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Primary treatment for estrogen receptor-positive (ER+) breast cancer is endocrine therapy. However, substantial evidence indicates a continued role for ER signaling in tumor progression. Selective estrogen receptor degraders (SERD), such as fulvestrant, induce effective ER signaling inhibition, although clinical studies with fulvestrant report insufficient blockade of ER signaling, possibly due to suboptimal pharmaceutical properties. Furthermore, activating mutations in the ER have emerged as a resistance mechanism to current endocrine therapies. New oral SERDs with improved drug properties are under clinical investigation, but the biological profile that could translate to improved therapeutic benefit remains unclear. Here, we describe the discovery of SAR439859, a novel, orally bioavailable SERD with potent antagonist and degradation activities against both wild-type and mutant Y537S ER. Driven by its fluoropropyl pyrrolidinyl side chain, SAR439859 has demonstrated broader and superior ER antagonist and degrader activities across a large panel of ER+ cells, compared with other SERDs characterized by a cinnamic acid side chain, including improved inhibition of ER signaling and tumor cell growth. Similarly, in vivo treatment with SAR439859 demonstrated significant tumor regression in ER+ breast cancer models, including MCF7-ESR1 wild-type and mutant-Y537S mouse tumors, and HCI013, a patient-derived tamoxifen-resistant xenograft tumor. These findings indicate that SAR439859 may provide therapeutic benefit to patients with ER+ breast cancer, including those who have resistance to endocrine therapy with both wild-type and mutant ER.

The purpose of the present study is to review the international literature, using a systematic review, for studies comparing propofol and dexmedetomidine for drug-induced sleep endoscopy (DISE) or sedation in which there is a description of the effect of the agents on the upper airway and associated variables (e.g., vital signs, sedation scores). This is a systematic review through October 4, 2016. PubMed/MEDLINE and four additional databases were accessed for this study. Two hundred twenty studies were screened, 79 were downloaded, and 10 met criteria. The majority of the studies identified dexmedetomidine as the preferred pharmacologic agent for DISE due to an overall safer and more stable profile based upon hemodynamic stability. However, propofol provided greater airway obstruction with oxygen desaturations. With either agent, the degree of obstruction in the upper airway lacks some degree of validity as to whether the obstructions accurately represent natural sleep or are simply a drug-induced effect. Dexmedetomidine and propofol have their advantages and disadvantages during DISE. Generally, dexmedetomidine was preferred and seemed to provide a more stable profile based upon cardiopulmonary status. However, propofol has a quicker onset, has a shorter half-life, and can demonstrate larger degrees of obstruction, which might more accurately reflect what happens during REM sleep. Additional research is recommended.

Objectives/Hypothesis To perform a systematic review with meta-analysis for sleep study outcomes in children who have undergone rapid maxillary expansion (RME) as treatment for obstructive sleep apnea (OSA). Data Sources PubMed/MEDLINE and eight additional databases. Review Methods Three authors independently and systematically reviewed the international literature through February 21, 2016. Results Seventeen studies reported outcomes for 314 children (7.6 ± 2.0 years old) with high-arched and/or narrow hard palates (transverse maxillary deficiency) and OSA. Data were analyzed based on follow-up duration: ≤3 years (314 patients) and >3 years (52 patients). For ≤3-year follow-up, the pre- and post-RME apnea–hypopnea index (AHI) decreased from a mean ± standard deviation (M ± SD) of 8.9 ± 7.0/hr to 2.7 ± 3.3/hr (70% reduction). The cure rate (AHI 3-year follow-up (range = 6.5–12 years), the AHI was reduced from an M ± SD of 7.1 ± 5.7/hr to 1.5 ± 1.8/hr (79% reduction). Conclusions Improvement in AHI and lowest oxygen saturation has consistently been seen in children undergoing RME, especially in the short term (

Objective To perform a systematic review and meta-analysis for studies evaluating genioplasty alone, genial tubercle advancement (GTA) alone, and GTA with hyoid surgery (GTA-HS) to treat obstructive sleep apnea (OSA). Data Sources Ten databases. Review Methods Three authors searched through November 15, 2015. Results 1,207 studies were screened; 69 were downloaded; and 13 studies met inclusion criteria. A total of 111 patients were included, with 27 standard genioplasty, 10 modified genioplasty, 24 GTA, and 50 GTA-HS patients. For standard genioplasty, the apnea-hypopnea index (AHI) reduced from a mean ± standard deviation (M ± SD) of 18.8 ± 3.8 (95% confidence interval [CI] 17.6, 20.0) to 10.8 ± 4.0 (95% CI 9.5, 12.1) events/hour (relative reduction 43.8%), P value = 0.0001. Genioplasty improved lowest oxygen saturation (LSAT) from 82.3 ± 7.3% (95% CI 80.0, 84.7) to 86.8 ± 5.2% (95% CI 85.1, 88.5), P value = 0.0032. For modified genioplasty AHI increased by 37.3%. For GTA, the AHI reduced from an M ± SD of 37.6 ± 24.2 (95% CI 27.9, 47.3) to 20.4 ± 15.1 (95% CI 14.4, 26.4) events/hour (relative reduction 45.7%), P value = 0.0049. GTA improved LSAT from 83.1 ± 8.3% (95% CI 79.8, 86.4) to 85.5 ± 6.8% (95% CI 82.8, 88.2), P value = 0.2789. For GTA-HS, the AHI reduced from an M ± SD of 34.5 ± 22.1 (95% CI 28.4, 40.6) to 15.3 ± 17.6 (95% CI 10.4, 20.2) events/hour (relative reduction 55.7%), P value < 0.0001; GTA-HS improved LSAT from 80.1 ± 16.6% (95% CI 75.5, 84.7) to 88.3 ± 6.9% (95% CI 86.4, 90.2), P value = 0.0017. Conclusion Standard genioplasty, GTA and GTA-HS can improve OSA outcomes such as AHI and LSAT. Given the low number of studies, these procedures remain as an area for additional OSA research. Laryngoscope, 127:984–992, 2017

