Home Medicine Evaluation of upper airway ultrasonographic measurements in predicting difficult intubation: A cross-section of the Turkish population
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Evaluation of upper airway ultrasonographic measurements in predicting difficult intubation: A cross-section of the Turkish population

  • Tugba Nur Sayir ORCID logo , Bilge Tuncer ORCID logo and Ezgi Erkilic ORCID logo EMAIL logo
Published/Copyright: August 21, 2024
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Open Medicine
From the journal Open Medicine Volume 19 Issue 1

Abstract

Objectives

Studies have shown that there are differences in clinical evaluation parameters and difficult intubation rates among different ethnic populations. In our study, we aimed to evaluate the efficacy of upper airway clinical and ultrasonographic measurement methods in Turkish population.

Methods

Our study is a single-center, prospective, observational study conducted with 402 patients. All patients underwent clinical airway measurements which are routinely used in pre-anesthetic evaluation. In addition, ultrasonographic anterior neck soft tissue thickness measurements of each patient were made and recorded.

Results

Among the clinical measurements, we found the neck circumference/thyromental distance (TMD) ratio to be significant with a cut-off value of 5.5 and a sensitivity of 92.9% and a specificity of 88.3%, while among the ultrasonographic anterior neck measurements, we found the skin–epiglottic distance to be the most sensitive measurement. We found that there was a positive relationship between the neck circumference/TMD ratio and skin–epiglottis.

Conclusions

In our study, we found that routine measurement methods used in airway examination alone are not sufficient, and measurements that take into account the body proportions of the patients, such as the neck circumference/TMD ratio and the ultrasonographic evaluations are more useful in predicting difficult intubation.

Keywords: ultrasonography; neck circumference/thyromental distance; difficult intubation

1 Introduction

Airway management is a very important issue in terms of the safety of perioperative anesthesia. Difficult ventilation and difficult intubation are important causes of anesthesia-related perioperative morbidity and mortality. It has been reported that approximately 30% of anesthesia-related deaths are associated with inadequate management of difficult airway [1,2].

Airway assessment constitutes an important part of the pre-anesthesia evaluation to identify patients who may encounter difficult intubation and difficult ventilation [3].

Routine clinical features that are evaluated for the risk prediction of difficult airway include age, gender, body mass index (BMI), weight, height, history of difficult intubation, abnormal airway anatomy, snoring, obstructive sleep apnea (OSA), measurement of facial and jaw features, mouth opening, prognathic ability, head and neck mobility, prominent upper incisors, beard presence, upper lip bite test (ULBT), Mallampati score, thyromental distance (TMD), sternomental distance, inter-incisor distance, neck circumference, hyomental distance, ratio of neck circumference to TMD, and ratio of neck to TMD.

Routine clinical parameters are valuable in predicting a difficult airway; however, studies have shown that they do not have sufficient negative predictive value to exclude a difficult airway. Clinicians may be faced with unexpected difficult laryngoscopy despite clinical airway examination that suggests otherwise [1].

The use of ultrasonography in preoperative airway evaluation has become widespread with the developing technology and increased use of ultrasonography in clinics. It is a real-time, non-invasive, easily accessible, mobile, safe, and painless diagnostic tool that can be used in the evaluation of both upper and lower airway [4]. Measurements from ultrasonography include skin–vocal cord distance, skin–hyoid distance, tongue volume, and skin–epiglottis distance [5].

It has been observed in studies that there are differences in clinical evaluation parameters and rates of difficult intubation between different ethnic populations [6–8]. Anthropometric studies have reported ethnic variations in body structure and morphometry and morphology of craniofacial bones (maxilla and mandible bones) [9]. Anatomical changes related to ethnic differences also significantly affect the risk of OSA [10].

In this study, which we thought could reflect the Turkish population, we aimed to determine and compare the efficacy of clinical and ultrasonographic measurement methods of the upper airway used in preoperative airway assessment in predicting difficult intubation and laryngoscopy. We also aimed to determine the specificity and sensitivity of these measurement methods for difficult intubation and laryngoscopy, and to find threshold values for the Turkish population. Our secondary aim in this study was to determine the rates of difficult intubation and difficult laryngoscopy in patients with OSA in the population.

2 Materials and methods

For this single-center, prospective, observational study, 402 patients aged between 18 and 65 years with ASA 1–2 characteristics who would undergo elective surgery under general anesthesia were included after obtaining the approval of the ethics committee. Patients who were pregnant, patients with neck mobility limitation (such as rheumatologic diseases, masses), cervical spine pathologies, masses and lesions in the mouth and airway that would make intubation difficult, cervical and maxillofacial trauma, a history of radiotherapy to the neck, subglottic stenosis, nasotracheal intubation, and double lumen tube use were excluded.

Weight (kg), height (cm), age (year), gender, BMI values, and ASA score were recorded after obtaining the written informed consent of the patients during preoperative evaluation. After the Mallampati score, ULBT and loose teeth were determined, neck circumference, TMD, sternomental distance, and mouth opening were measured. The results of STOP-Bang scoring which consists of eight questions and evaluated with yes/no answers to the questions were noted.

The patients were grouped into OSA risk classes (low-level OSA risk yes answer to 0–2 questions, moderate OSA risk yes answer to 3–4 questions, high-level OSA risk yes answer to 5–8 questions [or yes answer to 2 or more of 4 STOP questions + male participant or yes answer to 2 or more of 4 STOP questions + BMI >35 kg/m² or yes answer to 2 or more of 4 STOP questions + increased neck circumference]).

Afterward, the patients were placed in supine, neck flexion, head extension (sniffing-sniffing) position and prepared for ultrasonographic evaluation. Skin–hyoid bone, skin–epiglottis, skin–epiglottis, skin–vocal cord anterior commissure distance measurements were made and recorded with the 13–6 MHz linear probe of USG (SonoSite S-Nerve).

All patients underwent routine ASA monitoring (ECG, NIBP, SpO2) followed by pre-oxygenation before induction of general anesthesia. Anesthesia induction was chosen according to the practice of the clinic and the clinical status of the patients. After the appropriate muscle relaxant was administered and adequate muscle relaxation was achieved, orotracheal intubation was performed with the most appropriate number of tubes for each patient. Intubation was performed by an experienced anesthesiologist. The auxiliary stylet used during intubation, the need for cricoid compression, the number of extra attempts, the number of extra practitioners, the need for mandibular suspension, and the glottis patency without external compression seen during laryngoscopy were noted in accordance with the Cormack Lehane Grade. Advanced airway devices (video laryngoscopy and flexible fiber optic laryngoscopy) used when needed were recorded. Intubation Difficulty Scores (IDS) were calculated, and patients were divided into groups as “Easy” if IDS was 0, “Partially easy” if 0 < IDS > 5, and “Difficult” if IDS > 5.

