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THICKNESSES OF ANTERIOR NECK ANDUMBILICUS SKIN AND FAT TISSUE IN OSA PATIENTS

Kadriye Serife Ugur, MD1;Nebil Ark, MD1; Hanifi Kurtaran, MD1; Banu Cakir, MD2;Gultekin Kizilbulut, MD1; Duygu Ozol, MD3; Mehmet Gunduz, MD1

1Fatih University School of Medicine Department of Otorhinolaryngology Head and Neck Surgery,2 Fatih University School of Medicine Department of Radiology,

3Fatih University School of Medicine Department of Chest Diseases

INTRODUCTION

METHODS AND MATERIALS

CONCLUSIONS

DISCUSSIONRESULTS

REFERENCES

Table 2. Correlations between AHI, ODI and anthropometric findings, ultrasonographic findings (* circumference, * *thickness)

ABSTRACT

CONTACTKadriye Serife UgurFatih University School of Medicine Department of Otorhinolaryngology Head and Neck SurgeryEmail:kserifeboynukalin@yahoo.comPhone: 0903122035106

Introduction: Obesity and fat accumulations play a major role in obstructive sleep apnea (OSA) patients. Objective: To investigate whether the thickness of anterior neck skin and subcutaneous fat tissue, thickness of umbilicus skin and subcutaneous fat tissue contribute to polysomnographic findings of OSA and severity of OSA. Methods: Seventy three patients with OSA and 24 non-OSA patients in this prospective study were evaluated with one night polysomnography. OSAS patients (73) were classified into 3 groups; mild, moderate, severe. Body mass index (bmi) and anthropometric parameters (neck circumference, waist circumference, hip circumference) were also investigated. We assessed, thickness of anterior neck skin and subcutaneous fat tissue, thickness of umbilicus skin and subcutaneous fat tissue using ultrasound of all patients after one night polysomnography. The distances from the skin to the submandibular gland, thyroid isthmus, suprasternal notch and umbilical skin and subcutaneous fat tissue thickness were measured with ultrasound. Student’s t-test and Mann-WithneyU correlation test were used in statistical analysis.Results: Sixty seven patients were male, 30 were female. The whole study group’s polysomnographic findings (apnea-hypoapneaindex) were significantly correlated with bmi, antropometric findings (p<0,05), but notsignificantly correlated with ultrasonogrophicmeasurement of patients (p>0,05). Bmi, anthropometric findings and ultrasonographic measurements of patients were not significantly different between the non-OSA and OSA patient groups (p>0,05). Also there were not significant relation between three groups of OSA patients and non-OSA group in respect to bmi, anthropometricfindings and ultrasonographic measurements (p>0,05).Conclusion: These results suggest that anterior neck and umbilical subcutaneous fat tissue may not contribute to severity of OSA.

Baseline characteristics of the study population areshown in Table 1. The whole study group’s polysomnographic findings (AHI, oxygen desaturation index-ODI-) were significantly correlated with bmi, antropometric findings (p<0,05), but not with ultrasonogrophic measurement of patients (p>0,05). Bmi, anthropometric findings and ultrasonographic measurements of patients were not significantly different between the non-OSA and OSA patient groups (p>0,05). Also there were not significant relation between three groups of OSA patients and non-OSA patient group in respect to bmi, antropometric findings and ultrasonographic measurements (p>0,05).

In this study, we found a highly significant correlation between polysomnographic findings (AHI, ODI) and anthropometric measures of obesity but not a significant correlation between polysomnographic findings and ultrasonogrophic measurement of thickness of skin and subcutaneous tissue of anterior neck and umbilicus of patients. In the literature visceral (central) obesity has been recognized to be associated more often with OSA than other forms of obesity.4,5 The relation of fat deposits and polysomnographic findingswas observed using magnetic resonance imaging with small number of patients, and authors found that thevolume of the adipose tissue adjacent to the upperairway correlated with the AHI.5 These results are incontrast to the findings of Scha¨fer et al’s, in whichfound a correlation between AHI and BMI as well asAHI and intra-abdominal fat but not between AHI and parapharyngeal fat or neck subcutaneous fat.6 The discrepancies may arise from different studypopulations or from small sample sizes in general.

