Dr. Capasso is the Chief of Sleep Surgery, Professor of Otolaryngology and Head and Neck Surgery, Associate Dean of Research at Stanford University School of Medicine and Advisor to the Stanford Byers Center for Biodesign. His medical training includes Head and Neck Surgery, Neurosciences and Sleep Medicine. He has done research and published extensively on pre-treatment evaluation and surgical treatment of obstructive sleep apnea and currently his research interests have a focus on clinical utilization of large datasets and consumer-based devices for sleep disordered breathing management. The local and international recognition of this 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 30 countries, and dozens of Stanford Biodesign students who developed healthcare companies in the Bay Area, Japan, Brazil and Singapore, with the goal to utilize this acquired experience to foster health innovation training of multidisciplinary teams and engineers with broad impact globally. He is a member of the Stanford Medical Leadership Academy, an initiative to foster the development of innovative leadership across and outside departments at the School of Medicine and in the role of Associate Dean of Research I assist the Dean’s office and our CTSA group for the strategic development of translational research.

Clinical Focus

  • Sleep Surgery
  • Biodesign
  • Sleep Medicine

Academic Appointments

Administrative Appointments

  • Associate Dean of Research, Stanford Medicine (2020 - Present)
  • Chief, Division of Sleep Surgery, Stanford University Department of Otolaryngology, Head and Neck Surgery (2010 - Present)

Boards, Advisory Committees, Professional Organizations

  • Member, American Academy of Otolaryngology (2010 - Present)
  • Fellow, American Academy of Sleep Medicine (2011 - Present)
  • Member, Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head & Neck Surgery (2019 - Present)
  • Board Member at Large, International Sleep Surgery Society (2020 - Present)
  • Member, Health Information Management Committee, Stanford University School of Medicine (2020 - Present)

Professional Education

  • Fellowship, Stanford University, Sleep Medicine (2008)
  • Fellowship: Jackson Memorial Hospital (2001) FL
  • Residency: Jackson Memorial Hospital/University of Miami (2007) FL
  • Board Certification: American Board of Otolaryngology, Otolaryngology (2018)
  • Board Certification, Otolaryngology Head and Neck Surgery, American Board of Otolaryngology, Head and Neck Surgery (2018)
  • Residency: Universidade Federal Do Parana (1999) Brazil
  • Medical Education: Universidade Federal Do Parana (1995) Brazil

Community and International Work

  • Global Advisor: Biodesign


    Global Health Innovation



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Clinically relevant outcomes for OSA Surgery.
Wearables and Digital Health Technologies for Sleep.
Innovative approaches for OSA Management.
Innovation in Sleep and Otolaryngology

2023-24 Courses

All Publications

  • Health Inequalities in the Diagnosis and Treatment of Obstructive Sleep Apnea in Children and Adults. Otolaryngologic clinics of North America Howard, J. J., Capasso, R., Ishman, S. L. 2024


    Our understanding of the prevalence of obstructive sleep apnea (OSA) in the United States is confounded by significant inequalities in diagnosis and treatment based on gender, race and socioeconomic status. Health literacy and cultural norms contribute to these inequities. Large gaps in data exist, as certain populations like Native Americans, Pacific Islanders, and sexual minorities have been sparsely studied, or not at all. Future research should aim to develop more inclusive diagnostic strategies to address OSA in diverse populations.

    View details for DOI 10.1016/j.otc.2024.02.004

    View details for PubMedID 38485537

  • Value of Surgical and Nonsurgical Treatment for Sleep Apnea: A Closer Look at Healthcare Utilization. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Abdelwahab, M., Marques, S., Huang, A., De Moraes, T. P., Previdelli, I., Cruz, J. A., Al-Sayed, A. A., Capasso, R. 2023


    To determine how surgery, continuous positive airway pressure (CPAP), and no treatment impact healthcare utilization in patients who have obstructive sleep apnea (OSA).This is a retrospective cohort study of patients between the ages of 18 and 65 that were diagnosed with OSA (9th International Classification of Diseases) from January 2007 to December 2015. Data were collected over 2 years, and prediction models were generated to evaluate trends over time.A population-based study using real-world data and insurance databases.A total of 4,978,649 participants were identified, all with at least 25 months of continuous enrollment. Patients with previous soft tissue procedures not approved for OSA (nasal surgery), or without continuous insurance coverage were excluded. A total of 18,050 patients underwent surgery, 1,054,578 were untreated, and 799,370 received CPAP. IBM Marketscan Research database was utilized to describe patient-specific clinical utilization, and expenditures, across outpatient, and inpatient services, and medication prescriptions.When the cost of the intervention was eliminated in the 2-year follow-up, the monthly payments of group 1 (surgery) were significantly less than group 3 (CPAP) in overall, inpatient, outpatient, and pharmaceutical payments (p < .001). The surgery group was associated with less cumulative payments compared to the other 2 groups when the cost of the intervention (CPAP or surgery) was eliminated in all comorbidities and age groups.Treating OSA with surgery can lessen overall healthcare utilization compared to no treatment and CPAP.

    View details for DOI 10.1002/ohn.175

    View details for PubMedID 36794772

  • Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Fleury Curado, T., Pham, L., Otvos, T., Klopfer, T., Freire, C., Amorim, M. R., Nishimura, Y., Sennes, L. U., Psoter, K. J., Abdelwahab, M., Huang, A., Dedhia, R., Liu, S., Capasso, R., Oliven, A., Polotsky, V., Eisele, D., Schwartz, A. 2023


    STUDY OBJECTIVES: The major goal of the study was to determine whether changes in tongue morphology under selective hypoglossal nerve therapy for OSA were associated with alterations in airway patency during sleep when specific portions of the hypoglossal nerve were stimulated.METHODS: This case series was conducted at the Johns Hopkins Sleep Disorders Center at Johns Hopkins Bayview Medical Center. Twelve apneic patients implanted with a multi-channel targeted hypoglossal nerve stimulating system underwent mid-sagittal ultrasound tongue imaging during wakefulness. Changes in tongue shape were characterized by measuring its vertical height and polar dimensions between tongue surface and genioglossi origin in the mandible. Changes in patency were characterized by comparing airflow responses between stimulated and adjacent unstimulated breaths during NREM sleep.RESULTS: Two distinct morphologic responses were observed. Anterior tongue base and hyoid-bone movement (5.4(0.4) to 4.1(1.0)cm (median, IQR)) with concomitant increases in tongue height (5.0(0.9) to 5.6(0.7)cm) were associated with decreases in airflow during stimulation. In contrast, comparable anterior hyoid movement (tongue protrusion from 5.8(0.5) to 4.5(0.9)cm) without significant increases in height (5.2(1.6) to 4.6(0.8)cm) were associated with marked increases in in airflow during sleep.CONCLUSIONS: Tongue protrusion with preservation of tongue shape predicted increases in patency, whereas anterior movement with concomitant increases in height were associated with decreased pharyngeal patency. These findings suggest that pharyngeal patency can be best stabilized by stimulating lingual muscles that maintain tongue shape while protruding the tongue, thereby preventing it from prolapsing posteriorly during sleep.

    View details for DOI 10.5664/jcsm.10474

    View details for PubMedID 36727502

  • EEG response of dexmedetomidine during drug induced sleep endoscopy. Frontiers in neuroscience Han, L., Drover, D. R., Chen, M. C., Saxena, A. R., Eagleman, S. L., Nekhendzy, V., Pritchard, A., Capasso, R. 2023; 17: 1144141


    Introduction: Dexmedetomidine is one of the anesthetics of choice for drug induced sleep endoscopy (DISE), with advantages including limited respiratory depression, analgesia, and decreased incidence of emergence delirium. However, challenges with determining sedation levels and prolonged recovery have limited its usage. An improved understanding of the effect of dexmedetomidine on the level of sedation and the corresponding electroencephalographic (EEG) changes could help overcome these barriers.Methods: Fifty-one patients received dexmedetomidine sedation with Richmond Agitation-Sedation Scale (RASS) score assessment and continuous EEG monitoring via SedLine for DISE. We constructed a pharmacokinetic model to determine continuous dexmedetomidine blood concentration. From the SedLine, we extracted the patient state index (PSI), and from the EEG we calculated the spectral edge frequency 95% (SEF95) and the correlation dimension (CD), a type of fractal dimension used to assess the complexity of a system. These metrics were subsequently compared against one another and with the dexmedetomidine concentration.Results: Our pharmacokinetic model yielded a two-compartment model with volumes of 51.8L and 106.2L, with clearances of 69.5 and 168.9L/h, respectively, and a time to effect of 9min, similar to prior studies. Based on this model, decreasing RASS score, SEF95, CD, and PSI were all significantly associated with increasing dexmedetomidine concentration (p<0.001, p=0.006, p<0.001 respectively). The CD, SEF95, and PSI better captured the effects of increasing dexmedetomidine concentration as compared to the RASS score. Simulating dexmedetomidine concentration based on titration to target levels derived from CD and PSI confirmed commonly used dexmedetomidine infusion dosages.Conclusion: Dexmedetomidine use for DISE confirmed previous pharmacokinetic models seen with dexmedetomidine. Complex EEG metrics such as PSI and CD, as compared to RASS score and SEF95, better captured changes in brain state from dexmedetomidine and have potential to improve the monitoring of dexmedetomidine sedation.

    View details for DOI 10.3389/fnins.2023.1144141

    View details for PubMedID 37521700

  • Evaluation of patient state index, bispectral index, and entropy during drug induced sleep endoscopy with dexmedetomidine. Journal of clinical monitoring and computing Han, L., Drover, D. R., Chen, M. C., Saxena, A. R., Eagleman, S. L., Nekhendzy, V., Capasso, R. 2022


    Multiple electroencephalographic (EEG) monitors and their associated EEG markers have been developed to aid in assessing the level of sedation in the operating room. While many studies have assessed the response of these markers to propofol sedation and anesthetic gases, few studies have compared these markers when using dexmedetomidine, an alpha-2 agonist. Fifty-one patients underwent drug induced sleep endoscopy with dexmedetomidine sedation. Continuous EEG was captured using SedLine (Masimo, Inc), and a playback system was used to extract the bispectral index (BIS) (Medtronic Inc), the patient state index (PSI) (Masimo, Inc), the state and response Entropy (GE Healthcare), and calculate the spectral edge frequency 95% (SEF95). Richmond Agitation-Sedation Scale (RASS) scores were assessed continually throughout the procedure and in recovery. We assessed the correlation between EEG markers and constructed ordinal logistic regression models to predict the RASS score and compare EEG markers. All three commercial EEG metrics were significantly associated with the RASS score (p<0.001 for all metrics) whereas SEF95 alone was insufficient at characterizing dexmedetomidine sedation. PSI and Entropy achieved higher accuracy at predicing deeper levels of sedation as compared to BIS (PSI: 58.3%, Entropy: 58.3%, BIS: 44.4%). Lightening secondary to RASS score assessment is significantly captured by all three commercial EEG metrics (p<0.001). Commercial EEG monitors can capture changes in the brain state associated with the RASS score during dexmedetomidine sedation. PSI and Entropy were highly correlated and may be better suited for assessing deeper levels of sedation.