2.1 Statistical analysis

Data analysis was performed using IBM SPSS 25.0 (Armonk, NY: IBM Corp.) and MedCalc 15.8 (MedCalc Software bvba, Ostend, Belgium) statistical package programs. Descriptive statistical methods (frequency, percentage, mean, standard deviation, median, min–max) and Chi-square (χ 2) test were used to compare qualitative data. The conformity of the data to normal distribution was evaluated by Kolmogorov–Smirnov test, skewness and kurtosis, and graphical methods (histogram, Q–Q Plot, Stem and Leaf, Boxplot). Independent samples t-test (t-test in independent groups) was used in the evaluation of quantitative data showing normal distribution. Receiver operating characteristic (ROC) curve method was used to determine the discrimination of variables. Pearson correlation test and Spearman’s Rho correlation test were used to evaluate the relationships between variables. Statistical significance level was accepted as α = 0.05.

  1. Ethical approval: Approval of the ethics committee dated 15.03.2023 and numbered E2-23-3585 at the Ministry of Health Ankara City Hospital.

  2. Informed consent: Informed consent has been obtained from each patient.

3 Results

Our study included a total of 402 patients, 183 female (45.5%) and 219 (54.5%) male, aged between 18 and 65 years. Demographic characteristics of the participants and routine screening tests are shown in Tables 1 and 2.

Table 1

Demographic characteristics of participants

n Mean ± SD % Median (min–max)
Gender* Female 183 45.5
Male 219 54.5
Age (year)** 44.1 ± 14.2 45.0 (18.0–65.0)
Weight (kg)** 79.4 ± 10.9 78.0 (53.0–117.0)
Height (cm)** 168.8 ± 8.1 169.0 (154.0–190.0)
BMI (kg/m2)** 27.9 ± 3.5 27.7 (20.0–42.2)
<30* 289 71.9
≥30* 113 28.1
CPAP at home* No 394 98.0
Yes 8 2.0
Stop-Bang score* No OSA 337 83 > 8
Moderate OSA risk 32 8.0
High OSA risk 33 8.2

*n/%; **mean ± standard deviation/median (min–max).

Table 2

Comparison of study participants according to routine tests

n Mean ± SD % Median (min–max)
Mallampati score* 1 96 23.9
2 294 73.1
3 11 2.7
4 1 0.2
Mallampati intubation* Easy 390 97.0
Difficult 12 3.0
ULBT* Grade1 (easy) 288 71.6
Grade 2 (partially difficult) 83 20.6
Grade 3 (difficult) 31 7.7
TMD (cm)** 7.2 ± 0.5 7.3 (5.6–8.3)
Sternomental distance (cm)** 14.1 ± 0.8 14.0 (11.0–16.5)
Neck circumference (cm)** 38.0 ± 1.8 37.8 (34.0–46.0)
Height/TMD ratio** 23.4 ± 1.7 23.2 (19.2–29.2)
Neck circumference/TMD ratio** 5.3 ± 0.5 5.1 (4.3–7.6)
Skin–hyoid bone (cm)** 1.0 ± 0.1 1.0 (0.5–1.4)
Skin–epiglottis (cm)** 2.0 ± 0.3 2.0 (1.0–2.9)
Skin–anterior vocal cord (cm)** 1.0 ± 0.1 1.0 (0.7–1.9)

*n/%; **mean ± standard deviation/median (min–max).

Table 3 shows the comparison of demographic characteristics according to the level of intubation difficulty. In the comparisons between the groups, it was found that there was no statistically significant difference between the groups in terms of gender and age (p > 0.05), while there was a statistically significant difference between the groups in terms of weight, height, and BMI values (p < 0.05). It was found that the patient group with a Difficult IDS result had lower height values and higher weight and BMI values (BMI ≥ 30).

Table 3

Comparison of demographic characteristics according to IDS

IDS
Easy (n = 360) Difficult (n = 42) p
Gender Female 160 (44.4%) 23 (54.8%) 0.268a
Male 200 (55.6%) 19 (45.2%)
Age (year) 44.1 ± 14.3 44.3 ± 12.8 0.928b
Weight (kg) 78.4 ± 10.3 88.1 ± 12.3 <0.001 b
Height (cm) 169.1 ± 8.0 165.9 ± 8.2 0.014 b
BMI (kg/m2) 27.4 ± 3.1 32.1 ± 3.8 <0.001 b
<30 280 (77.8%) 9 (21.4%) <0 . 001 a
≥30 80 (22.2%) 33 (78.6%)

aChi-square test (n (%)); bIndependent samples t-test (mean ± SD).

Bold means significant p values. Italıc words means subgroup.

Intergroup comparisons showed that there was a statistically significant difference between the groups in terms of Mallampati score values (p < 0.05), and the patient group with Difficult Intubation Score Difficult had higher rates of Mallampati score 3–4.

In intergroup comparisons, it was found that there was a statistically significant difference between the groups in terms of ULBT values (p < 0.05), and the patient group with Difficult Intubation Score Difficult had higher rates of ULBT Grade 2–3. In intergroup comparisons, it was found that there was a statistically significant difference between the groups in terms of Stop-Bang Score values (p < 0.05), and the patient group with Difficult Intubation Score was found to have higher rates of high-level OSA risk.

In intergroup comparisons, a statistically significant difference (p < 0.05) was found between the groups in terms of all variables. It was found that thyromental and sternomental distance values were lower, while neck circumference, height/TMD ratio, neck circumference/TMD ratio, skin–hyoid bone, skin–epiglottis, and skin–anterior vocal cord values were higher in the patient group with Difficult IDS (Table 4).

Table 4

Comparison of distances and rates according to IDS

IDS
Easy (n = 360) Difficult (n = 42) p*
TMD (cm) 7.3 ± 0.4 6.5 ± 0.5 <0.001
Sternomental distance (cm) 14.2 ± 0.7 13.2 ± 1.1 <0.001
Neck circumference (cm) 37.7 ± 1.4 40.8 ± 2.0 <0.001
Height/TMD ratio 23.1 ± 1.5 25.6 ± 1.8 <0.001
Neck circumference/TMD ratio 5.2 ± 0.4 6.3 ± 0.6 <0.001
Skin–hyoid bone (cm) 0.96 ± 0.14 1.08 ± 0.16 <0.001
Skin–epiglottis (cm) 1.99 ± 0.21 2.49 ± 0.23 <0.001
Skin–anterior vocal cord (cm) 0.99 ± 0.13 1.11 ± 0.17 <0.001

*Independent samples t-test (mean ± SD).

