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Serghani MM, Heiser C, Schwartz AR, Amatoury J. Exploring hypoglossal nerve stimulation therapy for obstructive sleep apnea: A comprehensive review of clinical and physiological upper airway outcomes. Sleep Med Rev 2024; 76:101947. [PMID: 38788518 DOI: 10.1016/j.smrv.2024.101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/17/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of upper airway collapse during sleep, which can lead to serious health issues like cardiovascular disease and neurocognitive impairments. While positive airway pressure serves as the standard treatment, intolerance in some individuals necessitates exploration of alternative therapies. Hypoglossal nerve stimulation (HGNS) promises to mitigate OSA morbidity by stimulating the tongue muscles to maintain airway patency. However, its effectiveness varies, prompting research for optimization. This review summarizes the effects of HGNS on upper airway obstruction from human and animal studies. It examines physiological responses including critical closing pressure, maximal airflow, nasal and upper airway resistance, compliance, stiffness, and geometry. Interactions among these parameters and discrepant findings in animal and human studies are explored. Additionally, the review summarizes the impact of HGNS on established OSA metrics, such as the apnea-hypopnea index, oxygen desaturation index, and sleep arousals. Various therapeutic modalities, including selective unilateral or bilateral HGNS, targeted unilateral HGNS, and whole unilateral or bilateral HGNS, are discussed. This review consolidates our understanding of HGNS mechanisms, fostering exploration of under-investigated outcomes and approaches to drive advancements in HGNS therapy.
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Affiliation(s)
- Marie-Michèle Serghani
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon
| | - Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department ENT-HNS, Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Alan R Schwartz
- Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jason Amatoury
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon.
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Yue Z, Yi Z, Liu X, Chen M, Yin S, Liu Q, Chen X, Hu J. Comparison of invisalign mandibular advancement and twin-block on upper airway and hyoid bone position improvements for skeletal class II children: a retrospective study. BMC Oral Health 2023; 23:661. [PMID: 37705022 PMCID: PMC10500932 DOI: 10.1186/s12903-023-03295-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/09/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND This study is to evaluate and compare the improvement of upper airway morphology and hyoid bone position in children with Class II mandibular retrusion treated with Invisalign mandibular advancement (MA) and Twin-Block (TB) appliances, utilizing cone beam computed tomography (CBCT). METHODS 32 children aged between 8 and 11.5 years old were included in this study, with an average age of 10.2 years old. These children were divided into two groups, MA and TB, with 16 children in each group. Changes in upper airway morphology and hyoid bone position before and after treatment were analyzed using CBCT. RESULTS (1) Changes in upper airway before and after treatment: the oropharynx volume (Or-V), the oropharynx minimum cross-sectional area (Or-mCSA), the hypopharynx volume (Hy-V), and the hypopharynx minimum cross-sectional area (Hy-mCSA) in both the MA and TB groups increased after treatment, and the differences were statistically significant (P < 0.05) compared to pre-treatment status. (2) Changes in hyoid bone position before and after treatment: The distances between H point and third cervical vertebra (H-C3), H point and pogonion (H-RGN), H point and mandibular plane (H-MP), H point and Frankfort horizontal plane (H-FH), H and S point (H-S), and H point and palatal plane (H-PP) in both the MA and TB groups increased after treatment, and the differences were statistically significant (P < 0.05). CONCLUSION Both MA and TB appliances effectively improved the structural narrowness of the upper airway and reduced respiratory resistance, thus improving breath quality. However, MA showed more effectiveness in improving the narrowest part of the hypopharynx compared to TB. Both appliances also promoted anterior downward movement of the hyoid bone, which opens the upper airway of the oropharynx and hypopharynx and helps the upper airway morphology return to normal range.