    View details for DOI 10.1007/s10877-022-00952-9

    View details for PubMedID 36550344

  • Automatic scoring of drug-induced sleep endoscopy for obstructive sleep apnea using deep learning. Sleep medicine Hanif, U., Kiaer, E. K., Capasso, R., Liu, S. Y., Mignot, E. J., Sorensen, H. B., Jennum, P. 2022; 102: 19-29


    Treatment of obstructive sleep apnea is crucial for long term health and reduced economic burden. For those considered for surgery, drug-induced sleep endoscopy (DISE) is a method to characterize location and pattern of sleep-related upper airway collapse. According to the VOTE classification system, four upper airway sites of collapse are characterized: velum (V), oropharynx (O), tongue (T), and epiglottis (E). The degree of obstruction per site is classified as 0 (no obstruction), 1 (partial obstruction), or 2 (complete obstruction). Here we propose a deep learning approach for automatic scoring of VOTE obstruction degrees from DISE videos.We included 281 DISE videos with varying durations (6 s-16 min) from two sleep clinics: Copenhagen University Hospital and Stanford University Hospital. Examinations were split into 5-s clips, each receiving annotations of 0, 1, 2, or X (site not visible) for each site (V, O, T, and E), which was used to train a deep learning model. Predicted VOTE obstruction degrees per examination was obtained by taking the highest predicted degree per site across 5-s clips, which was evaluated against VOTE degrees annotated by surgeons.Mean F1 score of 70% was obtained across all DISE examinations (V: 85%, O: 72%, T: 57%, E: 65%). For each site, sensitivity was highest for degree 2 and lowest for degree 0. No bias in performance was observed between videos from different clinicians/hospitals.This study demonstrates that automating scoring of DISE examinations show high validity and feasibility in degree of upper airway collapse.

    View details for DOI 10.1016/j.sleep.2022.12.015

    View details for PubMedID 36587544

  • High prevalence of persistent smell loss and qualitative smell dysfunction during the COVID-19 pandemic in the United States: urgent need for clinical trials. International forum of allergy & rhinology Lechner, M., Liu, J., Counsell, N., Yan, C. H., Paun, S., Eynon-Lewis, N., Sutton, L., Jayaraj, S., Batterham, R. L., Hopkins, C., Philpott, C., Lund, V. J., Hatter, M., Abdelwahab, M., Holsinger, F. C., Capasso, R., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2022

    View details for DOI 10.1002/alr.23100

    View details for PubMedID 36409559

  • Safety of tongue base procedures for sleep apnoea in adults: A systematic review and metanalysis from the YO-IFOS study group. Acta otorrinolaringologica espanola Calvo-Henriquez, C., Boronat-Catala, B., Rivero-Fernandez, I., Camarotto, G., Ibrahim, B., Lechien, J. R., Martinez-Capoccioni, G., Carrasco-Llatas, M., Capasso, R., Martin-Martin, C. 2022; 73 (6): 384-393


    OBJECTIVE: Tongue base and hypopharynx are the major sites of obstruction in OSA patients with failed palatal surgery. In recent years, several minimally invasive procedures have been developed to address tongue base obstruction. However, the research focus has consistently been on the effectiveness of surgery in reducing obstructive sleep apnoea rather than on postoperative complications. In this systematic review and metanalysis we aim to review the complication rate of minimally invasive base of tongue procedures for OSAS in adults.DATA SOURCES: PubMed (Medline), the Cochrane Library, EMBASE, Scopus, SciELO and Trip Database.REVIEW METHODS: Data sources were checked by three authors of the YO-IFOS sleep apnoea study group. Three authors extracted the data. Main outcome was expressed as the complication rate and 95% confidence interval for each surgical technique.RESULTS: 20 studies (542 patients) met the inclusion criteria. The mean complication rate is 12.79%; 4.65% for minor complications, 6.42% if they are moderate, and 1.77% if severe. The most reported complication overall is infection, in 1.95% of cases, followed by transient swallowing disorder, occurring in 1.30% of the total sample.CONCLUSION: The heterogeneity amongst the included studies prevents us from obtaining solid conclusions. The available evidence suggests that minimally invasive base of tongue procedures may present a wide spectrum of complication rates, ranging from 4.4% in tongue base radiofrequency to up to 42.42% in tongue base ablation.

    View details for DOI 10.1016/j.otoeng.2021.10.004

    View details for PubMedID 36404101

  • Safety of tongue base procedures for sleep apnoea in adults: A systematic review and metanalysis from the YO-IFOS study group ACTA OTORRINOLARINGOLOGICA ESPANOLA Calvo-Henriquez, C., Boronat-Catala, B., Rivero-Fernandez, I., Camarotto, G., Ibrahim, B., Lechien, J. R., Martinez-Capoccioni, G., Carrasco-Llatas, M., Capasso, R., Martin-Martin, C. 2022; 73 (6): 384-393
  • International consensus statement on obstructive sleep apnea. International forum of allergy & rhinology Chang, J. L., Goldberg, A. N., Alt, J. A., Ashbrook, L., Auckley, D., Ayappa, I., Bakhtiar, H., Barrera, J. E., Bartley, B. L., Billings, M. E., Boon, M. S., Bosschieter, P., Braverman, I., Brodie, K., Cabrera-Muffly, C., Caesar, R., Cahali, M. B., Cai, Y., Cao, M., Capasso, R., Caples, S. M., Chahine, L. M., Chang, C. P., Chang, K. W., Chaudhary, N., Cheong, C. S., Chowdhuri, S., Cistulli, P. A., Claman, D., Collen, J., Coughlin, K., Creamer, J., Davis, E. M., Dupuy-McCauley, K. L., Durr, M. L., Dutt, M., Ali, M. E., Elkassabany, N. M., Epstein, L. J., Fiala, J. A., Freedman, N., Gill, K., Gillespie, M. B., Golisch, L., Gooneratne, N., Gottlieb, D. J., Green, K. K., Gulati, A., Gurubhagavatula, I., Hayward, N., Hoff, P. T., Hoffmann, O. M., Holfinger, S. J., Hsia, J., Huntley, C., Huoh, K. C., Huyett, P., Inala, S., Ishman, S., Jella, T. K., Jobanputra, A. M., Johnson, A. P., Junna, M. R., Kado, J. T., Kaffenberger, T. M., Kapur, V. K., Kezirian, E. J., Khan, M., Kirsch, D. B., Kominsky, A., Kryger, M., Krystal, A. D., Kushida, C. A., Kuzniar, T. J., Lam, D. J., Lettieri, C. J., Lim, D. C., Lin, H., Liu, S. Y., MacKay, S. G., Magalang, U. J., Malhotra, A., Maurer, J. T., May, A. M., Mitchell, R. B., Mokhlesi, B., Mullins, A. E., Nada, E. M., Naik, S., Nokes, B., Olson, M. D., Pack, A. I., Pang, E. B., Pang, K. P., Patil, S. P., de Perck, E. V., Piccirillo, J. F., Pien, G. W., Piper, A. J., Plawecki, A., Quigg, M., Ravesloot, M. J., Redline, S., Rotenberg, B. W., Ryden, A., Sarmiento, K. F., Sbeih, F., Schell, A. E., Schmickl, C. N., Schotland, H. M., Schwab, R. J., Seo, J., Shah, N., Shelgikar, A. V., Shochat, I., Soose, R. J., Steele, T. O., Stephens, E., Stepnowsky, C., Strohl, K. P., Sutherland, K., Suurna, M. V., Thaler, E., Thapa, S., Vanderveken, O. M., de Vries, N., Weaver, E. M., Weir, I. D., Wolfe, L. F., Woodson, B. T., Won, C. H., Xu, J., Yalamanchi, P., Yaremchuk, K., Yeghiazarians, Y., Yu, J. L., Zeidler, M., Rosen, I. M. 2022


    BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea is needed to consolidate and summarize key factors important for clinical management of the OSA adult patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA and treatment on the multiple comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.CONCLUSION: This review of the literature in OSA consolidates the available knowledge and identifies the limitations of the current evidence. This effort aims to highlight the basis of OSA evidence-based practice and identify future research needs. Knowledge gaps and opportunities for improvement include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23079

    View details for PubMedID 36068685

  • Does race-ethnicity affect upper airway stimulation adherence and treatment outcome of obstructive sleep apnea? Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Khan, M., Stone, A., Soose, R. J., Cohen, S. M., Howard, J., Capasso, R., Itayem, D., Gillespie, M. B., Mehra, R., Chio, E., Strollo, P. J., Menzl, A., Kaplan, A., Ni, Q. 2022


    STUDY OBJECTIVES: Untreated obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness, decreased quality of life, and cardiovascular disease. Positive airway pressure (PAP) is the first-line therapy for OSA, however, adherence is difficult. Upper airway stimulation (UAS) is an FDA approved treatment of OSA. The objective of this study was to evaluate for a difference in treatment efficacy and adherence of upper airway stimulation therapy for OSA between individuals who are White and non-White using data from the ADHERE registry.METHODS: ADHERE registry is a multicenter prospective study of real-world experience of UAS for treatment of OSA in the US and Europe. Propensity score matching was used to create a balanced data set between the White and non-White groups. T-tests at a significance level of 5% were used to compare numeric values between groups.RESULTS: There were 2,755 participants of the ADHERE registry. 27 were excluded due to not having a race identified. 125 participants identified as non-White, 2,603 identify as White, and 27 did not provide race information. Propensity score matching was used to select 110 participants with 55 White and 55 non-White for the non-inferiority analysis. We did not find a difference in adherence, treatment AHI, changes in Epworth Sleepiness Scale Score, or clinical global impression after intervention score between White and non-White individuals.CONCLUSIONS: Our study found that there was no statistically significant difference in adherence or efficacy with UAS therapy between White and non-White individuals. However, the percent of non-White people implanted is low which suggests a need to expand access to this therapy for non-White populations with OSA who cannot tolerate PAP therapy.

    View details for DOI 10.5664/jcsm.10068

    View details for PubMedID 35681251

  • Patient and family experience with telemedicine and in-person pediatric and obstetric ambulatory encounters throughout 2020, during the COVID-19 epidemic: the distance effect. BMC health services research Marques, S., Cruz, J. A., da Cunha, M. A., Tuon, F. F., de Moraes, T. P., Daiane Zdziarski, A., Bomher, S. T., Donnelly, L. F., Capasso, R. 2022; 22 (1): 659


    BACKGROUND: Telemedicine has grown significantly in recent years, mainly during the COVID-19 pandemic, and there has been a growing body of literature on the subject. Another topic that merits increased attention is differences in patient and family experience between telehealth and in-person visits. To our team's knowledge, this is the first study evaluating pediatric and obstetrics outpatients experience with telemedicine and in-person visit types in an academic maternal and children's hospital, and its correlation with geographic distance from the medical center throughout 2020, during the COVID-19 crisis.METHODS: We aim to evaluate and compare patients' telemedicine and in-person experience for ambulatory encounters based on survey data throughout 2020, during the COVID-19 pandemic, with particular focus on the influence of distance of the patient's home address from the medical facility. A total of 9,322 patient experience surveys from ambulatory encounters (6,362 in-person and 2,960 telemedicine), in a maternal and children's hospital during 2020 were included in this study. The percentage of patients who scored the question "Likelihood to recommend practice" with a maximum 5/5 (top box) score was used to evaluate patient experience. The k-means model was used to create distance clusters, and statistical t-tests were conducted to compare mean distances and Top Box values between telemedicine and in-person models. Logistic regression analysis was used to evaluate the correlation between Top Box scores and patients' distance to the hospital.RESULTS: Top Box likelihood to recommend percentages for in-person and telemedicine were comparable (in-person=81.21%, telemedicine=81.70%, p-value=0.5624). Mean distance from the hospital was greater for telemedicine compared to in-person patients (in-person=48.89 miles, telemedicine=61.23 miles, p-value<0.01). Patients who live farther displayed higher satisfaction scores regardless of the visit type (p-value<0.01).CONCLUSIONS: There is a direct relationship between the family experience and the distance from the considered medical center, during year 2020, i.e., patients who live farther from the hospital record higher Top Box proportion for "Likelihood to Recommend" than patients who live closer to the medical center, regardless of the approach, in-person or telemedicine.

