Original Article

A cone-beam computed tomography study of hyoid bone position and

airway volume in subjects with obstructive and nonobstructive
adenotonsillar hypertrophy
Amin S. Mohameda; Janvier Habumugishab; Bo Chenga; Minyue Zhaoa; Wenqing Bua; Lifeng Liuc;

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Yucheng Guod; Rui Zoue; Fei Wangd

ABSTRACT
Objectives: To investigate hyoid bone position and airway volume in subjects with adenoid
hypertrophy, tonsillar hypertrophy, and adenotonsillar hypertrophy compared to subjects with
nonobstructive adenoids or tonsils and to assess the correlation between hyoid bone and airway
parameters.
Materials and Methods: A total of 121 subjects were grouped based on adenoid or tonsillar
hypertrophy into four groups, as follows: (1) control group (C-group), (2) adenoid hypertrophy group
(AH-group), (3) adenotonsillar hypertrophy group (ATH-group), and (4) tonsillar hypertrophy group
(TH-group). Hyoid bone position and airway volumes were measured. The Kruskal-Wallis test was
used for intergroup comparison, followed by pairwise comparison using the Mann-Whitney U-test.
Bivariate correlation was conducted using Spearman correlation coefficients. Multiple linear regression
was performed to create a model for airway volume based on hyoid bone predictive variables.
Results: No significant difference was found between subjects with isolated adenoid or tonsillar
hypertrophy compared to the C-group. However, the ATH-group exhibited a significantly decreased
hyoid bone vertical distance (HV), total airway volume (TA volume), and retroglossal airway volume
(RG volume) compared to the C-group. HV and age had a high potential in terms of explaining the
RG volume, whereas the TA volume and retropalatal airway volume (RP volume) models were not
as successful as the RG volume counterpart.
Conclusions: Subjects in ATH-group were characterized by an elevated hyoid bone position and
constricted TA volume and RG volume compared to those in the C-group. HV and age were predictor
variables that best explained retroglossal airway volume. (Angle Orthod. 2023;93:467–475.)
KEY WORDS: Adenoid; Tonsils; Hyoid bone; Airway

a
Graduate Student, Department of Orthodontics; and Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine
Research, Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi’an Jiaotong
University, Xi’an, Shaanxi, China.
b
PhD Student, Department of Orthodontics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
University, Okayama, Japan.
c
Professor, Department of Otolaryngology and Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University,
Shaanxi, China.
d
Associate Professor, Department of Orthodontics; and Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine
Research, Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi’an Jiaotong
University, Xi’an, Shaanxi, China.
e
Professor, Department of Orthodontics; and Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research,
Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi’an Jiaotong University,
Xi’an, Shaanxi, China.
Corresponding author: Dr Fei Wang, Associate Professor, Department of Orthodontics, Xi’an Jiaotong University, 98 Xi Wu street,
710004, Xi’an, China
(e-mail: [email protected])
Accepted: February 2023. Submitted: November 2022.
Published Online: March 16, 2023
Ó 2023 by The EH Angle Education and Research Foundation, Inc.

DOI: 10.2319/110822-769.1 467 Angle Orthodontist, Vol 93, No 4, 2023

468 MOHAMED, HABUMUGISHA, CHENG, ZHAO, BU, LIU, GUO, ZOU, WANG

INTRODUCTION difference in hyoid bone vertical distance (HV) value.8

Twenty-two subjects in each group would be sufficient
The adenoids and palatine and lingual tonsils
for the comparison. Preoperative CBCT scans of
constitute the main component of the Waldeyer’s ring,
children aged 7 to 12 years with skeletal Class I (1 
a lymphoid tissue complex around the pharynx that
ANB8  4.9) or skeletal Class II (ANB8  5) and a
plays a crucial role in immunologic defense of the
normal vertical growth pattern (27 , FMA8 , 37) were
body. Moss’ functional matrix theory states that the soft
included. Subjects who displayed any of the following
tissue directs skeletal tissue development. Conse-
criteria were excluded: (1) previous history of adenoid-
quently, nasal resistance due to adenoid or tonsillar
ectomy or tonsillectomy, (2) subjects who had under-
hypertrophy is hypothesized1 to cause developmental
gone orthodontic treatment or had any syndromes
changes in the craniofacial complex.

