:

nce between posterior side of hypopharynx and C3.

Table 1Craniofacial and pharyngeal variables. (*: significant; **: very significant).

Cases Controls p-Value

Length of cranial base (NBa) 92.82 � 7.37 96.8 � 4.93 0.019*

Cranial base angle (SNBa) 129.20 � 4.6 130.53 � 5.51 1.002

Length of mandible (CoGn) 90.79 � 11.05 95.90 � 7.06 0.005**

Mandibular angle (CoGoGn) 126.13 � 6.11 124.06 � 3.66 0.23

Distance ANS-Ba (NL) 87.89 � 6.25 90.96 � 5.18 0.02*

Cranio-cervical angulation (C2C3/SN) 111.0 � 9.15 99.62 � 12.21 0.0002**

Posterior face height (SGo) 59.72 � 6.08 61.20 � 5.48 0.333

Distance hyoid bone-C3 (Hy-C3) 32.73 � 3.89 29.93 � 2.92 0.0007**

Length of soft palate (LSP) 28.44 � 5.22 27.20 � 3.56 0.44

Inferior angle hard palate/soft (PMi-PNS-ANS) 147.13 � 6.73 139.31 � 5.66 0.0001**

Distance between PNS and posterior side of nasopharynx (PNS-NPhp) 13.79 � 7.51 19.36 � 5.52 0.0001**

Distance soft palate-posterior side nasopharynx (PMm-NPh) 6.65 � 2.45 11.33 � 2.24 0.0001**

Distance anterior side-posterior side of oropharynx (OPha-OPhp) 17.75 � 5.29 13.43 � 4.78 0.0004**

Distance anterior side-posterior side of hypopharynx (HPha-HPhp) 17.13 � 4.34 13.56 � 3.65 0.0005**

Nasopharynx height (PMi-NL) 16.72 � 4.26 17.48 � 3.17 0.298

Distance PNS-posterior side of nasopharynx (NPh/?Ba) 9.29 � 3.97 13.40 � 2.78 0.0001**

M.-J. Tanon-Anoh et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 588–592590

- Gn: gnathion- C2: second cervical vertebra- C3: third cervical vertebra- Hy: hyoid bone- Epigl: base of the epiglottis

The linear and angle measurements are presented in Fig. 2.

2.3. Statistical analysis

Calculations were made for arithmetic means (moy) andstandard deviations (SD). Student’s test and Pearson’s correlationtest were used for testing the differences between means. Astatistical significance level of 5% was adopted (p < 0.05).

3. Results

Figs. 3 and 4 present, respectively, the population according tothe age and the sex.

Table 1 presents the craniofacial and pharyngeal variables. Thelength of the cranial base (N-Ba), the length of the mandibularplane (Go-Gn) and the nasal line (NL) were significantly shorter inthe studied group than the controls one. As well, the cranio-cervical angle was wider and the hyoid bone was more distantfrom the rachis in the studied group than the controls subjects.

The rhinopharyngeal airway space (PMm-NPh) was significant-ly more reduced in pathological cases. Quite the reverse, the

7

4

7

5

1110

4

10

29 29

0

5

10

15

20

25

30

Nu

mb

ers

3 year s 4 years 5 year s 6 year s Tota l

Age

Case

Control

Fig. 3. Population according to the age.

oropharyngeal and hypopharyngeal airway space were wider inpatients group with retronasal obstruction than the controls group.

Table 2 summarizes craniofacial and pharyngeal variables dataaccording to the sex. Any craniofacial variable was not significantlydifferent according to the sex in the studied group. In the controlsgroup, the length of the cranial base (N-Ba) and the length of themandibular plane (Go-Gn) were significantly different.

The pharyngeal variables were not statistically different in thestudied group. On the other hand, soft palate length (LPM) andnasopharynx height (PMi-NL) were statistically different accordingto the sex in the controls group.

4. Discussion

Few studies considered cephalometric analysis to determinethe role of upper airways (UA) obstruction and its consequences.Cephalometric is an accepted tool in adult obstructive sleepapnoea (OSA) patients for the evaluation of soft tissue and boneupper airways measures [5,6]. In children, it is also routinely used.Actually, a Japanese study compared cephalometric results inchildren with OSA and in age matched controls [7]. Thus,cephalometry is a valid measures method. Nevertheless, the limitof the method is related to the teleradiographs measurementsbecause of bidimensional pictures used. 3D cephalometry recoursecould permit to remove bidimensional cephalometry limitative

13

16

1415

0

2

4

6

8

10

12

14

16

Nu

mb

ers

Cases Control s

Category

Female

Male

Fig. 4. Population according to the sex.

Table 2Craniofacial and pharyngeal variables according to the sex. (*:significant; ns:not significant).

Cases males vs females Controls males vs females

Length of cranial base (NBa) ns *

Cranial base angle (SNBa) ns ns

Length of mandible (CoGn) ns *

Mandibular angle (CoGoGn) ns ns

Distance ANS-Ba (NL) ns ns

Cranio-cervical angulation (C2C3/SN) ns ns

Posterior face height (SGo) ns ns

Distance hyoid bone-C3 (Hy-C3) ns ns

Length of soft palate (LSP) ns *

Inferior angle hard palate/soft (PMi-PNS-ANS) ns ns

Distance between PNS and posterior side of nasopharynx (PNS-NPhp) ns ns

Distance soft palate-posterior side nasopharynx (PMm-NPh) ns ns

Distance anterior side-posterior side of oropharynx (OPha-OPhp) ns ns

Distance anterior side-posterior side hypopharynx (HPha-HPhp) ns ns

Nasopharynx height (PMi-NL) ns *

Distance PNS-posterior side of nasopharynx (NPh/?Ba) ns ns

M.-J. Tanon-Anoh et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 588–592 591

factors by offering reproducible methods based on identifiedanatomical references [8].