Bold means significant p values.

Around 396 (98.5%) patients were intubated with a Macintosh plate and 6 (1.5%) with a video laryngoscope. Among the patients with difficult airway, 37 (88.1%) patients were intubated with a Macintosh plate and 5 (11.9%) patients were intubated with a video laryngoscope. Around 326 (81%) patients were intubated on the first intubation attempt and 72 (17%) patients were intubated on the second attempt.

There was no statistically significant difference (p > 0.05) between the groups in terms of neck circumference/TMD ratio, skin–hyoid bone, skin–epiglottis, and skin–vocal cord anterior, while there was a statistically significant difference (p < 0.05) between the groups in terms of TMD, sternomental distance, neck circumference, and height/TMD ratio. In all cases where there was a difference, the values of males were found to be higher.

In the intergroup comparisons, it was found that there was a statistically significant difference (p < 0.05) between the groups in terms of all variables. It was found that the patient group with BMI ≥30 had lower thyromental and sternomental distance values and higher neck circumference, height/TMD ratio, neck circumference/TMD ratio, skin–hyoid bone, skin–epiglottis, and skin–vocal cord anterior values.

There was a statistically significant difference (p < 0.05) between the groups in terms of all variables. It was found that the thyromental and sternomental distance values were lower, while neck circumference, height/TMD ratio, neck circumference/TMD ratio, skin–hyoid bone, skin–epiglottis, and skin–vocal cord anterior values were higher in the patient group with difficult Cormack Lehane Grade.

As a result of the evaluations made with ROC analysis (Table 5) the variables were found to be different in the comparisons made according to the IDS:

  1. For weight values, >78 was found to be the cut-off point (AUC = 0.734, p < 0.001, 95% CI: 0.688–0.776).

  2. For height, ≤168 was found to be the cut-off point (AUC = 0.623, p = 0.006, 95% CI: 0.574–0.671).

  3. In BMI values, >30.7 was found to be the cut-off point (AUC = 0.83, p < 0.001, 95% CI: 0.790–0.865).

  4. In TMD values, ≤6.8 was found to be the cut-off point (AUC = 0.881, p < 0.001, 95% CI: 0.845–0.911).

  5. For sternomental distance values, ≤13.2 was found to be the cut-off point (AUC = 0.797, p < 0.001, 95% CI: 0.754–0.835).

  6. For neck circumference values, >38.7 was found to be the cut-off point (AUC = 0.909, p < 0.001, 95% CI: 0.876–0.935).

  7. In neck circumference/TMD ratio values, >5.5 was found to be the cut-off point (AUC = 0.94, p < 0.001, 95% CI: 0.912–0.961).

  8. In the height/TMD ratio values, >24.25 was found to be the cut-off point (AUC = 0.851, p < 0.001, 95% CI: 0.812–0.884).

  9. In skin–hyoid bone values, >0.99 was found to be the cut-off point (AUC = 0.708, p < 0.001, 95% CI: 0.661–0.752).

  10. In skin–epiglottis values, >2.23 was found to be the cut-off point (AUC = 0.923, p < 0.001, 95% CI: 0.892–0.947).

Table 5

ROC analysis

AUC 95% CI Cut-off Sensitivity Specificity Youden index +PV −PV p*
Weight (kg) 0.734 0.688–0.776 >78 85.7 55.0 0.407 18.2 97.1 <0.001
Height (cm) 0.623 0.574–0.671 ≤168 66.7 54.4 0.211 14.6 93.3 0.006
BMI (kg/m2) 0.830 0.790–0.865 >30.7 73.8 85.6 0.594 37.3 96.6 <0.001
TMD (cm) 0.881 0.845–0.911 ≤6.8 76.2 89.4 0.656 45.7 97.0 <0.001
Sternomental distance (cm) 0.797 0.754–0.835 ≤13.2 61.9 92.8 0.547 50.0 95.4 <0.001
Neck circumference (cm) 0.909 0.876–0.935 >38.7 90.5 83.6 0.741 39.2 98.7 <0.001
Height/TMD ratio 0.940 0.912–0.961 >5.5 92.9 88.3 0.812 48.1 99.1 <0.001
Neck circumference/TMD ratio 0.851 0.812–0.884 >24.25 81.0 79.7 0.607 31.8 97.3 <0.001
Skin–hyoid bone (cm) 0.708 0,661–0.752 >0.99 66.7 70.6 0,372 20.9 94.8 <0.001
Skin–epiglottis (cm) 0.923 0.892–0.947 >2.23 90.5 89.7 0.802 50.7 98.8 <0.001
TMD (cm) 0.726 0.680–0.769 >1.05 66.7 73.9 0.406 23.0 95.0 <0.001

*ROC curve analysis.

Bold means significant p values.

For skin–vocal cord anterior, >1.05 was found to be the cut-off point (AUC = 0.726, p < 0.001, 95% CI: 0.680–0.769).

4 Discussion

Airway management is a very important issue in terms of the safety of perioperative anesthesia. Complications of difficult airway can have devastating life-threatening consequences in anesthesia management. Therefore, predicting difficult airway is a very valuable step in the planning stage to avoid adverse situations in anesthesia management. Although the importance of ethnicity among airway risk factors is known, inter-ethnic studies with high participation remain limited in the literature. The hypothesis of this study was to determine the clinical and ultrasonographic airway measurements of the Turkish population and to determine and compare the sensitivity, specificity, and cut-off values of these values.

In a clinical meta-analysis study with 35 centers from different countries, the incidence of difficult intubation was found to be 1.5–13% in the general population and 14.3–17.5% in obese patients [11]. In our study, the incidence of difficult intubation was found to be 10% in the general population and 29% in obese patients. Hélène et al. compared 70 obese (BMI ≥ 30) and 61 lean (BMI < 30) patients and found that difficult tracheal intubation was more frequent in obese patients (14.3%) compared to lean patients (3%). They also found that TMD, BMI, large neck circumference, and high Mallampati score were associated with difficult intubation in patients with an IDS greater than 5. They found that neck circumference measurement was a valuable predictive test in both obese and lean patients [12].

In a study conducted by Brodsky et al. at Stanford University with 100 morbidly obese patients, neither absolute obesity nor BMI showed a direct relationship with intubation difficulty. However, they found that potential intubation problems increased as the neck circumference and Mallampati score increased in morbidly obese patients [13]. In a study by Ezri et al. in 50 morbidly obese (BMI > 35) patients, they found that neck circumference measurements were higher in the patient group in whom laryngoscopy was difficult [14].