    View details for DOI 10.1186/s12913-022-08037-8

    View details for PubMedID 35578239

  • Body mass index is superior to other body adiposity indexes in predicting incident hypertension in a highly admixed sample after 10-year follow-up: The Baependi Heart Study. Journal of clinical hypertension (Greenwich, Conn.) Maciel de Oliveira, C., Franca da Rosa, F., de Oliveira Alvim, R., Mourao Junior, C. A., Bacells, M., Liu, C., Pavani, J., Capasso, R., Lavezzo Dias, F. A., Eduardo Krieger, J., Costa Pereira, A. 2022


    Hypertension is the leading cause of overall mortality in low- and middle-income countries. In Brazil, there is paucity of data on the determinants of incident hypertension and related risk factors. We aimed to determine the incidence of hypertension in a sample from the Brazilian population and investigate possible relationships with body adiposity indexes. We assessed risk factors associated with cardiovascular disease, including adiposity body indexes and biochemical analysis, in a sample from the Baependi Heart Study before and after a 10-year follow-up. Hypertension was defined by the presence of systolic blood pressure (SBP) ≥140mmHg and/or diastolic blood pressure ≥90mmHg or the use of antihypertensive drugs. From an initial sample of 1693 participants, 498 (56% women; mean age 38 ± 13 years) were eligible to be included. The overall hypertension incidence was 24.3% (22.3% in men and 25.6% in women). Persons who developed hypertension had higher prevalence of obesity, higher levels for blood pressure, higher frequency of dyslipidemia, and higher body adiposity indexes at baseline. The best prediction model for incident hypertension includes age, sex, HDL-c, SBP, and Body Mass Index (BMI) [AUC=0.823, OR=1.58 (95% CI 1.23-2.04)]. BMI was superior in its predictive capacity when compared to Body Adiposity Index (BAI), Body Roundness Index (BRI), and Visceral Adiposity Index (VAI). Incident hypertension in a sample from the Brazilian population was 24.3% after 10-year follow-up and BMI, albeit the simpler index to be calculated, is the best anthropometric index to predict incident hypertension.

    View details for DOI 10.1111/jch.14480

    View details for PubMedID 35543312

  • Incidence and risk factors of chronic opioid use after sleep apnea surgery. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Abdelwahab, M., Marques, S., Howard, J., Huang, A., Lechner, M., Olds, C., Capasso, R. 2022


    STUDY OBJECTIVES: To assess the incidence and risk factors of chronic opioid use after OSA surgery.METHODS: Using IBM MarketScan research database, adults (>18) who underwent a variety of sleep surgery procedures between 2007 and 2015, were identified. Subjects with one year of insurance coverage before and after the surgical procedure were included. Additional anesthesia event(s) in the year following the procedure of interest, and those who filled an opioid prescription within the year prior to surgery (not naive) were excluded. Outcomes included rates of persistent opioid use (additional opioid prescriptions filled 90-180 days postoperatively), prolonged use (additional opioid prescriptions filled 181-365 days postoperatively) and inappropriate use (>100 MME). Evaluated variables include demographics, surgical procedures, and comorbidities.RESULTS: A total of 10,766 surgical procedures met inclusion criteria. There was a trend of increased rates of perioperative opioid prescription. After multivariable logistic regression analysis, perioperative opioid prescription and smoking were independent risk factors for inappropriate opioid use (OR= 31.51, p<0.001; OR= 1.41, p=0.016 respectively). Opioid prescription and hypertension were independent risk factors for persistent opioid use (OR=37.8, p<0.001, OR=1.38, p=0.008). Perioperative opioid prescription, previous opioid dependence diagnosis, smoking and male gender were associated with continuous prolonged opioid use (OR=73.1, 8.13, 1.95, 1.55, respectively; p<0.001, 0.020, 0.024, 0.032, respectively).CONCLUSIONS: While efforts by different societies are being implemented to control the opioid crisis, we found that perioperative opioid prescription for airway surgery targeting OSA is an independent risk factor for persistent, prolonged, and inappropriate opioid use.

    View details for DOI 10.5664/jcsm.9978

    View details for PubMedID 35393936

  • A Minimally Invasive Nasal Endoscopic Approach to Distraction Osteogenesis Maxillary Expansion to Restore Nasal Breathing for Adults with Narrow Maxilla. Facial plastic surgery & aesthetic medicine Liu, S. Y., Ibrahim, B., Abdelwahab, M., Chou, C., Capasso, R., Yoon, A. 2022


    Background: Patients with narrow high-arch palate present with limited response to standard septal, turbinate, and valve procedures for nasal obstruction. Objective: To measure the effectiveness of minimally invasive nasal endoscopic (MINE) Lefort I osteotomy among subjects with narrow high-arched palate in managing nasal obstruction. Methods: Prospective cohort study was performed where subjects with narrow high-arched palate underwent MINE distraction osteogenesis maxillary expansion (DOME) from August 2019 to January 2021. Nasal obstruction symptom evaluation (NOSE) score, mean time to opioid cessation, and mean duration of cranial nerve V2 hypoesthesia were evaluated. Results: Among 12 subjects, the. mean NOSE score decreased from 58.89 to 15.83 (p=0.004). There were no complaints of lip mobility or deformity. Conclusion: MINI-DOME can reduce nasal obstruction in a certain phenotype of patients and further improve patient-centric outcomes by limiting the approach to the Lefort I osteotomy to an endoscopic nasal approach.

    View details for DOI 10.1089/fpsam.2021.0154

    View details for PubMedID 35179990

  • Surgical procedure and treatment results of pharyngoplasty CWICKs for obstructive sleep apnea. Auris, nasus, larynx Inoue, D., Chiba, S., Kondo, M., Ikeda, K., Watanabe, S., Kitamura, K., Yagi, T., Tar, T. S., Capasso, R. 1800


    OBJECTIVE: Uvulopalatopharyngoplasty (UPPP) is performed as a surgical treatment at the oropharyngeal level for obstructive sleep apnea, but there are problems with variations in treatment effects and postoperative complications. Therefore, to improve those, we have devised and put into practice the so-called CWICKs, which is a modified version of barbed reposition pharyngoplasty as a surgical method. We outline the procedure of CWICKs and report the treatment results in comparison with the conventional UPPP.METHODS: CWICKs are surgeries that use resorbable wound closure devices to pull the posterior palatal arch outward and elevate it anteriorly and superiorly to maintain an open upper airway during sleep at the soft palate level. We compared the therapeutic effects of 46 patients evaluated by polysomnography before and after surgery among CWICKs performed in our department between January 2015 and December 2019 and 91 patients who underwent UPPP in our department between January 2000 and December 2008.RESULTS: In 46 patients who underwent CWICKs, significant improvement was observed before and after surgery using the apnea hypopnea index (AHI), obstructive apnea index (OAI), ration of each sleep stage, and SpO2 level > 90%. The improvement rate of AHI was 68.4%, and the surgical success rate was 58.7%. Postoperative patient satisfaction was also good, and significant improvement in subjective sleepiness (Epworth Sleepiness Scale) and subjective sleep quality (Pittsburgh Sleep Quality Index) was observed before and after surgery. No postoperative complications such as dysphagia or scar stenosis were observed in any of the patients in the CWICKs group. Compared with the 91 cases of UPPP, which is the conventional method, there was no significant difference in the improvement rate of AHI (p = 0.199), but the improvement rate of OAI had significantly improved (p = 0.013). Regarding the postoperative sleep stage, In the CWICKs group, a significant decrease in stage 1 and a significant increase in stage 2, stage 3, and stage rapid eye movement were observed, whereas in the UPPP group, no significant improvement in stage 3 was observed. Multivariate analysis of surgical success did not show an association with surgical methods (CWICKs or UPPP). On the other hand, an association was shown with age (<45), palatine tonsil size (≥3 / 5), high MPH (≥14 mm), and OAI rate (> 1/3).CONCLUSION: The treatment outcome of CWICKs was equal to or better than that of the conventional UPPP. Future follow-up is required for long-term prognosis, but no serious postoperative complications, such as dysphagia or scar stenosis, have been observed. CWICKs are considered to be minimally invasive, simple, and effective surgical procedures with few complications.

    View details for DOI 10.1016/j.anl.2021.11.015

    View details for PubMedID 34991916

  • Comparing different metabolic indexes to predict type 2 diabetes mellitus in a five years follow-up cohort: The Baependi Heart Study. PloS one de Oliveira, C. M., Pavani, J. L., Liu, C., Balcells, M., Capasso, R., Alvim, R. d., Mourao-Junior, C. A., Krieger, J. E., Pereira, A. C. 2022; 17 (6): e0267723


    This study evaluates the association of anthropometric indexes and the incidence of type 2 diabetes mellitus (T2DM) after a 5-year follow-up. This analysis included 1091 middle-aged participants (57% women, mean age 47 ± 15 years) who were free of T2DM at baseline and attended two health examinations cycles [cycle 1 (2005-2006) and cycle 2 (2010-2013)]. As expected, the participants who developed T2DM after five years (3.8%) had the worst metabolic profile with higher hypertension, dyslipidemia, and obesity rates. Besides, using mixed-effects logistic regression and adjustment for sex, age, and glucose, we found that one unit increase in body adiposity index (BAI) was associated with an 8% increase in their risk of developing T2DM (odds ratio [OR] = 1.08 [95% CI, 1.02-1.14]) and visceral adiposity index (VAI) was associated with a risk increase of 11% (OR = 1.11 [95% CI, 1.00-1.22]). Moreover, a one-unit increase in the triglycerides-glucose index (TyG) was associated with more than four times the risk of developing T2DM (OR = 4.27 [95% CI, 1.01-17.97]). The interquartile range odds ratio for the continuous predictors showed that TyG had the best discriminating performance. However, when any of them were additionally adjusted for waist circumference (WC) or even body mass index (BMI), all adiposity indexes lost the effect in predicting T2DM. In conclusion, TyG had the most substantial predictive power among all three indexes. However, neither BAI, VAI, nor TyG were superior to WC or BMI for predicting the risk of developing T2DM in a middle-aged normoglycemic sample in this rural Brazilian population.

    View details for DOI 10.1371/journal.pone.0267723

    View details for PubMedID 35657786

  • Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea. OTO open Cohen, S. M., Howard, J. J., Jin, M. C., Qian, J., Capasso, R. 2022; 6 (1): 2473974X221088870


    Objective: Determine risk factors for failure to receive surgical treatment among patients with obstructive sleep apnea.Study Design: Population-based observational longitudinal cohort study.Setting: Population-based database.Methods: Multivariate analysis of 500,792 individuals with obstructive sleep apnea from Optum's deidentified Clinformatics Data Mart database (2004-2018).Results: Black race, increased age, diabetes, atrial fibrillation, obesity, and congestive heart failure were independently associated with a decreased rate of surgery for obstructive sleep apnea. Asian race, hypertension, arrhythmias other than atrial fibrillation, pulmonary disease, and liver disease were independently associated with an increased rate of surgery for obstructive sleep apnea.Conclusion: Racial disparities in health outcomes related to health care access and in economic resources have an enormous impact on public health and social equity. We found differences in rates of surgery for obstructive sleep apnea based on race. These data are consistent with others demonstrating disparities in medical treatment of sleep apnea with positive pressure and underline a need for a change in awareness and treatment in these populations.