Objective This study sought to systematically review the international literature for articles evaluating maxillary expansion and maxillomandibular expansion as treatments for obstructive sleep apnea (OSA) in adults and to perform a meta-analysis. Data sources Nine databases (including MEDLINE/PubMed). Review methods Searches were performed through January 8, 2016. The PRISMA statement was followed. Results Eight adult studies (39 patients) reported polysomnography and/or sleepiness outcomes. Six studies reported outcomes for maxillary expansion (36 patients), and the apnea-hypopnea index (AHI) decreased from a mean (M) ± standard deviation (SD) of 24.3 ± 27.5 [95% CI 15.3, 33.3] to 9.9 ± 13.7 [95% CI 5.4, 14.4] events/hr (relative reduction: 59.3%). Maxillary expansion improved lowest oxygen saturation (LSAT) from a M ± SD of 84.3 ± 8.1% [95% CI 81.7, 87.0] to 86.9 ± 5.6% [95% CI 85.1, 88.7]. Maxillomandibular expansion was reported in two studies (3 patients) and AHI decreased from a M ± SD of 47.53 ± 29.81 [95% CI −26.5 to 121.5] to 10.7 ± 3.2 [95% CI 2.8, 18.6] events/hr (relative reduction: 77.5%). Maxillomandibular expansion improved LSAT from a M ± SD of 76.7 ± 14.5% [95% CI 40.7, 112.7] to 89.3 ± 3.1 [95% CI 81.6, 97]. Conclusion The current literature demonstrates that maxillary expansion can improve and maxillomandibular expansion can possibly improve AHI and LSAT in adults; however, given the paucity of studies, these remain open for additional research efforts.

Objectives/Hypothesis To determine if sleepiness and sleep study variables (e.g., Apnea-Hypopnea Index [AHI] and lowest oxygen saturation) improve following isolated tonsillectomy for adult obstructive sleep apnea (OSA). Study Design Systematic review and meta-analysis. Methods Nine databases (PubMed/MEDLINE included) were searched through November 24, 2015. Results Seventeen studies (n = 216 patients, 34.4 ± 10.0 years and body mass index: 29.0 ± 6.1 kg/m2) met criteria. Tonsils sizes were hypertrophied, large, enlarged, extremely enlarged, or grades 2 to 4. Apnea-Hypopnea Index decreased by 65.2% (from 40.5 ± 28.9/hour to 14.1 ± 17.1/hour) (n = 203). The AHI mean difference (MD) was −30.2 per hour (95% confidence interval [CI] −39.3, −21.1) (P value < 0.00001). The AHI SMD was −1.37 (−1.65, −1.09) (large effect). Lowest oxygen saturation improved from 77.7 ± 11.9% to 85.5 ± 8.2% (n = 186). Lowest oxygen saturation MD was 8.5% (95% CI 5.2, 11.8) (P value < 0.00001). The Epworth Sleepiness Scale decreased from 11.6 ± 3.7 to 6.1 ± 3.9 (P value < 0.00001) (n = 125). Individual patient outcomes (n = 54) demonstrated an 85.2% success rate (AHI < 20/hour and ≥ 50% reduction) and a 57.4% cure rate. Individual patient data meta-analysis showed preoperative AHI < 30 per hour to be a significant predictor of surgical success (P value < 0.001) and cure (P value = 0.043); among patients with preoperative AHI < 30 per hour, tonsillectomy success rate was 100% (25 of 25) and cure rate was 84% (21 of 25) with a mean postoperative AHI of 2.4 ± 2.1 per hour; this compares to tonsillectomy success rate of 72.4% (21 of 29), cure rate of 10 of 29 (34.4%), and mean postoperative AHI of 14.3 ± 13.9 per hour for patients with preoperative AHI ≥ 30 per hour. Conclusion Isolated tonsillectomy can be successful as treatment for adult OSA, especially among patients with large tonsils and mild to moderate OSA (AHI < 30/hour). Laryngoscope, 2016 Laryngoscope, 126:2176–2186, 2016

Objectives/Hypothesis The primary objective was to determine if sleep study variables (e.g., apnea-hypopnea index [AHI] and lowest oxygen saturation) and quantitative sleepiness data improve following isolated hyoid surgery for obstructive sleep apnea (OSA). Study Design Systematic review and meta-analysis. Methods Nine databases, including PubMed, were searched through September 5, 2015. Results Four hundred ninety-eight studies were screened, 64 were reviewed, and nine studies met inclusion criteria. A total of 101 patients were identified who underwent hyoid surgery alone for treatment of OSA. Subanalyses were performed for: 1) type of surgery, 2) primary versus secondary hyoid surgery, 3) positional versus nonpositional OSA, 4) age, and 5) body mass index. In patients undergoing isolated hyoid surgery, the AHI decreased from a mean ± standard deviation of 37.3 ± 21.1 (95% confidence interval [CI]: 33.1, 41.5) to 23.0 ± 18.6 (95% CI: 19.3, 26.7) events/hour, which correspond to a 38.3% reduction (P < .0001). AHI reduced by 38.3% for hyoid myotomy with suspension, by 50.7% for hyothyroidopexy, and by 7.1% for hyoid expansion. The Epworth Sleepiness Scale decreased by 3.2 points from 10.3 ± 4.9 (95% CI: 8.8, 11.8) to 7.1 ± 4.2 (95% CI: 5.8, 8.4; P = .0027). Conclusions Isolated hyoid surgery has reduced OSA severity and improved sleepiness in adults. Hyothyroidopexy provided a 50.7% reduction in AHI, followed by hyoid myotomy with suspension (38.3% reduction in AHI) and hyoid expansion (7.1% reduction in AHI). The current literature lacks high-quality evidence with regard to hyoid surgery, and additional studies are needed to further elucidate the effect of hyoid surgery in OSA. Level of Evidence NA Laryngoscope, 2015