In our study, we found statistically significant differences between the groups in terms of weight, height, and BMI values. We found that weight (cut-off > 78) and BMI (cut-off ≥ 30.7) values were higher and height values were lower in the patient group with intubation difficulty. Large neck circumference and high Mallampati score were also associated with difficult intubation in our study. There was a positive and statistically significant (p < 0.05) correlation between IDS and Mallampati score at the level of r = 0.134, with a cut-off value of >38.7 for neck circumference and a sensitivity of 90.5% and specificity of 83.6%.

Baker reported different cut-off values ranging between 6 and 8 cm for TMD measurement [15]. Selvi et al. found that TMD had 2.7% sensitivity and 98.31% specificity at a cut-off value of 6.5 cm and 70.27% sensitivity and 60.87% specificity at a cut-off value of 8.3 cm in their study with 451 Turkish patients [16]. In our study, we found sensitivity and specificity values of 76.2 and 89.4% at a cut-off value of ≤6.8 cm for TMD.

Since there are various cut-off values for TMD and sensitivity and specificity results in studies, new calculations such as height/TMD and neck circumference/TMD ratio, which take into account patient height and body proportions, have started to be used. There are studies showing that these new calculations are more sensitive and specific in predicting difficult intubation. Khan et al. reported that TMD may be insufficient in predicting laryngeal appearance and this value alone is not a sufficient measurement [17]. Therefore, in our study, we wanted to evaluate the relationship between the new evaluation criteria of neck/TMD and neck circumference/TMD ratios with difficult intubation, taking into account that the TMD measurement value is affected by the patient’s height and body proportions. We found the neck circumference/TMD ratio with 92.9% sensitivity and 88.3% specificity at a cut-off value of 5.5, and the neck/TMD ratio with 81% sensitivity and 79.7% specificity at a cut-off value of 24.25 more significant compared to commonly used measurements. We found a positive correlation between the IDS and the height/TMD ratio at the level of r = 0.365, and a positive correlation between the neck circumference/TMD ratio at the level of r = 0.471. When the two ratios were evaluated within themselves, a positive correlation was observed at the level of r = 0.810.

Khan et al. suggested using the ULBT, which evaluates the patient’s ability to close the upper lip mucosa with the lower incisors, in predicting difficult intubation [17]. This method is based on measurements of skeletal hard tissue and soft tissue profiles. Generally, these studies were conducted on Asian and Caucasian populations [17]. Selvi et al. found that the sensitivity and specificity of ULBT in Turkish patients were 18.92 and 99.03%, respectively, and concluded that ULBT may be useful in predicting easy intubation in the Turkish population, but it is not a sufficient test to be used alone in predicting difficult intubation [16]. Kim et al. aimed to evaluate the usefulness of ULBT in predicting difficult intubation in Koreans and found that it showed low false positive rates in Koreans. According to the researchers, these differences are actually due to the lower incidence of high-grade ULBT in Koreans compared to other ethnicities, and this is due to the excess of soft tissue and differences in skeletal structure in Far East Asians [7]. In our study, the rate of patients with ULBT Grade 3 in the IDS Difficult group was found to be similar to other studies with 52%.

In a study conducted in Singapore with 655 patients in which direct laryngoscopic views were evaluated with the Cormack-Lehane scoring system in the Asian population, direct laryngoscopic views of the patients were found as 73.9% Class 1, 21.0% Class 2A, 3.3% Class 2B, 1.6% Class 3, and 0.2% Class 4 [18]. Fernandez-Vaquero et al. found the rates of 58.9% Class 1, 19.1% Class 2A, 17.2% Class 2B, 4.8% Class 3, and 0% Class 4 in a study conducted in Spain in which they evaluated direct laryngoscopic views in 209 patients [19]. In our study, the rates were 58.2% (234 patients) Class 1, 22.4% (90 patients) Class 2A, 10.9% (44 patients) Class 2B, 6.5% (26 patients) Class 3, and 2% (8 patients) Class 4. There was a statistically significant positive correlation between IDS and Cormack Lehane Grade, r = 0.726. In our study, when we evaluated the difficult intubation patient group as easy and difficult laryngoscopy (CL Grade 1–2A: easy, CL Grade 2B, 3, 4: difficult), the rate of difficult laryngoscopy in difficult intubated patients was found to be 100%.

When the studies about ultrasonographic evaluations are examined, Ezri et al. found that the ultrasonographically measured skin–vocal cord distance was higher in the patient group in whom laryngoscopy was difficult than in the patient group in whom laryngoscopy was easy. They measured the skin–vocal cord distance in the range of 1.77–2.8 cm in patients with difficult laryngoscopy [14]. In a meta-analysis of 15 studies conducted by Carsetti et al. by searching Medline, Scopus, and Web of Science databases until December 2020, they found that skin–epiglottis, skin–vocal cord, and skin–hyoid bone distances were higher in patients with difficult laryngoscopy than in patients with easy laryngoscopy and that skin–epiglottis distance is the most studied index test in the literature to predict difficult laryngoscopy. They found the sensitivity of skin–epiglottis, skin–vocal cord, and skin–hyoid bone distances as 82, 71, and 75%, and specificity as 79, 71, and 72%, respectively. They determined the distance with the highest specificity and sensitivity as the skin–epiglottis distance [20]. In our measurements, a cut-off value of 0.99 and sensitivity and specificity rates of 66.7 and 70.6%, respectively, were found for the skin–hyoid bone distance, a cut-off value of 2.23 and sensitivity and specificity rates of 89.7 and 90.5%, respectively, for the skin–epiglottis distance, and a cut-off value of 1.05 and sensitivity and specificity rates of 66.7 and 73.9%, respectively, for the skin–vocal cord anterior distance.

Ultrasonographic measurements of the skin–epiglottis distance show differences depending on ethnicity [19]. Adhikari et al. defined a cut-off value of 2.8 cm for skin–epiglottis distance in Caucasian and African-American populations [21], while Wu et al. found a cut-off value of 1.78 cm in the Chinese population [22]. Parameswari et al. found a cut-off value of 1.8 cm in the Indian population [23]. In our study, we found a cut-off value of 2.23 for the skin–epiglottis distance in the Turkish population and sensitivity and specificity rates of 89.7 and 90.5%, respectively.

