Robson Capasso

All Publications

• 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., Jung, J., Capasso, R., Riley, R., Liu, S. C., Camacho, M. 2019; 41 (1)

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

  View details for Web of Science ID 000485140200001

• 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

• 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

  View details for DOI 10.1016/j.anl.2018.11.006

  View details for Web of Science ID 000477790500010

• THE EFFECT OF SLEEPING POSITION ON THE EFFICACY OF HYPOGLOSSAL NERVE STIMULATION Chou, C., Poomkonsarn, S., Liu, S. Y., Capasso, R., During, E. OXFORD UNIV PRESS INC. 2019

  View details for Web of Science ID 000471071002125

• 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

  Abstract

  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

  View details for DOI 10.1097/ALN.0000000000002430

  View details for Web of Science ID 000466747200009

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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)

  View details for DOI 10.1007/s10916-018-1098-z

  View details for Web of Science ID 000447742400001

• 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

  Abstract

  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

  Abstract

  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

• 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): 239

  Abstract

  To support the next generation of healthcare innovators - whether they be engineers, designers, clinicians, or business experts by training - education in the emerging field of medical innovation should be made easily and widely accessible to undergraduate students, graduate students, and young professionals, early in their careers. Currently, medical innovation curricula are taught through semester-long courses or year-long fellowships at a handful of universities, reaching only a limited demographic of participants. This study describes the structure and preliminary outcomes of a 1-2week "extended hackathon" course that seeks to make medical innovation education and training more accessible and easily adoptable for academic medical centers. Eight extended hackathons were hosted in five international locations reaching 245 participants: Beijing (June 2015 and August 2016), Hong Kong (June 2016, 2017, and 2018), Curitiba (July 2016), Stanford (October 2017), and Sao Paulo (May 2018). Pre- and post-hackathon surveys asking respondents to self-assess their knowledge in ten categories of medical innovation were administered to quantify the perceived degree of learning. Participants hailed from a diverse range of educational backgrounds, domains of expertise, and academic institutions. On average, respondents (n=161) saw a greater than twofold increase (114.1%, P<0.001) from their pre- to post-hackathon scores. In this study, the extended hackathon is presented as a novel educational model to teach undergraduate and graduate students a foundational skillset for medical innovation. Participants reported gaining significant knowledge across all ten categories assessed. To more robustly assess the educational value of extended hackathons, a standardized assessment for medical innovation knowledge needs to be developed, and a larger sample size of participants surveyed.

  View details for PubMedID 30328518

• 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

  Abstract

  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 ClinicalTrials.gov 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

• 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. H., Kushida, C. A., Capasso, R. 2018

  Abstract

  WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Evidence suggests that obstructive sleep apnea promotes postoperative pulmonary complications by enhancing vulnerability to opioid-induced ventilatory depression. We hypothesized that patients with moderate-to-severe obstructive sleep apnea are more sensitive to remifentanil-induced ventilatory depression than controls.METHODS: After institutional approval and written informed consent, patients received a brief remifentanil infusion during continuous monitoring of ventilation. We compared minute ventilation in 30 patients with moderate-to-severe obstructive sleep apnea diagnosed by polysomnography and 20 controls with no to mild obstructive sleep apnea per polysomnography. Effect site concentrations were estimated by a published pharmacologic model. We modeled minute ventilation as a function of effect site concentration and the estimated carbon dioxide. Obstructive sleep apnea status, body mass index, sex, age, use of continuous positive airway pressure, apnea/hypopnea events per hour of sleep, and minimum nocturnal oxygen saturation measured by pulse oximetry in polysomnography were tested as covariates for remifentanil effect site concentration at half-maximal depression of minute ventilation (Ce50) and included in the model if a threshold of 6.63 (P < 0.01) in the reduction of objective function was reached and improved model fit.RESULTS: Our model described the observed minute ventilation with reasonable accuracy (22% median absolute error). We estimated a remifentanil Ce50 of 2.20 ng · ml (95% CI, 2.09 to 2.33). The estimated value for Ce50 was 2.1 ng · ml (95% CI, 1.9 to 2.3) in patients without obstructive sleep apnea and 2.3 ng · ml (95% CI, 2.2 to 2.5) in patients with obstructive sleep apnea, a statistically nonsignificant difference (P = 0.081). None of the tested covariates demonstrated a significant effect on Ce50. Likelihood profiling with the model including obstructive sleep apnea suggested that the effect of obstructive sleep apnea on remifentanil Ce50 was less than 5%.CONCLUSIONS: Obstructive sleep apnea status, apnea/hypopnea events per hour of sleep, or minimum nocturnal oxygen saturation measured by pulse oximetry did not influence the sensitivity to remifentanil-induced ventilatory depression in awake patients receiving a remifentanil infusion of 0.2 mug · kg of ideal body weight per minute.