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related to the head and neck region, and (3) those with
The impact of mouth breathing on the dentoskeletal
distorted CBCT scans with nonobvious landmarks.
complex has been an area of debate and controversy
CBCT images were taken in the natural head
for decades. Some scholars believe that mouth
position. Participants were advised to remain in
breathing is associated with alteration of craniofacial
maximum intercuspation and to sit with a straight
development and position of the hyoid bone,2 while
posture while maintaining the lips and tongue in the
others disagree.3 This is primarily because nasal
rest position, and they were instructed to breathe
airway inadequacy is subjective, and different authors
normally. All of the CBCT images were acquired with a
judge breathing modes differently. Additionally, a
cone-beam machine (i-Cat, Imaging Sciences Interna-
recent systematic review and meta-analysis by Zhao
tional, Hatfield, Pa) using the following parameters:
et al.4 concluded that mouth breathing was linked to
120 kV, 5 mA, 14 317-cm field of view, 0.4-mm voxel
skeletal and dental developmental changes in children.
size, and 8.9-second scan duration. The CBCT images
The association between mouth breathing and
were stored as Digital Imaging and Communications in
craniofacial structure deformities appeared in the
Medicine (DICOM) files.
orthodontic literature a long time ago. However, in
Dolphin Imaging Software (version 11.7, Dolphin
mouth-breathing participants, the vast bulk of previous
Imaging & Management Solutionst, Chatsworth, Calif)
research asserted that the site of obstruction in the
was utilized to import the DICOM files. One investigator
airway would not be a confounding factor, which, to
was responsible for all of the measurements, and this
some extent, might explain the controversial findings.
investigator was unaware of any of the participants’
However, there is still a lack of comprehensive
demographic data. To orient the CBCT images, the
knowledge on the particular impact of adenoid and
axial plane was adjusted to the Frankfort horizontal
tonsillar hypertrophy on the stomatognathic system.
plane (FHP), the midsagittal plane was oriented in the
Additionally, several authors5–7 linked the position of
midline of the patient passing through Nasion, and the
the hyoid bone to airway adequacy, but their assump-
coronal plane was oriented to pass through Porion,
tions were speculative and debatable. Hence, this
perpendicular to the axial plane.
study aimed to assess hyoid bone position and airway
All patients underwent clinical examination by a
volume in subjects with obstructive and nonobstructive
multidisciplinary team comprising an orthodontist and
adenotonsillar hypertrophy and to investigate the
an otorhinolaryngologist. Initially, history was taken
relationship between airway volume and hyoid bone
from the patients’ parents to evaluate for the existence
position in subjects aged 7 to 12 years.
of bad sleeping habits: for instance, snoring, drooling
on the pillow, and sleeping with an opened mouth.
MATERIALS AND METHODS
Subsequently, the Glatzel mirror test9 was performed.
This retrospective study was reviewed and approved Otolaryngology examination was performed by a single
by the Ethics Committee of Xi’an Jiaotong University. investigator (LL) and included a physical examination
All participants’ parents were informed, and signed followed by endoscopy, flexible nasopharyngoscopy,
written consent forms allowing use of their data for and nasopharyngeal x-ray.
scientific purposes. The level of the adenoid or tonsillar hypertrophy was
The sample consisted of 121 cone-beam computed computed mathematically based on the CBCT images.
tomographic (CBCT) images from Chinese children (65 The percentage of adenoid hypertrophy was calculated
females, 56 males) who were treated in the Orthodon- as AS/TNPA 3 100; where AS indicates the linear
tic Department of Xi’an Jiaotong University from 2017 distance extending from the posterior soft palate to the
to 2022. Sample size was calculated using Minitabt nearest point of adenoid tissues and TNPA refers to the
v.18.1 software (Minitab Inc, State College, Pa), total linear distance of the nasopharyngeal airway in
considering a power of 80%, a significance level of the sagittal section. Percentage of tonsillar hypertrophy
.05, a standard deviation of 4.2, and a 4.4-mm ¼ TS/TOPA 3 100, where TS is the narrowest distance

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ADENOTONSILLAR HYPERTROPHY AND HYOID BONE 469

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Figure 1. (A) Obstructive adenoid hypertrophy in the sagittal section. (B) Obstructive adenoid hypertrophy in the axial section at the AS plane. (C)
Obstructive tonsillar hypertrophy in the Coronal section. (D) Obstructive tonsillar hypertrophy in the axial section at the TS plane.

