Robson Capasso is the Chief of Sleep Surgery, Associate Professor of Otolaryngology and Head and Neck Surgery at Stanford University School of Medicine and Global Advisor to Stanford Byers Center for Biodesign. His quite extensive and unique training includes training in Head and Neck Surgery, Neurosciences and Sleep Medicine.
Dr. Capasso has published extensively including book chapters, articles and original papers in peer-reviewed journals, and has been an investigator on pre-treatment evaluation, and surgical treatment of obstructive sleep apnea patients. Currently his research interests have a focus on clinical utilization of smartphone applications and consumer based devices for sleep disordered breathing, biomarkers for obstructive sleep apnea, pre-surgical evaluation and upper airway changes after surgery in obstructive sleep apnea sufferers.
The local and international recognition of his work is often associated with one of his favorite tasks: lecturing and trading knowledge nationally and internationally. He has been a mentor or supervisor to hundreds of medical students, residents, fellows or visiting scholars from more than 20 countries.
Dr Capasso has participated in several Stanford Biodesign and Lean Launchpad initiatives. It initiated as a fellowship mentor, leading to the development of projects in the Bay Area and Singapore, graduated as a Biodesign Faculty Fellow, and currently is a lecturer and mentor to Global Biodesign. His goal is to utilize this acquired experience to foster health innovation training of physician and engineers globally.
Dr Capasso is a currently a member of the Stanford Medical Leadership Academy, an initiative to foster the development of strategic initiatives that aims to develop innovative leadership across and outside departments at the School of Medicine and Stanford University.
- Sleep Surgery
Associate Professor - Med Center Line, Otolaryngology - Head & Neck Surgery Divisions
Chief, Division of Sleep Surgery, Stanford University Department of Otolaryngology, Head and Neck Surgery (2010 - Present)
Boards, Advisory Committees, Professional Organizations
Fellow, American Academy of Sleep Medicine (2011 - Present)
Member, American Academy of Otolaryngology (2010 - Present)
Fellowship:Stanford University School of Medicine (2008) CA
Medical Education:Universidade Federal Do Parana (1995) Brazil
Board Certification: Sleep Medicine, American Board of Psychiatry and Neurology (2009)
Fellowship:University of Miami Hospital and Clinics (2001) FL
Residency:University of Miami (2007) FL
Residency:Universidade Federal Do Parana (1999) Brazil
Board Certification: Psychiatry, American Board of Psychiatry and Neurology (2008)
Community and International Work
Global Advisor: Biodesign
Global Health Innovation
Opportunities for Student Involvement
Current Research and Scholarly Interests
Pre-operative evaluation and selection of potential candidates for OSA Surgery.
Wearables and Digital Health Technologies for Sleep.
Innovative approaches for OSA Management.
- Genial tubercle advancement and genioplasty for obstructive sleep apnea: A systematic review and meta-analysis LARYNGOSCOPE 2017; 127 (4): 984-992
The state of academic sleep surgery: A survey of United States residency and fellowship programs.
Our objectives were to describe otolaryngology residency programs' experience in and attitudes toward sleep surgery, and describe current otolaryngology sleep fellowships and their impact on future academic practice.E-mail survey.A survey was e-mailed to program directors of 106 Accreditation Council for Graduate Medical Education-accredited otolaryngology residencies assessing resident sleep medicine experience, program satisfaction, and impact of sleep faculty. A separate survey was sent to directors of the seven sleep medicine otolaryngology fellowships. Frequency of graduates pursuing academic careers was examined.Forty-six (43.4%) residency programs responded. Thirty-one (67.4%) have a faculty member with any time spent practicing sleep medicine or surgery. Nineteen (41.3%) have a faculty member with >50% dedicated sleep practice and/or who is board certified in sleep medicine. These programs were significantly more likely to respond "extremely" or "very" satisfied with resident sleep exposure than those without (P < .001). Most programs (69.6%) "strongly agreed" or "agreed" their program would benefit from a dedicated sleep surgeon; there was no significant difference in response rates between programs already with and those without dedicated sleep faculty. All fellowship directors responded. In the past 5 years these programs have trained 11 total fellows. Ten (90.9%) have remained in academic practice.There is significantly increased satisfaction in resident sleep education at otolaryngology programs with dedicated sleep providers. Concurrently, there is strong program interest in sleep surgeons' involvement in resident training. Sleep fellowships are producing surgeons who pursue academic careers. This study provides support to training fellowship-specialized sleep surgeons and encouraging otolaryngology sleep faculty.NA Laryngoscope, 2017.
View details for DOI 10.1002/lary.26572
View details for PubMedID 28349537
Sleep surgery tool: A medical checklist to review prior to operating.
Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery
2017; 45 (3): 381-386
The objective of this study was to systematically review the international literature for studies providing a preoperative checklist for medical disorders to be evaluated or treated before performing sleep surgery. If no checklist exists, then studies providing recommendations would be used to develop a checklist de novo.Systematic review combined with expert opinion.Four databases, including PubMed/Medline were searched through August 10, 2016.453 potentially relevant studies were screened, 32 were downloaded for full review. No study included a preoperative checklist. No study provided guidance for specific medical disorders to evaluate or screen for prior to sleep surgery. Therefore, we reviewed articles in adults that provided recommendations such as: (1) labs to review, (2) non-operative disorders to evaluate and treat, and (3) comorbidities to optimize prior to performing sleep surgery. These articles were utilized in conjunction with expert opinion to develop a preoperative checklist for surgical guidance.There are several items to review prior to performing sleep surgery on obstructive sleep apnea patients. This systematic review and expert opinion-based checklist provides over twenty items for reviewing prior to performing sleep surgery to reduce the chance of operating prematurely.
View details for DOI 10.1016/j.jcms.2017.01.001
View details for PubMedID 28169045
Impact of Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea During Drug Induced Sleep Endoscopy.
The primary objective of the study was to understand the differential impact of Continuous Positive Airway Pressure (CPAP) on the location, degree, and pattern of airway collapse in Obstructive Sleep Apnea (OSA) patients utilizing Drug Induced Sleep Endoscopy (DISE).Non-randomized trial.University Medical Center.15 consecutive OSA patients undergoing DISE.The patterns of airway collapse were videorecorded at baseline and under differential application of nasal CPAP (nCPAP) at 5,10, and 15 cm H2 O. For each modality, the pattern and degree of airway collapse were analyzed by three independent observers using the Velum, Oropharynx, Tongue Base, Epiglottis (VOTE) classification system.The modest nCPAP pressures (10cm H2 O) had the greatest impact on the lateral walls of the pharynx, followed by the palatal region. The collapsibility of the tongue base and epiglottis demonstrated significant resistance to nCPAP application, which was overcome by increasing nCPAP to 15 cm H2 O. Compared to 5 cm H2 O, nCPAP pressures of 10 and 15 cm H2 O improved complete collapse at least at one level of the upper airway (p = 0.016 and 0.001, respectively). Increased nCPAP pressures also led to changes in the configuration of airway collapse at the level of the velum.The differential nCPAP effects observed in this study may help to understand some of the mechanisms responsible for inadequate patient response and poor nCPAP compliance. The use of DISE in combination with CPAP may serve as a first step in optimizing patients that failed to adapt to treatment with CPAP. This approach can help the physician identify patterns of airway collapse that may require varying pressures different from the one the patient is using, as well as anatomical factors that may be corrected to help with compliance. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/coa.12851
View details for PubMedID 28207995
Sleep Surgery in the Elderly.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
Objective Assess the frequency and nature of postoperative complications following sleep surgery. Examine these issues specifically in elderly patients to provide guidance for their perioperative care. Study Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Methods We identified patients with obstructive sleep apnea undergoing sleep surgery procedures from 2006 to 2013 in the American College of Surgeons National Surgical Quality Improvement Program, a multi-institutional outcomes program designed to improve surgical quality. We analyzed patients by comparing age groups: <65 and ≥65 years. Summary data were analyzed, and multivariate regression was used to adjust for patient characteristics, comorbidities, and surgical procedure. Results We identified 2230 patients who had sleep surgery, which included 2123 patients <65 years old and 107 patients ≥65 years old. Elderly patients were significantly more likely to have hypertension requiring medication ( P < .001) and higher American Society of Anesthesiologists scores ( P < .001). There were no significant differences in the rates of nasal ( P = .87), palate ( P = .59), tongue base ( P = .73), and multilevel ( P = .95) surgery being performed on both groups of patients. Elderly patients had higher rates of wound complications and urinary tract infections as compared with younger patients. On multivariate analysis, age ≥65 was significantly associated with complications from sleep surgery (odds ratio, 2.35; 95% CI, 1.04-5.35). Conclusion Elderly patients undergoing sleep surgery have increased postoperative complication risk as compared with younger patients treated similarly. This information can help direct quality improvement efforts in the care of older patients.