    View details for DOI 10.1177/2473974X221088870

    View details for PubMedID 35321423

  • Comparison Between Surgery and Continuous Positive Airway Pressure for Obstructive Sleep Apnea Treatment-Reply. JAMA otolaryngology-- head & neck surgery Ibrahim, B., Capasso, R. 2021

    View details for DOI 10.1001/jamaoto.2021.1831

    View details for PubMedID 34351409

  • Upper airway collapse characteristics in adult patients with OSA and previous tonsillectomy. Sleep & breathing = Schlaf & Atmung Zhao, C., Viana, A., Ma, Y., Capasso, R. 2021


    PURPOSE: To analyze upper airway (UA) collapse patterns through drug-induced sleep endoscopy (DISE) in adult patients withobstructive sleep apnea (OSA) who previously underwent tonsillectomy.METHODS: This was a retrospective study on patients withOSA who underwent DISE between June 1, 2013 and July 30, 2017 at Stanford Hospital. Subjects who had prior tonsillectomy history were classified into the tonsil0 group, whereas others were classified into the tonsil1 and tonsil2/3/4 group based on tonsil grade. UA collapse characteristics were recorded and analyzed among groups according to Velum, Oropharynx, Tongue base and Epiglottis (VOTE) classification.RESULTS: A total of 205 individuals were included, 38 in tonsil0 group, 104 in tonsil1 and 63 in tonsil2/3/4. The tonsil0 group had a higher percentage of anterior-posterior (AP) velum (58%) and tongue base (45%) collapse compared with the tonsil2/3/4 group (22%, P=0.0003 and 22%, P=0.02, respectively) but less oropharyngeal lateral wall collapses (29% vs 53%, P=0.02). Most of the tonsil0 group (70%) showed multi-sites collapse pattern, the percentage of combined obstruction in both palatopharyngeal and hypopharyngeal region was higher (50% vs 29%, P=0.03). The difference of velum complete AP collapse remained significant after adjusting for age and BMI (Odds Ratio=0.33, 95% CI 0.12-0.86, P=0.02). No significant differences were found between the tonsil0 and tonsil1 groups.CONCLUSION: Compared with individuals with larger tonsils (grade 2 to 4), those with previous tonsillectomy and OSA were susceptible to the velum AP configuration collapse. Diversity of multi-sites obstruction and combined collapse in both palatopharyngeal and hypopharyngeal level was the main characteristic.

    View details for DOI 10.1007/s11325-021-02451-8

    View details for PubMedID 34319500

  • A Comprehensive Strategy for Improving Nasal Outcomes after Large Maxillomandibular Advancement for Obstructive Sleep Apnea. Facial plastic surgery & aesthetic medicine Abdelwahab, M., Poomkonsarn, S., Ren, X., Awad, M., Capasso, R., Riley, R., Most, S., Liu, S. Y. 2021


    Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Objective: Describe a comprehensive strategy to optimize nasal outcomes with MMA for OSA. Methods: A retrospective review of patients undergoing MMA for OSA in a tertiary referral center was performed, with a comprehensive perioperative intervention to optimize nasal outcomes from January 2014 to February 2018. Outcomes included the Apnea-Hypopnea Index (AHI), oxygen saturation (SpO2) nadir, corrective nasal surgery needed after MMA, and Nasal Obstruction Symptom Evaluation (NOSE) scores. Results: AHI after MMA showed significant reduction (-34.65, p<0.001), SpO2 nadir increased (+6.08, p<0.001), and NOSE scores decreased (-5.96, p<0.001). Corrective nasal surgery needed after MMA was reported in 6.5% (8 of 122) subjects at a mean of 8.5 months, ranging from 1 to 24.7 months. Six subjects underwent either septoplasty and/or valve stenosis repair, and two subjects underwent functional and aesthetic rhinoplasty. Conclusion: A perioperative strategy was applied since 2014 that showed effectiveness in reducing post-MMA corrective nasal surgery to 6.5%.

    View details for DOI 10.1089/fpsam.2020.0569

    View details for PubMedID 34287054

  • Virtual otolaryngologic management of sleep apnea patients: Lessons learned from COVID-19 pandemic. Laryngoscope investigative otolaryngology Huntley, C., Boon, M., Ishman, S., Capasso, R., Crawford, J., D'Agostino, M. A., Hoff, P. 2021; 6 (3): 564-569


    To discuss the virtual management options and strategies learned during the COVID-19 pandemic for treatment of patients with sleep complaints and sleep disordered breathing presenting to the otolaryngologist.The addition of a virtual evaluation can be beneficial in assessing the patient presenting to the otolaryngologist with sleep complaints. With the implementation of telemedicine, validated subjective assessment tools, and a limited physical exam, patients can be triaged for the need for treatment implementation, further evaluation or testing, and counseled regarding various management options.In this article, we discuss the lessons learned from the authors' collective experience on how to effectively use telemedicine as a tool in the management repertoire for patients with sleep disorders.The otolaryngologist will commonly see patients with sleep complaints, particularly patients diagnosed with obstructive sleep apnea not able to tolerate conservative therapies. These patients are well suited for virtual evaluation utilizing telemedicine. The technology and workflows which have been developed during the COVID-19 pandemic can be carried forward for select patients to improve access and efficiency of care.Level of evidence: 5.

    View details for DOI 10.1002/lio2.562

    View details for PubMedID 34195378

    View details for PubMedCentralID PMC8223474

  • The Impact of Maxillary Expansion on Adults' Nasal Breathing: A Systematic Review and Meta-Analysis. American journal of rhinology & allergy Calvo-Henriquez, C., Megias-Barrera, J., Chiesa-Estomba, C., Lechien, J. R., Maldonado Alvarado, B., Ibrahim, B., Suarez-Quintanilla, D., Kahn, S., Capasso, R. 2021: 1945892421995350


    OBJECTIVE: Nasal surgery fails to restore nasal breathing in some cases. Maxillary constriction is suggested as a major cause of failure. It is thought that maxillary constriction leads to the closure of the internal and external nasal valves. Moreover, it is well established in the literature that maxillary expansion, both in adults and children, increases upper airway volume. However, it is yet unclear whether maxillary expansion may improve nasal function.Review Methods: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked by two authors from the Rhinology Study Group of the Young Otolaryngologists section of the International Federation of Otorhinolaryngological Societies. Two authors extracted the data. The main outcome was expressed as the value (in variable units) prior to treatment (T0), after expansion procedures (T1), after the retention period (T2), and after a follow-up period (T3).RESULTS: A total of 10 studies (257 patients) met the inclusion criteria. The data pooled in the meta-analysis reveals a statistically significant reduction of 0.27 Pa/cm3/s (CI 95% 0.15, 0.39) in nasal resistance after palatal expansion As far as subjective changes are concerned, the pooled data for the change in the NOSE score shows a statistically significant mean reduction after maxillary expansion of 40.08 points (CI 95% 36.28, 43.89).CONCLUSION: The initial available evidence is too limited to suggest maxillary expansion as a primary treatment option to target nasal breathing. However the data is encouraging with regards to the effect of maxillary expansion on nasal function. Further higher quality studies are needed in order to define clearer patient selection criteria, distinguish optimal techniques, and demonstrate long-term efficacy in long term follow up studies.

    View details for DOI 10.1177/1945892421995350

    View details for PubMedID 33583193

  • Association of Systemic Diseases With Surgical Treatment for Obstructive Sleep Apnea Compared With Continuous Positive Airway Pressure. JAMA otolaryngology-- head & neck surgery Ibrahim, B., de Freitas Mendonca, M. I., Gombar, S., Callahan, A., Jung, K., Capasso, R. 2021


    Importance: The efficacy of surgical treatments for obstructive sleep apnea (OSA) is variable when considering only the Apnea Hypopnea Index as the treatment end point. However, only a few studies have shown an association between these procedures and improved clinically relevant outcomes, such as cardiovascular, endocrine, and neurological sequelae of OSA.Objective: To evaluate the association of surgery for OSA with clinically relevant outcomes.Design, Setting, and Participants: This retrospective cohort study used the Truven MarketScan Database from January 1, 2007, to December 31, 2015, to identify all patients diagnosed with OSA who received a prescription of continuous positive airway pressure (CPAP), were 40 to 89 years of age, and had at least 3 years of data on file. Data were analyzed September 19, 2019.Interventions: Soft tissue and skeletal surgical procedures for the treatment of OSA.Main Outcomes and Measures: The occurrence of cardiovascular, neurological, and endocrine complications was compared in patients who received CPAP alone and those who received surgery. High-dimensionality propensity score matching was used to adjust the models for confounders. Kaplan-Meier survival analysis with a log-rank test was used to compare differences in survival curves.Findings: A total of 54 224 patients were identified (33 405 men [61.6%]; mean [SD] age, 55.1 [9.2] years), including a cohort of 49 823 patients who received CPAP prescription alone (mean [SD] age, 55.5 [9.4] years) and 4269 patients who underwent soft tissue surgery (mean [SD] age, 50.3 [7.0] years). The median follow-up time was 4.47 (interquartile range, 3-8) years after the index CPAP prescription. In the unadjusted model, soft tissue surgery was associated with decreased cardiovascular (hazard ratio [HR], 0.92; 95% CI, 0.86-0.98), neurological (HR, 0.49; 95% CI, 0.39-0.61), and endocrine (HR, 0.80; 95% CI, 0.74-0.86) events. This finding was maintained in the adjusted model (HR for cardiovascular events, 0.91 [95% CI, 0.83-1.00]; HR for neurological events, 0.67 [95% CI, 0.51-0.89]; HR for endocrine events, 0.82 [95% CI, 0.74-0.91]). Skeletal surgery (n=114) and concomitant skeletal and soft tissue surgery (n=18) did not demonstrate significant differences in rates of development of systemic complications.Conclusions and Relevance: In this cohort study, soft tissue surgery for OSA was associated with lower rates of development of cardiovascular, neurological, and endocrine systemic complications compared with CPAP prescription in a large convenience sample of the working insured US adult population. These findings suggest that surgery should be part of the early treatment algorithm in patients at high risk of CPAP failure or nonadherence.

