Is Cheeks Appearance a Predictor of Obstructive Sleep Apnea Risk?

Cheeks appearance can serve as a predictor of obstructive sleep apnea (OSA), according to study findings published in the Journal of Clinical Sleep Medicine. 

Some well-established factors that increase OSA risk include body mass index (BMI), neck circumference, age, and gender. One predictor of OSA under investigation is cheeks appearance. Researchers conducted a prospective cross-sectional diagnostic accuracy study, Cheeks Appearance as a Novel Predictor of Obstructive Sleep Apnea The CASA Score Study(CASA; ClinicalTrials.gov Identifier: NCT04980586), to determine if the cheeks appearance for sleep apnea (CASA) score can predict OSA. 

A group of 3 speech and language therapists (SLTs) adjudicators with specialties in orofacial myology were recruited to analyze facial images. The CASA score classified cheek appearance by volume and flaccidity, with scores ranging from 0 to 3 for each factor for a maximum total score of 6. Lower scores indicated no alteration in volume or flaccidity and higher scores indicated severe volume or flaccidity. 

Study participants were individuals who presented to a sleep clinic affiliated with a university hospital to undergo an overnight polysomnography. Participants were aged 18 and older and had no previous OSA diagnosis or polysomnography. Exclusion criteria were previous surgery, previous aesthetic facial or neck procedures, refusal to be photographed, neurologic conditions, and poor photo quality. 

Of the 265 patients invited to participate, 248 were included in the analysis from January 2018 to December 2019. The average age for women was 46.54 and 45.47 for men. The average BMI between women and men was also similar (30.28 vs 29.99, respectively). While age and BMI were similar between groups, CASA score showed differences between men and women (P =.007).

The average apnea-hypopnea index (AHI) was 18.7 events per hour. A total of 177 (71.4%) patients were diagnosed with OSA by polysomnography, with 64 (25.8%) patients categorized as mild (AHI, 5-14 events/hour), 57 (23%) patients as moderate (AHI, 15 to 30 events/hour), and 45 (22.6%) severe (AHI, >30 events/hour).

Patients had average scores of 1.8 for volume and 1.8 for flaccidity. The overall average CASA score was 5.4 and scores were significantly correlated to AHI (P <.001).

The CASA score was able to predict OSA in 167 (94%) of participants with OSA. There was also a correlation between CASA scores and AHI, as patients with normal CASA scores more frequently had an AHI less than 5, and greater CASA scores reporting AHI greater than 5.

Study limitations included selection bias, the subjective nature of cheeks appearance, and the requirement of external validation of this concept before clinical recommendation.

“[O]ur findings bring to light the possibility to detect OSA by means of visual assessment of the cheeks, which is a novel and potentially useful instrument,” the researchers concluded.