Abstract
Objectives:
Recent evidence suggests that environmental factors impact craniofacial development. Specifically, the height and width of the maxilla may impact the degree of septal deviation. We sought to determine the relationship between transverse maxillary deficiency and severity of septal deviation.
Methods:
A prospective cohort of adult sleep surgery patients were evaluated by standardized CT imaging. Primary outcomes evaluated the relationship of a narrow, high-arched palate (the palatal height to width ratio) with the degree of septal deviation at the level of the 1st premolar and 1st molar. Secondary outcome evaluated the relationship of the palatal height-to-width ratio and nasal obstruction. Both adjusted and unadjusted linear regression were performed, including correction for multiple hypothesis testing.
Results:
Ninety-three patients were included. On average, the cohort was middle aged (54.7 ± 12.7 years), obese (BMI 30.1 ± 4.5 kg/m2), predominantly male (74.2%), White (73.1%), and with severe obstructive sleep apnea (OSA) (AHI 30.0 ± 18.7 events/h). A moderate correlation was observed between both the relative and absolute inter-premolar palatal height and the degree of septal deviation at the inter-molar region. No significant correlation was observed between palatal dimensions and NOSE score.
Conclusion:
This study found that transverse maxillary deficiency is moderately associated with greater degree of septal deviation among a sample of OSA patients. This contributes to the concept that craniofacial development impacts the nasal airway, promoting a comprehensive evaluation of both endonasal and extranasal structures.
Level of Evidence:
IV
Keywords: nasal obstruction, septal deviation, transverse maxillary deficiency
INTRODUCTION
Nasal obstruction is a remarkably common presenting complaint in otolaryngology clinics, and one of the top three reasons for visiting an otolaryngologist.1 Nasal pathology can arise from inflammatory and/or structural etiologies. Inflammatory conditions often include allergic rhinitis and chronic rhinosinusitis, leading to edema of the nasal mucosa and underlying stroma.2 Structural causes can involve narrowing of the piriform or choanal aperture, collapse of the nasal valve (upper and lower lateral cartilages), and, most frequently, deviation of the nasal septum.3 Nasal septal deviation is defined as displacement of the cartilaginous or bony septum away from the midline. Septal deviation, similar to other deformities, can be categorized as acquired (traumatic), congenital, or developmental.
In the case of a developmental etiology, there is an increasing body of evidence to suggest that the maxilla may be contracting in the transverse dimension over a period of generations.4–7 This has been attributed to a variety of environmental pressures including decreased rates of breastfeeding, environmental allergens/nasal obstruction, and dietary changes.8–13 It remains unclear if maldevelopment of craniofacial structures leads to worsening nasal obstruction or if nasal obstruction and chronic mouth breathing lead to the craniofacial maldevelopment. Nevertheless, studies have shown maldevelopment in children considered to be mouth breathers when compared with their nasal breathing counterparts.14–17 Septal deviation is thought to arise during development due to alterations in human craniofacial development. A leading hypothesis is increasing deflection of the nasal septum with increasing convexity of the hard palate (represented in Fig. 1).
Fig. 1.
(A) A patient with a narrow palate and a deviated nasal septum. (B) A patient with a broad palate and straight nasal septum. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
As a result, there have been several studies seeking to determine a relationship between transverse maxillary deficiency and septal deviation.18–21 These studies have produced inconsistent results, with some finding a relationship between the palatal morphology and degree of septal deviation and others failing to demonstrate an association. In this study, we utilized direct measures from three-dimensional computed tomography (CT) in a prospective cohort of well-characterized patients with nasal obstruction to determine if abnormal maxillary development (i.e., high-arched palate) contributes to a greater degree of septal deviation. We hypothesized that increased palatal height, both absolute and relative to palatal width, at the level of the premolars and molars would be associated with increased septal deviation. Secondarily, we hypothesized that patient-reported measures of nasal obstruction would be greater in patients with increased palatal height measures. Finally, we explored relationships between septal deviation and other anatomic characteristics, as well as obstructive sleep apnea (OSA) severity.