    View details for DOI 10.1001/jamaoto.2020.5179

    View details for PubMedID 33475682

  • Perioperative Antibiotic Use in Sleep Surgery: Clinical Relevance. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Abdelwahab, M., Marques, S., Previdelli, I., Capasso, R. 2021: 1945998211048745


    Upper airway surgery is a common therapeutic approach recommended for patients with obstructive sleep apnea (OSA) to decrease disease burden. We aimed to evaluate the effect of perioperative antibiotic prescription on complication rates.Retrospective cohort (national database).Tertiary referral center.This is a retrospective study of a large national health care insurance database (Truven MarketScan) from 2007 to 2015. Subjects diagnosed with OSA who had uvulopalatopharyngoplasty (UPPP) were included and stratified in single versus multilevel surgery. Other variables included smoking, age, sex, antibiotic prescription, and comorbidities based on the Elixhauser index. Evaluated outcomes were postoperative bleeding, intubation, pneumonia, superficial surgical site infection, tracheostomy, and hospital readmission. A multivariate regression model was created to assess each complication.A total of 5,798,528 subjects received a diagnosis of OSA, of which 39,916 were >18 years old and underwent UPPP, either alone or with additional procedures. The mean age was 43 years, and 73.4% were male. Antibiotic prescription was associated with less bleeding in UPPP alone, UPPP with nasal surgery, and UPPP with nasal and tongue surgery (P < .001, P < .001, and P = .006, respectively). It was also associated with a lower prevalence of surgical site infection, pneumonia, tracheostomy, intubation, and hospital readmission (P < .001). On a multivariate model, antibiotic prescription was significantly associated with a decreased rate of complications.Although former studies recommended against the use of antibiotics after tonsillectomy, our results suggest that antibiotic prescription after UPPP for OSA was associated with less bleeding, surgical site infection, pneumonia, intubation, tracheostomy, and hospital readmission 30 days postoperatively.

    View details for DOI 10.1177/01945998211048745

    View details for PubMedID 34582286

  • Integrated single-cell transcriptomics and epigenomics reveals strong germinal center-associated etiology of autoimmune risk loci. Science immunology King, H. W., Wells, K. L., Shipony, Z., Kathiria, A. S., Wagar, L. E., Lareau, C., Orban, N., Capasso, R., Davis, M. M., Steinmetz, L. M., James, L. K., Greenleaf, W. J. 2021; 6 (64): eabh3768


    [Figure: see text].

    View details for DOI 10.1126/sciimmunol.abh3768

    View details for PubMedID 34623901

  • Insights into Friedman stage II and III OSA patients through drug-Iinduced sleep endoscopy JOURNAL OF THORACIC DISEASE Zhao, C., Viana, A., Ma, Y., Capasso, R. 2020; 12 (7): 3663–72
  • Ethyl alcohol threshold test: a fast, reliable and affordable olfactory Assessment tool for COVID-19 patients. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery Calvo-Henriquez, C., Maldonado-Alvarado, B., Chiesa-Estomba, C., Rivero-Fernandez, I., Sanz-Rodriguez, M., Villarreal, I. M., Rodriguez-Iglesias, M., Marino-Sanchez, F., Rivero-de-Aguilar, A., Lechien, J. R., Martinez-Capoccioni, G., Saussez, S., Capasso, R., Karkos, P. D., Schriever, V., Martin-Martin, C., Alobid, I., Santamaria-Gadea, A., Fragola, C., Mayo-Yanez, M., Perez-Freixo, H., Ninchritz-Becerra, E., Soriano-Reixach, M., Mondragon-Rezola, E., Ruiz-Coello, M. D., Navarro, R. A., Garcia-Fernandez, A., Marchan-Lopez, A. 2020


    OBJECTIVE: COVID-19 patients may present mild symptoms. The identification of paucisymptomatic patients is paramount in order to interrupt the transmission chain of the virus. Olfactory loss could be one of those early symptoms which might help in the diagnosis of COVID-19 patients. In this study, we aim to develop and validate a fast, inexpensive, reliable and easy-to-perform olfactory test for the screening of suspected COVID-19 patients.STUDY DESIGN: Phase I was a case-control study and Phase II a transversal descriptive study.SUBJECTS AND METHODS: Olfaction was assessed with the ethyl alcohol threshold test and symptoms with visual analogue scales. The study was designed in two phases: In Phase I, we compared confirmed COVID-19 patients and healthy controls. In Phase II, patients with suspected COVID-19 infection referred for testing were studied.RESULTS: 275 participants were included in Phase I, 135 in Phase II. The ROC curve showed an AUC of 0.749 in Phase I, 0.737 in Phase II. The cutoff value which offered the highest amount of correctly classified patients was≥ 2 (10% alcohol) for all age intervals. The odds ratio was 8.19 in Phase I, 6.56 in Phase II with a 75% sensitivity. When cases report normal sense of smell (VAS<4), it misdiagnoses 57.89% of patients detected by the alcohol threshold test.CONCLUSION: The olfactory loss assessed with the alcohol threshold test has shown high sensitivity and odds ratio in both patients with confirmed COVID-19 illness and participants with suspected SARS-CoV-2 infection.

    View details for DOI 10.1007/s00405-020-06131-3

    View details for PubMedID 32583183

  • The role of pediatric maxillary expansion on nasal breathing. A systematic review and metanalysis. International journal of pediatric otorhinolaryngology Calvo-Henriquez, C., Capasso, R., Chiesa-Estomba, C., Liu, S. Y., Martins-Neves, S., Castedo, E., O'Connor-Reina, C., Ruano-Ravina, A., Kahn, S. 2020; 135: 110139


    OBJECTIVE: A reduced transversal dimension of the maxilla leads to narrower nasal cavities, which may reduce airflow to the lungs. Maxillary expansion widens nasal floor. However, there is huge controversy regarding whether this increase does actually lead to increased airflow. In this systematic review and meta-analysis we aim to resolve this question by evaluating studies that have undertaken rhinomanometric measurements.REVIEW METHODS: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked by two authors. Two authors extracted the data. Main outcome was expressed as the difference between resistance before and after treatment and the 95% confidence interval.RESULTS: 30 studies were selected for full text reading. A total of 12 studies (301 patients) met the inclusion criteria. All selected articles found reduced resistance after palatal expansion. The data pooled in the meta-analysis reveals a statistically significant difference of 0.12Pas/cm3 mean reduction after palatal expansion (CI 95% 0.06, 0.18) for nine uncontrolled studies. Regarding nasal airflow, the pooled data show a statistically significant difference of 29.9cm3/s increase after palatal expansion (CI 95% 9.17, 50.64).CONCLUSION: According to the available evidence, palatal expansion in pediatric patients decreases nasal resistance and increases nasal flow.

    View details for DOI 10.1016/j.ijporl.2020.110139

    View details for PubMedID 32502910

  • Safeness, subjective and objective changes after turbinate surgery in pediatric patients: A systematic review. International journal of pediatric otorhinolaryngology Calvo-Henriquez, C., Capasso, R., Martinez-Capoccioni, G., Rangel-Chaves, J., Liu, S. Y., O'Connor-Reina, C., Lechien, J. R., Martin-Martin, C. 2020; 135: 110128


    OBJECTIVE: Inferior turbinates are the main structure related to impaired nasal breathing. When medical treatment fails, surgery is the next step, according to clinical guidelines. However, despite the widespread acceptance of this procedure, there is some controversy about performing it in children.DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE, Scopus, Science direct, SciELO and Trip Database.REVIEW METHODS: We looked for articles in which the individual outcome of turbinate surgery in pediatric patients was investigated independently of whether it was the main objective of the study or not.RESULTS: 13 papers (1111 patients) met the inclusion criteria. 6 authors performed diverse objective assessment and 11 authors used subjective scales. All of them found improvement after surgery. Due to the heterogeneity of the methods used, they could not be included in a metanalysis. Eleven out of the 13 authors reported 3.12% complication rates, being minor bleeding the most common (1.30%), followed by crust (0.49%) and pain (0.47%).CONCLUSIONS: There is a lack of high quality studies in children. Turbinate surgery in children is a safe technique with low complication rates. The available evidence suggests improvement in subjective outcomes after turbinate surgery in children. We cannot make a formal recommendation of a surgical technique in children given the lack of high quality studies, and since comparison between available papers is not possible. Although the evidence at our disposal is weak, it suggests that the safest techniques are MAIT, radiofrequency, coblation and laser.

    View details for DOI 10.1016/j.ijporl.2020.110128

    View details for PubMedID 32485468

  • The Value of Oxygen Desaturation Index for Diagnosing Obstructive Sleep Apnea: A Systematic Review. The Laryngoscope Rashid, N. H., Zaghi, S., Scapuccin, M., Camacho, M., Certal, V., Capasso, R. 2020


    OBJECTIVES: Intermittent hypoxemia is a risk factor for developing complications in obstructive sleep apnea (OSA) patients. The objective of this systematic review was to identify articles evaluating the accuracy of the oxygen desaturation index (ODI) as compared with the apnea-hypopnea index (AHI) and then provide possible values to use as a cutoff for diagnosing adult OSA.STUDY DESIGN: Systematic Review of Literature.METHODS: PubMed, the Cochrane Library, and SCOPUS databases were searched through November 2019.RESULTS: Eight studies (1,924 patients) met criteria (age range: 28-70.9years, body mass index range: 21.9-37kg/m2 , and AHI range: 0.5-62 events/hour). Five studies compared ODI and AHI simultaneously, and three had a week to months between assessments. Sensitivities ranged from 32% to 98.5%, whereas specificities ranged from 47.7% to 98%. Significant heterogeneity was present; however, for studies reporting data for a 4% ODI ≥15 events/hour, the specificity for diagnosing OSA ranged from 75% to 98%, and only one study reported the positive predictive value, which was 97%. Direct ODI and AHI comparisons were not made because of different hypopnea scoring, different oxygen desaturation categories, and different criteria for grading OSA severity.CONCLUSION: Significant heterogeneity exists in studies comparing ODI and AHI. Based on currently published studies, consideration should be given for diagnosing adult OSA with a 4% ODI of ≥15 events/hour and for recommending further evaluation for diagnosing OSA with a 4% ODI ≥10 events/hour. Screening with oximetry may be indicated for the detection of OSA in select patients. Further study is needed before a definitive recommendation can be made. Laryngoscope, 2020.

    View details for DOI 10.1002/lary.28663

    View details for PubMedID 32333683

  • Skeletal Surgery for Obstructive Sleep Apnea. Otolaryngologic clinics of North America Awad, M., Capasso, R. 2020


    This article focuses on the role of skeletal surgery within the modified Stanford protocol with particular attention focused on the evolved role of MMA. First, surgery in patients presenting with congenital dentofacial deformity or characteristic drug-induced sleep endoscopy findings, then the growing role of maxillary expansion in a newly identified patient phenotype, and finally genioglossus advancement, are discussed. Less commonly used and validated techniques, such as isolated mandibular advancement and maxillomandibular expansion are not discussed in this article.

    View details for DOI 10.1016/j.otc.2020.02.008

    View details for PubMedID 32334864

  • Otolaryngology during COVID-19: Preventive care and precautionary measures. American journal of otolaryngology Zhao, C., Viana, A. J., Wang, Y., Wei, H., Yan, A., Capasso, R. 2020: 102508


    Since the outbreak of novel coronavirus disease (COVID-19) in December 2019, it has spread to various regions and countries, forming a global pandemic. Reducing nosocomial infection is a new issue and challenge for all healthcare systems. Otolaryngology is a high-risk specialty as it close contact with upper respiratory tract mucous, secretions, droplets and aerosols during procedures and surgery. Therefore, infection prevention and control measures for this specialty are essential. Literatures on the epidemiology, clinical characteristics and infection control measures of COVID-19 were reviewed, practical knowledge from first-line otolaryngologists in China, the United States, and Brazil were reviewed and collated. It was recommended that otolaryngology professionals should improve screening in suspected patients with relevant nasal and pharyngeal symptoms and signs, suspend non-emergency consultations and examinations in clinics, and rearrange the working procedures in operating rooms. The guidelines of personal protective equipment for swab sampling, endoscopy and surgery were listed. Indications for tracheotomy during the pandemic should be carefully considered to avoid unnecessary airway opening and aerosol-generation; precautions during surgery to reduce the risk of exposure and infection were illustrated. This review aimed to provide recommendations for otolaryngologists to enhance personal protection against COVID-19 and reduce the risk of nosocomial infection.