Numerous studies in different sample groups have shown a relationship between craniofacial skeletal morphology and the degree of sleep apnea [6]. Although Chinese patients are less obese than Caucasians, the prevalence of OSA is similar in the two populations [8]. In a study examining the differences in three-dimensional upper airway anatomy between Asian and European patients with OSA, it was observed that Chinese patients had narrower airways, especially in the retro palatal region, while Icelandic patients had larger tongue, para pharyngeal fat pads, pterygoid, and combined soft tissue volumes [8]. Buxbaum et al. thought that there is an underlying genetic basis for OSA independent of the contribution of BMI [24]. While differences in genetic risk factors may explain disparities in OSA severity, precise anatomical differences have not yet been defined [6]. Asians are thought to be predisposed to OSA because of their craniofacial bone anatomy. Asians with OSA have been shown to have a shorter skull base length than whites [25]. Daraze et al. evaluated the relationship between OSA and airway soft tissue elements and its correlation with gender and anthropometric variables in 117 Lebanese young adults and found that the Lebanese population had shorter soft palate length and their uvula thickness was greater than those reported in Indians compared with Caucasians, Blacks, and Hispanics. They found that the size of the uvula, tongue length, and distances between the epiglottis and the posterior pharyngeal wall were significantly larger in males than in females [26]. In our study, 8% of our patients had a moderate risk of OSA and 8.2% had a high risk of OSA. The number of patients who needed a home continuous positive airway pressure (CPAP) device was eight (2%). When the risk of OSA was evaluated according to gender, no statistically significant difference was found.

5 Conclusion

In this study in which clinical and ultrasonographic measurements of the upper airways in the Turkish population were evaluated, we found that the most significant values in terms of both specificity and sensitivity were the skin–epiglottis distance and neck circumference/TMD ratio measured by ultrasonography.

We think that the routine use of body proportions and ultrasonographic methods in preoperative airway assessment, as well as taking into account the ethnicity of the patients, may provide better results in predicting a difficult airway.

  1. Funding information: Authors state no funding involved.

  2. Author contributions: T.N.S.: research concept and design, collection and/or assembly of data, data analysis and interpretation, writing the article; B.T.: writing the article, critical revision of the article; E.E.: research concept and design, writing the article, critical revision of the article, final approval of the article. All authors revised the manuscript and approved its content.

  3. Conflict of interest: Authors state no conflict of interest.

  4. Data availability statement: Data are available on request to the corresponding authors.

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Received: 2024-02-08
Revised: 2024-07-16
Accepted: 2024-07-16
Published Online: 2024-08-21

© 2024 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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https://doi.org/10.1515/med-2024-1013
Keywords for this article
ultrasonography; neck circumference/thyromental distance; difficult intubation
Creative Commons
BY 4.0

