Treatment of obstructive sleep apnea syndrome (OSAS) with mandibular advancement devices-A statement of the Portuguese society of pulmonology, the Portuguese society of stomatology and dental medicine, the Portuguese dental association, and the Portuguese society of temporomandibular disorders, orofacial pain and sleep.

With the purpose of establishing a consensus around clinical orientations for professionals involved in managing patients with sleep breathing disorders (SBD), an interdisciplinary group of scientific societies involved in this field discussed and reviewed all the published international guidelines from the American Dental Association, American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and the European counterparts. Treatment of SBD is multidisciplinary and should be made in concert with the patient, the sleep physician, and the qualified dentist to solve the individual, social, and economic burden of the disease,. This consensus document represents the current thinking of a team of Portuguese experts on managing patients with SBD based on the available evidence.

The Potential Effect of Changing Patient Position on Snoring: A Systematic Review.

Approximately 45% of adults snore occasionally, and 25% snore regularly, with a higher prevalence in men and an increase among postmenopausal women due to hormonal changes. Snoring is a health concern linked to vascular disease and decreased quality of life for both snorers and their bed partners. Effective snoring treatment, which aims to reduce or eliminate the sound, is challenging and depends on factors like age, comorbidities, disease severity, and anatomical features. This review aims to provide a systematic overview of the current literature on the effects of positional therapy (PT) on snoring. Various devices facilitate PT, including anti-snoring pillows and vibration alarms. PT devices maintain head and neck alignment to keep airways open, while head of bed elevation (HOBE) solutions reduce upper airway collapses by elevating the head and trunk. Studies show that PT and HOBE reduce snoring by increasing airway cross-sectional area and decreasing closing pressure. Despite their benefits, these non-surgical treatments have limitations, such as discomfort in certain sleeping positions and intolerance to prolonged head elevation. While reducing snoring intensity is critical for health reasons, further comparative studies between the different devices are needed to enhance snoring management.

Triglyceride-glucose index and combined indicators: effective indicators for screening NAFLD in snoring patients.

AIMS: Nonalcoholic fatty liver disease (NAFLD) is a common complication in snoring patients, especially in patients with obstructive sleep apnea syndrome (OSA). Triglyceride-glucose (TyG) index was a simple indicator of metabolic status and a surrogate marker of insulin resistance. This study aimed to explore the relationship between NAFLD and TyG index in snoring patients. METHODS: A retrospective study was conducted. The successive snoring patients enrolled in the Sleep Center of the First Affiliated Hospital of Fujian Medical University and had abdominal ultrasonography were included. The clinical characteristics of patients in different quartile TyG groups were compared. The relationship of the TyG index and NAFLD were valued via logistic regression models and restricted cubic spline analysis. The value of TyG index in predicting NAFLD was determined by receiver operating characteristic curve (ROC curve). RESULTS: A total of 463 NAFLD cases were found among the 654 snoring patients. TyG index was a risk factor of NAFLD in snoring patients (OR = 2.38, 95% CI = 1.71-3.36). The risk of NAFLD was much higher in patients with the highest quartile of TyG index (OR = 5.12, 95% CI = 2.85-9.22), compared with the lowest quartile group. Restricted cubic spline (RCS) analysis showed a significant dose-response relationship between TyG index and risk of NAFLD (p for non-linearity < 0.001). A combination of TyG, neck circumference and ESS score presented the acceptable AUC for the detection of NAFLD in snoring patients (0.746, 95% CI 0.701-0.790, p < 0.001). CONCLUSION: The TyG index was a risk factor of NAFLD in snoring patients. A combination of TyG, neck circumferences and ESS score could act as a convenient and effective indicator for screening NAFLD in snoring patients.

Sex Differences in the Relationship Between Self-Reporting of Snoring and Cardiovascular Risk:An Analysis of NHANES.

