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Sleep May 2015To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Adenoidectomy; Adult; Child; Humans; Myofunctional Therapy; Oxygen; Palatal Expansion Technique; Polysomnography; Sleep Apnea, Obstructive; Sleep Stages; Snoring; Tonsillectomy
PubMed: 25348130
DOI: 10.5665/sleep.4652 -
Sleep Medicine Reviews Feb 2023Orthodontic treatment is suggested in growing individuals to correct transverse maxillary deficiency and mandibular retrusion. Since, as a secondary effect, these... (Meta-Analysis)
Meta-Analysis Review
Orthodontic treatment is suggested in growing individuals to correct transverse maxillary deficiency and mandibular retrusion. Since, as a secondary effect, these orthodontic procedures may improve pediatric obstructive sleep apnea (OSA), this systematic review assessed their effects on apnea-hypopnea index (AHI) and oxygen saturation (SaO2). Twenty-five (25) manuscripts were included for qualitative synthesis, 19 were selected for quantitative synthesis. Five interventions were analyzed: rapid maxillary expansion (RME, 15 studies), mandibular advancement (MAA, five studies), myofunctional therapy (MT, four studies), and RME combined with MAA (one study). RME produced a significant AHI reduction and minimum SaO2 increase immediately after active treatment, at six and 12 months from baseline. A significant AHI reduction was also observed six and 12 months after the beginning of MAA treatment. MT showed positive effects, with different protocols. In this systematic review and meta-analysis of data from mainly uncontrolled studies, interceptive orthodontic treatments showed overall favorable effects on respiratory outcomes in pediatric OSA. However, due to the low to very low level of the body evidence, this treatment cannot be suggested as elective for OSA treatment. An orthodontic indication is needed to support this therapy and a careful monitoring is required to ensure positive improvement in OSA parameters.
Topics: Humans; Child; Sleep Apnea, Obstructive; Mandibular Advancement; Palatal Expansion Technique
PubMed: 36525781
DOI: 10.1016/j.smrv.2022.101730 -
European Respiratory Review : An... Dec 2021Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have... (Review)
Review
Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear-nose-throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.
Topics: Adult; Continuous Positive Airway Pressure; Humans; Mandibular Advancement; Occlusal Splints; Respiratory System; Sleep Apnea, Obstructive
PubMed: 34853097
DOI: 10.1183/16000617.0200-2021 -
Journal of Clinical Sleep Medicine :... Jan 2015Obstructive sleep apnea (OSA) has been associated with psychiatric pathology. Psychiatric comorbidity in OSA may affect patient quality of life and adherence to CPAP. A... (Review)
Review
STUDY OBJECTIVES
Obstructive sleep apnea (OSA) has been associated with psychiatric pathology. Psychiatric comorbidity in OSA may affect patient quality of life and adherence to CPAP. A focused evaluation of OSA in highly selected groups of primarily psychiatric patients may provide further insights into the factors contributing to comorbidity of OSA and psychopathology. The goal of this study is to examine the prevalence and treatment of OSA in psychiatric populations.
METHODS
A systematic review following the PRISMA guidelines was conducted to determine the prevalence of OSA in schizophrenia and other psychotic disorders, mood disorders, and anxiety disorders, and to examine potential interventions. The PubMed, EMBASE, and PsycINFO databases were searched (last search April 26, 2014) using keywords based on the ICD-9-CM coding for OSA and the DSM-IV-TR diagnostic groups.
RESULTS
The search retrieved 47 records concerning studies of OSA in the selected disorders. The prevalence studies indicate that there may be an increased prevalence of OSA in individuals with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), despite considerable heterogeneity and a high risk of bias. There was insufficient evidence to support increased OSA in schizophrenia and psychotic disorders, bipolar and related disorders, and anxiety disorders other than PTSD. Studies of treatment of OSA indicate an improvement in both OSA and psychiatric symptoms. CPAP adherence was reduced in veterans with PTSD.
CONCLUSIONS
OSA prevalence may be increased in MDD and PTSD. In individuals with OSA and psychiatric illness, treatment of both disorders should be considered for optimal treatment outcomes.