METHODS
Study Design and Subjects
A prospective cohort study at a tertiary care medical center from 2020 to 2021 was undertaken. Subjects included adult patients (aged 18 years or older) who presented to the sleep surgery clinic of the senior author. Exclusion criteria included incomplete or missing CT imaging and DICOM (Digital Imaging and Communications in Medicine) files, previous iatrogenic manipulation of region of interest (nasal fracture with intervention, septoplasty, nonsurgical maxillary expansion, and maxillary surgery), absent maxillary molars, or craniofacial syndromes. This study was approved by the Institutional Review Board at the University of Pennsylvania (IRB # 848799).
Imaging Acquisition
All the patients underwent a hospital-grade CT scan. Imaging was performed on a variety of scanners in 13 urban and suburban locations in an integrated health system. The scanners, ranging from 40- to 256-slice, were manufactured either by GE (GE Medical Systems, Madison, USA) or Siemens (Siemens Healthineers). All scans were performed at 120 kV, with slice thickness <1 mm, pitch of 1.0, FOV of 25 cm, and no gantry tilt. Thin-section reconstructions were generated in axial, sagittal, and coronal planes, with bone and soft tissue algorithms.
Imaging Analysis
Data from CT scans were exported as DICOM files in a deidentified fashion to Invivo 6 software (Anatomage, Milan, Italy). The head position for each patient was standardized. The head yaw was adjusted in the axial view, referenced to the hard palate plane reference. The head roll was adjusted in the coronal view, referenced to the infraorbital rims. Finally, the head pitch was adjusted in the sagittal view, referenced to the Frankfurt horizontal plane (superior border of the internal auditory canal and the inferior edge of the infraorbital rim). Following standardization of the images, the lengths and angles were measured in the coronal plane and defined as follows:
Piriform distance: The distance between the inferior turbinate bone from side wall to side wall of the nasal cavity, viewed at the most anterior aspect where the complete nasal cavity rim is observed (Fig. 2).
Inter-premolar distance: The distance between the 1st maxillary premolars at the level of the most inferomedial aspect of the alveolar rim on the lingual surface (Fig. 3A).
Inter-premolar palatal height: The vertical distance from the midpoint between the 1st premolars to the midpoint of the palatal arch (Fig. 3A).
Inter-premolar nasal cavity height: Vertical distance from the origin of the perpendicular plate of the ethmoid (skull base) to the maxillary crest (Fig. 3A).
Inter-premolar septal length: The length of the septum from the origin of the perpendicular plate of the ethmoid to the maxillary crest at the level of the 1st premolars (Fig. 3A).
Inter-molar distance: The distance between the 1st maxillary molars at the level of the most inferior aspect of the alveolar rim on the lingual surface (Fig. 3B).
Inter-molar palatal height: The vertical distance from the midpoint between the 1st molars to the midpoint of the palatal arch at the level of the first molars (Fig. 3B).
Inter-molar nasal cavity height: Vertical distance from the origin of the perpendicular plate of the ethmoid (skull base) to the maxillary crest at the level of the first molars (Fig. 3B).
Inter-molar septal length: The length of the septum from the origin of the perpendicular plate of the ethmoid to the maxillary crest at the level of the 1st molars (Fig. 3B).
Lund-Mackay Score22
Fig. 2.
Piriform width measured at the most anterior aspect of the inferior turbinate bone where a complete nasal rim is observed on coronal view. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Fig. 3.
Primary outcomes: (A) palatal height and width along with septal length and nasal cavity height measured at the 1st premolar; (B) palatal height and width along with septal length and nasal cavity height measured at the 1st molar; (C1) palatal height and width at the 1st premolar; (C2) septal length and nasal cavity height at the 1st molar. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
All measurements were performed by two blinded reviewers.