Background: Identifying risk factors for cardiovascular disease (CVD) is critical for effective prevention and management. While classic CVD risk factors have been extensively studied, there is a scarcity of research on the association between snoring and CVD risk, particularly in the context of sex differences. Methods: This study utilized data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2015 and 2020. Participants were initially categorized based on the severity of snoring or the presence of snoring.Within the snoring group, they were further classified by sex. Analysis was carried out using multivariate logistic regression. Results: Our study included 12,681 participants aged 18 years or older. When compared to the non-snoring group, individuals in the moderate snoring group had a higher odds ratio (OR) of 1.418 (95% CI 1.083 to 1.857, p = 0.011), while those in the severe snoring group had a higher OR of 1.882 (95% CI 1.468 to 2.409, p < 0.001). In the snoring group, individuals were further categorized by gender: 4527 males and 4131 females. Importantly, male patients showed a higher OR for atrial fibrillation (4.945, 95% CI 1.187 to 20.598, p = 0.028) compared to females. Additionally, male patients had a higher OR for coronary heart disease (2.002, 95% CI 1.152 to 3.479, p = 0.014) compared to females. Conclusion: Sex plays a significant role in the relationship between snoring and CVD risk. Males with snoring have a higher risk of developing CVD compared to females. In particular, male snorers are nearly five times more likely to develop atrial fibrillation and about twice as likely to experience coronary artery disease in comparison to female snorers. It is recommended that healthcare providers and public health officials prioritize cardiovascular risk assessments for male individuals who exhibit symptoms of snoring.

The Diagnostic Value of CT Scan in Identifying Adenoid Hypertrophy in Adults: A Case Report.

The utility of computed tomography (CT) scan in diagnosing adenoid hyperplasia in adults. A 22-year-old woman presented with persistent bilateral nasal obstruction, anterior nasal discharge, mouth breathing, and snoring over the past three months. Despite attempts with both local and systemic decongestants, there was no improvement, and flexible nasopharyngoscopy could not be conducted. CT scans revealed a heterogeneously enhancing space-occupying mass in the nasopharynx, and a rare diagnosis of adult adenoid hypertrophy was reported. The patient responded to a combination of painkillers, antibiotics, and nasal decongestants. Adenoid hyperplasia in adults is quite rare and inadequate examination by indirect posterior rhinoscopy may lead to misdiagnosis and mismanagement. A CT scan not only provides a clearer view of the nasopharyngeal space and adenoids but also reveals details about the nature of lesions, including their extension and potential bone destruction, suggesting the presence of a malignant tumor. Additionally, a CT scan proves valuable in diagnosing chronic sinusitis.

Prevalence of sleep-disordered breathing in children and adolescents with large horizontal maxillary overjet due to mandibular retrognathia: a case control study.

STUDY OBJECTIVES: The aim of the study was to examine the prevalence of sleep-disordered breathing (SDB) in children and adolescents with large overjet due to mandibular retrognathia compared to a control group. METHODS: In this case-control study children with large overjet ≥ 6 mm due to mandibular retrognathia (study group) were compared to a group with neutral occlusion (controls). All participants underwent respiratory polygraphy (PG) and questionnaires regarding sleepiness and snoring. Differences across groups were tested by: Chi-square, general linear model adjusted for age, sex, and body mass index (BMI), and Mann-Whitney test. Differences in results of PG were also tested by general linear model adjusted for age, sex, and BMI according to severity of mandibular retrognathia. RESULTS: Thirty-seven (19 male;18 female, median age 12.3 years) participants were included in the study group and 32 (16 male;16 female, median age 12.2 years) in the control group. No significant difference in SDB assessed by PG or questionnaires between the groups was found even though the snore index was higher in the study group (p=0.051). The snore index was higher than the parent-reported snoring. Respiration rate was significantly reduced in the study group (p=0.043), and estimated sleep time efficiency was significantly reduced in males compared to females (p<0.001). CONCLUSIONS: No significant differences in SDB were found between the groups even though the snore index was higher in the study group. The snore index of the PG was higher than the parent-reported snoring. Estimated sleep time efficiency was reduced in males. The study improves the understanding of risk of SDB in non-obese children with large overjet due to mandibular retrognathia and may contribute to an interdisciplinary approach of risk assessment of SDB in children with malocclusion. CLINICAL TRIAL REGISTRATION: NCT04964830.

Exploring the relationship between smoking and poor sleep quality: a cross-sectional study using NHANES.

