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Kaffenberger TM, Plawecki A, Kaki P, Boon M, Huntley C. Troubleshooting Upper Airway Stimulation Therapy Using Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg 2024; 171:588-595. [PMID: 38643409 DOI: 10.1002/ohn.785] [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: 10/06/2023] [Revised: 01/17/2024] [Accepted: 02/17/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE This study assesses the utility of drug-induced sleep endoscopy (DISE) in guiding further treatment for patients with obstructive sleep apnea (OSA) who have difficulty tolerating upper airway stimulation (UAS) or have inadequate response to therapy. STUDY DESIGN We conducted a retrospective analysis of UAS patients at our institution who underwent DISE, post-UAS, and evaluated the efficacy of different electrode configurations and maneuvers. SETTING A tertiary care hospital. METHODS Out of 379 patients who received UAS therapy, 34 patients who underwent DISE post-UAS (DISE-UAS) were included. Palatal coupling (PC) was assessed with UAS stimulation alone, jaw thrust alone, and both simultaneously during DISE. RESULTS Among 34 patients, 5 had suboptimal adherence to UAS therapy, 19 had suboptimal therapy efficacy with residual OSA burden, and 10 had both. During DISE-UAS, PC was observed in 7 patients (21%) with UAS stimulation alone, 9 patients (26%) with jaw thrust alone, and 8 patients (24%) with both maneuvers combined. Notably, 10 patients (29%) did not exhibit PC with any maneuver. Based on DISE-UAS findings, 13 patients were recommended oral appliance therapy (OAT), and 8 patients underwent further surgical interventions. CONCLUSION DISE-UAS is a valuable adjunct in troubleshooting UAS therapy for patients intolerant to CPAP or with suboptimal therapy efficacy. This study provides an algorithm for targeted multimodality therapy based on DISE findings, facilitating personalized management approaches.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Andrea Plawecki
- Henry Ford Department of Otolaryngology, Detroit, Michigan, USA
| | - Praneet Kaki
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Veugen CC, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med 2024; 20:353-361. [PMID: 38426847 PMCID: PMC11019213 DOI: 10.5664/jcsm.10866] [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: 02/02/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 03/02/2024]
Abstract
STUDY OBJECTIVES To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT). METHODS Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment. RESULTS Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response. CONCLUSIONS The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation. CLINICAL TRIAL REGISTRATION Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741. CITATION Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353-361.
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Affiliation(s)
- Christianne C.A.F.M. Veugen
- Department of Otorhinolaryngology, Head and Neck Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Ellen Kant
- Department of Otorhinolaryngology, Head and Neck Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes C. Kelder
- Department of Epidemiology and Statistics, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Anna Schipper
- Department of Oral- and Maxillofacial Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert J. Stokroos
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcel P. Copper
- Department of Otorhinolaryngology, Head and Neck Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
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Fernández-Sanjuán P, Alcaraz M, Bosco G, Pérez-Martín N, Morato M, Lugo R, Arrieta JJ, Sanabria J, Ríos-Lago M, Plaza G. Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients. J Clin Med 2024; 13:1184. [PMID: 38592035 PMCID: PMC10932289 DOI: 10.3390/jcm13051184] [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: 01/20/2024] [Revised: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE. METHODS This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator. RESULTS In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue. CONCLUSIONS The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.