Articles in the same Issue

  1. Research Articles
  2. EDNRB inhibits the growth and migration of prostate cancer cells by activating the cGMP-PKG pathway
  3. STK11 (LKB1) mutation suppresses ferroptosis in lung adenocarcinoma by facilitating monounsaturated fatty acid synthesis
  4. Association of SOX6 gene polymorphisms with Kashin-Beck disease risk in the Chinese Han population
  5. The pyroptosis-related signature predicts prognosis and influences the tumor immune microenvironment in dedifferentiated liposarcoma
  6. METTL3 attenuates ferroptosis sensitivity in lung cancer via modulating TFRC
  7. Identification and validation of molecular subtypes and prognostic signature for stage I and stage II gastric cancer based on neutrophil extracellular traps
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  13. Serum levels of HMW adiponectin and its receptors are associated with cytokine levels and clinical characteristics in chronic obstructive pulmonary disease
  14. METTL3-mediated methylation of CYP2C19 mRNA may aggravate clopidogrel resistance in ischemic stroke patients
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  17. Metformin plus L-carnitine enhances brown/beige adipose tissue activity via Nrf2/HO-1 signaling to reduce lipid accumulation and inflammation in murine obesity
  18. Downregulation of carbonic anhydrase IX expression in mouse xenograft nasopharyngeal carcinoma model via doxorubicin nanobubble combined with ultrasound
  19. Feasibility of 3-dimensional printed models in simulated training and teaching of transcatheter aortic valve replacement
  20. miR-335-3p improves type II diabetes mellitus by IGF-1 regulating macrophage polarization
  21. The analyses of human MCPH1 DNA repair machinery and genetic variations
  22. Activation of Piezo1 increases the sensitivity of breast cancer to hyperthermia therapy
  23. Comprehensive analysis based on the disulfidptosis-related genes identifies hub genes and immune infiltration for pancreatic adenocarcinoma
  24. Changes of serum CA125 and PGE2 before and after high-intensity focused ultrasound combined with GnRH-a in treatment of patients with adenomyosis
  25. The clinical value of the hepatic venous pressure gradient in patients undergoing hepatic resection for hepatocellular carcinoma with or without liver cirrhosis
  26. Development and validation of a novel model to predict pulmonary embolism in cardiology suspected patients: A 10-year retrospective analysis
  27. Downregulation of lncRNA XLOC_032768 in diabetic patients predicts the occurrence of diabetic nephropathy
  28. Circ_0051428 targeting miR-885-3p/MMP2 axis enhances the malignancy of cervical cancer
  29. Effectiveness of ginkgo diterpene lactone meglumine on cognitive function in patients with acute ischemic stroke
  30. The construction of a novel prognostic prediction model for glioma based on GWAS-identified prognostic-related risk loci
  31. Evaluating the impact of childhood BMI on the risk of coronavirus disease 2019: A Mendelian randomization study
  32. Lactate dehydrogenase to albumin ratio is associated with in-hospital mortality in patients with acute heart failure: Data from the MIMIC-III database
  33. CD36-mediated podocyte lipotoxicity promotes foot process effacement
  34. Efficacy of etonogestrel subcutaneous implants versus the levonorgestrel-releasing intrauterine system in the conservative treatment of adenomyosis
  35. FLRT2 mediates chondrogenesis of nasal septal cartilage and mandibular condyle cartilage
  36. Challenges in treating primary immune thrombocytopenia patients undergoing COVID-19 vaccination: A retrospective study
  37. Let-7 family regulates HaCaT cell proliferation and apoptosis via the ΔNp63/PI3K/AKT pathway
  38. Phospholipid transfer protein ameliorates sepsis-induced cardiac dysfunction through NLRP3 inflammasome inhibition
  39. Postoperative cognitive dysfunction in elderly patients with colorectal cancer: A randomized controlled study comparing goal-directed and conventional fluid therapy
  40. Long-pulsed ultrasound-mediated microbubble thrombolysis in a rat model of microvascular obstruction
  41. High SEC61A1 expression predicts poor outcome of acute myeloid leukemia
  42. Comparison of polymerase chain reaction and next-generation sequencing with conventional urine culture for the diagnosis of urinary tract infections: A meta-analysis
  43. Secreted frizzled-related protein 5 protects against renal fibrosis by inhibiting Wnt/β-catenin pathway
  44. Pan-cancer and single-cell analysis of actin cytoskeleton genes related to disulfidptosis
  45. Overexpression of miR-532-5p restrains oxidative stress response of chondrocytes in nontraumatic osteonecrosis of the femoral head by inhibiting ABL1
  46. Autologous liver transplantation for unresectable hepatobiliary malignancies in enhanced recovery after surgery model
  47. Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section
  48. Abnormal sleep duration is associated with sarcopenia in older Chinese people: A large retrospective cross-sectional study
  49. No genetic causality between obesity and benign paroxysmal vertigo: A two-sample Mendelian randomization study
  50. Identification and validation of autophagy-related genes in SSc
  51. Long non-coding RNA SRA1 suppresses radiotherapy resistance in esophageal squamous cell carcinoma by modulating glycolytic reprogramming
  52. Evaluation of quality of life in patients with schizophrenia: An inpatient social welfare institution-based cross-sectional study
  53. The possible role of oxidative stress marker glutathione in the assessment of cognitive impairment in multiple sclerosis
  54. Compilation of a self-management assessment scale for postoperative patients with aortic dissection
  55. Left atrial appendage closure in conjunction with radiofrequency ablation: Effects on left atrial functioning in patients with paroxysmal atrial fibrillation
  56. Effect of anterior femoral cortical notch grade on postoperative function and complications during TKA surgery: A multicenter, retrospective study
  57. Clinical characteristics and assessment of risk factors in patients with influenza A-induced severe pneumonia after the prevalence of SARS-CoV-2
  58. Analgesia nociception index is an indicator of laparoscopic trocar insertion-induced transient nociceptive stimuli
  59. High STAT4 expression correlates with poor prognosis in acute myeloid leukemia and facilitates disease progression by upregulating VEGFA expression
  60. Factors influencing cardiovascular system-related post-COVID-19 sequelae: A single-center cohort study
  61. HOXD10 regulates intestinal permeability and inhibits inflammation of dextran sulfate sodium-induced ulcerative colitis through the inactivation of the Rho/ROCK/MMPs axis
  62. Mesenchymal stem cell-derived exosomal miR-26a induces ferroptosis, suppresses hepatic stellate cell activation, and ameliorates liver fibrosis by modulating SLC7A11
  63. Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke
  64. ANO6 (TMEM16F) inhibits gastrointestinal stromal tumor growth and induces ferroptosis
  65. Prognostic value of EIF5A2 in solid tumors: A meta-analysis and bioinformatics analysis
  66. The role of enhanced expression of Cx43 in patients with ulcerative colitis
  67. Choosing a COVID-19 vaccination site might be driven by anxiety and body vigilance
  68. Role of ICAM-1 in triple-negative breast cancer
  69. Cost-effectiveness of ambroxol in the treatment of Gaucher disease type 2
  70. HLA-DRB5 promotes immune thrombocytopenia via activating CD8+ T cells
  71. Efficacy and factors of myofascial release therapy combined with electrical and magnetic stimulation in the treatment of chronic pelvic pain syndrome
  72. Efficacy of tacrolimus monotherapy in primary membranous nephropathy
  73. Mechanisms of Tripterygium wilfordii Hook F on treating rheumatoid arthritis explored by network pharmacology analysis and molecular docking
  74. FBXO45 levels regulated ferroptosis renal tubular epithelial cells in a model of diabetic nephropathy by PLK1
  75. Optimizing anesthesia strategies to NSCLC patients in VATS procedures: Insights from drug requirements and patient recovery patterns
  76. Alpha-lipoic acid upregulates the PPARγ/NRF2/GPX4 signal pathway to inhibit ferroptosis in the pathogenesis of unexplained recurrent pregnancy loss
  77. Correlation between fat-soluble vitamin levels and inflammatory factors in paediatric community-acquired pneumonia: A prospective study
