title: MR Image Analytics to Characterize the Upper Airway Structure in Obese Children with Obstructive Sleep Apnea Syndrome.
abstract: OBJECTIVE
  Quantitative image analysis in previous research in obstructive sleep apnea syndrome (OSAS) has focused on the upper airway or several objects in its immediate vicinity and measures of object size. In this paper, we take a more general approach of considering all major objects in the upper airway region and measures pertaining to their individual morphological properties, their tissue characteristics revealed by image intensities, and the 3D architecture of the object assembly. We propose a novel methodology to select a small set of salient features from this large collection of measures and demonstrate the ability of these features to discriminate with very high prediction accuracy between obese OSAS and obese non-OSAS groups.
  
  
  METHODS
  Thirty children were involved in this study with 15 in the obese OSAS group with an apnea-hypopnea index (AHI) = 14.4 ± 10.7) and 15 in the obese non-OSAS group with an AHI = 1.0 ± 1.0 (p<0.001). Subjects were between 8-17 years and underwent T1- and T2-weighted magnetic resonance imaging (MRI) of the upper airway during wakefulness. Fourteen objects in the vicinity of the upper airways were segmented in these images and a total of 159 measurements were derived from each subject image which included object size, surface area, volume, sphericity, standardized T2-weighted image intensity value, and inter-object distances. A small set of discriminating features was identified from this set in several steps. First, a subset of measures that have a low level of correlation among the measures was determined. A heat map visualization technique that allows grouping of parameters based on correlations among them was used for this purpose. Then, through T-tests, another subset of measures which are capable of separating the two groups was identified. The intersection of these subsets yielded the final feature set. The accuracy of these features to perform classification of unseen images into the two patient groups was tested by using logistic regression and multi-fold cross validation.
  
  
  RESULTS
  A set of 16 features identified with low inter-feature correlation (< 0.36) yielded a high classification accuracy of 96% with sensitivity and specificity of 97.8% and 94.4%, respectively. In addition to the previously observed increase in linear size, surface area, and volume of adenoid, tonsils, and fat pad in OSAS, the following new markers have been found. Standardized T2-weighted image intensities differed between the two groups for the entire neck body region, pharynx, and nasopharynx, possibly indicating changes in object tissue characteristics. Fat pad and oropharynx become less round or more complex in shape in OSAS. Fat pad and tongue move closer in OSAS, and so also oropharynx and tonsils and fat pad and tonsils. In contrast, fat pad and oropharynx move farther apart from the skin object.
  
  
  CONCLUSIONS
  The study has found several new anatomic bio-markers of OSAS. Changes in standardized T2-weighted image intensities in objects may imply that intrinsic tissue composition undergoes changes in OSAS. The results on inter-object distances imply that treatment methods should respect the relationships that exist among objects and not just their size. The proposed method of analysis may lead to an improved understanding of the mechanisms underlying OSAS.
authors.affiliation: Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
authors.forename: Yubing
authors.initials: Y
authors.lastname: Tong
authors.affiliation: Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
authors.forename: Jayaram K
authors.initials: JK
authors.lastname: Udupa
authors.affiliation: Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York, United States of America.
authors.forename: Sanghun
authors.initials: S
authors.lastname: Sin
authors.affiliation: Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
authors.forename: Zhengbing
authors.initials: Z
authors.lastname: Liu
authors.affiliation: Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
authors.forename: E Paul
authors.initials: EP
authors.lastname: Wileyto
authors.affiliation: Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
authors.forename: Drew A
authors.initials: DA
authors.lastname: Torigian
authors.affiliation: Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York, United States of America.
authors.forename: Raanan
authors.initials: R
authors.lastname: Arens
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D009765:Obesity / Q000150:complications*; D017286:Polysomnography; D012137:Respiratory System / Q000000981:diagnostic imaging / Q000473:pathology*; D020181:Sleep Apnea, Obstructive / Q000000981:diagnostic imaging* / Q000473:pathology