View details for DOI 10.1177/0194599817691475
View details for PubMedID 28195824
Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review.
Sleep & breathing = Schlaf & Atmung
The purpose of the present study is to review the international literature, using a systematic review, for studies comparing propofol and dexmedetomidine for drug-induced sleep endoscopy (DISE) or sedation in which there is a description of the effect of the agents on the upper airway and associated variables (e.g., vital signs, sedation scores).This is a systematic review through October 4, 2016. PubMed/MEDLINE and four additional databases were accessed for this study.Two hundred twenty studies were screened, 79 were downloaded, and 10 met criteria. The majority of the studies identified dexmedetomidine as the preferred pharmacologic agent for DISE due to an overall safer and more stable profile based upon hemodynamic stability. However, propofol provided greater airway obstruction with oxygen desaturations. With either agent, the degree of obstruction in the upper airway lacks some degree of validity as to whether the obstructions accurately represent natural sleep or are simply a drug-induced effect.Dexmedetomidine and propofol have their advantages and disadvantages during DISE. Generally, dexmedetomidine was preferred and seemed to provide a more stable profile based upon cardiopulmonary status. However, propofol has a quicker onset, has a shorter half-life, and can demonstrate larger degrees of obstruction, which might more accurately reflect what happens during REM sleep. Additional research is recommended.
View details for DOI 10.1007/s11325-017-1465-x
View details for PubMedID 28130737
Tongue retaining devices for obstructive sleep apnea: A systematic review and meta-analysis.
American journal of otolaryngology
Tongue Retaining Devices (TRD) anteriorly displace the tongue with suction forces while patients sleep. TRD provide a non-surgical treatment option for patients with Obstructive Sleep Apnea (OSA). Our objective was to conduct a systematic review of the international literature for TRD outcomes as treatment for OSA.Three authors independently and systematically searched four databases (including PubMed/MEDLINE) through June 26, 2016. We followed guidelines set within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).Sixteen studies with 242 patients met criteria. The overall means±standard deviations (M±SD) for apnea-hypopnea index (AHI) decreased from 33.6±21.1/h to 15.8±16.0/h (53% reduction). Seven studies (81 patients) reported lowest oxygen saturation (LSAT), which improved from 79.8±17.5% to 83.9±8.6%. Four studies (93 patients) reported Epworth sleepiness scale (ESS), which decreased from 10.8±4.8 to 8.2±4.5, p <0.0001. Four studies (31 patients) reported Oxygen Desaturation Index (ODI) which decreased from 29.6±32.1 to 12.9±8.7, a 56.4% reduction.Current international literature demonstrates that tongue retaining devices reduce apnea-hypopnea index by 53%, increase lowest oxygen saturation by 4.1 oxygen saturation points, decrease oxygen desaturation index by 56% and decrease Epworth sleepiness scale scores by 2.8 points. Tongue retaining devices provide a statistically effective alternative treatment option for obstructive sleep apnea.
View details for DOI 10.1016/j.amjoto.2017.01.006
View details for PubMedID 28237516
- Introducing a new concept in obstructive sleep apnea: The continuum of treatment. Cranio : the journal of craniomandibular practice 2017; 35 (1): 1-2
Static craniofacial measurements and dynamic airway collapse patterns associated with severe obstructive sleep apnoea: a sleep MRI study
2016; 41 (6): 700-706
Using sleep MRI, we aimed to identify static craniofacial measurements and dynamic upper airway collapse patterns associated with severe obstructive sleep apnea (OSA) during natural sleep in age and BMI matched patients.Nested case-control study.Sleep MRI images (3.0 Tesla scanner) and synchronized acoustic recording were used to observe patterns of dynamic airway collapse in subjects with mild and severe OSA. Mid-sagittal images were also used for static craniofacial measurements.15 male subjects with severe OSA (mean AHI 70.3±23 events/hour) were matched by age and BMI to 15 subjects with mild OSA (mean AHI 7.8±1.4 events/hour). Subjects were selected from a consecutive sleep MRI study cohort.Static craniofacial measurements selected a priori included measurements that represent maxillomandibular relationships and airway morphology. Axial, sagittal, and coronal views of the airway were rated for dynamic collapse at retropalatal, retroglossal, and lateral pharyngeal wall regions by blinded reviewers. Bivariate analysis was used to correlate measures associated with severity of OSA using AHI. Statistical significance was set at p < 0.01.Lateral pharyngeal wall collapse from dynamic sleep MRI (ß=51.8, p<0.001) and upper airway length from static MRI images (ß=27.2, p<0.001) positively correlated with severity of OSA.Lateral pharyngeal wall collapse and upper airway length are significantly associated with severe OSA based on sleep MRI. Assessment of these markers can be readily translated to routine clinical practice, and their identification may direct targeted surgical treatment. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/coa.12598
View details for Web of Science ID 000387844100013
View details for PubMedID 26615985
Long-Term Outcomes of Radiofrequency Ablation of the Inferior Turbinates.
Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India
2016; 68 (4): 424-428
Radiofrequency ablation of the inferior turbinates (RFAIT) is a minimally invasive surgical technique that reduces turbinate size and decreases nasal obstruction. Few studies have assessed long-term outcomes of this procedure using standardized, symptom-specific evaluation instruments. The primary aim of this study is to assess the long-term effectiveness of RFAIT using a standardized, symptom-specific evaluation instrument. An additional outcome evaluated is the effect of RFAIT on therapeutic CPAP pressures in centimetres of water pressure (cwp) and overall CPAP use. Patients who had received RFAIT >14 months previously were identified via retrospective chart review and underwent a telephone interview with several questions to include the Nasal Obstruction Symptom Evaluation (NOSE) scale. Additionally, data regarding therapeutic pressures for continuous positive pressure devices (CPAP) and CPAP use was obtained for patients using these devices as treatment for obstructive sleep apnoea. The average NOSE scale score for the 40 patients who completed the NOSE scale questionnaire in our study was 6.35 ± 3.98 (0-20 scale). Crusting and mild, self-resolving epistaxis were the most common complications in the perioperative period. In general, unforeseen complications occurred in <13 % of patients. The mean therapeutic CPAP pressures reduced from 11.4 ± 2.7 to 10.1 ± 3.2 cwp, p = 0.085. This study supports that radiofrequency ablation of the inferior turbinates has low complication rates, is well-tolerated, may decrease therapeutic CPAP pressures, and provides symptomatic improvement that is sustained >14 months post-procedure.
View details for PubMedID 27833866
Genial tubercle advancement and genioplasty for obstructive sleep apnea: A systematic review and meta-analysis.
To perform a systematic review and meta-analysis for studies evaluating genioplasty alone, genial tubercle advancement (GTA) alone, and GTA with hyoid surgery (GTA-HS) to treat obstructive sleep apnea (OSA).Ten databases.Three authors searched through November 15, 2015.1,207 studies were screened; 69 were downloaded; and 13 studies met inclusion criteria. A total of 111 patients were included, with 27 standard genioplasty, 10 modified genioplasty, 24 GTA, and 50 GTA-HS patients. For standard genioplasty, the apnea-hypopnea index (AHI) reduced from a mean ± standard deviation (M ± SD) of 18.8 ± 3.8 (95% confidence interval [CI] 17.6, 20.0) to 10.8 ± 4.0 (95% CI 9.5, 12.1) events/hour (relative reduction 43.8%), P value = 0.0001. Genioplasty improved lowest oxygen saturation (LSAT) from 82.3 ± 7.3% (95% CI 80.0, 84.7) to 86.8 ± 5.2% (95% CI 85.1, 88.5), P value = 0.0032. For modified genioplasty AHI increased by 37.3%. For GTA, the AHI reduced from an M ± SD of 37.6 ± 24.2 (95% CI 27.9, 47.3) to 20.4 ± 15.1 (95% CI 14.4, 26.4) events/hour (relative reduction 45.7%), P value = 0.0049. GTA improved LSAT from 83.1 ± 8.3% (95% CI 79.8, 86.4) to 85.5 ± 6.8% (95% CI 82.8, 88.2), P value = 0.2789. For GTA-HS, the AHI reduced from an M ± SD of 34.5 ± 22.1 (95% CI 28.4, 40.6) to 15.3 ± 17.6 (95% CI 10.4, 20.2) events/hour (relative reduction 55.7%), P value < 0.0001; GTA-HS improved LSAT from 80.1 ± 16.6% (95% CI 75.5, 84.7) to 88.3 ± 6.9% (95% CI 86.4, 90.2), P value = 0.0017.Standard genioplasty, GTA and GTA-HS can improve OSA outcomes such as AHI and LSAT. Given the low number of studies, these procedures remain as an area for additional OSA research. Laryngoscope, 2016.