Objective.To systematically review the international literature for internal nasal septal deviation classification systems and summarize them for clinical and research purposes.Data Sources.Four databases (including PubMed/MEDLINE) were systematically searched through December 16, 2015.Methods.Systematic review, adhering to PRISMA.Results.After removal of duplicates, this study screened 952 articles for relevance. A final comprehensive review of 50 articles identified that 15 of these articles met the eligibility criteria. The classification systems defined in these articles included C-shaped, S-shaped, reverse C-shaped, and reverse S-shaped descriptions of the septal deviation in both the cephalocaudal and anteroposterior dimensions. Additional studies reported use of computed tomography and categorized deviation based on predefined locations. Three studies graded the severity of septal deviations based on the amount of deflection. The systems defined in the literature also included an evaluation of nasal septal spurs and perforations.Conclusion.This systematic review ascertained that the majority of the currently published classification systems for internal nasal septal deviations can be summarized by C-shaped or reverse C-shaped, as well as S-shaped or reverse S-shaped deviations in the anteroposterior and cephalocaudal dimensions. For imaging studies, predefined points have been defined along the septum. Common terminology can facilitate future research.

Objective. To search for articles evaluating the use of tracheostomies (either permanent stomas or tracheostomy tubes) in adult obstructive sleep apnea (OSA) patients and to evaluate the potential for the use of mini tracheostomies as treatment for OSA.Study Design. Systematic review.Methods. Nine databases were searched from inception through July 21, 2015.Results. The overall tracheostomy search yielded 516 articles, of which eighteen studies provided polysomnographic data. No study was identified (empty review) for the use of mini tracheostomies for treating OSA. The mini tracheostomy search yielded ninety-five articles which describe findings for either mini tracheostomy kits (inner cannula diameter of 4 mm) or the performance of mini tracheotomies. Six articles described the use of mini tracheostomies as a temporary procedure to relieve acute upper airway obstruction and none described the use for OSA. For tracheostomy stomal sites, suturing the skin directly to the tracheal rings with defatting can minimize stomal site collapse. The smallest tracheostomy stomal size that can successfully treat OSA has not been described.Conclusion. Mini tracheostomies as small as 4 mm have been successfully used in the short term to relieve upper airway obstruction. Given that polysomnography data are lacking, additional research is needed.

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

Objectives/Hypothesis To determine if apnea-hypopnea index (AHI) and lowest oxygen saturation (LSAT) improve following isolated supraglottoplasty for laryngomalacia with obstructive sleep apnea (OSA) in children. Study Design Systematic review and meta-analysis. Methods Nine databases, including PubMed/MEDLINE, were searched through September 30, 2015. Results A total of 517 studies were screened; 57 were reviewed; and 13 met criteria. One hundred thirty-eight patients were included (age range: 1 month–12.6 years). Sixty-four patients had sleep exclusive laryngomalacia, and in these patients: 1) AHI decreased from a mean (M) ± standard deviation (SD) of 14.0 ± 16.5 (95% confidence interval [CI] 10.0, 18.0) to 3.3 ± 4.0 (95% CI 2.4, 4.4) events/hour (relative reduction: 76.4% [95% CI 53.6, 106.4]); 2) LSAT improved from a M ± SD of 84.8 ± 8.4% (95% CI 82.8, 86.8) to 87.6 ± 4.4% (95% CI 86.6, 88.8); 3) standardized mean differences (SMD) demonstrated a small effect for LSAT and a large effect for AHI; and 4) cure (AHI < 1 event/hour) was 10.5% (19 patients with individual data). Seventy-four patients had congenital laryngomalacia, and in these patients: 1) AHI decreased from a M ± SD of 20.4 ± 23.9 (95% CI 12.8, 28.0) to 4.0 ± 4.5 (95% CI 2.6, 5.4) events/hour (relative reduction: 80.4% [95% CI 46.6, 107.4]); 2) LSAT improved from a M ± SD of 74.5 ± 11.9% (95% CI 70.9, 78.1) to 88.4 ± 6.6% (95% CI 86.4, 90.4); 3) SMD demonstrated a large effect for both AHI and LSAT; and 4) cure was 26.5% (38 patients with individual data). Conclusion Supraglottoplasty has improved AHI and LSAT in children with OSA and either sleep exclusive laryngomalacia or congenital laryngomalacia; however, the majority of them are not cured. Laryngoscope, 2015

Objectives Intermittent hypoxemia is a risk factor for developing complications in obstructive sleep apnea (OSA) patients. The objective of this systematic review was to identify articles evaluating the accuracy of the oxygen desaturation index (ODI) as compared with the apnea-hypopnea index (AHI) and then provide possible values to use as a cutoff for diagnosing adult OSA. Study design Systematic Review of Literature. Methods PubMed, the Cochrane Library, and SCOPUS databases were searched through November 2019. Results Eight studies (1,924 patients) met criteria (age range: 28-70.9 years, body mass index range: 21.9-37 kg/m2 , and AHI range: 0.5-62 events/hour). Five studies compared ODI and AHI simultaneously, and three had a week to months between assessments. Sensitivities ranged from 32% to 98.5%, whereas specificities ranged from 47.7% to 98%. Significant heterogeneity was present; however, for studies reporting data for a 4% ODI ≥ 15 events/hour, the specificity for diagnosing OSA ranged from 75% to 98%, and only one study reported the positive predictive value, which was 97%. Direct ODI and AHI comparisons were not made because of different hypopnea scoring, different oxygen desaturation categories, and different criteria for grading OSA severity. Conclusion Significant heterogeneity exists in studies comparing ODI and AHI. Based on currently published studies, consideration should be given for diagnosing adult OSA with a 4% ODI of ≥ 15 events/hour and for recommending further evaluation for diagnosing OSA with a 4% ODI ≥ 10 events/hour. Screening with oximetry may be indicated for the detection of OSA in select patients. Further study is needed before a definitive recommendation can be made. Laryngoscope, 131:440-447, 2021.