Relative palatal height was defined as the palatal height-to-width ratio at both the inter-premolar and inter-molar distances. This measurement was utilized as it includes both transverse and vertical aspects of the palate as well as to serve as an internal control for each patient. It was theorized that this measurement would more appropriately assess maxillary dimensions and illustrate craniofacial development as it relates to septal deviation. The degree of septal deviation was measured as a ratio of the overall septal length to the nasal cavity height (Fig. 3). This was utilized because it illustrates nasal cavity underdevelopment. As the nasal cavity height decreases due to increasing palatal height, the length of the cartilaginous septum remains the same. A ratio of septal length to nasal cavity height of 1 would exemplify a straight septum, whereas the larger the ratio, the higher degree of septal deviation. Initially, the nasal septum was to be compared with the maxilla at two locations, the 1st premolar and the 1st molar. However, while performing measurements, it was discovered that determining a consistent septal length at the level of the 1st premolar was inherently challenging given the wide variation in maxillary crest anatomy. This was due to the crest being taller in some patients with significant difficulties differentiating where the crest ended and the cartilaginous septum began, thus impacting septal length and nasal cavity height measurements. During inter-rater reliability testing, nasal cavity dimensions were found to be highly variable at the level of the 1st premolar which was reflected in a lower intra-class correlation coefficient (Table I). This measurement was much more consistent at the level of the 1st molar, where there was less variation. Because the palate is typically more narrow and high-arched at the level of the premolars, as demonstrated by Berwig et al., it was determined that comparing the septal length at the 1st molar and palatal morphology at the 1st premolar would better represent the impact of the palatal arch on nasal cavity dimensions.14 For reference, the location of the internal nasal valve, the narrowest part of the nasal cavity, is located just anterior to the piriform rim and the 1st premolar and 1st molar regions are posterior to both the internal nasal valve and piriform rim.
TABLE I.
Inter-Rater Reliability of Craniofacial Measurements.
| Measurement | ICC | CI |
|---|---|---|
|
| ||
| Piriform width | 0.952 | 0.930, 0.968 |
| IPM width | 0.929 | 0.897, 0.952 |
| IPM height | 0.717 | 0.606, 0.800 |
| IPM septal length | 0.821 | 0.746, 0.876 |
| IPM nasal cavity height | 0.574 | 0.425, 0.692 |
| IM width | 0.894 | 0.846, 0.927 |
| IM height | 0.672 | 0.548, 0.767 |
| IM septal length | 0.874 | 0.818, 0.913 |
| IM nasal cavity height | 0.889 | 0.840, 0.924 |
ICC = inter-rater, intra-class correlation coefficient. <0.5 indicated poor reliability, 0.5–0.75 moderate reliability, 0.75–0.9 good reliability and >0.9 excellent reliability; IM = inter-molar; IPM = inter-premolar.
Clinical Data Collection
Clinical variables were collected from a thorough chart review and included age, sex, body mass index (BMI), height, race, apnea–hypopnea index (AHI), past medical and surgical history, and Nasal Obstruction and Septoplasty Effectiveness (NOSE) score. Missing data, particularly regarding history of nonsurgical maxillary expansion as a child or adult, were obtained through telephone encounters with study subjects.
Definition of Variables
The primary hypothesis was tested by comparing the relative and absolute palatal height (predictor variable) to the degree of septal deviation calculated as a ratio of the septal length to the nasal cavity height (outcome variable). The secondary hypothesis was tested by comparing relative and absolute palatal height (predictor variable) to the NOSE score (outcome variable). Exploratory analysis was performed looking at associations between relative and absolute palatal height and palatal width as it relates to piriform width as well as OSA severity.
Statistical Methods
Continuous data are summarized using means and standard deviations (SDs) and categorical data using frequencies and percentages. It was determined that a sample size of 84 patients provided at least 80% power to detect a moderate correlation of 0.325, as defined by Cohen, at an alpha level of 5%. Relationships among anatomical traits of interest were assessed using unadjusted Pearson’s linear correlations and partial Pearson’s correlations adjusted for gender and height. Complementary analyses using Spearman’s rank correlations (unadjusted) were performed to understand any influence of non-normality. Statistical significance was determined using a Hochberg step-up correction, applied separately within the context of our primary, secondary and exploratory hypotheses. Intra-class correlation coefficient was utilized to evaluate for inter-rater reliability for all measurements of interest.
RESULTS
Baseline Characteristics
A total of 93 patients were included in the study. On average, the cohort was middle aged (54.7 ± 12.7 years), obese (BMI 30.1 ± 4.5 kg/m2), predominantly male (74.2%), White (73.1%), and with severe OSA (AHI 30.0 ± 18.7 events/h) (see Table II).
TABLE II.