between the tonsils in the coronal section and TOPA the airway was determined to be a plane that ran
indicates the total linear distance of the oropharyngeal parallel to the P plane and passed through the most
airway in the coronal plane (Figure 1). Subjects who superior point of the epiglottis. Subsequently, the
displayed less than 25% of adenoid or tonsillar airway was divided into an upper (retropalatal) seg-
hypertrophy were considered nonobstructive, and ment and a lower (retroglossal) segment using a plane
those who displayed more than 50% of adenoid or that was parallel to the P plane and passed through the
tonsillar hypertrophy were considered obstructive. A uvula. Finally, the volumes were measured using
similar approach was used by previous authors.10–12 Dolphin software, and the airway sensitivity was set
Subjects who met the inclusion criteria were divided to 73, as recommended by Alves et al.14 (Figure 2).
into four groups, as follows: (1) control group (C-group) Hyoid bone linear measurements were HME, HEB,
with nonobstructive adenoid or tonsillar hypertrophy, HC3, C3Me, HC3Me, HPNS, HH, and HV (Table 1;
(2) adenoid hypertrophy group (AH-group), (3) adenoid Figure 3).
and tonsillar hypertrophy group (ATH-group), and (4)
tonsillar hypertrophy group (TH-group). Statistical Analysis
According to Nath et al.,13 the superior boundary of All measurements for 30 randomly selected partic-
the airway was determined as a plane that ran ipants were repeated 2 weeks after the first measure-
posterior to the nasal spine (PNS) to the posterior wall ment, and the intraclass correlation coefficient (ICC)
of the pharynx (P plane), and the inferior boundary of was calculated to check the intrainvestigator reliability

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470 MOHAMED, HABUMUGISHA, CHENG, ZHAO, BU, LIU, GUO, ZOU, WANG

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Figure 2. (A) Volumetric measurement of the airway. (B) Three-dimensional reconstruction of the airway structure.

of the measurements. Dahlberg’s formula15 was used RESULTS

to assess the measurement error.
The ICC test revealed high intrainvestigator agree-
The Shapiro-Wilk test was used to check the normal
ment, ranging between 0.93 and 0.99 for linear
distribution of the data. Because the data showed measurements and between 0.90 and 0.97 for volu-
nonnormal distribution, the nonparametric Kruskal- metric measurements. The results of Dahlberg’s
Wallis test was used for intergroup comparison, formula were 0.81 to 1.60 mm and 165 to 323 mm3
followed by pairwise comparison using the Mann- for linear and volumetric measurements, respectively.
Whitney U-test with Bonferroni adjustment when a The baseline characteristics of the selected sample
significant variable was detected. are shown in Table 2. No significant difference was
Spearman correlation coefficient was performed to found in the demographic variables or in the sagittal or
investigate the correlation between airway and hyoid vertical skeletal pattern variables (P . .05).
bone parameters. Multiple linear regression analysis The intergroup comparison is displayed in Table 3.
was used after the logarithmic transformation of the No significant difference was found between subjects
dependent variable values to build a model for the with isolated adenoid or tonsillar hypertrophy in
airway to identify the airway predictive parameters. comparison to the control group with regard to hyoid
SPSS software (version 25.0, SPSS Inc, Chicago, Ill) bone position and airway parameters (P . .05). On the
was used, and a P value , .05 was considered other hand, subjects in the ATH-group demonstrated a
significant. statistically significant decrease in HV, total airway

Table 1. Explanation of the Landmarks and Measurements

Measurement Definition Interpretation
HME The distance extending from hyoid bone most superior The position of the hyoid bone relative to the mandible
point (H) to Menton point, which is the most inferior
point of the symphisis
HEB The distance extending between H point and the The position of hyoid bone relative to the epiglottis
epiglottis base
C3H The distance between H point and the most The position of hyoid bone relative to the third cervical
superoanterior point of the third cervical vertebrae vertebrae
C3ME The distance extending from the third cervical vertebrae This line, when paired with the H-Me line and the C3-H line,
to Menton point forms the hyoid bone triangle
HC3ME The perpendicular distance from H point to the C3ME The hyoid bone triangle’s vertical height; a positive score
line shows that the hyoid triangle is pointing downward, while
a negative value indicates that it is pointing upward
HPNS The distance extending from H point to posterior nasal The position of hyoid bone relative to the maxilla
spine point
HH The perpendicular distance from H point to a line Hyoid bone horizontal distance
extending vertically and passing through the Sella
point
HV The perpendicular distance from H point to a line Hyoid bone vertical distance
extending horizontally and passing through the Sella
point

