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Evaluation of auditory system in obstructive sleep apnea patients. Eur Arch Otorhinolaryngol 2022; 280:2201-2207. [PMID: 36350365 PMCID: PMC9643906 DOI: 10.1007/s00405-022-07711-1] [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: 07/24/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) has been associated with auditory dysfunction both to the cochlear and higher auditory pathways. However, available literatures presented conflicting results. We aimed to study the impact of OSA severity and their polysomnography parameters on hearing function. MATERIALS AND METHODS A total of 44 patients were included after evaluation for sleep disorders and were divided into four groups in accordance with apnea-hypopnea index (AHI). Pure tone audiometry (PTA), distortion product otoacoustic emission (DPOAE) and auditory brainstem response (ABR) were compared in commensurate with the severity of AHI. Polysomnography oximetry parameters of oxygen desaturation index, mean SPO2, minimum SPO2 and percent SPO2 < 90% were correlated with their respective PTA, DPOAE and ABR results. RESULTS There was no significant change in the PTA, DPOAE and ABR results in connection with AHI severity. However, we found significant correlations between mean SPO2 and percent SPO2 < 90% with ABR wave I, III and V absolute latencies. Minimum SPO2 was also significantly correlated with wave III peak latency changes. CONCLUSIONS Mean SPO2, percent SPO2 < 90% and minimum SPO2 could be key prognostic indicators of central auditory dysfunction in OSA patients. These parameters should be explored further as indicators of OSA severity rather than utilizing AHI alone. The hypoxic burden derived could be a better predictor of auditory function abnormalities rather than one derived from AHI.
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Kasemsuk N, Chayopasakul V, Banhiran W, Prakairungthong S, Rungmanee S, Suvarnsit K, Atipas S, Keskool P. Obstructive Sleep Apnea and Sensorineural Hearing Loss: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2022:1945998221120777. [PMID: 36040818 DOI: 10.1177/01945998221120777] [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: 11/16/2022]
Abstract
OBJECTIVES To evaluate the associations between obstructive sleep apnea (OSA) and sensorineural hearing loss (SNHL) and the effects of continuous positive airway pressure (CPAP) therapy on SNHL. DATA SOURCES Ovid Medline, Embase, and Scopus databases. REVIEW METHODS A systematic search was done for studies investigating relationships between OSA and SNHL in adults, with manual searches for additional references. The final update was done on December 22, 2021. The Risk of Bias Assessment Tool for Nonrandomized Studies was applied for quality assessments. RESULTS The 20 included studies had a total of 34,442 participants (66% male; mean age, 46.6 years). The OSA group had a significantly worse mean hearing threshold level (HTL) than the control group for midfrequency ranges (500, 1000, 2000 Hz; mean difference, 4.00 dB; 95% CI, 2.40-5.61) and high-frequency ranges (4000, 8000 Hz; mean difference, 6.24 dB; 95% CI, 2.99-9.49). An association between OSA and SNHL was found. When compared with controls, patients with OSA had an odds ratio of 1.52 (95% CI, 1.12-2.06) for midfrequency hearing impairment and 1.19 (95% CI, 1.05-1.34) for high-frequency hearing impairment. However, we did not find significant improvements in midfrequency HTL after CPAP therapy. CONCLUSIONS HTL was significantly poorer among participants with OSA (especially in severe cases) than non-OSA controls. Studies on patients with OSA with SNHL treated with CPAP did not show significant improvements in midfrequency HTL. Further studies are warranted on these issues.
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Affiliation(s)
- Navarat Kasemsuk
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Veeruth Chayopasakul
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wish Banhiran
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sarun Prakairungthong
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sarin Rungmanee
- Siriraj Sleep Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokrat Suvarnsit
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suvajana Atipas
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phawin Keskool
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Cho S, Park WJ, Ahn JS, Lim DY, Kim SH, Moon JD. Obstructive sleep apnea risk and hearing impairment among occupational noise-exposed male workers. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2022; 78:108-117. [PMID: 35833486 DOI: 10.1080/19338244.2022.2094306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This study aimed to investigate the association between obstructive sleep apnea (OSA) risk and hearing impairment among workers exposed to occupational noise. A cross-sectional study was conducted among 607 healthy male workers at a tire-manufacturing factory. The subjects underwent audiometric testing, and their OSA risk was examined based on the STOP-Bang questionnaire. Hearing impairment was defined as a hearing threshold >25 dB hearing level (HL) in any frequency of 1, 2, 3 and 4 kHz in either ear. High OSA risk was defined as a STOP-bang score of ≥3. Hearing thresholds at 1, 2, 3 and 4 kHz in both ears were significantly higher among workers with high OSA risk than among those with low OSA risk after adjusting for confounders. Multiple logistic regression analysis examining the association of OSA risk and STOP-Bang score with hearing impairment revealed an odds ratio of 1.738 (95% confidence interval [CI] 1.113-2.713, p = 0.015) and 1.256 (95% CI 1.031-1.529, p = 0.023), respectively, after adjusting for confounders. In addition, when the hearing impairment was reclassified into high- and low-frequency hearing impairment, a statistically significant OR was seen for high-frequency hearing impairment. In conclusion, high OSA risk was associated with hearing impairment in occupational noise-exposed workers, especially in the high-frequency range of 3 and 4 kHz. More efforts are required to improve the management of OSA and its risk factors to preserve hearing in occupational noise-exposed workers.