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Affiliation(s)
- Patricia Fernández-Sanjuán
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Universidad Rey Juan Carlos, 28002 Madrid, Spain
| | - Marta Alcaraz
- Department of Otolaryngology, Hospital Universitario La Moraleja, 28050 Madrid, Spain;
| | - Gabriela Bosco
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario La Zarzuela, 28023 Madrid, Spain
| | - Nuria Pérez-Martín
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario La Zarzuela, 28023 Madrid, Spain
| | - Marta Morato
- Department of Otolaryngology, Hospital Quirónsalud San José, 28002 Madrid, Spain;
| | - Rodolfo Lugo
- Department of Otolaryngology Head and Neck Surgery, Hospital San José, Monterrey 64718, Mexico;
| | - Juan José Arrieta
- Department of Stomatology, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Jaime Sanabria
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Marcos Ríos-Lago
- Department of Basic Psychology II, Faculty of Psychology, UNED—Universidad Nacional de Educación a Distancia, 28040 Madrid, Spain;
| | - Guillermo Plaza
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Universidad Rey Juan Carlos, 28002 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario La Zarzuela, 28023 Madrid, Spain
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Parikh SR, Boudewyns A, Friedman NR, Schwartz SR, Baldassari CM, Benedek P, Carr MM, Chan DK, Chan KC, Cheng AT, Couloigner V, Diala OR, DeRowe A, El-Hakim H, Fayoux P, Hsu WC, Ishman S, Kirkham EM, Mitchell RB, Thevasagayam R, Lam D. International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE). Int J Pediatr Otorhinolaryngol 2023; 171:111627. [PMID: 37441992 DOI: 10.1016/j.ijporl.2023.111627] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea. METHODS The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus. RESULTS A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids. CONCLUSION This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients.
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Affiliation(s)
- Sanjay R Parikh
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, USA.
| | - An Boudewyns
- Department of Otolaryngology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Norman R Friedman
- Department of Otolaryngology, University of Colorado, Children's Hospital Colorado, USA
| | - Seth Roslow Schwartz
- Department of Otolaryngology, University of Washington, Virginia Mason Hospital, Seattle, USA
| | - Cristina M Baldassari
- Department of Otolaryngology, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, USA
| | - Palma Benedek
- Department of Otolaryngology, Heim Pal National Pediatric Institute, Hungary
| | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, USA
| | - Dylan K Chan
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, USA
| | - Kate C Chan
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alan T Cheng
- Department of Otolaryngology, The University of Sydney, The Children's Hospital at Westmead, Australia
| | - Vincent Couloigner
- Department of Otolaryngology, Hôpital Necker-Enfants Malades, Université Paris Cité, France
| | - Obinna R Diala
- Department of Otolaryngology, University of Colorado, Children's Hospital Colorado, USA
| | - Ari DeRowe
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Israel
| | - Hamdy El-Hakim
- Department of Otolaryngology, University of Alberta, Stollery Children's Hospital, Canada
| | - Pierre Fayoux
- Pediatric Otolaryngology - Head Neck Surgery, Jeanne de Flandre Hospital, CHU Lille, France
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital and Children's Hospital, Taiwan
| | - Stacey Ishman
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Erin M Kirkham
- Department of Otolaryngology, University of Michigan, Mott Children's Hospital, USA
| | - Ron B Mitchell
- Department of Otolaryngology, University of Texas, Southwestern Medical Center, Children's Medical Center Dallas, USA
| | - Ravi Thevasagayam
- Department of Otolaryngology, Sheffield Children's Hospital, United Kingdom
| | - Derek Lam
- Department of Otolaryngology, Oregon Health and Science University, USA
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5
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Renslo B, Hobelmann K, Sagalow ES, Ananth A, Boon M, Huntley C. Palatal Coupling Maneuvers Do Not Predict Hypoglossal Nerve Stimulator Treatment Efficacy. Laryngoscope 2023; 133:431-436. [PMID: 36129159 DOI: 10.1002/lary.30397] [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: 04/16/2022] [Revised: 08/01/2022] [Accepted: 09/01/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE(S) Maneuvers during drug-induced sleep endoscopy (DISE), for patients with obstructive sleep apnea (OSA), have been used as predictors for success with oral appliances. Hypoglossal nerve stimulation (HGNS) promotes opening at the velum through palatoglossus coupling. In this study, we evaluate maneuvers during DISE as predictors for HGNS treatment efficacy. METHODS We evaluated patients undergoing HGNS between November, 2014 and February, 2021. We assessed maneuvers including jaw thrust and chin lift during preoperative DISE. The impact of tongue base and palatal opening during these maneuvers were rated from 1 to 4 (1: no improvement, 2: mild improvement, 3: moderate improvement, 4: significant improvement). Patients were grouped by a score of 1-2 (weak response) or 3-4 (strong response). Apnea hypopnea index (AHI) change was calculated from the difference between preoperative and postoperative sleep study. RESULTS One hundred and seventy one patients were included. With jaw thrust, there was no significant difference in AHI change between patients with weak or strong response at the palate (n = 68 vs. 94, 9.5 vs. 13.6, p = 0.21) or tongue base (n = 24 vs. 138, 16.6 vs. 11.3, p = 0.24). On chin lift, there was no significant difference at the palate (n = 82 vs. 18, 13.9 vs. 11.4, p = 0.63) or tongue base (n = 92 vs. 72, 10.8 vs. 14.6, p = 0.24). On multiple linear regression analysis, lower body mass index, higher preoperative AHI, and higher preoperative oxygen nadir were associated with a larger AHI change. CONCLUSION Palatal coupling maneuvers during DISE are not predictive of AHI change with HGNS. Findings using these maneuvers should not preclude HGNS candidacy. LEVEL OF EVIDENCE 3 Laryngoscope, 133:431-436, 2023.