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ADENOTONSILLAR HYPERTROPHY AND HYOID BONE 471

results for the AH-group revealed a moderate to strong

positive correlation. Correlation outcomes showed
moderate to weak positive correlations for the ATH-
group and TH-group.
Multiple linear regression analysis is shown in Table
5. The TA volume and retropalatal airway volume (RP
volume) models were not as successful as the RG
volume model. The RG volume model had a moderate
potential for explaining the RG volume, representing
40% of the variance. The variables HV and age had a
significant role in explaining the RG volume (beta ¼ 0.4

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and 0.17; P ¼ .002 and 0.037, respectively). A linear
regression equation was formulated as follows: Y ¼
2.099 þ 0.009(X1) þ 0.019(X2), where Y indicates the
log of RG volume; X1 indicates the HV value; and X2
indicates age. The predicted and actual logs of RG
volume are plotted in Figure 4.

DISCUSSION

Figure 3. The landmarks and measurements of hyoid bone position.

In the current study, a collaborative approach was
(1) hyoid bone (H) – Menton (Me); (2) hyoid bone (H) – epiglottis established between the Ear Nose and Throat and
(EB); (3) third cervical vertebrae (C3) – hyoid bone (H); (4) third Orthodontic Departments to aid in the proper grouping
cervical vertebrae (C3) – Menton (Me); (5) hyoid bone (H) – third of samples. Additionally, CBCT images were report-
cervical vertebrae to Menton line (C3Me); (6) hyoid bone (H) – ed10,12 to be a reliable and accurate tool for the
posterior nasal spine (PNS); (7) hyoid bone horizontal distance (HH);
and (8) hyoid bone vertical distance (HV).
assessment of adenoids and tonsils. Thus, CBCT
images were used as an adjunctive tool for evaluating
the extent of hypertrophy; images were only taken
volume (TA volume), and retroglossal airway volume
when they were expected to have an additive value for
(RG volume) values when compared to those in the C-
orthodontic diagnosis and treatment planning and
group.
following ALARA principles.16
The ATH-group showed significantly lesser values of The intergroup comparison revealed significantly
HV and all airway volumetric measurements when different vertical hyoid bone position, described by
compared to the AH-group. While the comparison the variable HV, between the C-group and ATH-group,
between the ATH-group and the TH-group showed indicating an elevated hyoid bone position in the ATH-
significantly decreased TA volume and RG volume group. This finding was similar to that of Chung et al.,2
only, no significant difference in hyoid bone variables who found that subjects with mouth breathing were
was observed. characterized by an elevated hyoid bone. In addition,
Bivariate correlation analysis between airway and Chaves et al.7 reported that an elevated hyoid bone
hyoid bone parameters is shown in Table 4. The position was found in asthmatic patients. On the
correlation results in the C-group showed a moderate contrary, another investigation by Behlfelt et al.6
to strong positive correlation. Likewise, correlation claimed that subjects with enlarged tonsils had a lower

Table 2. Baseline Characteristics of the Samplesa

C-Group (n ¼ 26) AH-Group (n ¼ 25) ATH-Group (n ¼ 38) TH-Group (n ¼ 32) P-Value
Age, y (mean 6 SD)b 9.96 6 1.63 9.16 6 2.13 9.05 6 1.76 9.93 6 1.38 .068
Gender, N (%)c
Male 14 (24.1) 13 (22.4) 19 (32.8) 12 (20.7) .574
Female 12 (19) 12 (19) 19 (30.2) 20 (31.7)
ANB, 8 (mean 6 SD)b 5.25 6 2.04 5.02 6 2.02 4.95 6 2.03 5.16 6 1.91 .888
SNA, 8 (mean 6 SD)b 81.60 6 3.74 81.63 6 3.80 80.15 6 3.73 80.35 6 3.60 .286
SNB, 8 (mean 6 SD)b 76.47 6 2.99 73.89 6 14.47 75.34 6 3.86 75.36 6 3.42 .526
FMA, 8 (mean 6 SD)b 30.64 6 2.38 30.95 6 2.93 30.03 6 3.02 30.80 6 3.32 .57
a
C-Group indicates control group; AH-Group, adenoid hypertrophy group; ATH-Group, adenotonsillar hypertrophy group; TH-Group, tonsillar
hypertrophy group; and SD, standard deviation.
b
Kruskal-Wallis test.
c
Chi-square test.