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Affiliation(s)
- Zheng Yue
- Department of Orthodontics, Kunming Medical University School and Hospital of Stomatology, Kunming, 650031, Yunnan, China
- Department of Orthodontics, Lianbang Institute of Stomatological Technology and Hospital of Stomatology, Xi'an, 710032, Shaanxi, China
| | - Zian Yi
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Key Laboratory of Stomatology, Department of Orthodontics, School of Stomatology, The Fourth Military Medical University, Xi'an, 710032, Shaanxi, China
| | - Xinyi Liu
- Department of Orthodontics, Kunming Medical University School and Hospital of Stomatology, Kunming, 650031, Yunnan, China
| | - Mengting Chen
- Department of Orthodontics, Kunming Medical University School and Hospital of Stomatology, Kunming, 650031, Yunnan, China
| | - Shuhui Yin
- Department of Orthodontics, Kunming Medical University School and Hospital of Stomatology, Kunming, 650031, Yunnan, China
| | - Qianqian Liu
- Department of Orthodontics, Kunming Medical University School and Hospital of Stomatology, Kunming, 650031, Yunnan, China
| | - Xuefeng Chen
- Xuefeng Dental Care, Huaian, 223000, Jiangsu, China.
| | - Jiangtian Hu
- Department of Orthodontics, Kunming Medical University School and Hospital of Stomatology, Kunming, 650031, Yunnan, China.
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Samaha CJ, Tannous HJ, Salman D, Ghafari JG, Amatoury J. Role of surgical hyoid bone repositioning in modifying upper airway collapsibility. Front Physiol 2022; 13:1089606. [PMID: 36582357 PMCID: PMC9792595 DOI: 10.3389/fphys.2022.1089606] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Surgical hyoid bone repositioning procedures are being performed to treat obstructive sleep apnea (OSA), though outcomes are highly variable. This is likely due to lack of knowledge regarding the precise influence of hyoid bone position on upper airway patency. The aim of this study is to determine the effect of surgical hyoid bone repositioning on upper airway collapsibility. Methods: Seven anaesthetized, male, New Zealand White rabbits were positioned supine with head/neck position controlled. The rabbit's upper airway was surgically isolated and hyoid bone exposed to allow manipulation of its position using a custom-made device. A sealed facemask was fitted over the rabbit's snout, and mask/upper airway pressures were monitored. Collapsibility was quantified using upper airway closing pressure (Pclose). The hyoid bone was repositioned within the mid-sagittal plane from 0 to 5 mm (1 mm increments) in anterior, cranial, caudal, anterior-cranial (45°) and anterior-caudal (45°) directions. Results: Anterior displacement of the hyoid bone resulted in the greatest decrease in Pclose amongst all directions (p = 0.002). Pclose decreased progressively with each increment of anterior hyoid bone displacement, and down by -4.0 ± 1.3 cmH2O at 5 mm. Cranial and caudal hyoid bone displacement did not alter Pclose (p > 0.35). Anterior-cranial and anterior-caudal hyoid bone displacements decreased Pclose significantly (p < 0.004) and at similar magnitudes to the anterior direction (p > 0.68). Conclusion: Changes in upper airway collapsibility following hyoid bone repositioning are both direction and magnitude dependent. Anterior-based repositioning directions have the greatest impact on reducing upper airway collapsibility, with no effect on collapsibility by cranial and caudal directions. Findings may have implications for guiding and improving the outcomes of surgical hyoid interventions for the treatment of OSA.