Objective Traditionally, upper airway examination is performed while the patient is awake. However, in the past two decades, drug-induced sleep endoscopy (DISE) has been used as a method of tridimensional evaluation of the upper airway during pharmacologically induced sleep. This study aimed to systematically review the evidence regarding the usefulness of DISE compared with that of traditional awake examination for surgical decision making in patients with obstructive sleep apnea (OSA). Data Sources Scopus, PubMed, and Cochrane Library databases were searched. Review Methods Only studies with a primary objective of evaluating the usefulness of DISE for surgical decision making in patients with OSA were selected. The included studies directly compared awake examination data with DISE outcome data in terms of possible influences on surgical decision making and operation success. Results A total of eight studies with 535 patients were included in this review. Overall, the surgical treatment changed after DISE in 50.24% (standard deviation 8.4) cases. These changes were more frequently associated with structures contributing to hypopharyngeal or laryngeal obstruction. However, these differences do not automatically indicate a higher success rate. Conclusion This review emphasized the direct impact of DISE compared with that of awake examination on surgical decision making in OSA patients. However, it is also clear that the available published studies lack evidence on the association between this impact and surgical outcomes. Laryngoscope, 2015

Objectives/Hypothesis Obstructive sleep apnea (OSA) is a syndrome frequently diagnosed in children; however, it lacks optimal diagnostic methods. This study aimed to provide a clinical decision rule for predicting pediatric OSA using commonly available clinical information. Study Design A prospective cohort study. Methods Children between the ages of 3 to 6 years-old, referred for an otorhinolaryngology consultation due to clinical suspicion of OSA, were recruited from January to June 2014. At baseline age, weight, height, gender, body mass index, Pediatric Sleep Questionnaire (PSQ) scores, tonsil size, and oxygen desaturation index (ODI) were assessed. A logistic regression modeling was used with backward stepwise elimination to develop a prediction model. Results Sixty-seven children were included with a mean age of 4.51 years. Of the 67 children included in this study, 25 (37.3%) subjects were diagnosed with pediatric OSA. Significant predictors of pediatric OSA in the final model (odds ratio, 95% confidence interval) included PSQ score (5.12; 3.3–6.5), ODI (1.34; 1.0–1.79) and tonsil size (6.7; 3.22–9.75). The final decision rule had a sensitivity of 88% and a specificity of 86%. The area under the receiver operating characteristic curve was 0.897. Conclusion The proposed clinical decision rule, based on three readily available variables, is a promising discriminating instrument for prediction of OSA among children between 3 and 6 years. Level of Evidence IIb. Laryngoscope, 2015

OBJECTIVE: To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data. DATA SOURCES: Web of Science, Scopus, MEDLINE, and The Cochrane Library. REVIEW METHODS: The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. RESULTS: Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apneahypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P = 0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y. CONCLUSION: Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments.

BACKGROUND The relationship between nasal surgery and its effect on continuous positive airway pressure (CPAP) device therapeutic treatment pressures and CPAP device use has not been previously systematically examined. STUDY OBJECTIVES To conduct a systematic review and meta-analysis evaluating the effect of isolated nasal surgery on therapeutic CPAP device pressures and use in adults with obstructive sleep apnea (OSA). METHODS MEDLINE, Scopus, Web of Science, and The Cochrane Library were searched through July 15, 2014. The MOOSE consensus statement and PRISMA statement were followed. RESULTS Eighteen studies (279 patients) reported CPAP data after isolated nasal surgery. Seven studies (82 patients) reported preoperative and postoperative mean therapeutic CPAP device pressures and standard deviations (SD), which reduced from 11.6 ± 2.2 to 9.5 ± 2.0 centimeters of water pressure (cwp) after nasal surgery. Pooled random effects analysis demonstrated a statistically significant pressure reduction, with a mean difference (MD) of -2.66 cwp (95% confidence interval (CI), -3.65 to -1.67); P < 0.00001. Eleven studies (153 patients) reported subjective, self-reported data for CPAP use; and a subgroup analysis demonstrated that 89.1% (57 of 64 patients) who were not using CPAP prior to nasal surgery subsequently accepted, adhered to, or tolerated it after nasal surgery. Objective, device meter-based hours of use increased in 33 patients from 3.0 ± 3.1 to 5.5 ± 2.0 h in the short term (

Objective.To quantify the effectiveness of nasal expiratory positive airway pressure (nasal EPAP) devices or Provent as treatment for obstructive sleep apnea (OSA).Methods.PubMed and six other databases were searched through November 15, 2015, without language limitations.Results.Eighteen studies (920 patients) were included. Pre- and post-nasal EPAP means ± standard deviations (M ± SD) for apnea-hypopnea index (AHI) in 345 patients decreased from27.32±22.24to12.78±16.89events/hr (relative reduction = 53.2%). Random effects modeling mean difference (MD) was −14.78 events/hr [95% CI −19.12, −10.45],pvalue < 0.00001. Oxygen desaturation index (ODI) in 247 patients decreased from21.2±19.3to12.4±14.1events/hr (relative reduction = 41.5%,pvalue < 0.00001). Lowest oxygen saturation (LSAT) M ± SD improved in 146 patients from83.2±6.8% to86.2±11.1%, MD 3 oxygen saturation points [95% CI 0.57, 5.63]. Epworth Sleepiness Scale (ESS) M ± SD improved (359 patients) from9.9±5.3to7.4±5.0, MD −2.5 [95% CI −3.2, −1.8],pvalue < 0.0001.Conclusion.Nasal EPAP (Provent) reduced AHI by 53.2%, ODI by 41.5% and improved LSAT by 3 oxygen saturation points. Generally, there were no clear characteristics (demographic factors, medical history, and/or physical exam finding) that predicted favorable response to these devices. However, limited evidence suggests that high nasal resistance could be associated with treatment failure. Additional studies are needed to identify demographic and polysomnographic characteristics that would predict therapeutic success with nasal EPAP (Provent).