  78. CD1d affects the proliferation, migration, and apoptosis of human papillary thyroid carcinoma TPC-1 cells via regulating MAPK/NF-κB signaling pathway
  79. miR-let-7a inhibits sympathetic nerve remodeling after myocardial infarction by downregulating the expression of nerve growth factor
  80. Immune response analysis of solid organ transplantation recipients inoculated with inactivated COVID-19 vaccine: A retrospective analysis
  81. The H2Valdien derivatives regulate the epithelial–mesenchymal transition of hepatoma carcinoma cells through the Hedgehog signaling pathway
  82. Clinical efficacy of dexamethasone combined with isoniazid in the treatment of tuberculous meningitis and its effect on peripheral blood T cell subsets
  83. Comparison of short-segment and long-segment fixation in treatment of degenerative scoliosis and analysis of factors associated with adjacent spondylolisthesis
  84. Lycopene inhibits pyroptosis of endothelial progenitor cells induced by ox-LDL through the AMPK/mTOR/NLRP3 pathway
  85. Methylation regulation for FUNDC1 stability in childhood leukemia was up-regulated and facilitates metastasis and reduces ferroptosis of leukemia through mitochondrial damage by FBXL2
  86. Correlation of single-fiber electromyography studies and functional status in patients with amyotrophic lateral sclerosis
  87. Risk factors of postoperative airway obstruction complications in children with oral floor mass
  88. Expression levels and clinical significance of serum miR-19a/CCL20 in patients with acute cerebral infarction
  89. Physical activity and mental health trends in Korean adolescents: Analyzing the impact of the COVID-19 pandemic from 2018 to 2022
  90. Evaluating anemia in HIV-infected patients using chest CT
  91. Ponticulus posticus and skeletal malocclusion: A pilot study in a Southern Italian pre-orthodontic court
  92. Causal association of circulating immune cells and lymphoma: A Mendelian randomization study
  93. Assessment of the renal function and fibrosis indexes of conventional western medicine with Chinese medicine for dredging collaterals on treating renal fibrosis: A systematic review and meta-analysis
  94. Comprehensive landscape of integrator complex subunits and their association with prognosis and tumor microenvironment in gastric cancer
  95. New target-HMGCR inhibitors for the treatment of primary sclerosing cholangitis: A drug Mendelian randomization study
  96. Population pharmacokinetics of meropenem in critically ill patients
  97. Comparison of the ability of newly inflammatory markers to predict complicated appendicitis
  98. Comparative morphology of the cruciate ligaments: A radiological study
  99. Immune landscape of hepatocellular carcinoma: The central role of TP53-inducible glycolysis and apoptosis regulator
  100. Serum SIRT3 levels in epilepsy patients and its association with clinical outcomes and severity: A prospective observational study
  101. SHP-1 mediates cigarette smoke extract-induced epithelial–mesenchymal transformation and inflammation in 16HBE cells
  102. Acute hyper-hypoxia accelerates the development of depression in mice via the IL-6/PGC1α/MFN2 signaling pathway
  103. The GJB3 correlates with the prognosis, immune cell infiltration, and therapeutic responses in lung adenocarcinoma
  104. Physical fitness and blood parameters outcomes of breast cancer survivor in a low-intensity circuit resistance exercise program
  105. Exploring anesthetic-induced gene expression changes and immune cell dynamics in atrial tissue post-coronary artery bypass graft surgery
  106. Empagliflozin improves aortic injury in obese mice by regulating fatty acid metabolism
  107. Analysis of the risk factors of the radiation-induced encephalopathy in nasopharyngeal carcinoma: A retrospective cohort study
  108. Reproductive outcomes in women with BRCA 1/2 germline mutations: A retrospective observational study and literature review
  109. Evaluation of upper airway ultrasonographic measurements in predicting difficult intubation: A cross-section of the Turkish population
  110. Prognostic and diagnostic value of circulating IGFBP2 in pancreatic cancer
  111. Postural stability after operative reconstruction of the AFTL in chronic ankle instability comparing three different surgical techniques
  112. Research trends related to emergence agitation in the post-anaesthesia care unit from 2001 to 2023: A bibliometric analysis
  113. Frequency and clinicopathological correlation of gastrointestinal polyps: A six-year single center experience
  114. ACSL4 mediates inflammatory bowel disease and contributes to LPS-induced intestinal epithelial cell dysfunction by activating ferroptosis and inflammation
  115. Affibody-based molecular probe 99mTc-(HE)3ZHER2:V2 for non-invasive HER2 detection in ovarian and breast cancer xenografts
  116. Effectiveness of nutritional support for clinical outcomes in gastric cancer patients: A meta-analysis of randomized controlled trials
  117. The relationship between IFN-γ, IL-10, IL-6 cytokines, and severity of the condition with serum zinc and Fe in children infected with Mycoplasma pneumoniae
  118. Paraquat disrupts the blood–brain barrier by increasing IL-6 expression and oxidative stress through the activation of PI3K/AKT signaling pathway
  119. Sleep quality associate with the increased prevalence of cognitive impairment in coronary artery disease patients: A retrospective case–control study
  120. Dioscin protects against chronic prostatitis through the TLR4/NF-κB pathway
  121. Association of polymorphisms in FBN1, MYH11, and TGF-β signaling-related genes with susceptibility of sporadic thoracic aortic aneurysm and dissection in the Zhejiang Han population
  122. Application value of multi-parameter magnetic resonance image-transrectal ultrasound cognitive fusion in prostate biopsy
  123. Laboratory variables‐based artificial neural network models for predicting fatty liver disease: A retrospective study
  124. Decreased BIRC5-206 promotes epithelial–mesenchymal transition in nasopharyngeal carcinoma through sponging miR-145-5p
  125. Sepsis induces the cardiomyocyte apoptosis and cardiac dysfunction through activation of YAP1/Serpine1/caspase-3 pathway
  126. Assessment of iron metabolism and iron deficiency in incident patients on incident continuous ambulatory peritoneal dialysis
  127. Tibial periosteum flap combined with autologous bone grafting in the treatment of Gustilo-IIIB/IIIC open tibial fractures
  128. The application of intravenous general anesthesia under nasopharyngeal airway assisted ventilation undergoing ureteroscopic holmium laser lithotripsy: A prospective, single-center, controlled trial
  129. Long intergenic noncoding RNA for IGF2BP2 stability suppresses gastric cancer cell apoptosis by inhibiting the maturation of microRNA-34a
  130. Role of FOXM1 and AURKB in regulating keratinocyte function in psoriasis
  131. Parental control attitudes over their pre-school children’s diet
  132. The role of auto-HSCT in extranodal natural killer/T cell lymphoma
  133. Significance of negative cervical cytology and positive HPV in the diagnosis of cervical lesions by colposcopy
  134. Echinacoside inhibits PASMCs calcium overload to prevent hypoxic pulmonary artery remodeling by regulating TRPC1/4/6 and calmodulin
  135. ADAR1 plays a protective role in proximal tubular cells under high glucose conditions by attenuating the PI3K/AKT/mTOR signaling pathway
  136. The risk of cancer among insulin glargine users in Lithuania: A retrospective population-based study
  137. The unusual location of primary hydatid cyst: A case series study
  138. Intraoperative changes in electrophysiological monitoring can be used to predict clinical outcomes in patients with spinal cavernous malformation
  139. Obesity and risk of placenta accreta spectrum: A meta-analysis
  140. Shikonin alleviates asthma phenotypes in mice via an airway epithelial STAT3-dependent mechanism
  141. NSUN6 and HTR7 disturbed the stability of carotid atherosclerotic plaques by regulating the immune responses of macrophages
  142. The effect of COVID-19 lockdown on admission rates in Maternity Hospital
  143. Temporal muscle thickness is not a prognostic predictor in patients with high-grade glioma, an experience at two centers in China
  144. Luteolin alleviates cerebral ischemia/reperfusion injury by regulating cell pyroptosis
  145. Therapeutic role of respiratory exercise in patients with tuberculous pleurisy