Our aim was to investigate the subcutaneous local fat tissue relation to polysomnographic findings with large number of patients using ultrasound. Mortimore et al demonstrated that nonobese patientswith OSA had substantially greater deposits of fat anterolaterally to the upper airway than BMI- and neck circumference-matched control subjects.7Nevertheless, as our data indicate, ultrosonographicfindings of sucutaneous fat of umbilicus, hyoid, submandibular, suprasternal region were not correlated to polysomnographic findings.

The study was approved by the Ethics Committee of the Medical Faculty, Fatih University. Written informed consent for participation was obtained from all individuals. Seventy three patients (20 women, 53 men) with OSA and 24 non-OSA patients (10 women, 14 men) in this prospective study were evaluated with one night polysomnography. OSA patients (73) were classified into 3 groups; mild (27), moderate (19), severe (27) according to apnea-hypoapnea index (AHI). Body mass index (bmi=kg/m2) and anthropometric parameters (neck circumference, waist circumference, hip circumference=cm) were also investigated. We assessed, thickness of anterior neck skin and subcutaneous fat tissue, thickness of umbilicus skin and subcutaneous fat tissue (mm) using ultrasound of all patients after one night polysomnography. The distances from the skin to the submandibular gland, thyroid isthmus, suprasternal notch and umbilical skin and subcutaneous fat tissue thickness were measured with ultrasound (Figure 1). Ultrasound was performed with a 13,5-MHz linear probe using a SONOLINE Anteres system (Siemens, Germany). Student’s t-test and Mann-Withney U correlation test were used in statistical analysis.

These results suggest that anterior neck and umbilicalsubcutaneous fat tissue may not contribute to severity of OSAS.

Obstructive sleep apnea (OSA) is characterized by repeated collapse of the pharynx during sleep, which leads to oxygen desaturation, fragmentation of sleep, and often daytime sleepiness, the latter leading to an increased risk of traffic accidents.1,2 Obstructive sleep apnea has a major impact in public health and cardiovascular health since it is closely associated with several coronary disease risk factors like hypertension, arrhythmia, left ventricular dysfunction, as well as with coronary heart disease, stroke and pulmonary hypertension.3 Obesity, male gender, and increasing age are found to be risk factors for OSA.1-4 Among all anthropometric variables, the neck circumference was the most powerful predictor of OSA rather than a more generalized distribution of body fat.3 The detection of the accumulation of fat tissue in the neck was studied by magnetic resonance imaging with small number of patients.3-6 The aim of this study; to investigate whether ultosonographic findings of the thickness of anterior neck skin and subcutaneous fat tissue, thickness of umbilicus skin and subcutaneous fat tissue contribute to polysomnographic findings of OSA and severity of OSA with large number of patients.

1. Guilleminault C. Clinical features and evaluation of obstructive sleep apnea. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia, PA: W.B. Saunders, 1994; 667–677.

2. Teran-Santos J, Jiminez-Gomez A, Cordero-Guevara J, et al. The association between sleep apnea and the risk of traffic accidents. N Engl J Med 1999; 340:847–851.

3. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328:1230–1235.

4. Shelton KE, Woodson H, Gay S, et al. Parapharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis 1993; 148:462–466.

5. Horner RL, Mohiaddin RH, Lowell DG, et al. Sites and sizes of fat deposits around the pharynx in obese patients with obstructive sleep apnoea and weight matched controls. Eur Respir J 1989; 2:613–622.

6.Schäfer H, Pauleit D, Sudhop T, Gouni-Berthold I, Ewig S,Berthold HK. Body fat distribution, serum leptin and Obstructive Sleep Apne Cardiovascular Risk Factors in Men With. Chest 2002; 122;829-839.

7. Mortimore IL, Marshall I, Wraith PK, et al. Neck and total body fat deposition in nonobese and obese patients with sleep apnea compared with that in control subjects. Am J Respir Crit Care Med 1998; 157:280–283.

Figure 1 Skin and fat tissue thicknessA.Hyoid B. Isthmus C.Submandibular D. Umbilicus.