Demographic Characteristics of the Study Sample.
| Characteristic | All Patients (n = 93) |
|---|---|
|
| |
| Age, years | 54.7 ± 12.7 |
| Male sex, % | 74.2% |
| Body mass index, kg/m2 | 30.1 ± 4.5 |
| Height, m | 1.74 ± 0.10 |
| Caucasian race, % | 73.1% |
| AHI, events/h | 30.0 ± 18.7 |
| NOSE score | 37.3 ± 25.6 |
Data presented as mean ± standard deviation or percentage.
Associations between Palatal Height and Septal Deviation
In regards to our primary hypotheses, neither the relative nor absolute palatal height at the inter-molar and inter-premolar regions was associated with the degree of septal deviation at the inter-premolar or inter-molar regions, respectively (see Table III). A moderate correlation was observed between both the relative and absolute inter-premolar palatal height and the degree of septal deviation at the inter-molar region (Table III). Results show that taller palatal height is associated with larger degrees of septal deviation. The magnitude of these correlations was reduced when examining nonparametric Spearman rank correlations (see Supplementary Table I).
TABLE III.
Association Between Palatal Height and Degree of Septal Deviation.
| Palatal Height Measurement | N | Inter-Premolar | Inter-Molar | ||||||
|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||
| Septal Deviation | Septal Deviation | ||||||||
|
|
|
||||||||
| Unadjusted | Adjusted* | Unadjusted | Adjusted* | ||||||
|
|
|
|
|
||||||
| rho | p | rho | P | rho | P | rho | p | ||
|
|
|
||||||||
| Inter-premolar | |||||||||
| Relative | 93 | −0.05 | 0.611 | −0.07 | 0.480 | 0.28 | 0.006 | 0.28 | 0.007 |
| Absolute | 93 | 0.00 | 0.996 | −0.03 | 0.751 | 0.31 | 0.002 | 0.31 | 0.003 |
| Inter-molar | |||||||||
| Relative | 93 | 0.09 | 0.411 | 0.03 | 0.767 | 0.15 | 0.140 | 0.15 | 0.151 |
| Absolute | 93 | 0.14 | 0.185 | 0.06 | 0.577 | 0.14 | 0.176 | 0.13 | 0.228 |
Sexand height adjusted partial Pearson correlation.
Relationship of Palatal Height and NOSE Score
In regards to the secondary hypothesis, no significant correlation was observed between the relative and absolute palatal height and NOSE score (see Table IV).
TABLE IV.
Secondary and Exploratory Correlations.
| Measurement | N | Unadjusted | Adjusted* | ||
|---|---|---|---|---|---|
|
|
|
||||
| rho | P | rho | P | ||
|
| |||||
| NOSE score | |||||
| Palatal height | |||||
| Inter-premolar | |||||
| Relative | 88 | −0.01 | 0.927 | −0.02 | 0.873 |
| Absolute | 88 | −0.00 | 0.978 | −0.01 | 0.947 |
| Inter-molar | |||||
| Relative | 88 | −0.07 | 0.503 | −0.11 | 0.311 |
| Absolute | 88 | −0.05 | 0.669 | −0.09 | 0.436 |
| Piriform width | |||||
| Palatal width | |||||
| Inter-premolar | 93 | 0.33 | 0.001 | 0.33 | 0.001 |
| Inter-molar | 93 | 0.37 | 0.0002 | 0.38 | 0.0002 |
| Palatal height | |||||
| Inter-premolar | |||||
| Relative | 93 | 0.01 | 0.948 | 0.01 | 0.931 |
| Absolute | 93 | 0.11 | 0.297 | 0.11 | 0.311 |
| Inter-molar | |||||
| Relative | 93 | −0.13 | 0.201 | −0.12 | 0.238 |
| Absolute | 93 | 0.00 | 0.979 | 0.00 | 0.976 |
| AHI | |||||
| Palatal height | |||||
| Inter-premolar | |||||
| Relative | 93 | 0.01 | 0.926 | 0.01 | 0.931 |
| Absolute | 93 | 0.00 | 0.985 | 0.00 | 0.980 |
| Inter-molar | |||||
| Relative | 93 | −0.06 | 0.573 | −0.07 | 0.537 |
| Absolute | 93 | −0.07 | 0.496 | −0.07 | 0.498 |
|
| |||||
| Measurement | N | Unadjusted | Adjusted* | ||
|
|
|
||||
| rho | P | rho | P | ||
|
| |||||
| Degree of septal deviation | |||||
| Palatal width | |||||
| Inter-premolar | 93 | 0.17 | 0.0934 | 0.14 | 0.184 |
| Inter-molar | 93 | −0.02 | 0.876 | −0.06 | 0.581 |
| Degree of septal deviation | |||||
| NOSE score | |||||
| Inter-premolar | 93 | 0.02 | 0.845 | 0.01 | 0.953 |
| Inter-molar | 93 | −0.06 | 0.607 | 0.18 | 0.633 |
Sexand height adjusted partial Pearson correlation
Exploratory Associations with Palatal Dimensions
In regards to the exploratory hypotheses (see Table IV), a moderate correlation was noted between piriform width and both the inter-premolar width and inter-molar width; these associations remained strong in non-parametric analysis (see Supplementary Table I). However, no significant correlation was observed between piriform width and either the relative or absolute palatal height. There was no correlation between the relative and absolute palatal height and the apnea–hypopnea index, suggesting palatal height is not associated with severity of OSA. Neither palatal width nor NOSE score were noted to correlate with degree of septal deviation. Overall, there was good inter-rater reliability across measurements (Table I). Average values for all measurements are included in Supplementary Table II and correlations by gender and race are included in Supplementary Tables III and IV.