Objective:To systematically review outcomes of adults with obstructive sleep apnoea treated with nasopharyngeal airway stenting devices.Methods:Medline, Scopus, Web of Science and the Cochrane Library databases were searched, and data on device use and tolerability, sleepiness, oxygen saturation, apnoea index, apnoea–hypopnoea index, and sleep quality were collected.Results:Of 573 potential studies, 29 were retrieved for detailed evaluation and 16 met the study criteria. Polysomnography data for patients treated with nasal trumpets as an isolated therapy were pooled for meta-analysis. The mean apnoea index ± standard deviation, for 53 patients, decreased from 32.4 ± 15.9 to 9.0 ± 7.2 episodes per hour (p p p Conclusion:Some studies have demonstrated limited effectiveness and low tolerability of nasopharyngeal airway stenting devices, while other studies have shown a significant benefit in treating obstructive sleep apnoea, with a high level of patient acceptance. Nasal trumpets have been successful in decreasing airway obstruction in the short term.

Objectives/Hypothesis Poor adherence to continuous positive airway pressure treatment in obstructive sleep apnea (OSA) adversely affects the effectiveness of this therapy. This study aimed to systematically review the evidence regarding the efficacy and safety of hypoglossal nerve stimulation as an alternative therapy in the treatment of OSA. Data Sources Scopus, PubMed, and Cochrane Library databases were searched (updated through September 5, 2014). Methods Studies were included that evaluated the efficacy of hypoglossal nerve stimulation to treat OSA in adults with outcomes for apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and effect on daytime sleepiness (Epworth Sleepiness Scale [ESS]). Tests for heterogeneity and subgroup analysis were performed. Results Six prospective studies with 200 patients were included in this review. At 12 months, the pooled fixed effects analysis demonstrated statistically significant reductions in AHI, ODI, and ESS mean difference of −17.51 (95% CI: −20.69 to −14.34); −13.73 (95% CI: −16.87 to −10.58), and −4.42 (95% CI: −5.39 to −3.44), respectively. Similar significant reductions were observed at 3 and 6 months. Overall, the AHI was reduced between 50% and 57%, and the ODI was reduced between 48% and 52%. Despite using different hypoglossal nerve stimulators in each subgroup analysis, no significant heterogeneity was found in any of the comparisons, suggesting equivalent efficacy regardless of the system in use. Conclusions This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. Further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes. Level of Evidence NA Laryngoscope, 125:1254–1264, 2015

Obstructive sleep apnea is a highly prevalent and poorly understood condition that not only leads to significant individual patient health damage, but carries a large societal cost secondary to excessive healthcare utilization, motor-vehicle accidents, and work absenteeism. While a significant fund of knowledge about its damaging effects on the cardiovascular system and neural pathways has been gathered over the past few decades, the translation to direct patient care still presents numerous challenges. With the exception of clear issues such as socially unacceptable snoring and breathing irregularities, the exact cause and effect relationship between airway narrowing, hypoxemia, and sleep fragmentation with subjective sleep-related complaints and neurocognitive symptoms is less clear. Besides better-defined clinical diagnostic criteria, the need for clear serum, saliva, or urine biomarkers to assess the physiologic burden of disease remains a work in progress, as are well-defined long-term clinically relevant outcomes of interest. Here, readers will be guided to a critical evaluation on the current main metrics of sleep study, suggested steps on diagnostic and treatment goals, and introduced to the concept of a continuum of disease.

Objectives/Hypothesis To develop a validated inferior turbinate grading scale. Study Design Development and validation study. Methods Phase 1 development (alpha test) consisted of a proposal of 10 different inferior turbinate grading scales (>1,000 clinic patients). Phase 2 validation (beta test) utilized 10 providers grading 27 standardized endoscopic photos of inferior turbinates using two different classification systems. Phase 3 validation (pilot study) consisted of 100 live consecutive clinic patients (n = 200 inferior turbinates) who were each prospectively graded by 18 different combinations of two independent raters, and grading was repeated by each of the same two raters, two separate times for each patient. Results In the development phase, 25% (grades 1–4) and 33% (grades 1–4) were the most useful systems. In the validation phase, the 25% classification system was found to be the best balance between potential clinical utility and ability to grade; the photo grading demonstrated a Cohen's kappa (κ) = 0.4671 ± 0.0082 (moderate inter-rater agreement). Live-patient grading with the 25% classification system demonstrated an overall inter-rater reliability of 71.5% (95% confidence interval [CI]: 64.8–77.3), with overall substantial agreement (κ = 0.704 ± 0.028). Intrarater reliability was 91.5% (95% CI: 88.7–94.3). Distribution for the 200 inferior turbinates was as follows: 25% quartile = grade 1, 50% quartile (median) = grade 2, 75% quartile = grade 3, and 90% quartile = grade 4. Mean turbinate size was 2.22 (95% CI: 2.07-2.34; standard deviation 1.02). Categorical κ was as follows: grade 1, 0.8541 ± 0.0289; grade 2, 0.7310 ± 0.0289; grade 3, 0.6997 ± 0.0289, and grade 4, 0.7760 ± 0.0289. Conclusions The 25% (grades 1–4) inferior turbinate classification system is a validated grading scale with high intrarater and inter-rater reliability. This system can facilitate future research by tracking the effect of interventions on inferior turbinates. Level of Evidence 2c Laryngoscope, 125:296–302, 2015

The objective of this study was to systematically assess the evidence for the diagnostic accuracy of unattended type 2 or type 3 multichannel studies for predicting and monitoring pediatric obstructive sleep apnea (OSA). Four medical databases were searched for eligible studies. Only studies that evaluated the ability of unattended multichannel devices to accurately diagnose or monitor OSA in children were included. Those with appropriate data were selected for meta-analysis. Study quality was assessed by using the Quality Assessment Tool for Diagnostic Accuracy Studies tool. Summary estimates of diagnostic accuracy were determined by using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, summary receiver operating characteristics, and the area under the curve (AUC). Ten diagnostic studies with 724 patients were included in the systematic review, which was followed by a meta-analysis using studies that provided sufficient information for the calculation of diagnostic parameters. The overall analysis revealed a moderate sensitivity of 76% (95% confidence interval [CI]: 64%-85%), a moderate specificity of 76% (95% CI: 60%-88%), and a pooled diagnostic odds ratio of 15.18 (95% CI: 3.52-65.43). The AUC (0.88) indicated that unattended multichannel devices showed good diagnostic performance for predicting pediatric OSA. Using a cutoff of AHI > 1 for the diagnosis of OSA, the results appeared to be more useful, with a higher sensitivity (88%) while maintaining a moderate specificity (71%). These findings suggest that unattended sleep studies are a good tool for predicting both the presence and severity of OSA in children, especially in those with mild-to-moderate disease.