Introduction: Sleeping disorders is a high prevalent disorder, and although previous research has suggested a link between smoking and sleep disorders, there is a lack of large-scale, nationally representative studies examining this association across multiple sleep outcomes and exploring dose-response relationships. Methods: This study used data from 30,269 participants from the NHANES database (2007-2020). Weighted logistic regression models were used to assess the associations between smoking status (non-smoker, light smoker, moderate smoker, and heavy smoker) and various sleep outcomes, including insufficient sleep duration, reported sleep problems, snoring, snorting, or stopping breathing during sleep, and daytime sleepiness. Dose-response relationships were explored using restricted cubic splines. Results: Compared to non-smokers, heavy smokers had significantly higher odds of experiencing insufficient sleep duration with OR 1.732 (95% CI 1.528-1.963, P <0.001), reported sleep problems with OR 1.990 (95% CI 1.766-2.243, P <0.001), occasional or frequent snoring with OR 1.908 (95% CI 1.164-3.128, P = 0.03), and occasional or frequent snorting or stopping breathing during sleep with OR 1.863 (95% CI 1.183-2.936, P = 0.022), while results for sometimes, often or almost always being overly sleepy during the day with OR 1.257 (95% CI 0.872-1.810, P = 0.115) are not significant. A trend of positive correlation was observed between smoking and all sleep disorder outcomes (P for trend < 0.05). Dose-response analyses revealed that the odds of these sleep outcomes increased with higher smoking levels. Conclusion: Smoking is significantly associated with various sleep disorders, and a dose-response relationship exists between smoking levels and the odds of experiencing these sleep problems. These findings underscore the importance of addressing smoking as a modifiable risk factor for poor sleep health and suggest that reducing smoking, even if complete cessation is not achieved, may have positive effects on sleep outcomes.

Sleep patterns, genetic susceptibility, and risk of cirrhosis among individuals with nonalcoholic fatty liver disease.

BACKGROUND: The associations between sleep patterns or behaviors and the risk of cirrhosis and the influence of genetic susceptibility on these associations among NAFLD participants remain inadequately elucidated. METHODS: This study conducted a prospective follow-up of 112,196 NAFLD participants diagnosed at baseline from the UK Biobank cohort study. Five sleep behaviors were collected to measure a healthy sleep score. Five genetic variants were used to construct a polygenic risk score. We used Cox proportional hazard model to assess hazard ratios (HR) and 95% confidence intervals (CIs) for incidence of cirrhosis. RESULTS: During the follow-up, 592 incident cirrhosis cases were documented. Healthy sleep pattern was associated with reduced risk of cirrhosis in a dose-response manner (ptrend < 0.001). Participants with favourable sleep score (versus unfavourable sleep score) had an HR of 0.55 for cirrhosis risk (95% CI 0.39-0.78). Multivariable-adjusted HRs (95% CIs) of cirrhosis incidence for NAFLDs with no frequent insomnia, sleeping for 7-8 h per day, and no excessive daytime dozing behaviors were 0.73 (0.61-0.87), 0.79 (0.66-0.93), and 0.69 (0.50-0.95), respectively. Compared with participants with favourable sleep pattern and low genetic risk, those with unfavourable sleep pattern and high genetic risk had higher risks of cirrhosis incidence (HR 3.16, 95% CI 1.88-5.33). In addition, a significant interaction between chronotype and genetic risk was detected for the incidence of cirrhosis (p for multiplicative interaction = 0.004). CONCLUSION: An association was observed between healthy sleep pattern and decreased risk of cirrhosis among NAFLD participants, regardless of low or high genetic risk.

Management of primary snoring in adults: A scoping review examining interventions, outcomes and instruments used to assess clinical effects.

While various treatment options for primary snoring are available, evidence-based recommendations to determine the optimal intervention remain unestablished. To inform future directions of research to guide clinical decision-making, this scoping review was conducted to map the existing evidence on interventions for primary snoring, the outcomes and instruments used to assess their clinical effects in adults. The feasibility of conducting further systematic reviews and comparing outcomes across these therapies using network meta-analysis was also assessed. Of the 1673 records identified, 38 interventional studies met the inclusion criteria with three-fifths of them being before-after studies. The most common reason for study exclusion was results being reported for patients with primary snoring and obstructive sleep apnoea (OSA) combined. Interventions were surgical (73 %), behavioural and the use of devices/medications. Twenty-six common outcomes were identified and categorised into six domains. Fifty-nine instruments were used to assess the outcomes and based mainly on non-validated questionnaires. Our findings indicated (1) the need for randomised controlled trials with strict discrimination between patients with primary snoring and OSA, (2) further network meta-analyses using some outcomes is feasible, and (3) a core outcome set to inform standardised reporting for future research should be developed.