View details for DOI 10.1002/lary.26218
View details for PubMedID 27546467
Risk factors for sleep impairment in adult patients with chronic rhinosinusitis
AURIS NASUS LARYNX
2016; 43 (4): 418-421
Although sleep impairment is reported by patients with chronic rhinosinusitis, the associated factors have not been well studied. Therefore, we determined the associated risk factors for sleep impairment in patients with chronic rhinosinusitis (CRS).This study was a prospective cohort study. A total of 572 adult patients (171 women, 401 men; mean age, 49.0 years; range, 18-64 years) who completed a questionnaire, had a clinical examination, and underwent endoscopic sinus surgery were analyzed using stepwise multiple linear regression.With regard to subjective symptoms, nasal obstruction (beta coef., 0.27; p<0.001), anterior nasal drainage (beta coef., 0.13; p=0.004), facial pain/pressure (beta coef., 0.09; p=0.048), headache (beta coef., 0.10; p=0.010), and cough (beta coef., 0.14; p<0.001) were predictors of an increased risk of sleep impairment of CRS (adjusted R(2), 0.240; p=0.048). In the matter of background parameters, total polyp score (polyp grading system) (beta coef., 0.16; p<0.001) and allergic rhinitis (beta coef., 0.09; p=0.034) were predictors of an increased risk of sleep impairment of CRS (adjusted R(2), 0.029; p=0.034).These results suggest that sleep impairment in these patients is caused by the various mechanisms associated with nasal symptoms themselves, CRS and allergic rhinitis. However, the specific pathophysiology has not been clarified yet; further studies are expected to elucidate that of sleep impairment in patients with CRS.
View details for DOI 10.1016/j.anl.2015.10.006
View details for Web of Science ID 000376470600009
View details for PubMedID 26559748
Variable Findings for Drug-Induced Sleep Endoscopy in Obstructive Sleep Apnea with Propofol versus Dexmedetomidine.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
2016; 154 (4): 765-770
To compare VOTE classification findings (velum, oropharyngeal-lateral walls, tongue base, and epiglottis) for drug-induced sleep endoscopy (DISE) among patients with obstructive sleep apnea (OSA) using 2 sedation protocols.Case series with chart review.Single tertiary institution.Patients with OSA who underwent DISE.A total of 216 patients underwent DISE between November 23, 2011, and May 1, 2015. DISE findings based on VOTE classification were compared between patients receiving the propofol- and dexmedetomidine-based sedation protocols.Patients with OSA (N = 216; age, 44.3 ± 11.7 years; body mass index, 27.9 ± 4.8 kg/m(2)) underwent DISE with intravenous administration of propofol (n = 52) or dexmedetomidine (n = 164). There were no statistically significant differences between the 2 groups in baseline apnea-hypopnea index, oxygen desaturation index, Mallampati score, tonsil size, Epworth Sleepiness Scale score, peripheral oxygen saturation nadir, age, sex, or body mass index. Patients in the propofol group had a significantly increased likelihood of demonstrating complete tongue base obstruction (75%, 39 of 52) versus partial or no obstruction (25%, 13 of 52) in the anterior-posterior dimension, as compared with the dexmedetomidine group (complete obstruction: 42.7%, 70 of 164; partial or no obstruction: 57.3%, 94 of 164; odds ratio: 4.0; 95% confidence interval: 2.0-8.1; P = .0001). Obstruction of other airway subsites was not significantly different.Use of propofol versus dexmedetomidine to induce sedation may have a significant effect on the pattern of upper airway obstruction observed during DISE. Randomized prospective studies are indicated to confirm these initial findings.
View details for DOI 10.1177/0194599815625972
View details for PubMedID 26814208
Awake examination versus DISE for surgical decision making in patients with OSA: A systematic review.
2016; 126 (3): 768-774
Traditionally, upper airway examination is performed while the patient is awake. However, in the past two decades, drug-induced sleep endoscopy (DISE) has been used as a method of tridimensional evaluation of the upper airway during pharmacologically induced sleep. This study aimed to systematically review the evidence regarding the usefulness of DISE compared with that of traditional awake examination for surgical decision making in patients with obstructive sleep apnea (OSA).Scopus, PubMed, and Cochrane Library databases were searched.Only studies with a primary objective of evaluating the usefulness of DISE for surgical decision making in patients with OSA were selected. The included studies directly compared awake examination data with DISE outcome data in terms of possible influences on surgical decision making and operation success.A total of eight studies with 535 patients were included in this review. Overall, the surgical treatment changed after DISE in 50.24% (standard deviation 8.4) cases. These changes were more frequently associated with structures contributing to hypopharyngeal or laryngeal obstruction. However, these differences do not automatically indicate a higher success rate.This review emphasized the direct impact of DISE compared with that of awake examination on surgical decision making in OSA patients. However, it is also clear that the available published studies lack evidence on the association between this impact and surgical outcomes. Laryngoscope, 126:768-774, 2016.
View details for DOI 10.1002/lary.25722
View details for PubMedID 26484801
Epiglottis collapse in adult obstructive sleep apnea: A systematic review.
2016; 126 (2): 515-523
To systematically review the international literature evaluating the role of the epiglottis in snoring and obstructive sleep apnea and to explore possible treatment options available.PubMed, Scopus, Embase, Google Scholar, Book Citation Index-Science, CINAHL, Conference Proceedings Citation Index-Science, The Cochrane Collaboration Databases, and Web of Science.The searches were performed from the first year of each database through March 5, 2015.Fourteen studies about the prevalence of epiglottis collapse in obstructive sleep apnea (OSA) were found. Most involved drug-induced sleep endoscopy studies that indirectly reported their findings about epiglottis collapse. The data suggests that the prevalence of epiglottis collapse in OSA is higher than previously described. The epiglottis has been implicated in 12% of cases of snoring, and sound originating from it has a higher pitch than palatal snoring. Continuous positive pressure (CPAP) surgery and positional therapy in the treatment of epiglottis collapse were also considered. Lateral position of the head may reduce the frequency of epiglottis collapse. With regard to CPAP, available reports suggest that it may accentuate collapse of the epiglottis. Surgery may help reduce snoring in some patients with a lax epiglottis and improve OSA in patients undergoing multilevel surgery.Knowledge regarding the role of the epiglottis in adult OSA and snoring patients is limited. The prevalence of this phenomenon in OSA seems to be greater than previously reported, and more research is needed to understand its role in OSA and the best way to treat it.NA. Laryngoscope, 2015.
View details for DOI 10.1002/lary.25589
View details for PubMedID 26371602
Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
2016; 154 (1): 189-195
To use drug-induced sedation endoscopy (DISE) and computational fluid dynamics (CFD) modeling to study dynamic airway and airflow changes after maxillomandibular advancement (MMA), and how the changes correlate with surgical success based on polysomnography parameters.Retrospective cohort study.University medical center.DISE was rated with the VOTE (velum, oropharynx, tongue, epiglottis) classification, and CFD was used to model airflow velocity and negative pressure exerted on pharyngeal wall. Changes in VOTE score by site and CFD measurements were correlated with perioperative polysomnography outcomes of apnea-hypopnea index (AHI), apnea index (AI), oxygenation desaturation index (ODI), and lowest oxygen saturation.After MMA, 20 subjects (17 males, 3 females) with a mean age of 44 ± 12 years and body mass index of 27.4 ± 4.6 kg/m(2) showed mean decreases in AHI (53.6 ± 26.6 to 9.5 ± 7.4 events/h) and ODI (38.7 ± 30.3 to 8.1 ± 9.2 events/h; P < .001). Improvement in lateral pharyngeal wall collapse during DISE based on VOTE score correlated with the most decrease in AHI (60.0 ± 25.6 to 7.5 ± 3.4 events/h) and ODI (46.7 ± 29.8 to 5.3 ± 2 events/h; P = .002). CFD modeling showed significant positive Pearson correlations between reduction of retropalatal airflow velocity and AHI (r = 0.617, P = .04) and ODI (r = 0.773, P = .005).AHI and ODI improvement after MMA is best correlated with (1) decreased retropalatal airflow velocity modeled by CFD and (2) increased lateral pharyngeal wall stability based on VOTE scoring from DISE.
