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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] [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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Ayyalasomayajula V, Moxness M, Skallerud B. Potential of computational models in personalized treatment of obstructive sleep apnea: a patient-specific partial 3D finite element study. Biomech Model Mechanobiol 2024; 23:507-524. [PMID: 37975969 DOI: 10.1007/s10237-023-01788-1] [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: 06/08/2023] [Accepted: 10/21/2023] [Indexed: 11/19/2023]
Abstract
The upper airway experiences mechanical loads during breathing. Obstructive sleep apnea is a very common sleep disorder, in which the normal function of the airway is compromised, enabling its collapse. Its treatment remains unsatisfactory with variable efficacy in the case of many surgeries. Finite element models of the upper airway to simulate the effects of various anatomic and physiologic manipulations on its mechanics could be helpful in predicting surgical success. Partial 3D finite element models based on patient-specific CT-scans were undertaken in a pilot study of 5 OSA patients. Upper airway soft tissues including the soft palate, hard palate, tongue, and pharyngeal wall were segmented around the midsagittal plane up to a width of 2.5 cm in the lateral direction. Simulations of surgical interventions such as Uvulopalatopharyngoplasty (UPPP), maxillo-mandibular advancement (MMA), palatal implants, and tongue implants have been performed. Our results showed that maxillo-mandibular advancement (MMA) surgery of 1 cm improved the critical closing pressure by at least 212.2%. Following MMA, the best improvement was seen via uvulopalatopharyngoplasty (UPPP), with an improvement of at least 19.12%. Palatal and tongue implants also offered a certain degree of improvement. Further, we observed possible interacting mechanisms that suggested simultaneous implementation of UPPP and tongue stiffening; and palatal and tongue stiffening could be beneficial. Our results suggest that computational modeling is a useful tool for analyzing the influence of anatomic and physiological manipulations on upper airway mechanics. The goal of personalized treatment in the case of OSA could be achieved with the use of computational modeling.
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Affiliation(s)
- Venkat Ayyalasomayajula
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Mads Moxness
- Department of Otolaryngology, Aleris Hospital, Trondheim, Norway
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørn Skallerud
- Department of Structural Engineering, Norwegian University of Science and Technology, Trondheim, Norway
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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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Ilegbusi OJ, Kuruppumullage DNS, Schiefer M, Strohl KP. A computational model of upper airway respiratory function with muscular coupling. Comput Methods Biomech Biomed Engin 2021; 25:675-687. [PMID: 34494928 DOI: 10.1080/10255842.2021.1973445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A two dimensional finite element model of upper airway respiratory function was developed emphasizing the effects of dilator muscular activation on the human retro-lingual airway. The model utilized an upright mid-sagittal computed tomography of the human head and neck to reconstruct relevant structures of the tongue, mandible, and the hyoid-related soft tissues, along with the retro-lingual airway. The reconstructed geometry was divided into fluid and solid domains and discretized into finite element (FE) meshes used for the computational model. Three cases were investigated: standing position; supine position; and supine position coupled with dilator muscle activation. Computations were performed for the inspiration stage of the breathing cycle, utilizing a fluid-structure interaction (FSI) method to couple structural deformation with airflow dynamics. The spatio-temporal deformation of the structures surrounding the airway wall were predicted to be in general agreement with known changes from upright to supine posture on luminal opening, as well as the distribution of airflow. The model effectively captured the effects of muscular stimulation on the upper airway anatomical changes, the flow characteristics relevant to airway reduction in the supine position and airway enlargement with muscle activation. The smallest airway opening in the retro-lingual section is predicted to occur at the epiglottic region in all the three cases considered, an unexpected vulnerable location of airway obstruction. The model also predicted that hyoid displacement would be associated with recovery from airway collapse. This information may be useful for building more complex models relevant to mechanisms and clinical interventions for obstructive sleep apnea.