Objectives/Hypothesis To systematically review outcomes for polysomnography, sleepiness, and mortality in patients who undergo tracheostomy for the treatment of adult obstructive sleep apnea (OSA). Data Sources MEDLINE, Scopus, and the Cochrane Library were searched from inception to March 2013, followed by extensive hand searching for the identification of relevant English language studies that met predefined criteria. Review Methods Adult studies of tracheostomies or tracheotomies as treatment for OSA with outcomes for apnea index (AI), apnea–hypopnea index (AHI), oxygen desaturation index (ODI), effect on daytime sleepiness or mortality were identified, abstracted and pooled (as appropriate). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results The systematic search identified 18 relevant studies that were primarily case series, using retrospective review. Posttracheostomy AI improved from 73.0 ± 27.1 to 0.2 ± 1.2/h and an AI mean difference of −83.47 (95% CI, −106.07 to −60.87; P

There is an extensive amount of literature on surgeries as treatment for obstructive sleep apnea syndrome on adults. Previous systematic reviews have been performed to summarize the outcomes for sleep surgeries, with conflicting results. The objective of this study was to critically evaluate these systematic reviews to provide an overview of their quality, strengths, and conclusions.MEDLINE, Scopus, and the Cochrane Collaboration databases were searched from inception to April 2013.An overview of systematic reviews was undertaken. Studies included in this review are the systematic reviews whose primary objective was to evaluate the outcomes of sleep apnea surgery on adults. The methodological quality of the studies was analyzed with AMSTAR checklist, and the quality of evidence was evaluated using the GRADE assessment tool. Primary outcome measures assessed the effect of surgery on snoring, sleepiness, and the apnea-hypopnea index.A total of 11 studies were included in this study, and the pooled overview includes 378 studies. The systematic reviews were mostly graded as low quality using the GRADE tool and low to moderate according to the AMSTAR checklist. Outcome for apnea-hypopnea index demonstrated substantial variation leading to conflicting results. Despite a high amount of heterogeneity, outcomes for sleepiness and snoring demonstrated significant improvement across included reviews.Although obstructive sleep apnea surgery is associated with improved outcomes in most studies, the level and quality of evidence reviews requires improvement.

Objective:To systematically search for studies reporting outcomes for adenoidectomy alone as a treatment for paediatric obstructive sleep apnoea and use the data to perform a meta-analysis.Methods:Nine databases, including PubMed and Medline, were systematically searched through to 1 April 2016. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.Results:A total of 1032 articles were screened and 126 full texts were reviewed. Three paediatric studies (47 patients) reported outcomes. Overall, apnoea–hypopnoea index values decreased from 18.1 ± 16.8 to 3.1 ± 5.5 events per hour (28 patients). Random-effects modelling demonstrated a mean difference of −14.43 events per hour (I2 = 23 per cent (low inconsistency)). The apnoea–hypopnoea index standardised mean difference was −1.14 (large magnitude of effect). The largest reduction in apnoea–hypopnoea index was observed in children aged less than 12 months (reduction of 56.6−94.9 per cent). Lowest oxygen saturation values improved from 80.0 ± 9.5 to 85.5 ± 6.0 per cent (13 children).Conclusion:Adenoidectomy alone has improved obstructive sleep apnoea in children, especially in those aged less than 12 months; however, given the low number of studies, isolated adenoidectomy remains an area for additional research.

Objectives/Hypothesis: Clinical symptoms and signs are routinely used to investigate pediatric obstructive sleep apnea (OSA). This study aimed to systematically assess the evidence for the diagnostic accuracy of individual or combined clinical symptoms and signs in predicting pediatric OSA. Study Design: A systematic review of the literature and diagnostic meta-analysis. Methods: Four medical databases were searched (from inception to August 2011). Studies were included that compared the clinical assessment with the current gold standard (full polysomnography). The study quality was assessed using the quality assessment tool for diagnostic accuracy studies. Summary estimates of diagnostic accuracy were determined using the sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and hierarchical summary receiver operating characteristic (HSROC) model for meta-analyses. Results: Ten diagnostic studies with 1,525 patients were included in the review. There was substantial variation in the sensitivity and specificity among different symptoms and signs, as well as across studies. Tonsillar size and snoring reported by parents or caregivers had high sensitivity but low specificity. In contrast, excessive daytime somnolence, observed apnea, and difficulty in breathing during sleep had high specificity but low sensitivity. Seven models of a combination of symptoms and signs presented moderate sensitivity (range, 0.04–0.94) and specificity (range, 0.28–0.99). The HSROC indicates poor diagnostic performance of the symptoms and signs in predicting pediatric OSA. Conclusions: Neither single nor combined symptoms and signs have satisfactory performance in predicting pediatric OSA. Alternative diagnostic models are necessary to improve the accuracy.

Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework.To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies.The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea.Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded.Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015.The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h.Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were -47.8 (25.0) and -44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates.Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.