View details for DOI 10.1177/0194599815611603
View details for PubMedID 26740522
- Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling OTOLARYNGOLOGY-HEAD AND NECK SURGERY 2016; 154 (1): 189-195
Treatment of Snoring with a Nasopharyngeal Airway Tube.
Case reports in medicine
2016; 2016: 3628716-?
Objective. To study the feasibility of a standard nasopharyngeal airway tube (NPAT) as treatment for snoring. Methods. An obese 35-year-old man, who is a chronic, heroic snorer, used NPATs while (1) the patient's bedpartner scored the snoring and (2) the patient recorded himself with the smartphone snoring app "Quit Snoring." Baseline snoring was 8-10/10 (10 = snoring that could be heard through a closed door and interrupted the bedpartner's sleep to the point where they would sometimes have to sleep separately) and 60-200 snores/hr. Several standard NPATs were tested, consisting of soft polyvinyl chloride material raging between 24- and 36-French (Fr) tubes. Results. The 24 Fr tube did not abate snoring. The 26 Fr tube was able to abate the snoring sound most of the night (smartphone app: 11.4 snores/hr, bedpartner VAS = 2/10). The 28 and 30 Fr tubes abated the snoring sound the entire time worn (smartphone app: 0 snores, bedpartner VAS 0/10) but could not be tolerated more than 2.5 hours. The tube of 36 Fr size could not be inserted, despite several attempts bilaterally. Conclusion. Appropriately sized nasopharyngeal airway tubes may abate the snoring sound; however, as in this patient, they may be too painful and intolerable for daily use.
View details for PubMedID 27795710
Predictors of Nasal Obstruction: Quantification and Assessment Using Multiple Grading Scales.
Plastic surgery international
2016; 2016: 6945297-?
Objective. To evaluate the association between nasal obstruction and (1) demographic factors, (2) medical history, (3) physical tests, and (4) nasal exam findings. Study Design.Methods. Chart review at a tertiary medical center. Results. Two hundred-forty consecutive patients (52.1 ± 17.5 years old, with a Nasal Obstruction Symptom Evaluation (NOSE) score of 32.0 ± 24.1) were included. Demographic factors and inferior turbinate sizes were not associated with NOSE score or Nasal Obstruction Visual Analog Scale (NO-VAS). A significant association was found between higher NOSE score on univariate analysis and positive history of nasal trauma (p = 0.0136), allergic rhinitis (p < 0.0001), use of nasal steroids (p = 0.0108), higher grade of external nasal deformity (p = 0.0149), higher internal nasal septal deviation grade (p = 0.0024), and narrow internal nasal valve angle (p < 0.0001). Multivariate analysis identified the following as independent predictors of high NOSE score: NO-VAS: ≥50 (Odds Ratio (OR) = 17.6 (95% CI 5.83-61.6), p < 0.0001), external nasal deformity: grades 2-4 (OR = 4.63 (95% CI 1.14-19.9), p = 0.0339), and allergic rhinitis: yes (OR = 5.5 (95% CI 1.77-18.7), p = 0.0041). Conclusion. Allergic rhinitis, NO-VAS score ≥ 50, and external nasal deformity (grades 2-4) were statistically significant independent predictors of high NOSE scores on multivariate analysis. Inferior turbinate size was not associated with NOSE scores or NO-VAS.
View details for DOI 10.1155/2016/6945297
View details for PubMedID 27293885
Five-Minute Awake Snoring Test for Determining CPAP Pressures (Five-Minute CPAP Test): A Pilot Study.
2016; 2016: 7380874-?
Objective. To develop a quick, simple, bedside test for determining continuous positive airway pressures (CPAP) for obstructive sleep apnea (OSA) patients. Study Design. Prospective case series at a tertiary medical center. Methods. The Five-Minute Awake Snoring Test for Determining CPAP (Five-Minute CPAP Test) was developed and tested. Patients wear a soft-gel nasal triangle mask while holding a tongue depressor with the wide section (1.75 cm) between the teeth. Fixed pressure nasal CPAP is applied while the patient simulates snoring at 4 centimeters of water pressure. The pressure is incrementally titrated up and then down to determine the lowest pressure at which the patient cannot snore (Quiet Pressure). Results. Overall, thirty-eight patients participated. All could simulate snoring. Correlation coefficients were statistically significant between Quiet Pressures and body mass index (r s = 0.60 [strong positive relationship], p = 0.0088), apnea-hypopnea index (r s = 0.49 [moderate positive relationship], p = 0.039), lowest oxygen saturation (r s = -0.47 [moderate negative relationship], p = 0.048), and oxygen desaturation index (r s = 0.62 [strong positive relationship], p = 0.0057). Conclusion. This pilot study introduces a new concept, which is the final product of over one year of exploration, development, and testing. Five-Minute CPAP Test is a quick, inexpensive, and safe bedside test based on supine awake simulated snoring with nasal CPAP.
View details for DOI 10.1155/2016/7380874
View details for PubMedID 26881088
Model for prediction of pediatric OSA: Proposal for a clinical decision rule.
2015; 125 (12): 2823-2827
Obstructive sleep apnea (OSA) is a syndrome frequently diagnosed in children; however, it lacks optimal diagnostic methods. This study aimed to provide a clinical decision rule for predicting pediatric OSA using commonly available clinical information.A prospective cohort study.Children between the ages of 3 to 6 years-old, referred for an otorhinolaryngology consultation due to clinical suspicion of OSA, were recruited from January to June 2014. At baseline age, weight, height, gender, body mass index, Pediatric Sleep Questionnaire (PSQ) scores, tonsil size, and oxygen desaturation index (ODI) were assessed. A logistic regression modeling was used with backward stepwise elimination to develop a prediction model.Sixty-seven children were included with a mean age of 4.51 years. Of the 67 children included in this study, 25 (37.3%) subjects were diagnosed with pediatric OSA. Significant predictors of pediatric OSA in the final model (odds ratio, 95% confidence interval) included PSQ score (5.12; 3.3-6.5), ODI (1.34; 1.0-1.79) and tonsil size (6.7; 3.22-9.75). The final decision rule had a sensitivity of 88% and a specificity of 86%. The area under the receiver operating characteristic curve was 0.897.The proposed clinical decision rule, based on three readily available variables, is a promising discriminating instrument for prediction of OSA among children between 3 and 6 years.IIb. Laryngoscope, 2015.
View details for DOI 10.1002/lary.25438
View details for PubMedID 26154921
- Model for Prediction of Pediatric OSA: Proposal for a Clinical Decision Rule LARYNGOSCOPE 2015; 125 (12): 2823-2827
Lateral pharyngeal wall collapse associated with hypoxemia in obstructive sleep apnea.
2015; 125 (10): 2408-2412
Review drug-induced sleep endoscopy (DISE) findings and correlate the patterns of airway collapse with body mass index (BMI) and objective sleep study respiratory variables, with particular emphasis on oxygen desaturation variables.Retrospective chart review.From January 2010 to March 2014, 64 patients underwent DISE, and its findings were registered using the VOTE (velum, oropharynx, tongue base, epiglottis) classification system. Associations were analyzed between DISE, BMI, and polysomnographic parameters.Complete lateral oropharyngeal collapse was significantly associated with increased severity of obstructive sleep apnea (OSA), reflected by a higher oxygen desaturation index, apnea-hypopnea index, apnea index, the percent of the total time with oxygen saturation level lower than 90%, and minimal oxygen saturation). Complete concentric collapse of the velum and complete lateral oropharyngeal collapse were associated with higher BMI values.The results of this study demonstrate a strong association between complete lateral oropharyngeal wall collapse and increased OSA severity, particularly with objective oximetry measures. Patients with a complete lateral oropharyngeal wall collapse may need aggressive treatment strategies because of the high probability of subsequent cardiovascular complications.4 Laryngoscope, 2015.