    View details for DOI 10.1016/j.amjoto.2020.102508

    View details for PubMedID 32345446

  • Palatopharyngoplasty Resolves Concentric Collapse in Patients Ineligible for Upper Airway Stimulation. The Laryngoscope Liu, S. Y., Hutz, M. J., Poomkonsarn, S., Chang, C. P., Awad, M., Capasso, R. 2020


    OBJECTIVE: To determine if a modified tissue-preserving palatopharyngoplasty could convert retropalatal concentric collapse to anteroposterior or lateral patterns of collapse on drug-induced sleep endoscopy (DISE) in patients who are not candidates for upper airway stimulation due to complete circumferential collapse at the velum.METHODS: A prospective, nonconsecutive, single-blinded cohort study was performed by two sleep surgeons at a tertiary care center from 2015 to 2018. Inclusion criteria included adults >18years of age with a diagnosis of obstructive sleep apnea with an Apnea-Hypopnea Index (AHI) >15, a body mass index (BMI) <32, and <25% central apneas on polysomnography. Twelve patients with complete circumferential collapse underwent a modified palatopharyngoplasty. Postoperatively, a repeat sleep study was performed. A repeat DISE was recommended for those with incomplete surgical response (clinically and/or AHI).RESULTS: Twelve patients with complete circumferential collapse were eligible for the study. Mean BMI was 30.5. Mean preoperative AHI was 54.0 events per hour. Following a modified palatopharyngoplasty, the mean AHI was reduced to 33.1 events per hour, and 100% (12 of 12) of the patients converted from a pattern of complete circumferential collapse to either no collapse at the level of the velum (3) or an anteroposterior pattern of collapse (9).CONCLUSION: We demonstrate that a modified palatopharyngoplasty can successfully convert collapse patterns in patients with complete circumferential collapse. Further studies are required to determine the outcome of these patients following upper airway stimulation implantation.LEVEL OF EVIDENCE: 1B Laryngoscope, 2020.

    View details for DOI 10.1002/lary.28595

    View details for PubMedID 32109324

  • New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2019. OTO open Rameau, A. n., Hong, R. S., Djalilian, H. n., Erbele, I. D., Phillips, K. M., Capasso, R. n., Rose, A. S., Brenner, M. J., Santa Maria, P. L. 2020; 4 (2): 2473974X20932506


    To review new devices and drugs relevant to otolaryngology-head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2019.Approval notifications for 2019 were extracted from the ENT (ear, nose, and throat) and general and plastic surgery sections of the FDA's medical devices and therapeutics listings.New therapeutics and medical devices identified from the query were analyzed by members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee. Technologies were assessed by 2 independent reviewers to ascertain relevance to otolaryngology, prioritized, and classified to subspecialty field with critical review based on extant scientific literature.Query of the FDA drug and device database returned 105 ENT devices (50 cleared, 55 with premarket approval, and 0 de novo), 543 general and plastic surgery devices (372 cleared, 170 with premarket approval, and 1 de novo), and 46 new otolaryngology-relevant drug approvals that occurred in 2019. Advances spanned all subspecialty areas with otology predominating, primarily due to hearing-related technologies. While scientific evidence was available for all new devices, there was significant heterogeneity in rigor of supporting scientific data.Technological and pharmaceutical innovation is an important catalyst for advances in the surgical specialties. Familiarity with new devices and therapeutics in otolaryngology-head and neck surgery ensures that clinicians keep abreast of developments with potential to improve prevailing standards of care.

    View details for DOI 10.1177/2473974X20932506

    View details for PubMedID 32537556

    View details for PubMedCentralID PMC7268138

  • High Tongue Position is a Risk Factor for Upper Airway Concentric Collapse in Obstructive Sleep Apnea: Observation Through Sleep Endoscopy NATURE AND SCIENCE OF SLEEP Zhao, C., Viana, A., Ma, Y., Capasso, R. 2020; 12: 767–74


    Identification of upper airway (UA) obstruction based on pharyngeal factors is important for obstructive sleep apnea (OSA) evaluation. This study is to assess the association between UA collapse characteristics and Friedman tongue position (FTP) in patients with OSA through drug-induced sleep endoscopy (DISE).Retrospective study in individuals with OSA who were intolerant to continuous positive airway pressure (CPAP) treatment, submitted to DISE between June 1, 2013, and July 31, 2017. All subjects were classified as having an FTP grade of I to IV, and the velum, oropharynx, tongue base, epiglottis (VOTE) classification was used to analyze the DISE findings. UA collapse characteristics by DISE and FTP grading were compared between groups. The associations between specific DISE findings and FTP were analyzed.In total, 205 patients were assessed. A positive and significant correlation was identified between the presence of retropalatal complete concentric collapse (CCC) and FTP grade, according to the following distributions: I, 17.4%; II, 22.9%; III, 33.7%; and IV, 48.7% (P = 0.014). A logistic regression model revealed that CCC was associated with FTP grade IV. After adjusting for age, sex, body mass index (BMI), and tonsil size (TS), the grade IV individuals had a 4.4-fold higher risk of having CCC than grade I individuals (P = 0.026). Multiple collapse sites and palatopharyngeal or combined (palatopharyngeal and hypopharyngeal) collapse were more prevalent in grade IV individuals.OSA patients intolerant to CPAP have a strong positive correlation between the FTP grade and presence of retropalatal CCC. FTP grade IV is an independent risk factor for velum-CCC, controlling for sex, age, BMI, and TS grade.

    View details for DOI 10.2147/NSS.S273129

    View details for Web of Science ID 000579149300001

    View details for PubMedID 33117012

    View details for PubMedCentralID PMC7585274

  • Genial tubercle position and genioglossus advancement in obstructive sleep apnea (OSA) treatment: a systematic review. Maxillofacial plastic and reconstructive surgery Chang, E. T., Kwon, Y. D., Jung, J., Capasso, R., Riley, R., Liu, S. C., Camacho, M. 2019; 41 (1): 34


    To systematically review the literature for methods to localize the genial tubercle as a means for performing an advancement of the genioglossus muscle.PubMed, Google Scholar, CRISP, EMBASE, CINAHL, and Scopus were searched from inception through June 16, 2015.One hundred fifty-two articles were screened, and the full text versions of 12 articles were reviewed in their entirety and 7 publications reporting their methodology for localizing the genial tubercle. Based upon these measurements and the results published from radiographic imaging and cadaveric dissections of all the papers included in this study, we identified the genial tubercle as being positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandibular border.Based upon the results of this review, the genial tubercles were positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandible border. It may serve as an additional reference for localizing the genial tubercle and the attachment of the genioglossus muscle to the mandible, although the preoperative radiological evaluation and the palpation of the GT are recommended to accurately isolate.

    View details for DOI 10.1186/s40902-019-0217-1

    View details for PubMedID 31544097

    View details for PubMedCentralID PMC6732264

  • Nasal function and CPAP compliance AURIS NASUS LARYNX Inoue, A., Chiba, S., Matsuura, K., Osafune, H., Capasso, R., Wada, K. 2019; 46 (4): 548–58
  • Clinical Trials in Obstructive Sleep Apnea: Recognizing Trends and Future Opportunities Singh, S. K., Gu, D., Capasso, R., Liu, S., Gouveia, C. J. WILEY. 2019: 1940–44

    View details for DOI 10.1002/lary.27453

    View details for Web of Science ID 000481836100038

  • The Role of the Revised Stanford Protocol in Today's Precision Medicine. Sleep medicine clinics Liu, S. Y., Awad, M., Riley, R., Capasso, R. 2019; 14 (1): 99–107


    Whereas the original Stanford protocol relied on a tiered approach to care to avoid unnecessary surgery, it did not address the issue of surgical relapse, a common concern among sleep medicine specialists. With 3 decades of experience since the original 2-tiered Powell-Riley protocol was introduced and the role of evolving skeletal techniques and upper airway stimulation, we are pleased to present our current protocol. This update includes emphasis on the facial skeletal development with impact on function including nasal breathing, and the incorporation of upper airway stimulation. The increased versatility of palatopharyngoplasty as an adjunctive procedure is also discussed.

    View details for PubMedID 30709539

  • Tonsillectomy and Pharyngoplasty: Tissue-Preserving Techniques. Atlas of the oral and maxillofacial surgery clinics of North America Awad, M., Gouveia, C., Capasso, R., Liu, S. Y. 2019; 27 (1): 17–22

    View details for PubMedID 30717919

  • Non-steady State Modeling of the Ventilatory Depressant Effect of Remifentanil in Awake Patients Experiencing Moderate-to-severe Obstructive Sleep Apnea ANESTHESIOLOGY Doufas, A. G., Shafer, S. L., Rashid, N., Kushida, C. A., Capasso, R. 2019; 130 (2): 213–26
  • The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings LARYNGOSCOPE Viana, A., Zhao, C., Rosa, T., Couto, A., Neves, D., Araujo-Melo, M., Capasso, R. 2019; 129 (2): 506–13


    Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients.Case series prospective study.Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016.Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O2 nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value.Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O2 levels, and lower BIS index values. Propofol resulted in an O2 nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation.4 Laryngoscope, 129:506-513, 2019.

    View details for PubMedID 30194726

  • Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study. The Laryngoscope Green, K. K., Kent, D. T., D'Agostino, M. A., Hoff, P. T., Lin, H., Soose, R. J., Boyd Gillespie, M., Yaremchuk, K. L., Carrasco-Llatas, M., Tucker Woodson, B., Jacobowitz, O., Thaler, E. R., Barrera, J. E., Capasso, R., Liu, S. Y., Hsia, J., Mann, D., Meraj, T. S., Waxman, J. A., Kezirian, E. J. 2018


    OBJECTIVE: To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort.METHODS: Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression.RESULTS: Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4±11.8 years, and body mass index was 30.1±5.2kg/m2 . There was moderate interrater reliability (kappa=0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely).CONCLUSION: DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique.LEVEL OF EVIDENCE: 2b Laryngoscope, 2018.

    View details for PubMedID 30588639

  • Nasal function and CPAP compliance. Auris, nasus, larynx Inoue, A., Chiba, S., Matsuura, K., Osafune, H., Capasso, R., Wada, K. 2018


    OBJECTIVE: Continuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination.METHODS: In total, 711 adult patients with initial diagnosis of OSA and an apnea-hypopnea index of ≥20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1year), treatment continuation rate at 2 months and 1year, and nasal treatments for all patients.RESULTS: CPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1year. Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of ≥0.35Pa/cm3/s were independent predictors of surgical treatment.CONCLUSION: Long-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.