  146. Effects of CFTR-ENaC on spinal cord edema after spinal cord injury
  147. Irisin-regulated lncRNAs and their potential regulatory functions in chondrogenic differentiation of human mesenchymal stem cells
  148. DMD mutations in pediatric patients with phenotypes of Duchenne/Becker muscular dystrophy
  149. Combination of C-reactive protein and fibrinogen-to-albumin ratio as a novel predictor of all-cause mortality in heart failure patients
  150. Significant role and the underly mechanism of cullin-1 in chronic obstructive pulmonary disease
  151. Ferroptosis-related prognostic model of mantle cell lymphoma
  152. Observation of choking reaction and other related indexes in elderly painless fiberoptic bronchoscopy with transnasal high-flow humidification oxygen therapy
  153. A bibliometric analysis of Prader-Willi syndrome from 2002 to 2022
  154. The causal effects of childhood sunburn occasions on melanoma: A univariable and multivariable Mendelian randomization study
  155. Oxidative stress regulates glycogen synthase kinase-3 in lymphocytes of diabetes mellitus patients complicated with cerebral infarction
  156. Role of COX6C and NDUFB3 in septic shock and stroke
  157. Trends in disease burden of type 2 diabetes, stroke, and hypertensive heart disease attributable to high BMI in China: 1990–2019
  158. Purinergic P2X7 receptor mediates hyperoxia-induced injury in pulmonary microvascular endothelial cells via NLRP3-mediated pyroptotic pathway
  159. Investigating the role of oviductal mucosa–endometrial co-culture in modulating factors relevant to embryo implantation
  160. Analgesic effect of external oblique intercostal block in laparoscopic cholecystectomy: A retrospective study
  161. Elevated serum miR-142-5p correlates with ischemic lesions and both NSE and S100β in ischemic stroke patients
  162. Correlation between the mechanism of arteriopathy in IgA nephropathy and blood stasis syndrome: A cohort study
  163. Risk factors for progressive kyphosis after percutaneous kyphoplasty in osteoporotic vertebral compression fracture
  164. Predictive role of neuron-specific enolase and S100-β in early neurological deterioration and unfavorable prognosis in patients with ischemic stroke
  165. The potential risk factors of postoperative cognitive dysfunction for endovascular therapy in acute ischemic stroke with general anesthesia
  166. Fluoxetine inhibited RANKL-induced osteoclastic differentiation in vitro
  167. Detection of serum FOXM1 and IGF2 in patients with ARDS and their correlation with disease and prognosis
  168. Rhein promotes skin wound healing by activating the PI3K/AKT signaling pathway
  169. Differences in mortality risk by levels of physical activity among persons with disabilities in South Korea
  170. Review Articles
  171. Cutaneous signs of selected cardiovascular disorders: A narrative review
  172. XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis
  173. A narrative review on adverse drug reactions of COVID-19 treatments on the kidney
  174. Emerging role and function of SPDL1 in human health and diseases
  175. Adverse reactions of piperacillin: A literature review of case reports
  176. Molecular mechanism and intervention measures of microvascular complications in diabetes
  177. Regulation of mesenchymal stem cell differentiation by autophagy
  178. Molecular landscape of borderline ovarian tumours: A systematic review
  179. Advances in synthetic lethality modalities for glioblastoma multiforme
  180. Investigating hormesis, aging, and neurodegeneration: From bench to clinics
  181. Frankincense: A neuronutrient to approach Parkinson’s disease treatment
  182. Sox9: A potential regulator of cancer stem cells in osteosarcoma
  183. Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients
  184. Advanced neuroimaging and criminal interrogation in lie detection
  185. Maternal factors for neural tube defects in offspring: An umbrella review
  186. The chemoprotective hormetic effects of rosmarinic acid
  187. CBD’s potential impact on Parkinson’s disease: An updated overview
  188. Progress in cytokine research for ARDS: A comprehensive review
  189. Utilizing reactive oxygen species-scavenging nanoparticles for targeting oxidative stress in the treatment of ischemic stroke: A review
  190. NRXN1-related disorders, attempt to better define clinical assessment
  191. Lidocaine infusion for the treatment of complex regional pain syndrome: Case series and literature review
  192. Trends and future directions of autophagy in osteosarcoma: A bibliometric analysis
  193. Iron in ventricular remodeling and aneurysms post-myocardial infarction
  194. Case Reports
  195. Sirolimus potentiated angioedema: A case report and review of the literature
  196. Identification of mixed anaerobic infections after inguinal hernia repair based on metagenomic next-generation sequencing: A case report
  197. Successful treatment with bortezomib in combination with dexamethasone in a middle-aged male with idiopathic multicentric Castleman’s disease: A case report
  198. Complete heart block associated with hepatitis A infection in a female child with fatal outcome
  199. Elevation of D-dimer in eosinophilic gastrointestinal diseases in the absence of venous thrombosis: A case series and literature review
  200. Four years of natural progressive course: A rare case report of juvenile Xp11.2 translocations renal cell carcinoma with TFE3 gene fusion
  201. Advancing prenatal diagnosis: Echocardiographic detection of Scimitar syndrome in China – A case series
  202. Outcomes and complications of hemodialysis in patients with renal cancer following bilateral nephrectomy
  203. Anti-HMGCR myopathy mimicking facioscapulohumeral muscular dystrophy
  204. Recurrent opportunistic infections in a HIV-negative patient with combined C6 and NFKB1 mutations: A case report, pedigree analysis, and literature review
  205. Letter to the Editor
  206. Letter to the Editor: Total parenteral nutrition-induced Wernicke’s encephalopathy after oncologic gastrointestinal surgery
  207. Erratum
  208. Erratum to “Bladder-embedded ectopic intrauterine device with calculus”
  209. Retraction
  210. Retraction of “XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis”
  211. Corrigendum
  212. Corrigendum to “Investigating hormesis, aging, and neurodegeneration: From bench to clinics”
  213. Corrigendum to “Frankincense: A neuronutrient to approach Parkinson’s disease treatment”
  214. Special Issue The evolving saga of RNAs from bench to bedside - Part II
  215. Machine-learning-based prediction of a diagnostic model using autophagy-related genes based on RNA sequencing for patients with papillary thyroid carcinoma
  216. Unlocking the future of hepatocellular carcinoma treatment: A comprehensive analysis of disulfidptosis-related lncRNAs for prognosis and drug screening
  217. Elevated mRNA level indicates FSIP1 promotes EMT and gastric cancer progression by regulating fibroblasts in tumor microenvironment
  218. Special Issue Advancements in oncology: bridging clinical and experimental research - Part I
  219. Ultrasound-guided transperineal vs transrectal prostate biopsy: A meta-analysis of diagnostic accuracy and complication rates
  220. Assessment of diagnostic value of unilateral systematic biopsy combined with targeted biopsy in detecting clinically significant prostate cancer
  221. SENP7 inhibits glioblastoma metastasis and invasion by dissociating SUMO2/3 binding to specific target proteins
  222. MARK1 suppress malignant progression of hepatocellular carcinoma and improves sorafenib resistance through negatively regulating POTEE
  223. Analysis of postoperative complications in bladder cancer patients
  224. Carboplatin combined with arsenic trioxide versus carboplatin combined with docetaxel treatment for LACC: A randomized, open-label, phase II clinical study
  225. Special Issue Exploring the biological mechanism of human diseases based on MultiOmics Technology - Part I
  226. Comprehensive pan-cancer investigation of carnosine dipeptidase 1 and its prospective prognostic significance in hepatocellular carcinoma
  227. Identification of signatures associated with microsatellite instability and immune characteristics to predict the prognostic risk of colon cancer
  228. Single-cell analysis identified key macrophage subpopulations associated with atherosclerosis
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