Oral Appliances for Obstructive Sleep Apnea.

The use of mandibular repositioning devices (MRDs) in the management of patients with obstructive sleep apnea (OSA) has gained extensive recognition with relevant clinical evidence of its effectiveness. MRDs are designed to advance and hold the mandible in a protrusive position to widen the upper airway and promote air circulation. This review of the MRD aims to provide an evidence-based update on the optimal design features of an MRD, an analysis of the variety of appliances available, and the current understanding of the action mechanism.

Snoring and risk of dementia: a prospective cohort and Mendelian randomization study.

STUDY OBJECTIVES: The association between snoring, a very common condition that increases with age, and dementia risk is controversial. We aimed to investigate the observational and causal relationship between snoring and dementia, and to elucidate the role of body mass index (BMI). METHODS: Using data from 451,250 participants who were dementia-free at baseline, we examined the association between self-reported snoring and incident dementia using Cox proportional-hazards models. Causal relationship between snoring and Alzheimer's disease (AD) was examined using bidirectional two-sample Mendelian randomization (MR) analysis. RESULTS: During a median follow-up of 13.6 years, 8,325 individuals developed dementia. Snoring was associated with a lower risk of all-cause dementia (hazard ratio [HR] 0.93; 95% confidence interval [CI] 0.89 to 0.98) and AD (HR 0.91; 95% CI 0.84 to 0.97). The association was slightly attenuated after adjusting for BMI, and was stronger in older individuals, APOE ε4 allele carriers, and during shorter follow-up periods. MR analyses suggested no causal effect of snoring on AD, however, genetic liability to AD was associated with a lower risk of snoring. Multivariable MR indicated that the effect of AD on snoring was primarily driven by BMI. CONCLUSIONS: The phenotypic association between snoring and lower dementia risk likely stems from reverse causation, with genetic predisposition to AD associated with reduced snoring. This may be driven by weight loss in prodromal AD. Increased attention should be paid to reduced snoring and weight loss in older adults as potential early indicators of dementia risk.

Effects of orthognathic surgery on respiratory function during sleep: A prospective longitudinal study.

When treating patients with orthognathic surgery, there might be a risk of obstructive sleep apnoea (OSA) due to soft tissue changes in the upper airways, especially in patients treated with isolated mandibular setback or mandibular setback in combination with maxillary advancement. In the present study, we assessed respiratory function during sleep with home cardiorespiratory polygraphy in 62 patients who had not been previously been diagnosed with OSA at three times: prior to orthognathic surgery for aesthetic and functional indications, and then 3 months and 1 year after surgery. We evaluated surgical displacement based on measurements in three dimensions using pre- and post-operative computed tomography. There were only minor changes in the respiratory parameters such as the apnoea-hypopnoea index (AHI), the apnoea-hypopnoea index in the supine position (AHIsup), the oxygen saturation index (ODI) and the snore index. There was no significant correlation between surgical displacement and the AHI, AHIsup and ODI. There was a weak but significant correlation between vertical displacement of the anterior mandible and the snore index. Within the limitations of the present study, the risk for iatrogenic obstruction of the upper airways seems to be low in patients without OSA treated with orthognathic surgery.

Diagnosis and management of obstructive sleep apnoea in adults.

Obstructive sleep apnoea is the most common form of sleep-disordered breathing. It is characterised by recurrent occlusion of the airway during sleep. Ensuing apnoeas terminate in arousal from sleep and lead to non-restorative sleep, excessive daytime sleepiness and adverse cardiovascular and neurocognitive effects. A sleep study should be offered to patients reporting witnessed apnoeas or symptoms related to non-restorative sleep. It should also be considered in the presence of predisposing factors for obstructive sleep apnoea (e.g. obesity, tonsillar hypertrophy, retrognathia, refractory hypertension). Treatment should aim to improve symptoms and reduce cardiovascular and neurocognitive risk. The treatment approach should consider the symptom burden, severity, anatomical factors, and patient preference. Positive airway pressure is the most effective treatment option, although intolerance and non-adherence are common. Other options include positional therapy, oral appliances and upper airway surgery. Weight loss and optimisation of cardiovascular disease risk should be considered in selected patients.