  View details for PubMedID 30247202

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

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

  Abstract

  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

• 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

  Abstract

  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

• 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. 2017; 127 (4): 984-992

  Abstract

  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 Web of Science ID 000397572700043

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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-?

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

• 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-?

  Abstract

  Objective. To evaluate the association between nasal obstruction and (1) demographic factors, (2) medical history, (3) physical tests, and (4) nasal exam findings. Study Design.Methods. Chart review at a tertiary medical center. Results. Two hundred-forty consecutive patients (52.1 ± 17.5 years old, with a Nasal Obstruction Symptom Evaluation (NOSE) score of 32.0 ± 24.1) were included. Demographic factors and inferior turbinate sizes were not associated with NOSE score or Nasal Obstruction Visual Analog Scale (NO-VAS). A significant association was found between higher NOSE score on univariate analysis and positive history of nasal trauma (p = 0.0136), allergic rhinitis (p < 0.0001), use of nasal steroids (p = 0.0108), higher grade of external nasal deformity (p = 0.0149), higher internal nasal septal deviation grade (p = 0.0024), and narrow internal nasal valve angle (p < 0.0001). Multivariate analysis identified the following as independent predictors of high NOSE score: NO-VAS: ≥50 (Odds Ratio (OR) = 17.6 (95% CI 5.83-61.6), p < 0.0001), external nasal deformity: grades 2-4 (OR = 4.63 (95% CI 1.14-19.9), p = 0.0339), and allergic rhinitis: yes (OR = 5.5 (95% CI 1.77-18.7), p = 0.0041). Conclusion. Allergic rhinitis, NO-VAS score ≥ 50, and external nasal deformity (grades 2-4) were statistically significant independent predictors of high NOSE scores on multivariate analysis. Inferior turbinate size was not associated with NOSE scores or NO-VAS.

  View details for DOI 10.1155/2016/6945297

  View details for PubMedID 27293885

• Five-Minute Awake Snoring Test for Determining CPAP Pressures (Five-Minute CPAP Test): A Pilot Study 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

• 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-?

  Abstract

  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

• 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: 7380874-?

  Abstract

  Objective. To develop a quick, simple, bedside test for determining continuous positive airway pressures (CPAP) for obstructive sleep apnea (OSA) patients. Study Design. Prospective case series at a tertiary medical center. Methods. The Five-Minute Awake Snoring Test for Determining CPAP (Five-Minute CPAP Test) was developed and tested. Patients wear a soft-gel nasal triangle mask while holding a tongue depressor with the wide section (1.75 cm) between the teeth. Fixed pressure nasal CPAP is applied while the patient simulates snoring at 4 centimeters of water pressure. The pressure is incrementally titrated up and then down to determine the lowest pressure at which the patient cannot snore (Quiet Pressure). Results. Overall, thirty-eight patients participated. All could simulate snoring. Correlation coefficients were statistically significant between Quiet Pressures and body mass index (r s = 0.60 [strong positive relationship], p = 0.0088), apnea-hypopnea index (r s = 0.49 [moderate positive relationship], p = 0.039), lowest oxygen saturation (r s = -0.47 [moderate negative relationship], p = 0.048), and oxygen desaturation index (r s = 0.62 [strong positive relationship], p = 0.0057). Conclusion. This pilot study introduces a new concept, which is the final product of over one year of exploration, development, and testing. Five-Minute CPAP Test is a quick, inexpensive, and safe bedside test based on supine awake simulated snoring with nasal CPAP.

  View details for DOI 10.1155/2016/7380874

  View details for PubMedID 26881088

• 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

  Abstract

  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

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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-?

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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 Web of Science ID 000345266000013

• 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

  Abstract

  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

  Abstract

  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

• 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

  Abstract

  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

  Abstract

  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., Kezirian, E., Jacobowitz, O., Weaver, E. M. 2014; 160 (5): 367

  View details for DOI 10.7326/L14-5005

  View details for PubMedID 24589933

• 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

• 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

  Abstract

  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

  Abstract

  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

  View details for DOI 10.5935/1808-8694.20130139

  View details for Web of Science ID 000330031700019

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  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

  Abstract

  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

  Abstract

  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