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Affiliation(s)
- Seunghyeon Cho
- Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Won-Ju Park
- Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Ji-Sung Ahn
- Department of Occupational and Environmental Medicine, Mokpo Hankook Hospital, Mokpo, Republic of Korea
| | - Dae-Young Lim
- Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Su-Hwan Kim
- Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Jai-Dong Moon
- Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
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Cheung IC, Thorne PR, Hussain S, Neeff M, Sommer JU. The Relationship between Obstructive Sleep Apnea with Hearing and Balance: a Scoping Review. Sleep Med 2022; 95:55-75. [DOI: 10.1016/j.sleep.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/29/2022] [Accepted: 04/09/2022] [Indexed: 02/08/2023]
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CPAP Treatment Improves Pure Tone Audiometry Threshold in Sensorineural Hearing Loss Patients with Sleep-Disordered Breathing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136768. [PMID: 34202447 PMCID: PMC8297118 DOI: 10.3390/ijerph18136768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022]
Abstract
This article investigates the effects of continuous positive airway pressure (CPAP) on hearing impairment in sensorineural hearing loss (SNHL) patients with sleep-disordered breathing (SDB). This retrospective and observational study took place from September 2016 to February 2021, accumulating 77 subjects with SNHL and SDB (60.7 ± 11.1 years). Of which, 28 received CPAP treatment (63.0 ± 8.5 years). In our methodology, hearing thresholds at low, medium, high, and average frequencies are assessed by pure-tone audiometry at baseline (BL), three (3 m), six (6 m), and 12 (12 m) months. Our results show that the BL of at least three frequencies in all subjects is positively associated with old age, males, smoking, alcohol, coronary artery disease, hypertension, and apnea-hypopnea index [AHI] (all p < 0.05). Moreover, low, medium, and average frequencies are negatively correlated at CPAP-6 m (-5.60 ± 2.33, -5.82 ± 2.56, and -5.10 ± 2.26 dB; all p < 0.05) and CPAP-12 m (-7.97 ± 2.74, -8.15 ± 2.35, and -6.67 ± 2.37 dB; all p < 0.01) against corresponding measures of CPAP-BL. High, medium, and average frequencies positively correlated with age (p < 0.001 for high and average frequencies and <0.01 for medium frequencies). We conclude that in SNHL patients with SDB, hearing thresholds at low and medium frequencies improves under CPAP use after six months, which persists at least to the end of one year.
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Chen CK, Shen SC, Lee LA, Sun MH, Chen NH, Chuang LP, Li HY. Idiopathic Sudden Sensorineural Hearing Loss in Patients with Obstructive Sleep Apnea. Nat Sci Sleep 2021; 13:1877-1885. [PMID: 34703345 PMCID: PMC8526947 DOI: 10.2147/nss.s331880] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/27/2021] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Obstructive sleep apnea (OSA) is characterized by recurring hypoxic-apneic events during sleep, and labyrinthine vascular compromise is a pathophysiologic hallmark of idiopathic sudden sensorineural hearing loss (ISSNHL). Some reports have discussed the relationship between OSA and hearing impairment; however, few have examined hearing prognosis in OSA and patients without OSA with ISSNHL. We aimed to investigate clinical manifestations of ISSNHL in patients with OSA, including severity of hearing loss and response to treatment. PATIENTS AND METHODS A case-control study was conducted by extracting data from the sleep center and cochlea center databases of the Chang Gung Memorial Hospital. A retrospective chart review was performed to include confirmed adult OSA patients diagnosed with unilateral ISSNHL. Age and sex-matched patients without OSA with ISSNHL were enrolled as controls. Pure-tone average (PTA) thresholds were measured at specific frequencies. Changes in PTA before and after standard treatment with oral prednisolone (1mg/kg/day for 5 days, then tapered) and between participants with OSA and without OSA were compared. Standard treatment was given to all ISSNHL patients. RESULTS Twenty-eight out of 8500 (0.33%) OSA patients experienced subsequent ISSNHL in 9 years. Patients with OSA (n=28) had poorer high-frequency perception in the unaffected ear than the patients without OSA (n=120), although the difference was not significant. Hearing in the affected ear among patients with OSA was comparable to that patients without OSA at individual frequencies and average, suggesting no difference in hearing loss in the affected ear between the two groups. In terms of high-frequencies (4000 and 8000 Hz) perception, patients with OSA had significantly poorer responses to steroid treatment than patients without OSA. CONCLUSION ISSNHL may be one of the auditory complications associated with OSA. Patients with OSA had poorer prednisolone related hearing improvement in high frequencies than patients without OSA. Despite study limitations, OSA-related hypoxia and snoring noise is hazardous to hearing and standard treatments with CPAP is suggested in OSA patients for both holistic and auditory health.