DISCUSSION
The primary hypotheses of this study evaluated the relationship between a narrow, high-arched palate and deviated nasal septum. Specifically, we hypothesized that increased palatal height, both absolute and relative to palatal width, at the level of the pre-molars and molars would be associated with increased septal deviation. No significant correlation was found between palatal dimensions and septal deviation at either the 1st premolar or 1st molar. However, in our most reliable measurement (see “Imaging Analysis” in Methods for details), a moderate correlation was observed between both the relative and absolute inter-premolar palatal height and degree of septal deviation at the level of the molar, meaning the higher the palatal arch at the premolar, the more deviated the nasal septum at the molar. The notion that septal length and nasal cavity dimensions were more difficult to obtain at the inter-premolar region was supported by poorer inter-rater reliability of nasal cavity height measurements at the premolar as compared with the molar region (Table I). In regards to our secondary hypothesis, there was no significant correlation between either the relative or absolute palatal height and NOSE score. While a moderate correlation was observed between the palatal width and piriform width, no correlation was noted between relative or absolute palatal height and piriform width.
Several prior studies have sought to find an association between maxillary width and the degree of septal deviation with varying results. Akbay et al. evaluated the relationship between palatal height and the degree of posterior bony septal deviation.19 They noted a strong correlation between palatal height and posterior septal deviation (rho = 0.48). Our results support these previous findings given their measurement of the septum more posteriorly, where it was found to be more reliably measured. However, the study was noted to have several flaws. First, the degree of septal deviation was measured via a horizontal line from the point of maximal deviation which may not represent the full degree of deviation. They also utilized the septal deviation angle from the cribriform to point of maximal septal deviation. This angle can be highly variable depending on the vertical location of the point of maximal deviation along the septum. They also utilized 3 separate groupings, limiting their ability to evaluate all patients on a continuum. Dalili Kajan et al. evaluated cone beam CT scans (a type of CT commonly utilized in dental practices) of patients presenting to an oral and maxillofacial radiology clinic.21 They found a correlation between the deviated septal curve angle and palatal height to width ratio in the group with both septal deviation and concha bullosa. While a relationship between septal deviation and palatal height to width ratio was observed, a notable limitation of this study is again the use of the septal curve angle, similar to Akbay given the wide variability of this measurement. They also utilized 4 separate groupings, limiting their ability to evaluate all patients on a continuum. Similarly, Ballanti et al. evaluated 66 pediatric patients with the use of anterior radiographs and found no significant association between the degree of septal deviation and maxillary width.20 However, the notable limitation in this study was the use of a 2-dimensional radiograph to evaluate 3-dimensional anatomy such as the maxilla and nasal septum. Awuapara et al. also failed to find any significant correlation between degree of septal deviation and differences in facial patterns after categorizing patients into three separate groupings.18 The most notable difference between our study and prior studies includes the measurements utilized. These studies determined degree of septal deviation based on the distance of a horizontal line from the midline at the point of maximal deviation.18,19,21 Our study is the first to evaluate the actual nasal septal length in regards to other craniofacial measurements. By measuring the actual length of the septum and comparing it with the height of the nasal cavity, a better understanding of how the nasal cavity height may have been impacted by facial growth (i.e., a narrow, high-arched palate) might be obtained.