Few studies [7,9] concerning boys and girls, aged from 3 to 6years with nasal obstruction due to adenotonsillar hypertrophywere performed. Our study did not show significant differenceaccording to the sex. Vilella et al. [10] quite the opposite, found thatfor girls, the craniofacial growth might be significantly moreprecocious and rapid in comparison to that of boys.

Our study revealed morphological changing in patients pre-senting chronic upper airway obstruction. Indeed, the length of thecranial base (Na-Ba), the length of the mandibular plane (Go-Gn)and the nasal line (NL) were significantly shorter in the studiedgroup. Thus, the study evidenced an anteroposterior craniofacialgrowth. Nevertheless, the direct relationship of the nasal obstruc-tion might be proved. Some authors [10–12] incriminate thebreathing mode in craniofacial abnormalities appearance duringchildhood. For Lessa et al. [12] mouth breathing should beconsidered as the major etiological factor of induced excessivevertical growth. It is now known that, mouth breathing is theconsequence for nasal obstruction, which does not offer normalenvironmental conditions for facial growth and development [13].Consequently, our study suggests, as well as other authors [14,15]that causal association between nasal obstruction and facialgrowth in children, seem to be of multi-factorial nature. Theassociated factors are the age, the long duration and the severity ofthe nasal obstruction. Table 3 compares our craniofacial variablesdata to other authors in the literature [12,16]. Relating to the hyoidbone position, the current work found that it was more distantfrom cervical vertebrae in the nasal obstruction subjects groupthan the controls subjects. In contrast, the literature findings arecontroversial and different. Actually, a Japanese study found thatchildren with obstructive sleep apnoea had an inferiorly positioned

Table 3Craniofacial variables compared to the literature data.

Our study Cote d’Ivoire

Length of cranial base Reduced

Cranial base flexure Idem

Length of mandible Reduced

Mandibular angle Idem

Facial height

Posterior Idem

Anterior –

Cranio-cervical angle Opened

Nasopharyngeal airway space Narrow

Hyoid bone position More distant from rachis

hyoid bone [17]. Moreover, according to an American study,children with primary snoring without apnoea had smallermandibular length and inferiorly positioned hyoid [11]. Besides,the present study found that craniocervical angle was wider in theretro nasal obstruction subjects group. This would induce amodification of the cervical vertebrae inclination. These findingsare in agreement with the literature’s ones. In fact, extension andcephalic curvature are accented [18].

In our present study, we found the pathological subjects to havea narrower pharyngeal space than the controls subjects. Thenasopharyngeal airway measured by PMm-NPh distance wassignificantly more reduced in the studied group than the controlssubjects. This finding is due to adenoid hypertrophy. Thesignificant narrowing of the nasopharyngeal width in thepathological subjects would lead to mouth breathing and snoring.The present results are in accordance with the findings of theliterature [9,11]. However, there is no correlation betweenadenoidal growth and the nasopharyngeal airway space narrow-ing. The apparent contradiction between the nasopharyngeal freeairway space increase as well as that of the adenoidal thickness inthe same age group can be explained by the increasing depth of thebony nasopharynx. From 8–9 to 10–11 years, the bony nasophar-ynx depth was significantly higher than the adenoidal thicknessincreased [10].

According to the children’s gender, it was noticed that for boysthe bony nasopharynx was significantly higher in comparison togirls in the age group 1415 years [10]. However, in our presentstudy, the difference between male and female subjects was notstatistically significant in both cases and controls groups.

The oropharyngeal airway assessed by OPha-OPhp distance wassignificantly wider in the studied group than the controls one. Thisfinding could be explained by the forwardness position of the

Finkelstein et al. [16] (Israel) Lessa et al. [12] (Brasilia)

Idem –

Closed –

Reduced –

Opened Opened

Smaller

Greater

–

Reduced –

Modified –

M.-J. Tanon-Anoh et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 588–592592

hyoid bone. The relationship between oropharyngeal airway andhyoid position has been described as when the mandibular bodylengthens, the attachments of the genioglossus and geniohyoidmuscles move forward away from the oropharynx, thus increasingoropharyngeal airway [19]. Otherwise, the hypopharyngeal airwayevaluated by HPha-HPhp distance, was significantly wider in thepathological group than the controls one.

5. Conclusions

This airway case–control study of children aged from 3 to 6years, evidences skeletal modifications in patients presenting retronasal obstruction. The modifications lead to pharyngeal airwayreadjustment in order to ease airflow. Despite the fact that manyunknowns persist, breathing mode’s influence has been proved.Consequently, retro nasal obstruction of long duration must beavoided throughout the growing process. Persistent nasal obstruc-tion should be corrected surgically early in life, before skeletalmodifications appearance. In this respect, three-dimensionalimaging could provide changes to retro nasal obstructiontreatment plans, as the evolution of dentofacial orthopedicstreatments perspectives.

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