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Affiliation(s)
- Chin-Kuo Chen
- Department of Otolaryngology-Head and Neck Surgery, Sleep Center, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shih Chieh Shen
- Department of Otolaryngology-Head and Neck Surgery, Sleep Center, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Li-Ang Lee
- Department of Otolaryngology-Head and Neck Surgery, Sleep Center, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Ming-Hui Sun
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Ophthalmology, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan
| | - Ning-Hung Chen
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Pulmonary and Critical Care Medicine, Sleep Center, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan
| | - Li-Pang Chuang
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Pulmonary and Critical Care Medicine, Sleep Center, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan
| | - Hsueh-Yu Li
- Department of Otolaryngology-Head and Neck Surgery, Sleep Center, Chang Gung Memorial Hospital (Linkou), Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
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Park DJ, Ha S, Choi JS, Lee SH, Park JE, Seo YJ. Induced Short-Term Hearing Loss due to Stimulation of Age-Related Factors by Intermittent Hypoxia, High-Fat Diet, and Galactose Injection. Int J Mol Sci 2020; 21:ijms21197068. [PMID: 32992845 PMCID: PMC7582260 DOI: 10.3390/ijms21197068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Age-related hearing loss (ARHL) is the most common sensory disorder among the elderly, associated with aging and auditory hair cell death due to oxidative-stress-induced mitochondrial dysfunction. Although transgenic mice and long-term aging induction cultures have been used to study ARHL, there are currently no ARHL animal models that can be stimulated by intermittent environmental changes. In this study, an ARHL animal model was established by inducing continuous oxidative stress to promote short-term aging of cells, determined on the basis of expression of hearing-loss-induced phenotypes and aging-related factors. The incidence of hearing loss was significantly higher in dual- and triple-exposure conditions than in intermittent hypoxic conditions, high-fat diet (HFD), or d-galactose injection alone. Continuous oxidative stress and HFD accelerated cellular aging. An increase in Ucp2, usually expressed during mitochondrial dysfunction, was observed. Expression of Cdh23, Slc26a4, Kcnq4, Myo7a, and Myo6, which are ARHL-related factors, were modified by oxidative stress in the cells of the hearing organ. We found that intermittent hypoxia, HFD, and galactose injection accelerated cellular aging in the short term. Thus, we anticipate that the development of this hearing loss animal model, which reflects the effects of intermittent environmental changes, will benefit future research on ARHL.
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Affiliation(s)
- Dong Jun Park
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon-do 26426, Korea; (D.J.P.); (J.S.C.); (S.H.L.)
| | - Sunmok Ha
- Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, wonju 26493, Korea;
| | - Jin Sil Choi
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon-do 26426, Korea; (D.J.P.); (J.S.C.); (S.H.L.)
| | - Su Hoon Lee
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon-do 26426, Korea; (D.J.P.); (J.S.C.); (S.H.L.)
| | - Jeong-Eun Park
- Department of Otorhinolaryngology Head and Neck Surgery, Hallym University College of Medicine, Dongtan Sacred Heart Hospital, Hwaseong 18450, Korea;
| | - Young Joon Seo
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon-do 26426, Korea; (D.J.P.); (J.S.C.); (S.H.L.)