Objective:To identify and systematically evaluate user-friendly smartphone snoring apps.Methods:The Apple iTunes app store was searched for snoring apps that allow recording and playback. Snoring apps were downloaded, evaluated and rated independently by four authors. Two patients underwent polysomnography, and the data were compared with simultaneous snoring app recordings, and one patient used the snoring app at home.Results:Of 126 snoring apps, 13 met the inclusion and exclusion criteria. The most critical app feature was the ability to graphically display the snoring events. The Quit Snoring app received the highest overall rating. When this app's recordings were compared with in-laboratory polysomnography data, app snoring sensitivities ranged from 64 to 96 per cent, and snoring positive predictive values ranged from 93 to 96 per cent. A chronic snorer used the app nightly for one month and tracked medical interventions. Snoring decreased from 200 to 10 snores per hour, and bed partner snoring complaint scores decreased from 9 to 2 (on a 0–10 scale).Conclusion:Select smartphone apps are user-friendly for recording and playing back snoring sounds. Preliminary comparison of more than 1500 individual snores demonstrates the potential clinical utility of such apps; however, further validation testing is recommended.

Introduction Patients with obstructive sleep apnea (OSA) often face the challenge of how to power their positive airway pressure (PAP) devices when alternating current power supplies are not available in remote areas with lack of electricity or frequent power outages. This article elucidates portable power supply options for PAP devices with the aim to increase alternative power source awareness among medical providers. Methods A search of scientific databases (Medline, Scopus, Web of Science, Google Scholar, and the Cochrane Library) was carried out on the topic of alternative portable power supply options for treatment of OSA. Results Scientific databases listed above yielded only limited results. Most articles were found via Google search. These articles were reviewed for alternative power supply options for OSA patients when alternating current is not available. The power supply options in this article include lead-acid batteries (starter, marine and deep-cycle batteries), lithium ion batteries, solar kits, battery packs, backup power systems, portable generators, and travel-size PAP devices. Conclusions There are several options to power PAP devices with direct current when alternating current is not available. Knowledgeable primary care physicians especially in rural and remote areas can help OSA patients improve PAP compliance in order to mitigate morbidity and long-term complications of OSA.

Objective. To evaluate the effect of turbinate sizes on the titrated continuous positive airway pressure (CPAP) therapeutic treatment pressures for patients with obstructive sleep apnea (OSA) who have not had nasal surgery.Study Design. Retrospective case series.Methods. A chart review was performed for 250 consecutive patients.Results. 45 patients met inclusion criteria. The mean ± standard deviation (M ± SD) for age was54.6±22.4years and for body mass index was28.5±5.9 kg/m2. The Spearman’s rank correlation coefficient (rs) between CPAP therapeutic treatment pressures and several variables were calculated and were weakly correlated (agers=0.29, nasal obstructionrs=-0.30), moderately correlated (body mass indexrs=0.42and lowest oxygen saturationrs=-0.47), or strongly correlated (apnea-hypopnea indexrs=0.60and oxygen desaturation index (rs=0.62)). No statistical significance was found with one-way analysis of variance (ANOVA) between CPAP therapeutic treatment pressures and inferior turbinate size (right turbinatespvalue = 0.2012, left turbinatepvalue = 0.3064), nasal septal deviation (pvalue = 0.4979), or mask type (pvalue = 0.5136).Conclusion. In this study, CPAP titration based therapeutic treatment pressures were not found to be associated with inferior turbinate sizes; however, the CPAP therapeutic treatment pressures were strongly correlated with apnea-hypopnea index and oxygen desaturation index.

Objective Obstructive sleep apnea (OSA) can be a challenging disorder to treat. Maxillomandibular advancements (MMAs) generally have high success rates; however, larger advancements have higher success and cure rates. Our aim is to present and to describe the current technique used by the senior authors, which has been successful for performing large advancements, thereby improving post-operative outcomes. Methods The senior authors have developed and modified their maxillomandibular advancement operative techniques significantly over the past 30 years. The current version of the Riley–Powell MMA technique is described in a step-by-step fashion in this article. Results Initially, as part of the MMAs, patients underwent maxillomandibular fixation with wires, lag screws and harvested split calvarial bone grafts. The current technique utilizes plates, screws, Erich Arch Bars, and suspension wires which are left in place for 5–6 weeks. Guiding elastics are worn for the first week. The MMA technique described in this article has yielded a success rate over 90% for patients with a body mass index (BMI) 2 and 81% for patients with a BMI ≥40 kg/m 2 . Conclusion Large advancements during maxillomandibular advancement surgeries can help improve post-operative obstructive sleep apnea outcomes.

Objective. To systematically review the international literature for mathematical equations used to predict effective pressures for positive airway pressure (PAP) devices.Methods. Google Scholar, PubMed, Scopus, Embase, Web of Science, CINAHL, and The Cochrane Library were searched through June 27, 2015. The PRISMA statement was followed. There was no language limitation.Results. 709 articles were screened, fifty were downloaded, and twenty-six studies presented equations that met the inclusion and exclusion criteria. In total, there were 4,436 patients in the development phases and 3,489 patients in the validation phases. Studies performed multiple linear regressions analyses as part of the equation(s) development and included the following variables: physical characteristics, polysomnography data, behavioral characteristics, and miscellaneous characteristics, which were all predictive to a variable extent. Of the published variables, body mass index (BMI) and mean oxygen saturation are the most heavily weighted, while BMI (eighteen studies), apnea-hypopnea index (seventeen studies), and neck circumference (eleven studies) were the variables most frequently used in the mathematical equations. Ten studies were from Asian countries and sixteen were from non-Asian countries.Conclusion. This systematic review identified twenty-six unique studies reporting mathematical equations which are summarized. Overall, BMI and mean oxygen saturation are the most heavily weighted.

Objective The need for culturally appropriate and linguistically accessible instruments for assessing sleep quality among children has expanded. The Pediatric Sleep Questionnaire (PSQ) is a validated tool for sleep disordered breathing among children. Our aim was to cross-culturally translate and adapt the PSQ into Portuguese language for use in clinical and research settings. Methods The PSQ was translated into Portuguese language in accordance with the stages recommended by International Guidelines and reviewed by a panel of experts. The caregivers of 180 children (aged from 4 to 12 years) answered the Portuguese version of PSQ. The reliability of the translated questionnaire was measured by Cronbach α, Pearson correlation and Kappa statistics. Results Reliability analysis yielded an overall Cronbach α of 0.781, confirming the survey's consistency. The Cronbach α of the Portuguese PSQ domains ranged between 0.61 and 0.7. Test–retest reliability for all items was robust with correctness of >90.0% in all items, and the Kappa statistic ranged between 0.5 and 0.8. Conclusion The Portuguese version of PSQ has sufficient reliability and validity to measure sleep disordered breathing outcomes, and showed to be linguistically accurate and acceptable for use by children in Portugal.