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472 MOHAMED, HABUMUGISHA, CHENG, ZHAO, BU, LIU, GUO, ZOU, WANG

Table 3. Kruskal-Wallis Test for Intergroup Comparison Followed by Pairwise Comparisons Using Mann-Whitney U-Test With Bonferroni
Adjustmenta
Pairwise Comparisons

C-Group C-Group AH-Group C-Group ATH-Group ATH-Group

C-Group AH-Group ATH-Group TH-Group vs vs vs vs vs vs
(Mean 6 SD) (Mean 6 SD) (Mean 6 SD) (Mean 6 SD) P-Value AH-Group TH-Group TH-Group ATH-Group AH-Group TH-Group

Hyoid bone measurements

HME 41.14 6 5.84 40.67 6 5.07 41.09 6 4.47 39.88 6 1.26 .757 NS NS NS NS NS NS
HEB 8.99 6 3.83 9.62 6 3.97 8.08 6 3.85 8.95 6 3.61 .414 NS NS NS NS NS NS
C3H 27.36 6 3.12 28.34 6 5.49 26.27 6 3.71 25.97 6 3.98 .29 NS NS NS NS NS NS
C3ME 67.56 6 5.82 67.62 6 6.97 65.44 6 8.03 65.10 6 8.89 .305 NS NS NS NS NS NS
HC3ME 3.15 6 4.39 1.7 6 5.71 0.20 6 4.39 1.54 6 4.45 .12 NS NS NS NS NS NS
HPNS 51.75 6 5.83 52.48 6 6.85 48.94 6 5.41 49.99 6 5.33 .105 NS NS NS NS NS NS

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HH 15.38 6 6.03 13.81 6 8.80 13.61 6 8.98 13.6 6 13.28 .287 NS NS NS NS NS NS
HV 86.76 6 6.80 88.39 6 9.78 81.30 6 6.58 84.68 6 8.92 .004** NS NS NS S S NS
Airway measurements
TA volume 15,994.61 6 6780.71 16,816.02 6 6377.16 11,042.39 6 4527.83 16,282.43 6 8567.79 .001** NS NS NS S S S
RP volume 8607.54 6 3933.45 8849.30 6 3591.13 5996.05 6 2639.45 8161.35 6 3918.03 .007** NS NS NS NS S NS
RG volume 7326 6 3006.96 7782.62 6 2905.88 5028.67 6 2052.18 6858.46 6 2982.45 .0001*** NS NS NS S S S
a
C-Group indicates control group; AH-Group, adenoid hypertrophy group; ATH-Group, adenotonsillar hypertrophy group; TH-Group, tonsillar
hypertrophy group; and SD, standard deviation; NS, not significant; and S, significant. See Table 1 for additional abbreviations.
* P , .05; ** P , .01; *** P , .001.