    View details for PubMedID 30538069

  • An Extended Hackathon Model for Collaborative Education in Medical Innovation JOURNAL OF MEDICAL SYSTEMS Wang, J. K., Pamnani, R. D., Capasso, R., Chang, R. T. 2018; 42 (12)
  • Thirty-five alternatives to positive airway pressure therapy for obstructive sleep apnea: an overview of meta-analyses. Expert review of respiratory medicine Camacho, M., Chang, E. T., Neighbors, C. L., Noller, M. W., Mack, D., Capasso, R., Kushida, C. A. 2018; 12 (11): 919–29


    INTRODUCTION: Positive airway pressure (PAP) devices are generally considered to be the first-line treatment of choice for most adults with obstructive sleep apnea (OSA). However, there are several alternatives. It is important for patients and their sleep providers to be aware of the most up-to-date information regarding the current international literature. Areas covered: The objective is to provide an overview of the meta-analyses evaluating non-PAP treatments for OSA. Four authors searched four databases, including PubMed/MEDLINE through 30 November 2017, for meta-analyses evaluating non-PAP therapies as treatment for OSA. Thirty-five non-PAP treatments were identified and were categorized based on the following anatomical subsites: (1) nose, (2) palate and oropharynx, (3) tongue, (4) skeletal surgery and jaw repositioning, and (5) other surgical and medical interventions. Treatments identified included surgeries, drugs, behavior modifications, nonsurgical weight loss, medical devices, body positioning, and oxygen treatment. Expert commentary: The 35 treatments described vary in their effectiveness in treating OSA in adults. In general, isolated nasal treatments are the least effective, whereas treatments that bypass the upper airway, significantly open the upper airway, and/or address multiple levels of the upper airway are more effective in improving apnea-hypopnea index and lowest oxygen saturation.

    View details for DOI 10.1080/17476348.2018.1522253

    View details for PubMedID 30204000

  • The effect of aging on drug-induced sleep endoscopy findings LARYNGOSCOPE Zhao, C., Viana, A., Ma, Y., Capasso, R. 2018; 128 (11): 2644–50


    To evaluate the correlation of aging and upper airway collapse characteristics observed by drug-induced sleep endoscopy (DISE), and report the observed differences on obstructive sleep apnea (OSA) subjects, older and younger than 60 years.Case series.This study analyzed the data of 200 OSA patients who underwent DISE between January 1, 2013 and June 30, 2017. The variables sex, body mass index (BMI), Epworth Sleepiness Scale score, tonsil size, modified Mallampati (MM) classification, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), lowest oxygen saturation, and VOTE (velum, oropharynx, tongue base, epiglottis) classification were compared between two groups: <60 and ≥60 years old.Older age had significant correlation with higher AHI, ODI, lower O2 nadir, multisite obstruction, combined upper (palatopharyngeal) + lower (hypopharyngeal) level obstructions, and complete anterior-posterior (AP) velum collapse pattern. Lateral oropharyngeal wall collapse was significantly lower in the older group. Findings remained statistically significant when adjusted for sex, BMI, tonsil size, and MM.Aging was an independent factor that directly correlated with increased AHI and hypoxemia, multisites, combined levels of obstruction, and complete AP velum collapse pattern. Being older than 60 years had higher of complete AP velum collapse and lower incidence of lateral oropharyngeal wall collapse, regardless of OSA severity and tonsil size.4 Laryngoscope, 2644-2650, 2018.

    View details for PubMedID 30194857

    View details for PubMedCentralID PMC6265065

  • Clinical Trials in Obstructive Sleep Apnea: Recognizing Trends and Future Opportunities. The Laryngoscope Singh, S. K., Gu, D., Capasso, R., Liu, S., Gouveia, C. J. 2018


    OBJECTIVES/HYPOTHESIS: Examine US and international clinical trials in obstructive sleep apnea (OSA) to characterize researchers involved, interventions being studied, and opportunities for future investigation.STUDY DESIGN: Retrospective database review.METHODS: The information from was used to assess OSA clinical trials between 1999 and 2017. Information was gathered on principle investigator (PI) demographics, interventions studied, study funding source, and regional distribution of research institutions.RESULTS: There were 813 clinical trials studied. The majority of trials examined continuous positive airway pressure interventions (43.7%), with pharmacotherapies being the second most commonly investigated treatment (19.2%). Surgical interventions made up 10.7% (n=87) of clinical trials for OSA. Most studies were based internationally (59.9%). PIs were predominantly male (72.0%); 72.7% had an MD and 28.6% had a PhD. There were no significant differences in funding source (National Institutes of Health vs. industry, P=.14) or institutional geography (international vs. US, P=.73) between surgical and nonsurgical studies. Surgical trials were significantly more likely to have a male PI and involve pediatric patients compared to nonsurgical trials (P<.001). Otolaryngologists represented 9.2% of all PIs and had similar rates of NIH funding compared to other medical specialists (P=.22).CONCLUSIONS: This study provides a broad overview of past, current, and future treatment paradigms for OSA. Sleep surgery, specifically otolaryngology, is a small voice in the overall landscape of clinical trials for OSA. This information can help guide future research efforts and direct our specialty when setting priorities regarding research funding while encouraging a broad and interdisciplinary pursuit.LEVEL OF EVIDENCE: NA. Laryngoscope, 2018.

    View details for PubMedID 30284271

  • Digital Health and Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Rosa, T., Bellardi, K., Viana, A. J., Ma, Y., Capasso, R. 2018; 14 (9): 1605–20


    STUDY OBJECTIVES: Sleep disorders in most individuals remain undiagnosed and without treatment. The use of novel tools and mobile technology has the potential to increase access to diagnosis. The objective of this study was to perform a quantitative and qualitative analysis of the available literature evaluating the accuracy of smartphones and portable devices to screen for sleep-disordered breathing (SDB).METHODS: A literature review was performed between February 18, 2017 and March 15, 2017. We included studies evaluating adults with SDB symptoms through the use mobile phones and/or portable devices, using standard polysomnography as a comparison. A qualitative evaluation of studies was performed with the QUADAS-2 rating. A bivariate random-effects meta-analysis was used to obtain the estimated sensitivity and specificity of screening SDB for four groups of devices: bed/mattress-based, contactless, contact with three or more sensors, and contact with fewer than three sensors. For each group, we also reported positive predictive values and negative predictive values for mild, moderate, and severe obstructive sleep apnea (OSA) screening.RESULTS: Of the 22 included studies, 18 were pooled in the meta-analysis. Devices that were bed/mattress-based were found to have the best sensitivity overall (0.921, 95% confidence interval [CI] 0.870, 0.953). The sensitivity of contactless devices to detect mild OSA cases was the highest of all groups (0.976, 95% CI 0.899, 0.995), but provided a high false positive rate (0.487, 95% CI 0.137, 0.851). The remaining groups of devices showed low sensitivity and heterogeneous results.CONCLUSIONS: This study evidenced the limitations and potential use of portable devices in screening patients for SDB. Additional research should evaluate the accuracy of devices when used at home.

    View details for PubMedID 30176971

  • YouTube as a source of information for obstructive sleep apnea AMERICAN JOURNAL OF OTOLARYNGOLOGY Singh, S. K., Liu, S., Capasso, R., Kern, R. C., Gouveia, C. J. 2018; 39 (4): 378–82


    Assess the quality of information on obstructive sleep apnea (OSA) presented on YouTube for patients."Obstructive sleep apnea" was entered into the YouTube search. Two independent reviewers categorized and analyzed videos utilizing a customized scoring-system along with search position, likes, and views.Forty-eight videos were analyzed. Most were educational (52.1%). Educational and news videos had significantly higher scores, but had no significant differences in search position, likes/day, or views/day. Most videos mentioned positive airway pressure (65%), and nearly half (44%) mentioned mandibular devices in the management of OSA. Few videos discussed surgery (13%) or otolaryngology (15%).YouTube is a promising source of information for OSA patients. Educational and news videos are of highest quality. General quality measures like search position, views, and likes are not correlated with formally scored value. Sleep surgery and otolaryngologists are minimally mentioned, representing an opportunity for improvement.

    View details for PubMedID 29605236

  • Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY Beswick, D. M., Santa Maria, C., Ayoub, N. F., Capasso, R., Santa Maria, P. 2018; 275 (2): 569–78


    To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model.A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0-14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers.Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4-5 vs. day 6, p = 0.01) occurred earlier with HB-EGF.In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH.NA-animal studies or basic research.

    View details for PubMedID 29188436

  • Integrating the Divided Nasal Cannula Into Routine Polysomnography to Assess Nasal Cycle: Feasibility and Effect on Outcomes JOURNAL OF CLINICAL SLEEP MEDICINE Scapuccin, M., Schneider, L., Rashid, N., Zaghi, S., Rosa, T., Tsuo, Y., Liu, S., Lazarini, P., Capasso, R., Ruoff, C. 2018; 14 (4): 641–50


    Patients suspected to have sleep-disordered breathing underwent an overnight polysomnography using a divided nasal cannula to gain additional information about the nasal cycle during sleep.This was a prospective, observational cohort study replacing the undivided nasal cannula with a divided nasal cannula during routine polysomnography (n = 28).Integration of the divided nasal cannula pressure transducer system into routine polysomnography was easy and affordable. Most patients (89%) demonstrated nasal cycle changes during the test. Nasal cycle changes tended to occur during body position changes (62%) and transitions from non-rapid eye movement sleep to rapid eye movement sleep (41%). The mean nasal cycle duration was 2.5 ± 2.1 hours. Other sleep study metrics did not reveal statistically significant findings in relation to the nasal cycle.Replacing an undivided nasal cannula with a divided nasal cannula is easy to implement, adding another physiologic measure to polysomnography. Although the divided nasal cannula did not significantly affect traditional polysomnographic metrics such as the apnea-hypopnea index or periodic limb movement index based on this small pilot study, we were able to replicate past nasal cycle findings that may be of interest to sleep clinicians and researchers. Given the ease with which the divided nasal cannula can be integrated, we encourage other sleep researchers to investigate the utility of using a divided nasal cannula during polysomnography.

    View details for PubMedID 29609709

    View details for PubMedCentralID PMC5886442

  • Publication trends and levels of evidence in obstructive sleep apnea literature. The Laryngoscope Gouveia, C. J., Zaghi, S. n., Awad, M. n., Camacho, M. n., Liu, S. Y., Capasso, R. n., Kern, R. C. 2018


    Examine trends in clinical research and levels of evidence related to obstructive sleep apnea (OSA) in the medical literature. Describe the features and trends of OSA research within otolaryngology journals.Retrospective analysis.Review of OSA research articles from 2006, 2011, and 2016 in four leading medical sleep and otolaryngology journals. Level of evidence was graded, and study characteristics were measured.Seven hundred eight total articles were reviewed. OSA articles significantly increased in both number and proportion of total articles in the medical sleep (P < .001) and otolaryngology (P = .004) journals. Surgically focused articles did not significantly increase in either literature. There was no significant difference between medical sleep and otolaryngology literature levels of evidence regarding OSA, and no trend toward higher levels of evidence over time. Medical sleep publications had significantly higher proportions of grant-funded (P < .001) and National Institutes of Health (NIH)-funded (P < .001) publications versus otolaryngology journals. Over time, otolaryngology journals had decreasing numbers of grant-funded and NIH-funded projects.OSA research is increasingly present in medical sleep and otolaryngology literature. Levels of evidence are modest for the two specialties, and have shown no trend toward increasing over time. Concurrently, otolaryngologists are less likely to be grant funded than their medical colleagues, and sleep surgery has stagnated in the studied journals. This study encourages continued efforts to publish high-quality research on OSA. It may also help guide our specialty when setting priorities regarding research funding and support for sleep surgeons.NA Laryngoscope, 2018.