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Affiliation(s)
- Bryan Renslo
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kealan Hobelmann
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emily S Sagalow
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashwin Ananth
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Viana A, Estevão D, Zhao C. The clinical application progress and potential of drug-induced sleep endoscopy in obstructive sleep apnea. Ann Med 2022; 54:2909-2920. [PMID: 36269026 PMCID: PMC9590429 DOI: 10.1080/07853890.2022.2134586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: Obstructive sleep apnoea (OSA) is characterized by nocturnal repetitive upper airway (UA) collapse. For sleep physicians, the recognition of UA collapse characteristics is critical for understanding OSA mechanisms and developing individualized treatment plans. Drug-induced sleep endoscopy (DISE) is an exam during simulated sleep that allows the dynamic assessment of the UA of individuals with OSA. The initial recognition of DISE was to locate the sites of UA obstruction and direct the surgical selection of OSA since it was introduced in the 1990s. After approximately 30 years of studies, based on advances in endoscopic operative techniques and innovative treatments of OSA, DISE had been performed to explore mechanisms and comprehensive treatments related to UA collapse. Methods: This article reviewed contemporary DISE advances, including indications and contraindications, technique of induced sleep, endoscopic operation, UA characteristics classification.Results and Conclusions: Precise selection based on the association between collapse patterns and treatment modalities, such as continuous positive airway pressure, oral appliance, positional therapy, robotic surgery and neurostimulator implanting, is the future research prospect based on DISE.Key messagesDISE provides sleep physicians with valuable information about the upper airway collapse characteristics and dynamic changes during sleep.The studies based on DISE findings improve the selectivity and efficiency of treatment modalities, including classical therapies such as continuous positive airway pressure, oral appliance, positional therapy, and innovative therapies such as neurostimulator implanting and robotic surgery, promote the advancement of OSA precision medicine.
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Affiliation(s)
- Alonço Viana
- Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcilio Dias Naval Hospital, Rio de Janeiro, Brazil
| | - Débora Estevão
- Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Glória D'Or Hospital - Rede D'Or São Luiz, Rio de Janeiro, Brazil
| | - Chen Zhao
- Department of Otorhinolaryngology, the First Hospital of China Medical University, Shenyang, China
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Bastier PL, Gallet de Santerre O, Bartier S, De Jong A, Trzepizur W, Nouette-Gaulain K, Bironneau V, Blumen M, Chabolle F, de Bonnecaze G, Dufour X, Ameline E, Kérimian M, Latournerie V, Monteyrol PJ, Thiery A, Tronche S, Vergez S, Bequignon E. Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome. Eur Ann Otorhinolaryngol Head Neck Dis 2022; 139:216-225. [PMID: 35871981 DOI: 10.1016/j.anorl.2022.05.003] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome. DESIGN A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data. METHODS The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results. RESULTS Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion. CONCLUSION Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.