View details for DOI 10.1002/lary.25126
View details for PubMedID 25582498
Smartphone apps for snoring
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2015; 129 (10): 974-979
To identify and systematically evaluate user-friendly smartphone snoring apps.The Apple iTunes app store was searched for snoring apps that allow recording and playback. Snoring apps were downloaded, evaluated and rated independently by four authors. Two patients underwent polysomnography, and the data were compared with simultaneous snoring app recordings, and one patient used the snoring app at home.Of 126 snoring apps, 13 met the inclusion and exclusion criteria. The most critical app feature was the ability to graphically display the snoring events. The Quit Snoring app received the highest overall rating. When this app's recordings were compared with in-laboratory polysomnography data, app snoring sensitivities ranged from 64 to 96 per cent, and snoring positive predictive values ranged from 93 to 96 per cent. A chronic snorer used the app nightly for one month and tracked medical interventions. Snoring decreased from 200 to 10 snores per hour, and bed partner snoring complaint scores decreased from 9 to 2 (on a 0-10 scale).Select smartphone apps are user-friendly for recording and playing back snoring sounds. Preliminary comparison of more than 1500 individual snores demonstrates the potential clinical utility of such apps; however, further validation testing is recommended.
View details for DOI 10.1017/S0022215115001978
View details for Web of Science ID 000363039000010
View details for PubMedID 26333720
Large maxillomandibular advancements for obstructive sleep apnea: An operative technique evolved over 30 years.
Journal of cranio-maxillo-facial surgery
2015; 43 (7): 1113-1118
Obstructive sleep apnea (OSA) can be a challenging disorder to treat. Maxillomandibular advancements (MMAs) generally have high success rates; however, larger advancements have higher success and cure rates. Our aim is to present and to describe the current technique used by the senior authors, which has been successful for performing large advancements, thereby improving post-operative outcomes.The senior authors have developed and modified their maxillomandibular advancement operative techniques significantly over the past 30 years. The current version of the Riley-Powell MMA technique is described in a step-by-step fashion in this article.Initially, as part of the MMAs, patients underwent maxillomandibular fixation with wires, lag screws and harvested split calvarial bone grafts. The current technique utilizes plates, screws, Erich Arch Bars, and suspension wires which are left in place for 5-6 weeks. Guiding elastics are worn for the first week. The MMA technique described in this article has yielded a success rate over 90% for patients with a body mass index (BMI) <40 kg/m(2) and 81% for patients with a BMI ≥40 kg/m(2).Large advancements during maxillomandibular advancement surgeries can help improve post-operative obstructive sleep apnea outcomes.
View details for DOI 10.1016/j.jcms.2015.05.015
View details for PubMedID 26116307
Lateral Pharyngeal Wall Tension After Maxillomandibular Advancement for Obstructive Sleep Apnea Is a Marker for Surgical Success: Observations From Drug-Induced Sleep Endoscopy.
Journal of oral and maxillofacial surgery
2015; 73 (8): 1575-1582
The efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) with anatomic airway changes has previously been studied using static imaging and endoscopy in awake subjects. The aim of the present study was to use drug-induced sleep endoscopy (DISE) to evaluate the dynamic upper airway changes in sleeping subjects before and after MMA and their association with the surgical outcome.This was a retrospective cohort study of subjects with OSA who had undergone MMA at the Stanford University Sleep Surgery Division from July 2013 to July 2014. The subjects were included if perioperative polysomnography and DISE had been performed. The predictor variable was the perioperative DISE velum-oropharynx-tongue-epiglottis score. The outcome variables were the apnea-hypopnea index (AHI), oxygen-desaturation index (ODI), and Epworth Sleepiness Scale (ESS). A subgroup analysis was performed for the subjects who had undergone primary and secondary MMA. The statistical analyses included Cronbach's α coefficient, the McNemar test, and the independent Student t test. The P value was set at <.01.A total of 16 subjects (15 males, 1 female) were included in the present study, with an average age of 47 ± 10.9 years and body mass index of 29.4 ± 5.1 kg/m(2). Significant post-MMA decreases were found in the AHI (from 59.8 ± 25.6 to 9.3 ± 7.1 events/hr) and ODI (from 45 ± 29.7 to 5.7 ± 4.1 events/hr; P < .001). Greater improvement in the AHI occurred in the primary MMA group (P = .022). The post-MMA change in airway collapse was most significant at the lateral pharyngeal wall (P = .001). The subjects with the most improvement in lateral pharyngeal wall collapsibility demonstrated the largest changes in the AHI (from 60.0 ± 25.6 events/hr to 7.5 ± 3.4 events/hr) and ODI (from 46.7 ± 29.8 to 5.3 ± 2 events/hr; P = .002).Using DISE, we observed that after MMA, the greatest reduction in upper airway collapsibility is seen at the lateral pharyngeal wall of the oropharynx, followed by the velum, and then the tongue base. The stability of the lateral pharyngeal wall is a marker of surgical success after MMA using the AHI, ODI, and ESS.
View details for DOI 10.1016/j.joms.2015.01.028
View details for PubMedID 25843814
Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.
2015; 38 (5): 669-675
To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data.Web of Science, Scopus, MEDLINE, and The Cochrane Library.The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed.Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apnea-hypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P =0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y.Current literature demonstrates that myofunctional therapy decreases AHI by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other OSA treatments.
View details for DOI 10.5665/sleep.4652
View details for PubMedID 25348130
- Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis SLEEP 2015; 38 (5): 669-?
Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-analysis
2015; 125 (5): 1254-1264
Poor adherence to continuous positive airway pressure treatment in obstructive sleep apnea (OSA) adversely affects the effectiveness of this therapy. This study aimed to systematically review the evidence regarding the efficacy and safety of hypoglossal nerve stimulation as an alternative therapy in the treatment of OSA.Scopus, PubMed, and Cochrane Library databases were searched (updated through September 5, 2014).Studies were included that evaluated the efficacy of hypoglossal nerve stimulation to treat OSA in adults with outcomes for apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and effect on daytime sleepiness (Epworth Sleepiness Scale [ESS]). Tests for heterogeneity and subgroup analysis were performed.Six prospective studies with 200 patients were included in this review. At 12 months, the pooled fixed effects analysis demonstrated statistically significant reductions in AHI, ODI, and ESS mean difference of -17.51 (95% CI: -20.69 to -14.34); -13.73 (95% CI: -16.87 to -10.58), and -4.42 (95% CI: -5.39 to -3.44), respectively. Similar significant reductions were observed at 3 and 6 months. Overall, the AHI was reduced between 50% and 57%, and the ODI was reduced between 48% and 52%. Despite using different hypoglossal nerve stimulators in each subgroup analysis, no significant heterogeneity was found in any of the comparisons, suggesting equivalent efficacy regardless of the system in use.This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. Further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes.NA Laryngoscope, 2014.
View details for DOI 10.1002/lary.25032
View details for Web of Science ID 000353996900049
View details for PubMedID 25389029
- 2-Year Sleep Surgery and Medicine Fellowships for Otolaryngologists OTOLARYNGOLOGY-HEAD AND NECK SURGERY 2015; 152 (4): 766-767
Maxillomandibular Advancement and Tracheostomy for Morbidly Obese Obstructive Sleep Apnea: A Systematic Review and Meta-analysis
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2015; 152 (4): 619-630
The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m(2)) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes.MEDLINE, Scopus, Web of Science, and the Cochrane Library.A search was performed from inception through April 8, 2014, in each database.Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m(2)) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m(2)) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h (P < .00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% (P < .00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h (P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h (P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% (P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy (P = .0034).Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.
View details for DOI 10.1177/0194599814568284
View details for Web of Science ID 000352580000013
View details for PubMedID 25644497
Inferior Turbinate classification system, grades 1 to 4: Development and validation study.
2015; 125 (2): 296-302
To develop a validated inferior turbinate grading scale.Development and validation study.Phase 1 development (alpha test) consisted of a proposal of 10 different inferior turbinate grading scales (>1,000 clinic patients). Phase 2 validation (beta test) utilized 10 providers grading 27 standardized endoscopic photos of inferior turbinates using two different classification systems. Phase 3 validation (pilot study) consisted of 100 live consecutive clinic patients (n = 200 inferior turbinates) who were each prospectively graded by 18 different combinations of two independent raters, and grading was repeated by each of the same two raters, two separate times for each patient.In the development phase, 25% (grades 1-4) and 33% (grades 1-4) were the most useful systems. In the validation phase, the 25% classification system was found to be the best balance between potential clinical utility and ability to grade; the photo grading demonstrated a Cohen's kappa (κ) = 0.4671 ± 0.0082 (moderate inter-rater agreement). Live-patient grading with the 25% classification system demonstrated an overall inter-rater reliability of 71.5% (95% confidence interval [CI]: 64.8-77.3), with overall substantial agreement (κ = 0.704 ± 0.028). Intrarater reliability was 91.5% (95% CI: 88.7-94.3). Distribution for the 200 inferior turbinates was as follows: 25% quartile = grade 1, 50% quartile (median) = grade 2, 75% quartile = grade 3, and 90% quartile = grade 4. Mean turbinate size was 2.22 (95% CI: 2.07-2.34; standard deviation 1.02). Categorical κ was as follows: grade 1, 0.8541 ± 0.0289; grade 2, 0.7310 ± 0.0289; grade 3, 0.6997 ± 0.0289, and grade 4, 0.7760 ± 0.0289.The 25% (grades 1-4) inferior turbinate classification system is a validated grading scale with high intrarater and inter-rater reliability. This system can facilitate future research by tracking the effect of interventions on inferior turbinates.2c Laryngoscope, 2014.