hyoid bone position. However, it is worth noting that volumes, but it constricts at relatively high airway
these previous investigations used different methodol- volumes.19 This suggests that alteration of hyoid bone
ogies than the current study, which, to some extent, position could affect muscle tonicity and, hence, the
might explain the controversial findings. airway patency.
Jiang5 highlighted that a positive correlation between The relationship between obstructive sleep apnea
airway volumes and HME and HV was found, which and the hyoid bone has been investigated by several
was in agreement with the current correlation results. authors. Young and McDonald20 found a significant
This could explain the previous findings, which correlation between all hyoid bone vertical measure-
reported17 airway and hyoid bone positional changes ments and the AHI. In addition, Chang and Shiao21
after orthodontic or orthognathic surgery treatment studied the craniofacial variables that could be
involving mandibular growth modification or advance- contributing in obstructive sleep apnea; they highlight-
ment. Although the ATH-group showed the fewest ed that a positive correlation was found between the
correlations between airway and hyoid bone parame- distance extending from the hyoid bone to the
ters, positive correlations were still found, especially in mandibular plane (H-MP) and AHI. A previous inves-
the RG volume (C3H: r ¼ 0.447, HPNS: r ¼ 0.355, HV: r tigation by Pae and Harper22 investigated factors that
¼ 0.486). These findings were similar to those of the could be associated with a positive response to oral
previous case series performed by Riley et al.,18 who appliances for the treatment of obstructive sleep
proposed the hyoid suspension technique as a surgical apnea; their findings showed that the hyoid bone
approach for treatment of obstructive sleep apnea. moved superiorly after oral appliance therapy in
They concluded that suspending the hyoid bone subjects who demonstrated a greater decrease in
antero-inferiorly contributed significantly in increasing AHI, suggesting that H-MP could be a useful marker for
the hypopharyngeal airway size, and a significant the favorable response to oral appliance treatment.
decrease in the apnea-hypopnea index (AHI) was A collection of predictor variables that best explains
observed postsurgically. variations in the dependent variable can be identified
The muscular complex around the hyoid bone using linear multiple regression analysis. For TA
mainly consists of the suprahyoid and infrahyoid volume, RP volume, and RG volume, every regression
muscles. The suprahyoid muscles are largely respon- analysis was carried out independently. According to
sible for lifting the hyolaryngeal complex and opening the results of the linear regression models, HV was a
the upper esophageal sphincter during swallowing, significant explanatory variable for the variation in RG
while the infrahyoid muscles are responsible for volume. Another variable in the predicted model for RG
maintaining the hyoid bone during swallowing to volume was age. Previous research20 underlined the
provide a stable foundation for the suprahyoid muscles significance of the vertical position of the hyoid bone in
to assist with mandibular depression. The middle the severity of obstructive sleep apnea syndrome.
pharyngeal constrictor muscle, which inserts into the Additionally, Schendel et al.23 illustrated the potential
hyoid bone, plays a vital role in maintaining airway impact of age on airway volume. Thus, it makes sense
patency. When the pharyngeal constrictor muscles are that the predictive model was able to adequately
activated, the airway dilates at relatively low airway explain the variance in RG volume. The same

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ADENOTONSILLAR HYPERTROPHY AND HYOID BONE 473

Table 4. Spearman Correlation Between Airway Volumes and Hyoid Bone Parametersa
HME HEB C3H C3ME HC3ME HPNS HH HV
C-group
TA volume
Correlation coefficient 0.725** 0.322 0.014 0.713** 0.124 0.195 0.193 0.205
P-value ,.001 .109 .946 ,.001 .548 .340 .346 .315
RP volume
Correlation coefficient 0.671** 0.287 0.011 0.628** 0.033 0.067 0.242 0.037
P-value ,.001 .155 .956 .001 .873 .744 .234 .857
RG volume
Correlation coefficient 0.579** 0.322 0.024 0.530** 0.239 0.402* 0.056 0.628**
P-value .002 .109 .908 .005 .239 .042 .787 .001

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AH-group
TA volume
Correlation coefficient 0.616** 0.027 0.292 0.647** 0.371 0.626** 0.112 0.438*
P-value .001 .900 .157 ,.001 .068 .001 .593 .028
RP volume
Correlation coefficient 0.595** 0.003 0.247 0.573** 0.355 0.531** 0.107 0.288
P-value .002 .990 .234 .003 .081 .006 .610 .162
RG volume
Correlation coefficient 0.542** 0.018 0.222 0.569** 0.446* 0.743** 0.160 0.625**
P-value .005 .933 .287 .003 .025 ,.001 .446 .001
ATH-group
TA volume
Correlation coefficient 0.094 0.088 0.366* 0.202 0.162 0.194 0.088 0.170
P-value .575 .598 .024 .225 .332 .243 .600 .306
RP volume
Correlation coefficient 0.118 0.170 0.298 0.211 0.085 0.091 0.145 0.003
P-value .481 .307 .069 .203 .613 .589 .384 .984
RG volume
Correlation coefficient 0.032 0.014 0.447** 0.142 0.308 0.355* 0.039 0.486**
P-value .850 .934 .005 .394 .060 .029 .818 .002
TH-group
TA volume
Correlation coefficient 0.346 0.031 0.209 0.355* 0.018 0.086 0.195 0.067
P-value .052 .866 .250 .047 .922 .638 .284 .714
RP volume
Correlation coefficient 0.541** 0.158 0.166 0.507** 0.081 0.058 0.237 0.025
P-value .001 .387 .365 .003 .658 .753 .192 .891
RG volume
Correlation coefficient 0.404* 0.042 0.319 0.454** 0.210 0.424* 0.177 0.451**
P-value .022 .821 .075 .009 .250 .016 .333 .010
a
TA volume indicates total airway volume; RP volume, retropalatal airway volume; RG volume, retroglossal airway volume; C-group, control
group; AH-group, adenoid hypertrophy group; ATH-group, adenotonsillar hypertrophy group; and TH-group, tonsillar hypertrophy group. See
Table 1 for additional abbreviations.
* Correlation is significant at .05; ** Correlation is significant at .01.