A

C D

B

N: Number of patients Mean±Standart deviationAge Non-OSA

OSA2473

47,3±14,6043851,6±12,8

BMI Non-OSAOSA

2473

29,0±5,432,3±5,7

Neck C.* Non-OSAOSA

2473

40,3±3,341,8±1,8

Waist C. Non-OSAOSA

2473

100,3±13,2106,0±15,2

Hip C. Non-OSAOSA

2473

101,9±20,0110,7±14,7

Umbilicus T.** Non-OSAOSA

2473

29,3±8,930,0±9,6

Hyoid T. Non-OSAOSA

2473

21,9±7,019,8±7,5

Isthmus T. Non-OSAOSA

2473

6,6±1,97,8±4,8

Sm. T.***. Non-OSAOSA

2473

6,3±1,26,7±1,9

Suptasternal T. Non-OSAOSA

2473

34,2±9,332,5±11,9

AHI ODI BMI Neck c. * Waist c. * Hip c. * Umbl t. * *Submand.t. *

*Hyoid t. *

*Isthmus

t. * *Suprasternal

t. * *AHI Pearson

Correlation1 0,91(**) 0,32(**) 0,28(**) 0,26(*) 0,21(*) -0,02 0,06 -0,17 0,07 -0,17

Sig. (2-tailed) 0,00 0,001 0,005 0,01 0,03 0,81 0,50 0,08 0,45 0,09

ODI Pearson Correlation

0,91(**) 1 0,38(**) 0,25(*) 0,32(**) 0,28(**) 0,04 0,12 -0,21(*) 0,14 -0,18

Sig. (2-tailed) 0,00 0,00 0,01 0,001 0,005 0,67 0,21 0,03 0,15 0,06

BMI Pearson Correlation

0,32(**) 0,38(**) 1 0,32(**) 0,81(**) 0,70(**) 0,50(**) 0,59(**) 0,12 0,32(**) 0,20(*)

Sig. (2-tailed) 0,001 0,000 0,001 0,000 0,000 0,000 0,000 0,21 0,001 0,04

Neck c. . * Pearson Correlation

0,28(**) 0,25(*) 0,32(**) 1 0,40(**) 0,16 0,18 0,19 0,17 0,07 0,14

Sig. (2-tailed) 0,005 0,012 0,001 0,000 0,10 0,07 0,06 0,08 0,48 0,17

Waıst c. . * Pearson Correlation

0,26(*) 0,32(**) 0,81(**) 0,40(**) 1 0,81(**) 0,49(**) 0,58(**) 0,13 0,22(*) 0,12

Sig. (2-tailed) 0,01 0,001 0,00 0,00 0,00 0,00 0,00 0,17 0,03 0,21

Hip c. . * Pearson Correlation 0,21(*) 0,28(**) 0,70(**) 0,16 0,81(**) 1 0,41(**) 0,48(**) 0,05 0,19 0,07

Sig. (2-tailed) 0,03 0,005 0,000 0,10 0,000 0,000 0,000 0,58 0,05 0,46

Umbl t. * * Pearson Correlation

-0,02 0,04 0,50(**) 0,18 0,49(**) 0,41(**) 1 0,50(**) 0,53(**) 0,27(**) 0,53(**)

Sig. (2-tailed) 0,81 0,67 0,000 0,07 0,000 0,000 0,000 0,000 0,007 0,000

Submandibular t. * *

Pearson Correlation 0,06 0,12 0,59(**) 0,19 0,58(**) 0,48(**) 0,50(**) 1 0,28(**) 0,32(**) 0,34(**)

Sig. (2-tailed) 0,50 0,21 0,00 0,06 0,00 0,000 0,000 0,004 0,001 0,001

Hyoid t. * * Pearson Correlation

-0,17 -0,21(*) 0,12 0,17 0,13 0,05 0,53(**) 0,28(**) 1 -0,03 0,84(**)

Sig. (2-tailed) 0,08 0,03 0,21 0,08 0,17 0,58 0,000 0,004 0,70 0,000

Istmus t. * * Pearson Correlation 0,07 0,14 0,32(**) 0,07 0,22(*) 0,19 0,27(**) 0,32(**) -0,03 1 0,23(*)

Sig. (2-tailed) 0,45 0,15 0,001 0,48 0,03 0,05 0,007 0,001 0,70 0,01

Suprasternal t. * *

Pearson Correlation -0,17 -0,18 0,20(*) 0,14 0,12 0,07 0,53(**) 0,34(**) 0,84(**) 0,23(*) 1

Sig. (2-tailed) 0,09 0,06 0,042 0,17 0,21 0,46 0,000 0,001 0,000 0,019

Table 1 Baseline characteristics of study population* Circumference, * *Thickness, * * *Submandibular Thickness