View details for DOI 10.1002/lary.24923
View details for PubMedID 25215619
- The Effect of Nasal Surgery on Continuous Positive Airway Pressure Device Use and Therapeutic Treatment Pressures: A Systematic Review and Meta-Analysis SLEEP 2015; 38 (2): 279-?
Unattended sleep studies in pediatric OSA: A systematic review and meta-analysis.
2015; 125 (1): 255-262
Objective: To systematically assess the evidence for the diagnostic accuracy of unattended type 2 or type 3 multichannel studies for predicting and monitoring pediatric obstructive sleep apnea (OSA). Data Sources: Four medical databases were searched for eligible studies. Review Methods: Only studies that evaluated the ability of unattended multichannel devices to accurately diagnose or monitor OSA in children were included. Those with appropriate data were selected for meta-analysis. Study quality was assessed by using the QUADAS tool. Summary estimates of diagnostic accuracy were determined by using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, summary receiver operating characteristics, and the area under the curve (AUC). Results: Ten diagnostic studies with 724 patients were included in the systematic review, which was followed by a meta-analysis using studies that provided sufficient information for the calculation of diagnostic parameters. The overall analysis revealed a moderate sensitivity of 76% (95% confidence interval [CI]: 64-85%), a moderate specificity of 76% (95% CI: 60-88%), and a pooled diagnostic odds ratio (DOR) of 15.18 (95% CI: 3.52-65.43). The AUC (0.88) indicated that unattended multichannel devices showed good diagnostic performance for predicting pediatric OSA. Using a cut-off of AHI > 1 for the diagnosis of OSA, the results appeared to be more useful with a higher sensitivity (88%) while maintaining a moderate specificity (71%). Conclusions: These ﬁndings suggest that unattended sleep studies are a good tool for predicting both the presence and severity of OSA in children, especially in those with mild-to-moderate disease.
View details for DOI 10.1002/lary.24662
View details for PubMedID 24596029
Nasopharyngeal airway stenting devices for obstructive sleep apnoea: A systematic review and meta-analysis.
journal of laryngology and otology
2015; 129 (1): 2-10
To systematically review outcomes of adults with obstructive sleep apnoea treated with nasopharyngeal airway stenting devices.Medline, Scopus, Web of Science and the Cochrane Library databases were searched, and data on device use and tolerability, sleepiness, oxygen saturation, apnoea index, apnoea-hypopnoea index, and sleep quality were collected.Of 573 potential studies, 29 were retrieved for detailed evaluation and 16 met the study criteria. Polysomnography data for patients treated with nasal trumpets as an isolated therapy were pooled for meta-analysis. The mean apnoea index ± standard deviation, for 53 patients, decreased from 32.4 ± 15.9 to 9.0 ± 7.2 episodes per hour (p < 0.00001). The mean apnoea-hypopnoea index, for 193 patients, decreased from 44.1 ± 18.9 to 22.7 ± 19.3 episodes per hour (p < 0.00001). The mean lowest oxygen saturation, for 193 patients, increased from 66.5 ± 14.2 to 75.5 ± 13.9 per cent (p < 0.00001).Some studies have demonstrated limited effectiveness and low tolerability of nasopharyngeal airway stenting devices, while other studies have shown a significant benefit in treating obstructive sleep apnoea, with a high level of patient acceptance. Nasal trumpets have been successful in decreasing airway obstruction in the short term.
View details for DOI 10.1017/S0022215114003119
View details for PubMedID 25544266
The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis.
2015; 38 (2): 279-286
The relationship between nasal surgery and its effect on continuous positive airway pressure (CPAP) device therapeutic treatment pressures and CPAP device use has not been previously systematically examined.To conduct a systematic review and meta-analysis evaluating the effect of isolated nasal surgery on therapeutic CPAP device pressures and use in adults with obstructive sleep apnea (OSA).MEDLINE, Scopus, Web of Science, and The Cochrane Library were searched through July 15, 2014. The MOOSE consensus statement and PRISMA statement were followed.Eighteen studies (279 patients) reported CPAP data after isolated nasal surgery. Seven studies (82 patients) reported preoperative and postoperative mean therapeutic CPAP device pressures and standard deviations (SD), which reduced from 11.6 ± 2.2 to 9.5 ± 2.0 centimeters of water pressure (cwp) after nasal surgery. Pooled random effects analysis demonstrated a statistically significant pressure reduction, with a mean difference (MD) of -2.66 cwp (95% confidence interval (CI), -3.65 to -1.67); P < 0.00001. Eleven studies (153 patients) reported subjective, self-reported data for CPAP use; and a subgroup analysis demonstrated that 89.1% (57 of 64 patients) who were not using CPAP prior to nasal surgery subsequently accepted, adhered to, or tolerated it after nasal surgery. Objective, device meter-based hours of use increased in 33 patients from 3.0 ± 3.1 to 5.5 ± 2.0 h in the short term (<6 mo of follow-up).Isolated nasal surgery in patients with OSA and nasal obstruction reduces therapeutic CPAP device pressures and the currently published literature's objective and subjective data consistently suggest that it also increases CPAP use in select patients.
View details for DOI 10.5665/sleep.4414
View details for PubMedID 25325439
- Limited palatal muscle resection with tonsillectomy: A novel palatopharyngoplasty technique for obstructive sleep apnea AURIS NASUS LARYNX 2014; 41 (6): 558-562
Limited palatal muscle resection with tonsillectomy: a novel palatopharyngoplasty technique for obstructive sleep apnea.
Auris, nasus, larynx
2014; 41 (6): 558-562
The ideal palatal surgery for obstructive sleep apnea (OSA) and snoring must maintain the airway patency and correct anatomic abnormalities without complications. The purpose of this study was to investigate the efficacy of limited palatal muscle resection (LPMR) to improve OSA severity.Twenty-three patients with OSA underwent LPMR. The LPMR was initiated with a bilateral tonsillectomy in patients with tonsil size 2 and 3. The LPMR consisted of partial resection of palatal muscles (levator veli palatini, palatoglossus, and musculus uvulae) with preservation of the uvula and a simple double layer suturing. The retropalatal space and the length of soft palate were evaluated by magnetic resonance imaging. Subjective outcomes using visual analog scales, Epworth Sleepiness Scale, and overnight polysomnography (PSG) data were assessed.Six months after the operation, there was significant symptomatic improvement in snoring, morning headaches, tiredness, and daytime sleepiness. Postoperative magnetic resonance images showed upward and forward movement of uvula and soft palate after LPMR. The length of the soft palate was significantly shortened and the retropalatal space was significantly increased. Postoperative PSG revealed significant improvement in apnea-hypopnea index (AHI) and the total sleep time spent with oxygen saturation below 90%, and reduction in AHI following PMR was found in all patients. Furthermore, no patient experienced velopharyngeal insufficiency, voice changes, and pharyngeal dryness at 6 months follow-up.The LPMR obtained significant improvement in subjective and objective outcomes in OSA, with preserved pharyngeal function. PMR is an effective and safe technique to treat oropharyngeal obstruction in OSA surgery.