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Affiliation(s)
- Corine J. Samaha
- Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon,Division of Orthodontics and Dentofacial Orthopedics, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hiba J. Tannous
- Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon,Division of Orthodontics and Dentofacial Orthopedics, American University of Beirut Medical Center, Beirut, Lebanon
| | - Diane Salman
- Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon,Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon
| | - Joseph G. Ghafari
- Division of Orthodontics and Dentofacial Orthopedics, American University of Beirut Medical Center, Beirut, Lebanon,Department of Orthodontics, University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Amatoury
- Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon,Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon,*Correspondence: Jason Amatoury,
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Muscling Up Pharyngeal Airflow. Chest 2021; 159:912-914. [PMID: 33678276 DOI: 10.1016/j.chest.2020.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 12/24/2022] Open
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Bamagoos AA, Cistulli PA, Sutherland K, Ngiam J, Burke PGR, Bilston LE, Butler JE, Eckert DJ. Dose-dependent effects of mandibular advancement on upper airway collapsibility and muscle function in obstructive sleep apnea. Sleep 2019; 42:5361366. [DOI: 10.1093/sleep/zsz049] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/31/2019] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ahmad A Bamagoos
- Sleep Research Group, Charles Perkins Centre, Sydney Medical School, University of Sydney, Sydney, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, Australia
- Department of Physiology, Rabigh Medical School, King Abdulaziz University, Jeddah, Saudi Arabia
- Sleep and Breathing Group, Neuroscience Research Australia (NeuRA), Randwick, Australia
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre, Sydney Medical School, University of Sydney, Sydney, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, Australia
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, Sydney Medical School, University of Sydney, Sydney, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, Australia
| | - Joachim Ngiam
- Sleep Research Group, Charles Perkins Centre, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Peter G R Burke
- Sleep and Breathing Group, Neuroscience Research Australia (NeuRA), Randwick, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Lynne E Bilston
- Sleep and Breathing Group, Neuroscience Research Australia (NeuRA), Randwick, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Jane E Butler
- Sleep and Breathing Group, Neuroscience Research Australia (NeuRA), Randwick, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Danny J Eckert
- Sleep and Breathing Group, Neuroscience Research Australia (NeuRA), Randwick, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia
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Lambeth C, Kolevski B, Amis T, Kairaitis K. Feedback modulation of surrounding pressure determines the onset of negative effort dependence in a collapsible tube bench model of the pharyngeal airway. J Appl Physiol (1985) 2017; 123:1118-1125. [PMID: 28819002 DOI: 10.1152/japplphysiol.00378.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/24/2017] [Accepted: 08/15/2017] [Indexed: 01/10/2023] Open
Abstract
Negative effort dependence (NED), decreased airflow despite increased driving pressure, has been proposed as a specific obstructive sleep apnea (OSA) phenotypic characteristic. We examined conditions under which NED occurs in a collapsible tube, pharyngeal airway bench model with the chamber enclosed, focusing on relationships with surrounding pressure levels and longitudinal strain. Using a vacuum source, graded airflows (V̇; 0-5 l/s) were generated through a thin-walled latex tube enclosed within a rigid, cylindrical chamber, sealed with initial chamber pressures (Pci) of 0-5 cmH2O (separate runs), or opened to the atmosphere. Upstream minus downstream pressure (Pu - Pd), maximum airflow (V̇max), and chamber pressure (Pc) were measured at 0-50% longitudinal strain. NED occurred across the range of Pci and strains studied but was most pronounced for the chamber open condition. With a sealed chamber, V̇ increased and Pc decreased with increasing Pu - Pd until the onset of NED at V̇max and a Pc value that was designated as critical (Pcc). Pcc was lowest (-17 cmH20) and V̇max was highest (~5 l/s) with chamber sealed: Pci = 0 cmH2O and 12.5 to 25% strain. We conclude that for our collapsible tube model, the achievable V̇max before the onset of NED depends on both the initial conditions (Pci and strain) and the dynamics of feedback between driving pressure and chamber pressure (chamber sealed vs. open). NED-based phenotypic analyses for OSA may need to focus on potential feedback control mechanisms (eg lung volume change, muscle activity) that may link peripharyngeal tissue pressure levels to driving pressures for airflow.NEW & NOTEWORTHY A collapsible tube, pharyngeal airway bench model was used to study the role of surrounding pressure and longitudinal wall strain at the onset of negative effort dependence (NED). NED occurred to varying degrees across all conditions tested, but maximum airflow was achieved with 1) low initial surrounding pressure, 2) a feedback mechanism between surrounding pressure and driving pressure; and 3) a moderate amount of strain applied. Potential impacts on OSA phenotypic analyses are discussed.