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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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Kohno A, Kitamura Y, Kato S, Imai H, Masuda Y, Sato Y, Isono S. Displacement of the hyoid bone by muscle paralysis and lung volume increase: the effects of obesity and obstructive sleep apnea. Sleep 2019; 42:5146165. [PMID: 30371885 PMCID: PMC6335873 DOI: 10.1093/sleep/zsy198] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Indexed: 12/11/2022] Open
Abstract
Study Objectives Animal studies suggest a pivotal role of the hyoid bone in obstructive sleep apnea (OSA). We aimed to explore the role of the hyoid bone in humans by testing the hypotheses that muscle paralysis and lung volume (LV) changes displace the hyoid bone position particularly in people with obesity and/or OSA. Methods Fifty patients undergoing general anesthesia participated in this study (20 participants with nonobese, non-OSA; 8 people with nonobese OSA; and 22 people with obese OSA). Three lateral neck radiographs to assess the hyoid position (primary variable) and craniofacial structures were taken during wakefulness, complete muscle paralysis under general anesthesia, and LV increase under general anesthesia. LV was increased by negative extrathoracic pressure application and LV changes were measured with a spirometer. Analysis of covariance was used to identify statistical significance. Results Muscle paralysis under general anesthesia significantly displaced the hyoid bone posteriorly (95% CI: 1.7 to 4.6, 1.5 to 5.2, and 1.1 to 4.0 mm in nonobese non-OSA, nonobese OSA, and obese OSA groups, respectively), and this was more prominent in people with central obesity. LV increase significantly displaced the hyoid bone caudally in all groups (95% CI: 0.2 to 0.7, 0.02 to 0.6, and 0.2 to 0.6 mm/0.1 liter LV increase in nonobese non-OSA, nonobese OSA, and obese OSA groups, respectively). Waist–hip ratio was directly associated with the caudal displacement during LV increase. Conclusions The hyoid bone plays an important role in the pathophysiology of pharyngeal airway obstruction due to muscle paralysis and LV reduction, particularly in people with obesity. Clinical Trial UMIN Clinical Trial Registry, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=cR000022635&language=E, UMIN000019578
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Affiliation(s)
- Akane Kohno
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuji Kitamura
- Department of Anesthesiology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Shinichiro Kato
- Department of Anesthesiology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Hirohisa Imai
- Department of Radiology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Yoshitada Masuda
- Department of Radiology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Yasunori Sato
- Department of Global Clinical Research, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shiroh Isono
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Tong J, Jugé L, Burke PG, Knapman F, Eckert DJ, Bilston LE, Amatoury J. Respiratory-related displacement of the trachea in obstructive sleep apnea. J Appl Physiol (1985) 2019; 127:1307-1316. [PMID: 31513451 DOI: 10.1152/japplphysiol.00660.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Tracheal displacement is thought to be the primary mechanism by which changes in lung volume influence upper airway patency. Caudal tracheal displacement during inspiration may help preserve the integrity of the upper airway in response to increasing negative airway pressure by stretching and stiffening pharyngeal tissues. However, tracheal displacement has not been previously quantified in obstructive sleep apnea (OSA). Accordingly, we aimed to measure tracheal displacements in awake individuals with and without OSA. The upper head and neck of 34 participants [apnea-hypopnea index (AHI) = 2-74 events/h] were imaged in the midsagittal plane using dynamic magnetic resonance imaging (MRI) during supine awake quiet breathing. MRI data were analyzed to identify peak tracheal displacement and its timing relative to inspiration. Epiglottic pressure was measured separately for a subset of participants (n = 30) during similar experimental conditions. Nadir epiglottic pressure and its timing relative to inspiration were quantified. Peak tracheal displacement ranged from 1.0-9.6 mm, with a median (25th-75th percentile) of 2.3 (1.7-3.5) mm, and occurred at 89 (78-99)% of inspiratory time. Peak tracheal displacement increased with increasing OSA severity (AHI) (R2 = 0.28, P = 0.013) and increasing negative nadir epiglottic pressure (R2 = 0.47, P = 0.023). Relative inspiratory timing of peak tracheal displacement also correlated with OSA severity, with peak displacement occurring earlier in inspiration with increasing AHI (R2 = 0.36, P = 0.002). Tracheal displacements during quiet breathing are larger in individuals with more severe OSA and tend to reach peak displacement earlier in the inspiratory cycle. Increased tracheal displacement may contribute to maintenance of upper airway patency during wakefulness in OSA, particularly in those with severe disease.NEW & NOTEWORTHY Tracheal displacement is thought to play an important role in stabilizing the upper airway by stretching/stiffening the pharyngeal musculature. Using dynamic magnetic resonance imaging, this study shows that caudal tracheal displacement is more pronounced during inspiration in obstructive sleep apnea (OSA) compared with healthy individuals. Softer pharyngeal muscles and greater inspiratory forces in OSA may underpin greater tracheal excursion. These findings suggest that tracheal displacement may contribute to maintenance of pharyngeal patency during wakefulness in OSA.