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Affiliation(s)
- P-L Bastier
- Pôle Tête et Cou, Maison de Santé Protestante de Bordeaux-Bagatelle, 203, route de Toulouse, 33401 Talence, France
| | | | - S Bartier
- Service d'ORL et de Chirurgie Cervico-Faciale, Hôpital Henri-Mondor, 1, rue Gustave-Eiffel, 94000 Créteil, France
| | - A De Jong
- Département d'Anesthésie-Réanimation Saint-Éloi, Hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - W Trzepizur
- Département de Pneumologie et de Médecine du Sommeil, CHU d'Angers, 4, rue Larrey, 49100 Angers, France
| | - K Nouette-Gaulain
- Service d'Anesthésie-Réanimation, Hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33700 Bordeaux, France
| | - V Bironneau
- Service de Pneumologie, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - M Blumen
- Centre Médical Veille Sommeil, 59, avenue de Villiers, 75017 Paris, France; Service d'ORL, Hôpital Foch, 40, rue Worth, 92140 Suresnes, France
| | - F Chabolle
- Cabinet d'ORL, 20, rue Parmentier, 92200 Neuilly-sur-Seine, France
| | - G de Bonnecaze
- Service d'ORL et Chirurgie Cervico-Faciale, Hôpital Larrey, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - X Dufour
- Service d'ORL et Chirurgie Cervico-faciale, CHU de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - E Ameline
- Cabinet d'ORL, 1, rue des Iris, 41260 La Chaussée-Saint-Victor, France
| | - M Kérimian
- Service d'ORL et de Chirurgie Cervico-Faciale, Hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33700 Bordeaux, France
| | - V Latournerie
- Service d'ORL, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France
| | - P-J Monteyrol
- Nouvelle Clinique Bordeaux Tondu, avenue Jean-Alfonséa, 33270 Floirac, France
| | - A Thiery
- Service d'ORL, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France
| | - S Tronche
- SFORL, 26, rue Lalo, 75016 Paris, France
| | - S Vergez
- Service d'ORL et Chirurgie Cervico-Faciale, Hôpital Larrey, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - E Bequignon
- Service d'ORL, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France.
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Camañes-Gonzalvo S, Bellot-Arcís C, Marco-Pitarch R, Montiel-Company JM, García-Selva M, Agustín-Panadero R, Paredes-Gallardo V, Puertas-Cuesta FJ. Comparison of the phenotypic characteristics between responders and non-responders to obstructive sleep apnea treatment using mandibular advancement devices in adult patients: systematic review and meta-analysis. Sleep Med Rev 2022; 64:101644. [DOI: 10.1016/j.smrv.2022.101644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 12/28/2022]
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Gogou ES, Psarras V, Giannakopoulos NN, Koutsourelakis I, Halazonetis DJ, Tzakis MG. Drug-induced sleep endoscopy improves intervention efficacy among patients treated for obstructive sleep apnea with a mandibular advancement device. Sleep Breath 2022; 26:1747-1758. [DOI: 10.1007/s11325-021-02561-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/12/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022]
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10
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Veugen CC, Sanders RM, Stokroos RJ, Copper MP. Drug-induced Sleep Endoscopy: Are there Predictors for Failure of Oral Appliance Treatment? Int Arch Otorhinolaryngol 2021; 26:e339-e347. [PMID: 35846824 PMCID: PMC9282964 DOI: 10.1055/s-0041-1731368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 03/19/2021] [Indexed: 10/28/2022] Open
Abstract
Abstract
Introduction In the literature, evidence is lacking on the predictive value of drug-induced sleep endoscopy (DISE) for oral appliance treatment (OAT).
Objectives The aim of the present study is to evaluate whether DISE with concomitant mandibular advancement maneuver can predict failure of OAT.
Methods An observational retrospective study including patients diagnosed with obstructive sleep apnea (OSA) who previously received OAT. Results of DISE were analyzed in a group with documented OAT failure (apnea-hypopnea index [AHI] > 10 events/hour or < 50% reduction) and a group with OAT benefit (AHI <10 events/hour or > 50% reduction). The upper airway was assessed using the velum, oropharynx, tongue base, epiglottis (VOTE) classification. Additionally, a mandibular advancement maneuver, manually protruding the mandible by performing a jaw thrust, was performed to mimic the effect of OAT.