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Affiliation(s)
- Christopher Lambeth
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia;
| | - Benjamin Kolevski
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia; and.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia
| | - Terence Amis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia
| | - Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia; and.,University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia
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Amatoury J, Cheng S, Kairaitis K, Wheatley JR, Amis TC, Bilston LE. Development and validation of a computational finite element model of the rabbit upper airway: simulations of mandibular advancement and tracheal displacement. J Appl Physiol (1985) 2016; 120:743-57. [DOI: 10.1152/japplphysiol.00820.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/12/2016] [Indexed: 11/22/2022] Open
Abstract
The mechanisms leading to upper airway (UA) collapse during sleep are complex and poorly understood. We previously developed an anesthetized rabbit model for studying UA physiology. On the basis of this body of physiological data, we aimed to develop and validate a two-dimensional (2D) computational finite element model (FEM) of the passive rabbit UA and peripharyngeal tissues. Model geometry was reconstructed from a midsagittal computed tomographic image of a representative New Zealand White rabbit, which included major soft (tongue, soft palate, constrictor muscles), cartilaginous (epiglottis, thyroid cartilage), and bony pharyngeal tissues (mandible, hard palate, hyoid bone). Other UA muscles were modeled as linear elastic connections. Initial boundary and contact definitions were defined from anatomy and material properties derived from the literature. Model parameters were optimized to physiological data sets associated with mandibular advancement (MA) and caudal tracheal displacement (TD), including hyoid displacement, which featured with both applied loads. The model was then validated against independent data sets involving combined MA and TD. Model outputs included UA lumen geometry, peripharyngeal tissue displacement, and stress and strain distributions. Simulated MA and TD resulted in UA enlargement and nonuniform increases in tissue displacement, and stress and strain. Model predictions closely agreed with experimental data for individually applied MA, TD, and their combination. We have developed and validated an FEM of the rabbit UA that predicts UA geometry and peripharyngeal tissue mechanical changes associated with interventions known to improve UA patency. The model has the potential to advance our understanding of UA physiology and peripharyngeal tissue mechanics.
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Affiliation(s)
- Jason Amatoury
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - Shaokoon Cheng
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- Department of Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - John R. Wheatley
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - Terence C. Amis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - Lynne E. Bilston
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Subramaniam DR, Mylavarapu G, McConnell K, Fleck RJ, Shott SR, Amin RS, Gutmark EJ. Upper Airway Elasticity Estimation in Pediatric Down Syndrome Sleep Apnea Patients Using Collapsible Tube Theory. Ann Biomed Eng 2015; 44:1538-52. [PMID: 26314989 DOI: 10.1007/s10439-015-1430-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 08/13/2015] [Indexed: 01/10/2023]
Abstract
Elasticity of the soft tissues surrounding the upper airway lumen is one of the important factors contributing to upper airway disorders such as snoring and obstructive sleep apnea. The objective of this study is to calculate patient specific elasticity of the pharynx from magnetic resonance (MR) images using a 'tube law', i.e., the relationship between airway cross-sectional area and transmural pressure difference. MR imaging was performed under anesthesia in children with Down syndrome (DS) and obstructive sleep apnea (OSA). An airway segmentation algorithm was employed to evaluate changes in airway cross-sectional area dilated by continuous positive airway pressure (CPAP). A pressure-area relation was used to make localized estimates of airway wall stiffness for each patient. Optimized values of patient specific Young's modulus for tissue in the velopharynx and oropharynx, were estimated from finite element simulations of airway collapse. Patient specific deformation of the airway wall under CPAP was found to exhibit either a non-linear 'hardening' or 'softening' behavior. The localized airway and tissue elasticity were found to increase with increasing severity of OSA. Elasticity based patient phenotyping can potentially assist clinicians in decision making on CPAP and airway or tissue elasticity can supplement well-known clinical measures of OSA severity.
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Affiliation(s)
| | - Goutham Mylavarapu
- Department of Aerospace Engineering and Engineering Mechanics, CEAS, University of Cincinnati, Cincinnati, OH, 45221-0070, USA
| | - Keith McConnell
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert J Fleck
- Division of Pediatric Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sally R Shott
- Department of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Raouf S Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Ephraim J Gutmark
- Department of Aerospace Engineering and Engineering Mechanics, CEAS, University of Cincinnati, Cincinnati, OH, 45221-0070, USA. .,UC Department of Otolaryngology-Head and Neck Surgery, Cincinnati, OH, USA.
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