variables utilized for TA volume and RP volume, in detailed grouping and a bigger sample size are
contrast to the RG volume model, provided low recommended to better determine the effect of
predictive value for the variances. adenotonsillar hypertrophy on the craniofacial com-
Despite the fact that the cross-sectional design of plex. In addition, the results of this study were limited to
this study was not capable of assessing causation Chinese patients, and future studies should consider
principles, a longitudinal design was not used because racial differences when evaluating the findings.
of the possible increased radiation associated with it.
Another limitation of this study was that it did not CONCLUSIONS
include Class III subjects because of the lack of a large
enough sample size. Variations of the hyoid bone  A significant decrease in HV, TA volume, and RG
position and, thus, the angulation and the relative volume was found in subjects with adenotonsillar
muscular tone of the associated muscles in subjects hypertrophy compared to the control group.
with different skeletal phenotypes were previously  HV and age were significantly positively correlated
reported.24 Therefore, further investigations with more predictors for explaining the RG volume.

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474 MOHAMED, HABUMUGISHA, CHENG, ZHAO, BU, LIU, GUO, ZOU, WANG

Table 5. Multiple Linear Regression Model for Retroglossal Airway Volume as a Dependent Variable After Logarithmic Transformationa
Unstandardized Standardized
Coefficients Coefficients ANOVA
Dependent Variable:
Log of RG Volume Beta SE Beta t P F P Adjusted R 2
Constant 2.099 0.393 5.342 .000 6.907 ,.0001**** 0.4
Age 0.019 0.009 0.173 2.105 .037*
Gender 0.038 0.029 0.098 1.329 .187
ANB8 0.010 0.009 0.098 1.105 .271
SNA8 0.005 0.005 0.100 0.991 .324
SNB8 0.002 0.002 0.079 0.865 .389
FMA8 0.003 0.005 0.047 0.597 .551

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HME 0.004 0.005 0.113 0.839 .403
HEB 0.003 0.005 0.064 0.734 .464
C3H 0.004 0.005 0.088 0.838 .404
C3ME 0.004 0.004 0.174 1.144 .255
HC3ME 0.005 0.006 0.111 0.808 .421
HPNS 0.007 0.005 0.207 1.313 .192
HH 0.000 0.002 0.024 0.314 .754
HV 0.009 0.003 0.399 3.151 .002**
a
SE indicates standard error; ANOVA, analysis of variance. See Table 1 for additional abbreviations.
* P , .05; ** P , .01; *** P , .001; **** P , .0001.

Figure 4. Multiple linear regression analysis.

ACKNOWLEDGMENTS 4. Zhao Z, Zheng L, Huang X, Li C, Liu J, Hu Y. Effects of

mouth breathing on facial skeletal development in children: a
This project was funded by (1) a general project from the field
systematic review and meta-analysis. BMC Oral Health.
of Social Development in the Department of Science and
2021;21:1–14.
Technology of Shaanxi Province, grant/award 2019SF-081; (2)
the Science and Technology Project of Xi ’an, grant/award 5. Jiang Y-Y. Correlation between hyoid bone position and
20YXYJ0010(3); and (3) Clinical New Technology from airway dimensions in Chinese adolescents by cone beam
Stomatological Hospital of Xi’an Jiaotong University in 2018. computed tomography analysis. Int J Oral Maxillofacl Surg.
2016;45:914–921.
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