Results The present study included 50 patients with OAT failure and 20 patients with OAT benefit. A subgroup analysis of patients with OAT failure and an AHI < 30 events/hour included 26 patients. In the OAT failure group, 74% had a negative jaw thrust maneuver. In the subgroup with an AHI < 30 events/hour, 76.9% had a negative jaw thrust maneuver. In the OAT benefit group, 25% had a negative jaw thrust maneuver (p < 0.001).
Conclusions A negative jaw thrust maneuver during DISE can be a valuable predictor for OAT failure, independent of AHI. Drug-induced sleep endoscopy should be considered as a diagnostic evaluation tool before starting OAT.
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Affiliation(s)
- Christianne C.A.F.M. Veugen
- Department of Otorhinolaryngology, Head and Neck Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Rineke M.C. Sanders
- Department of Otorhinolaryngology, Head and Neck Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Robert J. Stokroos
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel P. Copper
- Department of Otorhinolaryngology, Head and Neck Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
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11
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Seay EG, Keenan BT, Schwartz AR, Dedhia RC. Evaluation of Therapeutic Positive Airway Pressure as a Hypoglossal Nerve Stimulation Predictor in Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2021; 146:691-698. [PMID: 32496539 DOI: 10.1001/jamaoto.2020.1018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Recent retrospective hypoglossal nerve stimulation (HGNS) outcomes data suggest that patients with low therapeutic positive airway pressure (PAP) levels achieve greater success than patients with high therapeutic PAP levels. Objective To examine the use of therapeutic nasal PAP levels at the soft palate in predicting the outcomes of HGNS for patients with obstructive sleep apnea. Design, Setting, and Participants This prospective cohort study used drug-induced sleep endoscopy (DISE) to evaluate the predictive capacity of therapeutic PAP levels in HGNS outcomes. In an academic sleep surgery center, 27 consecutive patients with obstructive sleep apnea who underwent DISE before implantation of an HGNS device were evaluated. The study was conducted from May 1, 2018, to June 26, 2019. Exposures Positive airway pressure delivered through a nasal mask during DISE. Main Outcomes and Measures Improvement in apnea-hypopnea index as measured from full-night preoperative and postoperative efficacy studies. Results Twenty-seven patients met all inclusion criteria. The mean (SD) age was 62.0 (14.4) years, 14 participants were men (51.9%), and mean body mass index was 28.1 (4.0). Responders to HGNS therapy (n = 18) had significantly lower mean (SD) palatal opening pressure compared with nonresponders (n = 9) (5.0 [2.8] vs 9.2 [3.7] cm H2O, respectively; mean difference, -4.2; 95% CI, -6.8 to -1.6 cm H2O). After adjusting for age, sex, and body mass index, the mean palatal opening pressure value for the responders remained 3.5 cm H2O lower (95% CI, -6.7 to -0.4 cm H2O) than that of nonresponders. A palatal opening pressure cutoff level less than 8 cm H2O demonstrated a positive predictive value of 82.4%; sensitivity, 77.8%; and specificity, 66.7%. Conclusions and Relevance In this small prospective cohort study, therapeutic nasal PAP levels during DISE differed significantly between responder and nonresponders to HGNS. Because DISE represents a mandatory, relatively standardized diagnostic tool for HGNS candidacy, the use of therapeutic nasal PAP through DISE can be broadly implemented and studied across multiple centers to possibly improve patient selection for HGNS.
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Affiliation(s)
- Everett G Seay
- Perelman School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Alan R Schwartz
- Perelman School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia.,Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Raj C Dedhia
- Perelman School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia.,Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
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12
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Jain N, Rodin J, Boon MS, Huntley CT. A systematic approach to the evaluation and management of obstructive sleep apnea: The Jefferson Protocol. Am J Otolaryngol 2021; 42:102866. [PMID: 33418179 DOI: 10.1016/j.amjoto.2020.102866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/22/2020] [Indexed: 12/20/2022]
Abstract
Obstructive sleep apnea (OSA) has become increasingly prevalent in the United States. While continuous positive airway pressure (CPAP) therapy remains the gold standard for treatment, surgical intervention can enhance compliance and improve outcomes for those intolerant of CPAP. Since the majority of OSA patients have multilevel obstruction, it is critical that otolaryngologists understand each patient's pattern and anatomic level of obstruction before solidifying a treatment plan. This publication serves as a comprehensive review of evaluation, characterization, and management of OSA. Further, the authors outline their departmental algorithm for identifying ideal surgical candidates and tailoring corresponding surgical interventions.