- Correspondence: ; Tel.: +82-33-741-0644
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8
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Gozeler MS, Sengoz F. Auditory Function of Patients with Obstructive Sleep Apnea Syndrome: A Study. Eurasian J Med 2020; 52:176-179. [PMID: 32612427 DOI: 10.5152/eurasianjmed.2019.18373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/22/2019] [Indexed: 11/22/2022] Open
Abstract
Objective Obstructive sleep apnea syndrome (OSAS) is a respiratory syndrome that manifests during sleep. For the auditory system to be able to function normally, the inner ear and cochlear nerve require healthy oxygen support. The purpose of this study was to assess the hearing function of patients with OSAS and to reveal the relationship between polysomnographic parameters and hearing test results. Materials and Methods The study was performed with 35 patients diagnosed with moderate or severe OSAS using polysomnography and a control group consisting of 30 individuals. The snoring, tiredness, observed apnea, blood pressure, body mass index, age, neck circumference and gender (STOP-Bang) questionnaire was used to establish the control group. Detailed otoscopic examinations were administered to all subjects by the same otolaryngologist, followed by a tympanogram, pure-tone audiometry (PTA) and transient evoked otoacoustic emissions (TEOAE) tests. Results We determined mild sensorineural hearing loss in patients with OSAS. When the different frequencies were evaluated separately, hearing threshold values in the patients with OSAS were significantly higher compared to the control group at 500, 1000, 2000, 4000, and 8000 Hz in both ears. TEOAE test reproducibility values in both ears were significantly lower in the study group compared to the control group. Conclusion The hearing system is affected to varying degrees in patients with OSAS. If hearing loss is detected in patients presenting at otolaryngology clinics due to snoring, then assessing these subjects in terms of risk of OSAS is important to reduce mortality and morbidity that may develop at later stages in association with OSAS.
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Affiliation(s)
- Mustafa Sitki Gozeler
- Department of Otorhinolaryngology, Ataturk University School of Medicine, Erzurum, Turkey
| | - Furkan Sengoz
- Department of Otorhinolaryngology, Ataturk University School of Medicine, Erzurum, Turkey
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Seo YJ, Ju HM, Lee SH, Kwak SH, Kang MJ, Yoon JH, Kim CH, Cho HJ. Damage of Inner Ear Sensory Hair Cells via Mitochondrial Loss in a Murine Model of Sleep Apnea With Chronic Intermittent Hypoxia. Sleep 2018; 40:3896165. [PMID: 28934520 DOI: 10.1093/sleep/zsx106] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Study Objectives Investigating the exact pathophysiology of obstructive sleep apnea syndrome (OSAS)-induced hearing loss is critical. We sought to verify the hypothesis that a correlation exists between mitochondrial dysfunction in inner ear hair cells and the auditory dysfunction induced by chronic intermittent hypoxia (CIH) in a murine model of sleep apnea. Methods C57BL/6J adult male mice were randomized to 4 weeks of CIH (n = 12) or normoxia (Sham) (n = 12). Hearing threshold was determined by auditory brainstem response. The activity of mitochondria was compared between CIH and Sham mice. Histological assessment and transmission electron microscopy were performed for assessing morphologic changes in mitochondria. The number of mtDNA copies as well as the levels of PGC1-α, Tfam, and VDAC (voltage-dependent anion channel) were determined in the hair cells of CIH mice. Results We observed that hearing ability in CIH mice was impaired and hair-cell mitochondria in CIH mice were fewer compared to that in Sham and also displayed an aberrant morphology. The mRNA levels of PGC-1α and Tfam were higher in the CIH group than in the Sham group. Moreover, the expression of VDAC was increased in the tectorial membrane, the basilar membrane, and especially in the inner hair cells of CIH mice. Conclusions This study using CIH mice as a model for OSAS provides evidence of an association between OSAS and auditory function alteration, as well as of mitochondria being part of the pathophysiology of hearing impairment. Further investigation is required to determine whether mitochondria could serve as a valid target for preventive or therapeutic purposes.
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Affiliation(s)
- Young Joon Seo
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Hyun Mi Ju
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Sun Hee Lee
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Sang Hyun Kwak
- Department of Otolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Jung Kang
- Research Center for Human Natural Defense System, Yonsei University College of Medicine, Seoul, South Korea
| | - Joo-Heon Yoon
- Department of Otolaryngology, Yonsei University College of Medicine, Seoul, South Korea.,Research Center for Human Natural Defense System, Yonsei University College of Medicine, Seoul, South Korea.,The Airway Mucus Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang-Hoon Kim
- Department of Otolaryngology, Yonsei University College of Medicine, Seoul, South Korea.,The Airway Mucus Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung-Ju Cho
- Department of Otolaryngology, Yonsei University College of Medicine, Seoul, South Korea.,The Airway Mucus Institute, Yonsei University College of Medicine, Seoul, South Korea
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Sharafkhaneh A, Hirshkowitz M. Can You Hear Me Now? J Clin Sleep Med 2016; 12:641-2. [PMID: 27092694 DOI: 10.5664/jcsm.5780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/21/2016] [Indexed: 11/13/2022]
Affiliation(s)
- Amir Sharafkhaneh
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX.,Medical Care Line, Section of Pulmonary, Critical Care and Sleep Medicine, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Max Hirshkowitz
- Consulting Professor, Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, Stanford, CA
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