Automatic detection of obstructive sleep apnea based on speech or snoring sounds: a narrative review.

Background and Objective: Obstructive sleep apnea (OSA) is a common chronic disorder characterized by repeated breathing pauses during sleep caused by upper airway narrowing or collapse. The gold standard for OSA diagnosis is the polysomnography test, which is time consuming, expensive, and invasive. In recent years, more cost-effective approaches for OSA detection based in predictive value of speech and snoring has emerged. In this paper, we offer a comprehensive summary of current research progress on the applications of speech or snoring sounds for the automatic detection of OSA and discuss the key challenges that need to be overcome for future research into this novel approach. Methods: PubMed, IEEE Xplore, and Web of Science databases were searched with related keywords. Literature published between 1989 and 2022 examining the potential of using speech or snoring sounds for automated OSA detection was reviewed. Key Content and Findings: Speech and snoring sounds contain a large amount of information about OSA, and they have been extensively studied in the automatic screening of OSA. By importing features extracted from speech and snoring sounds into artificial intelligence models, clinicians can automatically screen for OSA. Features such as formant, linear prediction cepstral coefficients, mel-frequency cepstral coefficients, and artificial intelligence algorithms including support vector machines, Gaussian mixture model, and hidden Markov models have been extensively studied for the detection of OSA. Conclusions: Due to the significant advantages of noninvasive, low-cost, and contactless data collection, an automatic approach based on speech or snoring sounds seems to be a promising tool for the detection of OSA.

A comparison of caregiver-reported snoring and objective snoring in children from urban neighborhoods.

OBJECTIVE: Sleep Disordered Breathing (SDB) is both prevalent and under-recognized in pediatric minority populations. Recognition of SDB is often triggered by symptoms of caregiver-reported snoring. However, the validity and utility of caregiver reports likely vary across populations. Our objective is to assess the association between caregiver-reported snoring and objectively recorded snoring in a low-income urban community and explore factors associated with agreement between objective and subjective snoring. METHODS: 169 6 to 12 year old participants underwent at-home sleep studies with a WatchPAT device as part of the Environmental Assessment of Sleep in Youth (EASY) cohort study. Differences in subjective snoring, objective snoring, and concordance between subjective and objective snoring based on socioeconomic and clinical characteristics were assessed. RESULTS: The sample had a high proportion of non-white (78.9 %) and low income (39.6 %) children. Caregivers reported snoring for 20.7 % of the children and snoring was measured objectively for 21.9 %. Of those with objective snoring, only 29.7 % were identified as snorers by caregiver report (sensitivity: 0.30; specificity: 0.82). Primary Spanish language and co-sleeping were associated with increased caregiver reported snoring, and allergy was associated with increased objective snoring. Older child age and normal range BMI percentile were associated with higher concordance between caregiver and objective snoring. CONCLUSIONS: Among a community-based, predominantly minority sample, caregiver-reported snoring resulted in under-estimation of prevalence of objectively assessed snoring. Reliance on caregiver report may poorly identify children with snoring or SDB in clinical practice.

Validation of Downloadable Mobile Snore Applications by Polysomnography (PSG).

Purpose: Obstructive sleep apnea (OSA) is a common breathing disorder during sleep that is associated with symptoms such as snoring, excessive daytime sleepiness, and breathing interruptions. Polysomnography (PSG) is the most reliable diagnostic test for OSA; however, its high cost and lengthy testing duration make it difficult to access for many patients. With the availability of free snore applications for home-monitoring, this study aimed to validate the top three ranked snore applications, namely SnoreLab (SL), Anti Snore Solution (ASS), and Sleep Cycle Alarm (SCA), using PSG. Patients and Methods: Sixty participants underwent an overnight PSG while simultaneously using three identical smartphones with the tested apps to gather sleep and snoring data. Results: The study discovered that all three applications were significantly correlated with the total recording time and snore counts of PSG, with ASS showing good agreement with snore counts. Furthermore, the Snore Score, Time Snoring of SL, and Sleep Quality of SCA had a significant correlation with the natural logarithm of apnea hypopnea index (lnAHI) of PSG. The Snore Score of SL and the Sleep Quality of SCA were shown to be useful for evaluating snore severity and for pre-diagnosing or predicting OSA above moderate levels. Conclusion: These findings suggest that some parameters of free snore applications can be employed to monitor OSA progress, and future research could involve adjusted algorithms and larger-scale studies to further authenticate these downloadable snore and sleep applications.