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Affiliation(s)
- Joshua Tong
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Lauriane Jugé
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter Gr Burke
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Fiona Knapman
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - 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
| | - 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.,Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon
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Frey R, Gabrielova B, Gladilin E. A combined planning approach for improved functional and esthetic outcome of bimaxillary rotation advancement for treatment of obstructive sleep apnea using 3D biomechanical modeling. PLoS One 2018; 13:e0199956. [PMID: 30092020 PMCID: PMC6084856 DOI: 10.1371/journal.pone.0199956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/18/2018] [Indexed: 11/25/2022] Open
Abstract
In recent years, bimaxillary rotation advancement (BRA) has become the method of choice for surgical treatment of obstructive sleep apnea (OSA). As dislocation of the jaw bones affects both, airways and facial contours, surgeons are facing the challenge of finding an optimal jaw position that allows for the reestablishment of normal airway ventilation and esthetic surgical outcome. Owing to the complexity of the facial anatomy and its mechanical behavior, individual planning of surgical OSA treatment under consideration of functional and esthetic aspects presents a challenge that surgeons typically approach in a non-quantitative manner using subjective evaluation and clinical experience. This paper describes a framework for individual planning of OSA treatment using bimaxillary rotation advancement, which relies on computational modeling of hard and soft tissue mechanics. The described framework for simulation of functional and esthetic post-surgery outcome was used in 10 OSA patients. Comparison of the simulation results with post-surgery data reveals that biomechanical simulation provides a reliable estimate for post-surgery facial tissue behavior and antero-posterior airway extension, but fails to accurately describe a surprisingly large lateral stretch of the velopharyngeal region. This discrepancy is traced back to anisotropic effects of pharyngeal muscles. Possible approaches to improving the accuracy of model predictions and defining sharp criteria for optimizing combined OSA planning are discussed.
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Affiliation(s)
- Robert Frey
- Department of Oral and Maxillofacial Surgery, Seegartenklinik, Adenauerplatz 4/1, 69115 Heidelberg, Germany
- * E-mail:
| | - Barbora Gabrielova
- BioQuant, University Heidelberg, Im Neuenheimer Feld 267, 69120 Heidelberg, Germany
| | - Evgeny Gladilin
- BioQuant, University Heidelberg, Im Neuenheimer Feld 267, 69120 Heidelberg, Germany
- Division of Theoretical Bioinformatics, German Cancer Research Center, Berliner Str. 41, 69120 Heidelberg, Germany
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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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Subramaniam DR, Mylavarapu G, Fleck RJ, Amin RS, Shott SR, Gutmark EJ. Effect of airflow and material models on tissue displacement for surgical planning of pharyngeal airways in pediatric down syndrome patients. J Mech Behav Biomed Mater 2017; 71:122-135. [DOI: 10.1016/j.jmbbm.2017.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 12/01/2022]
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