There were limitations to our study, specifically selection and measurement bias. The study was conducted in a sleep surgery clinic with the majority of patients suffering from OSA. As this cohort may have unique demographics and features of craniofacial maldevelopment, it is unclear if similar findings would be observed in the general population.23 Of note, there are limited normative data in regards to maxillary width. Lee et al. utilized a similar measurement of the maxilla at the inferior aspect of the alveolar crest and found a width of 34.8 mm in men and 32.9 mm in women.24 Miner et al. measured the width of the maxilla at the midpoint of the 1st maxillary molar tooth root and noted an average width of 27.73 mm.25 We chose to measure the maxilla from the inferomedial aspect of the alveolar bone, similar to Lee et al. given the high consistency of this measurement in addition to our interest in the skeletal features of the airway and not the dentition. For reference, Supplementary Tables II and TABLE III include averages for all measurements as well as by sex. In addition, NOSE score is a subjective finding and may be related to other factors (e.g., allergic rhinitis) and not be associated with the degree of septal deviation.
Conversely, this study has several notable strengths. As stated previously, this is the first study to measure septal length as a variable and compare it to nasal cavity height when evaluating the impact of maxillary development on septal deviation. This is an improvement upon all prior studies that utilized a single point of maximal deviation. Second, the use of CT imaging, rather than 2-dimensional radiographs, allowed for evaluation of these relationships in three dimensions. Two independent, blinded reviewers performed all measurements and there was good inter-rater reliability in the measurements. Finally, to minimize confounding, the study was performed with strict inclusion criteria, excluding all patients with previous nasal surgery and surgical or nonsurgical maxillary expansion.
The correlation between a narrow, high-arched palate and the degree of septal deviation is notable because it underlines the impact of maxillary development on the nasal cavity. Otolaryngologists are particularly cognizant of nasal cavity findings when evaluating for nasal obstruction, but often overlook midface skeletal deficiencies (i.e., an endoscope is placed in the nose to evaluate nasal cavity structures, but the oral cavity is largely ignored). The clinical impact of this relationship was demonstrated by Williams et al., who evaluated 89 patients following nasal surgery for nasal obstruction. They found a narrow maxillary width and a high-arched palate were associated with persistent nasal obstruction postoperatively.26 These findings were followed by a second study from the same group evaluating additional skeletal remodeling procedures (i.e., surgically assisted rapid palatal expansion) on patients with persistent nasal obstruction following nasal surgery. They found significant improvement in NOSE score and objective increases in nasal floor width following a second-stage maxillary expansion surgery (Distraction Osteogenesis Maxillary Expansion) with a significant improvement in nasal obstruction postoperatively.27
CONCLUSION
This study found that transverse maxillary deficiency (i.e., a narrow, high-arched palate) measured at the 1st inter-molar region is moderately associated with greater septal deviation among a population of OSA patients. Our data contribute to the concept that craniofacial development impacts endonasal structures, promoting a comprehensive evaluation of the nasal airway which includes the transverse maxillary dimension. By extension, surgical therapy should be guided by relative contributions of septal deviation and maxillary constriction to nasal airway obstruction to maximize patient outcomes.
Supplementary Material
Footnotes
The authors have no funding, financial relationships, or conflicts of interest to disclose.
Additional supporting information may be found in the online version of this article.
Contributor Information
Michael J. Hutz, Section of Sleep Surgery, Department of Otolaryngology – Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Section of Sleep Medicine, Department of Pulmonary, Critical Care and Sleep Medicine, Rush University Medical Center, Chicago, Illinois, U.S.A.
Eric Thuler, Division of Sleep Surgery, Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A..
Crystal Cheong, Division of Sleep Surgery, Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A..
Chau Phung, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A..
Marianna Evans, Division of Sleep Surgery, Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A..
John Woo, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A..
Brendan T. Keenan, Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A..
Raj C. Dedhia, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.; Division of Sleep Surgery, Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.
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