An audio-semantic multimodal model for automatic obstructive sleep Apnea-Hypopnea Syndrome classification via multi-feature analysis of snoring sounds.

Introduction: Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a common sleep-related breathing disorder that significantly impacts the daily lives of patients. Currently, the diagnosis of OSAHS relies on various physiological signal monitoring devices, requiring a comprehensive Polysomnography (PSG). However, this invasive diagnostic method faces challenges such as data fluctuation and high costs. To address these challenges, we propose a novel data-driven Audio-Semantic Multi-Modal model for OSAHS severity classification (i.e., ASMM-OSA) based on patient snoring sound characteristics. Methods: In light of the correlation between the acoustic attributes of a patient's snoring patterns and their episodes of breathing disorders, we utilize the patient's sleep audio recordings as an initial screening modality. We analyze the audio features of snoring sounds during the night for subjects suspected of having OSAHS. Audio features were augmented via PubMedBERT to enrich their diversity and detail and subsequently classified for OSAHS severity using XGBoost based on the number of sleep apnea events. Results: Experimental results using the OSAHS dataset from a collaborative university hospital demonstrate that our ASMM-OSA audio-semantic multimodal model achieves a diagnostic level in automatically identifying sleep apnea events and classifying the four-class severity (normal, mild, moderate, and severe) of OSAHS. Discussion: Our proposed model promises new perspectives for non-invasive OSAHS diagnosis, potentially reducing costs and enhancing patient quality of life.

Automatically detecting OSAHS patients based on transfer learning and model fusion.

Objective. Snoring is the most typical symptom of obstructive sleep apnea hypopnea syndrome (OSAHS) that can be used to develop a non-invasive approach for automatically detecting OSAHS patients.Approach. In this work, a model based on transfer learning and model fusion was applied to classify simple snorers and OSAHS patients. Three kinds of basic models were constructed based on pretrained Visual Geometry Group-16 (VGG16), pretrained audio neural networks (PANN), and Mel-frequency cepstral coefficient (MFCC). The XGBoost was used to select features based on feature importance, the majority voting strategy was applied to fuse these basic models and leave-one-subject-out cross validation was used to evaluate the proposed model.Main results. The results show that the fused model embedded with top-5 VGG16 features, top-5 PANN features, and MFCC feature can correctly identify OSAHS patients (AHI > 5) with 100% accuracy.Significance. The proposed fused model provides a good classification performance with lower computational cost and higher robustness that makes detecting OSAHS patients at home possible.

Snoring-generated fluid droplets as a potential mechanistic link between sleep-disordered breathing and pneumonia.

The soft palate and back of the throat represent vulnerable early infection sites for SARS-CoV-2, influenza, streptococci, and many other pathogens. We demonstrate that snoring causes aerosolization of pharyngeal fluid that covers these surfaces, which previously has escaped detection because the inspired airstream carries the micron-sized droplets into the lung, inaccessible to traditional aerosol detectors. While many of these droplets will settle in the lower respiratory tract, a fraction of the respirable smallest droplets remains airborne and can be detected in exhaled breath. We distinguished these exhaled droplets from those generated by the underlying breathing activity by using a chemical tracer, thereby proving their existence. The direct transfer of pharyngeal fluids and their pathogens into the deep lung by snoring represents a plausible mechanistic link between the previously recognized association between sleep-disordered breathing and pneumonia incidence.

An unusual case of long-standing retained nasopharyngeal foreign body.

The nasopharynx is a rare anatomical location where a foreign body may become lodged after being ingested or inhaled. We are presenting a rare case of nasopharyngeal foreign body impaction in a two-and-a-half-year-old child that had been missed for almost a year. The child presented with a history of right-sided foul-smelling nasal discharge, snoring and mouth breathing. An X-Ray soft tissue lateral view of the post-nasal space showed an irregular partially radiopaque nasopharyngeal foreign body. The removal of the foreign body was performed under general anaesthesia successfully. Foreign body impaction in the nasopharynx can easily be missed and it is important to keep this region in mind when dealing with missing inhaled or ingested foreign bodies.