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13
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Cheong CS, Loke W, Thong MKT, Toh ST, Lee CH. The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 14:149-158. [PMID: 33092317 PMCID: PMC8111386 DOI: 10.21053/ceo.2020.01704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 11/22/2022] Open
Abstract
Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.
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Affiliation(s)
- Crystal Sj Cheong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Weiqiang Loke
- Faculty of Dentistry, National University of Singapore, Singapore
| | - Mark Kim Thye Thong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Song Tar Toh
- Department of Otolaryngology, Singapore General Hospital, SingHealth Duke-NUS Sleep Centre, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
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14
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Koutsourelakis I, Kontovazainitis G, Lamprou K, Gogou E, Samartzi E, Tzakis M. The role of sleep endoscopy in oral appliance therapy for obstructive sleep apnea. Auris Nasus Larynx 2020; 48:255-260. [PMID: 32859441 DOI: 10.1016/j.anl.2020.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/09/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Although oral appliance therapy is considered a validated treatment for obstructive sleep apnea, its therapeutic success varies significantly among patients. Drug-induced sleep endoscopy is often employed in order to identify candidates for upper airway surgery; however, it remains unknown whether its findings can be associated with success of oral appliance therapy. This study tested the hypothesis that drug-induced sleep endoscopy variables can predict the outcome of oral appliance therapy in obstructive sleep apnea patients. METHODS Forty-nine obstructive sleep apnea patients [45 men; mean apnea-hypopnea index 25.3 ± 7.5 events/h; mean body mass index 28.2 ± 3.0 kg/m2] underwent drug-induced sleep endoscopy, followed by a one-month of oral appliance therapy, and subsequently a follow-up polysomnography to assess outcome. RESULTS Thirty-three patients (67.3%) were responders and sixteen were non-responders (32.6%). Non-responders had a higher occurrence of complete or partial circumferential collapse at velum in comparison with responders. Multivariate logistic regression analysis revealed that, among baseline clinical and polysomnographic characteristics and sleep endoscopy findings, the presence of complete circumferential collapse at velum and increased body mass index were the only independent predictors of oral appliance therapy failure. CONCLUSION Drug-induced sleep endoscopy can be used to predict a higher likelihood of success to oral appliance therapy in obstructive sleep apnea patients.
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Affiliation(s)
| | | | - Kallirroi Lamprou
- Orofacial Pain Clinic of the Dental School of University of Athens, Greece
| | - Evgenia Gogou
- Orofacial Pain Clinic of the Dental School of University of Athens, Greece
| | - Eliana Samartzi
- Orofacial Pain Clinic of the Dental School of University of Athens, Greece
| | - Michalis Tzakis
- Orofacial Pain Clinic of the Dental School of University of Athens, Greece
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15
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Ho LI, Leung YY. Skeletal Advancement Surgery in Patients with Moderate-to-Severe Obstructive Sleep Apnea. CURRENT SLEEP MEDICINE REPORTS 2020. [DOI: 10.1007/s40675-020-00169-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Lavigne G, Herrero Babiloni A, Beetz G, Dal Fabbro C, Sutherland K, Huynh N, Cistulli P. Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea. J Dent Res 2019; 99:26-35. [DOI: 10.1177/0022034519885644] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.