    View details for PubMedID 29314068

  • The state of academic sleep surgery: A survey of United States residency and fellowship programs. Laryngoscope Gouveia, C. J., Kern, R. C., Liu, S. Y., Capasso, R. 2017


    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 Camacho, M., Riley, R. W., Capasso, R., O'Connor, P., Chang, E. T., Reckley, L. K., Guilleminault, C. 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. Clinical otolaryngology Torre, C., Liu, S. Y., Kushida, C. A., Nekhendzy, V., Huon, L., Capasso, R. 2017


    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 Gouveia, C. J., Cramer, J. D., Liu, S. Y., Capasso, R. 2017: 194599817691475-?


    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 Chang, E. T., Certal, V., Song, S. A., Zaghi, S., Carrasco-Llatas, M., Torre, C., Capasso, R., Camacho, M. 2017


    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 Chang, E. T., Fernandez-Salvador, C., Giambo, J., Nesbitt, B., Liu, S. Y., Capasso, R., Kushida, C. A., Camacho, M. 2017


    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 Certal, V., Camacho, M., Song, S. A., Capasso, R. 2017; 35 (1): 1-2

    View details for DOI 10.1080/08869634.2016.1259864

    View details for PubMedID 27875929

  • Nocturnal Hypoxemia is Associated With Low Testosterone Levels in Overweight Males and Older Men With Normal Weight JOURNAL OF CLINICAL SLEEP MEDICINE Viana, A., Daflon, A., Couto, A., Neves, D., de Araujo-Melo, M., Capasso, R. 2017; 13 (12): 1395–1401


    The relationship among obstructive sleep apnea (OSA), body mass index (BMI), and testosterone levels has long been suggested. Obese men have shown a negative correlation between testosterone level and sleep apnea severity. Yet, little is known about the association between testosterone levels and sleep apnea in men who are not obese. This study evaluated the association between the total testosterone (TT) level and OSA in patients who are not obese.A retrospective review of 523 records of patients in whom OSA was diagnosed from 2013-2016 was performed. The study included men with a BMI < 30 kg/m2 and with TT levels measured in a blood sample collected the morning after a sleep study.In all, 153 nonobese men met inclusion criteria, of whom 47 (30.7%) had testosterone levels below the reference values; 44 of these individuals (93.6%) were overweight (P = .029). Reduced testosterone levels showed significant correlations with the oxygen desaturation index, the lowest oxygen saturation < 80% (O2 nadir < 80%), and rapid eye movement (REM) sleep duration, after adjusting for BMI. Among patients with normal weight, only 3 who had O2 nadir < 80% and were older than 50 years presented with a reduced TT level.In a large population of nonobese men with OSA, we demonstrated that hypoxemia (O2 nadir < 80%) and overweight are associated with reduced testosterone levels. This association was only observed among normal-weight individuals older than 50 years.

    View details for PubMedID 29065959

    View details for PubMedCentralID PMC5695985

  • Static craniofacial measurements and dynamic airway collapse patterns associated with severe obstructive sleep apnoea: a sleep MRI study CLINICAL OTOLARYNGOLOGY Liu, S. Y., Huon, L., Lo, M., Chang, Y., Capasso, R., Chen, Y., Shih, T. T., Wang, P. 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 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 Means, C., Camacho, M., Capasso, R. 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. Laryngoscope Song, S. A., Chang, E. T., Certal, V., Del Do, M., Zaghi, S., Liu, S. Y., Capasso, R., Camacho, M. 2016


    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 Ando, Y., Chiba, S., Capasso, R., Okushi, T., Kojima, H., Otori, N., Wada, K. 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 Capasso, R., Rosa, T., Tsou, D. Y., Nekhendzy, V., Drover, D., Collins, J., Zaghi, S., Camacho, M. 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. Laryngoscope Certal, V. F., Pratas, R., Guimarães, L., Lugo, R., Tsou, Y., Camacho, M., Capasso, R. 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. Laryngoscope Torre, C., Camacho, M., Liu, S. Y., Huon, L., Capasso, R. 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

  • Five-Minute Awake Snoring Test for Determining CPAP Pressures (Five-Minute CPAP Test): A Pilot Study Sleep Disorders Camacho, M., Ruoff, C. M., Kawai, M., Modi, R., Arbee, J., Hekmat, A., Robertson, M., Zaghi, S., Certal, V., Capasso, R., Kushida, C. A. 2016; 2016: 8

    View details for DOI 10.1155/2016/7380874

  • Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling OTOLARYNGOLOGY-HEAD AND NECK SURGERY Liu, S. Y., Huon, L., Iwasaki, T., Yoon, A., Riley, R., Powell, N., Torre, C., Capasso, R. 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 Web of Science ID 000367745700028

  • Treatment of Snoring with a Nasopharyngeal Airway Tube. Case reports in medicine Camacho, M., Chang, E. T., Fernandez-Salvador, C., Capasso, R. 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 Camacho, M., Zaghi, S., Certal, V., Abdullatif, J., Modi, R., Sridhara, S., Tolisano, A. M., Chang, E. T., Cable, B. B., Capasso, R. 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

  • Model for Prediction of Pediatric OSA: Proposal for a Clinical Decision Rule LARYNGOSCOPE Certal, V., Silva, H., Carvalho, C., Costa-Pereira, A., Azevedo, I., Winck, J., Capasso, R., Camacho, M. 2015; 125 (12): 2823-2827

    View details for DOI 10.1002/lary.25438

    View details for Web of Science ID 000367187700045

  • Lateral pharyngeal wall collapse associated with hypoxemia in obstructive sleep apnea. Laryngoscope Lan, M., Liu, S. Y., Lan, M., Modi, R., Capasso, R. 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 Camacho, M., Robertson, M., ABDULLATIF, J., Certal, V., Kram, Y. A., Ruoff, C. M., Brietzke, S. E., Capasso, R. 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 Camacho, M., Liu, S. Y., Certal, V., Capasso, R., Powell, N. B., Riley, R. W. 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 Liu, S. Y., Huon, L., Powell, N. B., Riley, R., Cho, H. G., Torre, C., Capasso, R. 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. Sleep Camacho, M., Certal, V., Abdullatif, J., Zaghi, S., Ruoff, C. M., Capasso, R., Kushida, C. A. 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

  • Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-analysis LARYNGOSCOPE Certal, V. F., Zaghi, S., Riaz, M., Vieira, A. S., Pinheiro, C. T., Kushida, C., Capasso, R., Camacho, M. 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 Camacho, M., Kushida, C. A., Capasso, R. 2015; 152 (4): 766-767

    View details for DOI 10.1177/0194599815574258

    View details for Web of Science ID 000352580000038

    View details for PubMedID 25833930

  • Maxillomandibular Advancement and Tracheostomy for Morbidly Obese Obstructive Sleep Apnea: A Systematic Review and Meta-analysis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Camacho, M., Teixeira, J., Abdullatif, J., Acevedo, J. L., Certal, V., Capasso, R., Powell, N. B. 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. Laryngoscope Camacho, M., Zaghi, S., Certal, V., Abdullatif, J., Means, C., Acevedo, J., Liu, S., Brietzke, S. E., Kushida, C. A., Capasso, R. 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 Camacho, M., Riaz, M., Capasso, R., Ruoff, C. M., Guilleminault, C., Kushida, C. A., Certal, V. 2015; 38 (2): 279-?


    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 Web of Science ID 000348757800016

    View details for PubMedID 25325439

  • Unattended sleep studies in pediatric OSA: A systematic review and meta-analysis. Laryngoscope Certal, V., Camacho, M., Winck, J. C., Capasso, R., Azevedo, I., Costa-Pereira, A. 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 Kumar, A. R., Guilleminault, C., Certal, V., Li, D., Capasso, R., Camacho, M. 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. Sleep Camacho, M., Riaz, M., Capasso, R., Ruoff, C. M., Guilleminault, C., Kushida, C. A., Certal, V. 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 Cho, K., Koo, S., Lee, J., Hong, S., Capasso, R., Roh, H. 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 Camacho, M., Capasso, R., Schendel, S. 2014; 128 (9): 824-830


    This study aimed to describe total volume and cross-sectional area measurement changes in obstructive sleep apnoea patients associated with a supine versus an upright position.A retrospective chart review of patients who underwent cone beam computed tomography in upright and supine positions was performed, and the images were analysed.Five obstructive sleep apnoea patients (all male) underwent both upright and supine cone beam computed tomography imaging. Mean age was 35.0 ± 9.3 years, mean body mass index was 28.1 ± 2.7 kg/m2 and mean apnoea-hypopnoea index was 39.3 ± 23.0 per hour. The airway was smaller when patients were in a supine compared with an upright position, as reflected by decreases in the following airway measurements: total volume; posterior nasal spine, uvula tip, retrolingual and tongue base (not significant) cross-sectional areas; and site of the minimum cross-sectional area (of the overall airway). Total airway volume decreased by 32.6 per cent and cross-sectional area measurements decreased between 32.3 and 75.9 per cent when patients were in a supine position.In this case series, the airway of obstructive sleep apnoea patients was significantly smaller when patients were in a supine compared with an upright position.

    View details for DOI 10.1017/S0022215114001686

    View details for Web of Science ID 000342623400015

  • In reference to redefining successful therapy in obstructive sleep apnea: A call to arms. The Laryngoscope Certal, V., Camacho, M., Capasso, R. 2014

    View details for DOI 10.1002/lary.24794

    View details for PubMedID 24939457

  • Snoring exclusively during nasal breathing: a newly described respiratory pattern during sleep SLEEP AND BREATHING Hsia, J. C., Camacho, M., Capasso, R. 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. Laryngoscope Camacho, M., Certal, V., Brietzke, S. E., Holty, J. C., Guilleminault, C., Capasso, R. 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 Capasso, R. n., Kezirian, E. n., Jacobowitz, O. n., Weaver, E. M. 2014; 160 (5): 367

    View details for DOI 10.7326/L14-5005

    View details for PubMedID 24589933

  • Reviewing the Systematic Reviews in OSA Surgery OTOLARYNGOLOGY-HEAD AND NECK SURGERY Certal, V., Nishino, N., Camacho, M., Capasso, R. 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 Shin, L. K., Holbrook, A. B., Capasso, R., Kushida, C. A., Powell, N. B., Fischbein, N. J., Pauly, K. B. 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 Camacho, M., Certal, V., Capasso, R. 2013; 79 (6): 780-788
  • Phase of nasal cycle during sleep tends to be associated with sleep stage LARYNGOSCOPE Kimura, A., Chiba, S., Capasso, R., Yagi, T., Ando, Y., Watanabe, S., Moriyama, H. 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 NEUROTHERAPEUTICS Carvalho, B., Hsia, J., Capasso, R. 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

    View details for PubMedCentralID PMC3480570

  • The effect of continuous positive airway pressure on middle ear pressure LARYNGOSCOPE Lin, F. Y., Gurgel, R. K., Popelka, G. R., Capasso, R. 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 Shen, T., Shimahara, E., Cheng, J., Capasso, R. 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 Web of Science ID 000311799200030

  • Caregiver Reports of Sleep Problems in Non-Hispanic White, Hispanic, and African American Patients with Alzheimer Dementia JOURNAL OF CLINICAL SLEEP MEDICINE Ownby, R. L., Saeed, M., Wohlgemuth, W., Capasso, R., Acevedo, A., Peruyera, G., Sevush, S. 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 Kaza, S., Capasso, R., Casiano, R. R. 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