The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m(2)) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes.MEDLINE, Scopus, Web of Science, and the Cochrane Library.A search was performed from inception through April 8, 2014, in each database.Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m(2)) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m(2)) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h (P.00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% (P.00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h (P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h (P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% (P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy (P = .0034).Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.

Existem várias modalidades cirúrgicas utilizadas no tratamento da síndrome de apneia obstrutiva do sono (SAOS). Esta afecção pode causar sonolência diurna excessiva, bem como aumentar o risco de morbidade e mortalidade cardiovascular. Os doentes que não aderem ao tratamento médico convencional são frequentemente encaminhados para tratamento por procedimento cirúrgico. OBJETIVO: Recapitular e descrever as principais opções cirúrgicas, do foro otorrinolaringológico, disponíveis para o tratamento de SAOS, bem como apresentar os resultados em termos de melhoria do índice de apneia/hipopneia e benefícios sobre a mortalidade. MÉTODO: Revisão bibliográfica acerca dos diferentes tratamentos cirúrgicos, tanto de tecidos moles como de tecidos esqueléticos. Foram apenas incluídos os artigos que apresentavam as descrições originais. Revisões sistemáticas e artigos que apresentavam resultados funcionais das cirurgias também foram incluídos nesta análise. RESULTADOS: Vinte e nove modalidades cirúrgicas foram identificadas, tendo sido apresentados os autores dos artigos originais e o seu ano de descrição. Foram, ainda, apresentados dados polissonográficos relativos ao índice de apneia, índice de apneia/hipopneia e dados sobre a mortalidade. CONCLUSÃO: Existe uma grande heterogeneidade nos resultados da cirurgia no tratamento de SAOS. A combinação de diversos procedimentos cirúrgicos parece melhorar as taxas de sucesso bem como as taxas de cura. A tecnologia neste domínio evolui rapidamente, e os cirurgiões que se dedicam a esta afecções devem manter-se atualizados e integrar equipes multidisciplinares, a fim de maximizar os resultados. There are several surgical treatment modalities utilized for obstructive sleep apnea syndrome (OSAS). OSAS can cause excessive daytime sleepiness as well as cardiovascular morbidity and mortality. Patients who fail medical management often seek surgical treatment. OBJECTIVE: This paper reviews surgical treatment options for obstructive sleep apnea syndrome to include original descriptions as well as outcomes for snoring, apnea-hypopnea indices, and mortality benefits. METHOD: A literature review was performed for OSAS surgical treatment options for soft tissue and skeletal surgeries. Articles with the original descriptions and surgical reviews are included for each procedure. RESULTS: A total of twenty-eight surgical treatment modalities for OSAS were identified. Original article authors and year of description were obtained and presented. Polysomnographic data for apnea indices, apnea-hypopnea indices and mortality are presented. CONCLUSION: There is a large amount of variability in outcomes for sleep surgeries, however, in order to maximize success and cure rates, multiple procedures are most often necessary. Sleep surgeons must get familiar with modern surgical concepts and techniques, and participate in multi-disciplinary care in order to maximize treatment outcomes.

Background Several organizations and individual authors have been proposing quality indicators for the assessment of clinical care in HIV/AIDS patients. Nevertheless, the definition of a consensual core set of indicators remains controversial and its practical use is largely limited. This study aims not only to identify and characterize these indicators through a systematic literature review but also to propose a parsimonious model based on those most used. Methods MEDLINE, SCOPUS, Cochrane databases and ISI Web of Knowledge, as well as official websites of organizations dealing with HIV/AIDS care, were searched for articles and information proposing HIV/AIDS clinical care quality indicators. The ones that are on patient’s perspective and based on services set were excluded. Data extraction, using a predefined data sheet based on Cochrane recommendations, was done by one of the authors while a second author rechecked the extracted data for any inconsistency. Results A total of 360 articles were identified in our search query but only 12 of them met the inclusion criteria. We also identified one relevant site. Overall, we identified 65 quality indicators for HIV/AIDS clinical care distributed as following: outcome (n=15) and process-related (n=50) indicators; generic (n=36) and HIV/AIDS disease-specific (n=29) indicators; baseline examinations (n=19), screening (n=9), immunization (n=4), prophylaxis (n=5), HIV monitoring (n=16), and therapy (=12) indicators. Conclusions There are several studies that set up HIV clinical care indicators, with only a part of them useful to assess the HIV clinical care. More importantly, HIV/AIDS clinical care indicators need to be valid, reliable and most of all feasible.

Objectives: The goal of this study was to make a review of the patients who underwent ossicular chain reconstruction with titanium prosthesis during an 8-year period in our Department. Methods: A retrospective study was made on the ossiculoplasty cases over a period of eight years in a Public Hospital District. The information was extracted by clinical process consultation. Between 1999 and 2008, 124 ossiculoplasties using Kurz ® titanium prosthesis for chronic otitis media were performed (78 partial ossicular chain reconstructions and 46 total ossicular chain reconstructions). The single stage, staged and revision ossicular chain reconstruction were included in the analysis. All patients had a minimum of 6-month postoperative follow-up (mean 3 years and 4 months). Comparisons of preoperative and postoperative pure tone averages were performed. Air-bone gap and implant extrusion rates were measured. The success of the reconstruction was defined as a postoperative air-bone gap (ABG) of 20 dB or better. Results: Successful ossiculoplasty was obtained in 73.1% of partial ossicular chain reconstructions and 30.4% of total ossicular chain reconstructions (P