View details for DOI 10.1016/j.anl.2014.03.001
View details for PubMedID 24862295
- Airway changes in obstructive sleep apnoea patients associated with a supine versus an upright position examined using cone beam computed tomography JOURNAL OF LARYNGOLOGY AND OTOLOGY 2014; 128 (9): 824-830
Snoring exclusively during nasal breathing: a newly described respiratory pattern during sleep
SLEEP AND BREATHING
2014; 18 (1): 159-164
PURPOSE: The aim of this study is to describe a distinctive respiratory pattern seen in subjects with inferior turbinate hypertrophy, nasal obstruction, and a polysomnogram-proven diagnosis of primary snoring or mild obstructive sleep apnea. These subjects demonstrated increased snoring with purely nasal breathing and alleviation of snoring with oral breathing. The study design is case series with chart review. The setting was a university-based tertiary care hospital. METHODS: A retrospective chart review was performed for patients with complaints of nasal obstruction with associated inferior turbinate hypertrophy and a polysomnogram-proven diagnosis of mild obstructive sleep apnea or primary snoring. Demographic and polysomnography information were collected and analyzed. Snoring and airflow patterns were reviewed. RESULTS: Twenty-five subjects were identified as having met the inclusion and exclusion criteria on polysomnography for either primary snoring or mild obstructive sleep apnea with inferior turbinate hypertrophy and no other significant nasal deformity or abnormality. Seventeen (68 %) of these patients had polysomnograms which demonstrated snoring during nasal breathing and alleviation of snoring with oral breathing. Of the 17 who snored during nasal breathing, ten of the subjects were female and seven of the subjects were male. The mean age was 27 years (range 18 to 68 years). The mean apnea-hypopnea index was 2.3 events/h (range 0 to 9.7 events/h). The mean body mass index was 25 kg/m(2) (range 20 to 43 kg/m(2)). CONCLUSION: Our study describes a newly recognized pattern of snoring in patients with a polysomnogram-proven diagnosis of either primary snoring or mild obstructive sleep apnea. This pattern of breathing demonstrates patients who snore during nasal breathing even with known nasal obstruction present and subsequently have resolution or improvement of the snoring with oral breathing.
View details for DOI 10.1007/s11325-013-0864-x
View details for Web of Science ID 000335577100024
View details for PubMedID 23716022
Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis.
2014; 124 (3): 803-811
To systematically review outcomes for polysomnography, sleepiness, and mortality in patients who undergo tracheostomy for the treatment of adult obstructive sleep apnea (OSA).MEDLINE, Scopus, and the Cochrane Library were searched from inception to March 2013, followed by extensive hand searching for the identification of relevant English language studies that met predefined criteria.Adult studies of tracheostomies or tracheotomies as treatment for OSA with outcomes for apnea index (AI), apnea-hypopnea index (AHI), oxygen desaturation index (ODI), effect on daytime sleepiness or mortality were identified, abstracted and pooled (as appropriate). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.The systematic search identified 18 relevant studies that were primarily case series, using retrospective review. Posttracheostomy AI improved from 73.0 ± 27.1 to 0.2 ± 1.2/h and an AI mean difference of -83.47 (95% CI, -106.07 to -60.87; P < 0.0001). Mean AHI decreased from 92.0 ± 34.8 to 17.3 ± 20.5/h and an AHI mean difference -79.82 (95% CI, -63.74 to -95.90; P < 0.0001) compared with preoperative status was observed. Postsurgically, there was a development of central apneas; however, the central AI demonstrated near normalization to a mean of 2.1 ± 3.5/h after 14 weeks. ODI decreased from 78.2 ± 25.8/h to 20.8 ± 25.5/h. Four studies demonstrated a statistically significant improvement in subjective sleepiness posttracheostomy. Postoperative statistically significant reductions in overall and in cardiovascular mortality compared with untreated historical cohorts was reported.Tracheostomies significantly decrease apnea index, oxygen desaturation index, sleepiness, and mortality in OSA subjects.NA. Laryngoscope, 124:803-811, 2014.
View details for DOI 10.1002/lary.24433
View details for PubMedID 24549987
- Management of obstructive sleep apnea in adults. Annals of internal medicine 2014; 160 (5): 367
- In reference to redefining successful therapy in obstructive sleep apnea: A call to arms. The Laryngoscope 2014
Reviewing the Systematic Reviews in OSA Surgery
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013; 149 (6): 817-829
There is an extensive amount of literature on surgeries as treatment for obstructive sleep apnea syndrome on adults. Previous systematic reviews have been performed to summarize the outcomes for sleep surgeries, with conflicting results. The objective of this study was to critically evaluate these systematic reviews to provide an overview of their quality, strengths, and conclusions.MEDLINE, Scopus, and the Cochrane Collaboration databases were searched from inception to April 2013.An overview of systematic reviews was undertaken. Studies included in this review are the systematic reviews whose primary objective was to evaluate the outcomes of sleep apnea surgery on adults. The methodological quality of the studies was analyzed with AMSTAR checklist, and the quality of evidence was evaluated using the GRADE assessment tool. Primary outcome measures assessed the effect of surgery on snoring, sleepiness, and the apnea-hypopnea index.A total of 11 studies were included in this study, and the pooled overview includes 378 studies. The systematic reviews were mostly graded as low quality using the GRADE tool and low to moderate according to the AMSTAR checklist. Outcome for apnea-hypopnea index demonstrated substantial variation leading to conflicting results. Despite a high amount of heterogeneity, outcomes for sleepiness and snoring demonstrated significant improvement across included reviews.Although obstructive sleep apnea surgery is associated with improved outcomes in most studies, the level and quality of evidence reviews requires improvement.
View details for DOI 10.1177/0194599813509959
View details for Web of Science ID 000327245700005
View details for PubMedID 24154748
Improved sleep MRI at 3 tesla in patients with obstructive sleep apnea.
Journal of magnetic resonance imaging
2013; 38 (5): 1261-1266
PURPOSE: To describe a real-time MR imaging platform for synchronous, multi-planar visualization of upper airway collapse in obstructive sleep apnea at 3 Tesla (T) to promote natural sleep with an emphasis on lateral wall visualization. MATERIALS AND METHODS: A real-time imaging platform was configured for sleep MR imaging which used a cartesian, partial k-space gradient-echo sequence with an inherent temporal resolution of 3 independent slices every 2 s. Combinations of axial, mid-sagittal, and coronal scan planes were acquired. The system was tested in five subjects with polysomnography-proven obstructive sleep apnea during sleep, with synchronous acquisition of respiratory effort and combined oral-nasal airflow data. RESULTS: Sleep was initiated and maintained to allow demonstration of sleep-induced, upper airway collapse as illustrated in two subjects when using a real-time, sleep MR imaging platform at 3T. Lateral wall collapse could not be visualized on mid-sagittal imaging alone and was best characterized on multiplanar coronal and axial imaging planes. CONCLUSION: Our dedicated sleep MR imaging platform permitted an acoustic environment of constant "white noise" which was conducive to sleep onset and sleep maintenance in obstructive sleep apnea patients at 3T. Apneic episodes, specifically the lateral walls, were more accurately characterized with synchronous, multiplanar acquisitions. J. Magn. Reson. Imaging 2013;. © 2013 Wiley Periodicals, Inc.
View details for DOI 10.1002/jmri.24029
View details for PubMedID 23390078
- Comprehensive review of surgeries for obstructive sleep apnea syndrome BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 2013; 79 (6): 780-788
Phase of nasal cycle during sleep tends to be associated with sleep stage
2013; 123 (8): 2050-2055
BACKGROUND AND OBJECTIVES: The phenomena of periodic cycles of vascular engorgement on the nasal cavity mucosa that alternate between right and left sides are termed the "nasal cycle." The physiologic mechanisms underlying this cycle have not been entirely clarified, even more so during sleep. In this study, we measured the periodic patterns of the normal nasal cycle, not only during wakefulness but also during sleep. STUDY DESIGN: CASE SERIES METHODS: Our team utilized a method for functional rhinologic assessment, the portable rhinoflowmeter (Rhinocycle, Rhinometrics, Lynge, Denmark), measuring airflow independently through each nostril during 24 hours on 20 healthy subjects aged 20 to 56 years, and without any nasal pathology or diagnosed medical, psychiatric, or sleep disorders. In addition, a nocturnal polysomnogram was simultaneously performed during sleep. RESULTS: Nineteen of 20 subjects showed a detectable nasal cycle, and 16 of 19 subjects presented a change of the cyclic phase during sleep. The mean nasal cycle duration was 234.2±282.4 minutes (median, 164.1 minutes), although variation was considerable. The mean cycle duration time during sleep was significantly longer than that in wakefulness (P <0.005). The reversal of cyclic phase during sleep tended to be associated with REM sleep (68.8%) and postural changes (18.8%). It never occurred in slow-wave sleep. CONCLUSIONS: Nasal cycle duration during sleep is longer than in wakefulness. Changes in laterality of nasal cycle frequently coincide with switches in posture, tend to occur in REM sleep, never occur in slow-wave sleep, and may be absent in subjects with severe nasal septal deviations. LEVEL OF EVIDENCE: 4. Laryngoscope, 2012.