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Affiliation(s)
- G.J. Lavigne
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
- Division of Experimental Medicine, McGill University, Montréal, Canada
| | - A. Herrero Babiloni
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
- Division of Experimental Medicine, McGill University, Montréal, Canada
| | - G. Beetz
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
| | | | - K. Sutherland
- Charles Perkins Centre and Sydney Medical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
| | - N. Huynh
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
| | - P.A. Cistulli
- Charles Perkins Centre and Sydney Medical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
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17
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Park D, Kim JS, Heo SJ. The Effect of the Modified Jaw-Thrust Maneuver on the Depth of Sedation During Drug-Induced Sleep Endoscopy. J Clin Sleep Med 2019; 15:1503-1508. [PMID: 31596216 PMCID: PMC6778345 DOI: 10.5664/jcsm.7986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The modified jaw-thrust maneuver (MJTM) during drug-induced sleep endoscopy (DISE) is known to predict the treatment effect of mandibular advancement devices. However, its effect on the depth of sedation and potential to provoke arousal by awakening patients during the maneuver has not been studied so far. This study investigated the effect of the MJTM on the depth of sedation during DISE. METHODS Forty patients on whom the MJTM was performed during DISE were included. The effect of the maneuver was evaluated at the levels of the velum, lateral wall of the oropharynx, base of the tongue, and epiglottis. Obstruction was defined as the collapse of the upper airway exceeding 75%, and improvement with the MJTM was defined as the widening of the upper airway by more than 50% during the maneuver. A bolus injection of midazolam was used to induce sedation and control the depth of sedation (bispectral index value of 60 to 80). RESULTS Obstructions were present in the velum of all patients, lateral wall of the oropharynx of 13 patients, base of the tongue of 28 patients, and epiglottis of 6 patients. After the MJTM, improvement of the obstruction was observed in 57.5%, 61.5%, 82%, and 66.7% of patients with velum, lateral wall of the oropharynx, base of the tongue, and epiglottis obstructions, respectively. An increase in the bispectral index value of more than 20 was observed in 8 patients. Four patients awakened during the procedure. CONCLUSIONS The MJTM significantly relieved obstruction during DISE, especially at the base of the tongue. However, this might have been caused by an increase in the degree of awakening during the maneuver. Therefore, MJTM's effect on the depth of sedation may help in improving the degree of airway obstruction.
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Affiliation(s)
- Donghwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Daegu, South Korea
| | - Jung-Soo Kim
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Sung Jae Heo
- Department of Otorhinolaryngology – Head and Neck Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
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18
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Cagna DR, Donovan TE, McKee JR, Eichmiller F, Metz JE, Albouy JP, Marzola R, Murphy KR, Troeltzsch M. Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry. J Prosthet Dent 2019; 122:198-269. [PMID: 31405523 DOI: 10.1016/j.prosdent.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/13/2022]
Abstract
This comprehensive review of the 2018 dental literature is provided to inform busy dentists about progress in the profession. Developed by the Committee on Scientific Investigation of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to one of the 8 sections of the report including (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information that will likely influence day-to-day treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source materials if greater detail is desired. As the profession continues its march toward evidence-based clinical decision-making, an already voluminous library of potentially valuable dental literature continues to grow. It is the intention of this review and its authors to provide assistance in navigating the extensive dental literature published in 2018. It is our hope that readers find this work useful in the clinical management of patients moving forward.
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Affiliation(s)
- David R Cagna
- Professor, Associate Dean, and Residency Director, Department of Prosthodontics, University of Tennessee Health Sciences Center, College of Dentistry, Memphis, Tenn.
| | - Terence E Donovan
- Professor and Head of Biomaterials, Department of Restorative Sciences, University of North Carolina School of Dentistry, Chapel Hill, NC
| | - James R McKee
- Private practice, Restorative Dentistry, Downers Grove, Ill
| | | | - James E Metz
- Private practice, Restorative Dentistry, Columbus, Ohio
| | - Jean-Pierre Albouy
- Assistant Professor, Department of Restorative Sciences, University of North Carolina School of Dentistry, Chapel Hill, NC
| | | | - Kevin R Murphy
- Associate Clinical Professor, Department of Periodontics, University of Maryland College of Dentistry, Baltimore, MD; Private practice, Periodontics and Prosthodontics, Baltimore, MD
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19
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Affiliation(s)
- Michael Awad
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford Hospital and Clinics, 801 Welch Road, Stanford, CA 95304, USA.
| | - Tyler S Okland
- Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, 801 Welch Road, Stanford, CA 95304, USA
| | - Vladimir Nekhendzy
- Department of Anesthesia, Stanford Hospital and Clinics, 801 Welch Road, Stanford, CA 95304, USA
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