View details for DOI 10.1002/lary.23986
View details for Web of Science ID 000322004400039
View details for PubMedID 23576311
Surgical Therapy of Obstructive Sleep Apnea: A Review
2012; 9 (4): 710-716
Obstructive sleep apnea (OSA) is a disease characterized by intermittent and repetitive narrowing of the airway during sleep. Surgical therapies for the treatment of OSA aim to improve airway patency by addressing selected site(s) of obstruction. Because several areas may each be responsible for the narrowing, different surgical modalities have also been developed. In this review, we give an overview of surgery for each of potential obstruction site(s). As a consequence of the multi-factorial and heterogeneous etiology of OSA, surgical therapies need to be selected and performed specifically for each patient, as there is no perfect surgery that will fit all patients. As with any other treatment modalities for OSA, surgical therapies have variable efficacy, but are a very important tool on OSA management in selected patients and have been shown effectiveness in decreasing the morbidity and mortality associated with the disease.
View details for DOI 10.1007/s13311-012-0141-x
View details for Web of Science ID 000310325000004
View details for PubMedID 22915293
The effect of continuous positive airway pressure on middle ear pressure
2012; 122 (3): 688-690
While continuous positive airway pressure (CPAP) is commonly used for obstructive sleep apnea treatment, its effect on middle ear pressure is unknown. The purpose of this study was to measure the effect of CPAP on middle ear pressure and describe the correlation between CPAP levels and middle ear pressures.Retrospective review of normal tympanometry values and a prospective cohort evaluation of subjects' tympanometric values while using CPAP at distinct pressure levels.A total of 3,066 tympanograms were evaluated to determine the normal range of middle ear pressures. Ten subjects with no known history of eustachian tube dysfunction or obstructive sleep apnea had standard tympanometry measurements while wearing a CPAP device. Measurements were taken at baseline and with CPAP air pressures of 0, 5, 10, and 15 cm H(2)O.The percentage of normal control patients with middle ear pressures above 40 daPa was 0.03%. In the study population, prior to a swallowing maneuver to open the eustachian tube, average middle ear pressures were 21.67 daPa, 22.63 daPa, 20.42, daPa, and 21.58 daPa with CPAP pressures of 0, 5, 10, and 15 cm H(2) 0, respectively. After swallowing, average middle ear air pressures were 18.83 daPa, 46.75 daPa, 82.17 daPa, and 129.17 daPa with CPAP pressures of 0, 5, 10, and 15 cm H(2)0, respectively. The postswallow Pearson correlation coefficient correlating CPAP and middle ear pressures was 0.783 (P < 0.001).Middle ear air pressure is directly proportional to CPAP air pressure in subjects with normal eustachian tube function. Middle ear pressure reaches supraphysiologic levels at even minimal CPAP levels. Although further investigation is necessary, there may be otologic implications for patients who are chronically CPAP dependent. These findings may also influence the perioperative practice of otologic and skull base surgeons.
View details for DOI 10.1002/lary.22442
View details for Web of Science ID 000300680200035
View details for PubMedID 22252535
Sleep medicine clinical and surgical training during otolaryngology residency: a national survey of otolaryngology residency programs.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
2011; 145 (6): 1043-1048
The authors sought to assess the otolaryngology residency training experiences in adult sleep medicine and sleep surgery in the United States.Internet survey.US academic otolaryngology residency programs.This Internet survey was emailed to the program directors of 103 US Accreditation Council for Graduate Medical Education (ACGME)-approved otolaryngology residency programs in 2010.A total of 47 program directors responded, representing 46% of programs surveyed. In 59% of these programs, there was at least 1 faculty member with clinical practice dedicated to adult medicine. Most commonly, these clinicians spent less than 50% of their clinical time on adult sleep medicine. While most otolaryngology residents were reported being well trained in commonly performed procedures such as septoplasty and uvulopalatopharyngoplasty (UPPP), the training on hypopharyngeal or multilevel surgeries, such as partial glossectomy, tongue base resection, hyoid or tongue suspension, or geniotubercle advancement, was considered less frequent. The overall exposure to education regarding the interpretation of original data of laboratory-based sleep studies or portable home monitoring devices was infrequent. A significant portion of respondents indicated that they would like to expand their residents' exposure to adult sleep medicine and sleep surgery.This survey provides a starting point to further assess the rigor of sleep medicine/sleep surgery training in US residency programs. Continued assessment and strengthening of the current curriculum are crucial to keep residents up to date with this evolving field. This result calls attention to the importance of bolstering sleep medicine and surgery curriculum to meet the academic requirements of otolaryngology training.
View details for DOI 10.1177/0194599811416765
View details for PubMedID 21791704
- Sleep Medicine Clinical and Surgical Training during Otolaryngology Residency: A National Survey of Otolaryngology Residency Programs OTOLARYNGOLOGY-HEAD AND NECK SURGERY 2011; 145 (6): 1043-1048
Caregiver Reports of Sleep Problems in Non-Hispanic White, Hispanic, and African American Patients with Alzheimer Dementia
JOURNAL OF CLINICAL SLEEP MEDICINE
2010; 6 (3): 281-289
Sleep problems are common in persons with dementing illnesses and among the most stressful patient behaviors for caregivers. Although studies have shown differences in sleep across ethnic groups, little information is available on ethnic differences among persons with dementia. The purpose of this study was to investigate possible ethnic differences in sleep problems among patients with Alzheimer dementia.Caregiver reports of 5 sleep- or circadian rhythm-related behavioral problems (behavior disturbance worse in the evening, difficulties falling asleep, frequent awakenings, early awakenings, and excessive daytime sleep) were evaluated in 395 patients who had received a diagnosis of Alzheimer disease after diagnostic evaluation. The average cognitive score of the groups suggested that they could be characterized as having moderately severe impairment. The frequency of sleep problems was then evaluated across subgroups defined by self-reported ethnicity (African American, Hispanic, and non-Hispanic white). As patient and caregiver characteristics may affect caregivers' reports of patients' behaviors, mixed effects regression models were used to adjust for patient and caregiver variables that might affect caregiver reports.Analyses revealed ethnic differences in sleep or circadian rhythm disturbances. African American and Hispanic patients were reported to have more severe sleep disturbances than non-Hispanic whites. After correction for patient and caregiver variables that might have affected caregiver reports, differences between African Americans and others remained.Sleep problems in patients with dementing illnesses are reported by caregivers with differing frequencies across groups of African Americans, Hispanics, and non-Hispanic whites. Clinicians should be aware of these differences in assessing sleep disturbance in patients with dementia as well as the potential effects of patient and caregiver variables on reports of these problems.
View details for Web of Science ID 000278786300011
View details for PubMedID 20572423
Endoscopic resection of inverted papilloma: University of Miami experience
Meeting of the American-Rhinologic-Society
OCEAN SIDE PUBLICATIONS INC. 2003: 185–90
The aim of this study was to evaluate the efficacy and safety of endoscopically resecting paranasal sinus inverted papillomas at a tertiary medical center.Over a 9-year period, 51 patients with a diagnosis of inverted papilloma underwent endoscopic resection at the University of Miami/Jackson Memorial Medical Center. The study group consisted of 14 women and 37 men with a mean age of 59 years (range, 20-88 years) enrolled in a clinical data base. All of the patients were followed endoscopically at regular intervals on an outpatient basis.Endoscopic evidence of extensive papillomas involving the anterior and posterior ethmoid sinuses and at least one (usually the maxillary) dependent sinus was found in 60% of the cases. Extensive radiological disease (varying degrees of mucoperiosteal thickening or opacification of all five cavities) was evident in 50% of the cases. All but two had unilateral disease. An association with chronic inflammatory polyps (clinically and pathologically) was observed in 25 of 51 patients (49%). Follow-up ranged from 6 to 99 months (mean, 30 months). There have been seven recurrences (14%). Four of these have been managed in the office under topical anesthesia. Three recurrences were managed surgically in the operating room. All of the patients have been free of disease. Complications included an intraoperative CSF leak (three patients); temporary infraorbital hypesthesia (three patients); periorbital ecchymosis, hematoma, or cheek edema (four patients); and orbital symptoms (two patients). Carcinoma was found in four patients (8%) who received postoperative radiotherapy and remain free of disease.The endoscopic approach continues to provide at least equivalent short-term results as compared with external techniques for the removal of paranasal sinus inverted papilloma. The final cavity should allow for adequate postoperative surveillance and potential resection of recurrences in the office setting, without the need for a return to the operating room in most patients. The association of inverted papilloma with chronic inflammatory polyps and tobacco use warrants additional study.
View details for Web of Science ID 000185068000002
View details for PubMedID 12962186