Topics: Humans; Mental Disorders; Sleep Apnea, Obstructive
PubMed: 25406268
DOI: 10.5664/jcsm.4466 -
Sleep Medicine Reviews Dec 2021Obstructive Sleep Apnea (OSA) is often treated with Mandibular Advancement Devices (MADs). It is unclear whether particular design features are superior to others in... (Meta-Analysis)
Meta-Analysis Review
Obstructive Sleep Apnea (OSA) is often treated with Mandibular Advancement Devices (MADs). It is unclear whether particular design features are superior to others in terms of OSA alleviation. In order to facilitate clinical decision-making, this systematic review summarizes the objective and subjective outcomes of different available MAD designs. Studies comparing different MAD designs in OSA treatment were searched. After screening 1887 titles and abstracts, 20 original RCTs and six cohort studies were included. 14 articles were systematically reviewed in a meta-analysis. The decrease in AHI was significantly different between some of the MAD designs. The clinical relevance of the observed differences was however limited. Monoblock appliances performed more favorable, compared to bilateral thrust (effect size:-0.37; CI:-1.81 to 0.07). Midline traction appliances performed more favorable, compared to other designs. Custom appliances performed more favorable, compared to thermoplastic appliances (effect size:0.86; CI:-0.62 to 2.35). Furthermore, there were no clinically relevant differences between MAD designs in reduction of ESS, compliance, preference, side effects, and cost effectiveness. With respect to the included trials, presently there is not one superior custom MAD design in OSA treatment regarding the effect on AHI reduction, ESS improvement, compliance, preference, side effects, cost effectiveness, and other disease-related outcomes. We confirm custom MAD designs perform superior to thermoplastic MAD designs.
Topics: Continuous Positive Airway Pressure; Humans; Mandibular Advancement; Occlusal Splints; Sleep Apnea, Obstructive; Treatment Outcome
PubMed: 34662769
DOI: 10.1016/j.smrv.2021.101557 -
Chest Dec 2020Therapy options for OSA and central sleep apnea (CSA) are limited, thus many patients remain untreated. Clinically, acetazolamide is sometimes used for CSA; however,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Therapy options for OSA and central sleep apnea (CSA) are limited, thus many patients remain untreated. Clinically, acetazolamide is sometimes used for CSA; however, given overlapping pathophysiologic properties of OSA and CSA, we hypothesized that acetazolamide is equally effective for both types. Prior reviews focused on specific subtypes of sleep apnea, study designs, and languages, thus including few studies (typically ≤3) limiting insights.
RESEARCH QUESTION
How efficacious is acetazolamide for sleep apnea, and is its effect modified by sleep apnea type or acetazolamide dose?
STUDY DESIGN AND METHODS
We queried MEDLINE, EMBASE, and ClinicalTrials.gov from inception until March 11, 2019. Any study in which adults with OSA/CSA received oral acetazolamide vs no acetazolamide (control) that reported sleep apnea-related outcomes was eligible, independent of study design or language. Two reviewers independently assessed eligibility and abstracted data. Primary outcomes were apnea-hypopnea index (AHI) and oxygen saturation nadir. Quality of evidence (QoE) was rated with the use of Grades of Recommendation Assessment, Development and Evaluation methods.
RESULTS
We included 28 studies (13 OSA/15 CSA; N = 542; N = 553) that enabled meta-analyses for 24 outcomes. Acetazolamide doses ranged from 36 to 1000 mg/d and treatment duration from 1 to 90 d (median, 6 d). Overall, acetazolamide vs control lowered the AHI by -0.7 effect sizes (95% CI, -0.83 to -0.58; I = 0%; moderate QoE) that corresponded to a reduction of 37.7% (95% CI, -44.7 to -31.3) or 13.8/h (95% CI, -16.3 to -11.4; AHI = 36.5/h). The AHI reduction was similar in OSA vs CSA, but significantly greater with higher doses (at least up to 500 mg/d). Furthermore, acetazolamide improved oxygen saturation nadir by +4.4% (95% CI, 2.3 to 6.5; I = 63%; no evidence of effect modification; very low QoE) and several secondary outcomes that included sleep quality measures and BP (mostly low QoE).
INTERPRETATION
Short-term acetazolamide improved both OSA and CSA. Rigorous studies with long-term follow up are warranted to assess Acetazolamide's value for the chronic treatment of patients with sleep apnea.
CLINICAL TRIAL REGISTRATION
PROSPERO (CRD42019147504).
Topics: Acetazolamide; Carbonic Anhydrase Inhibitors; Humans; Sleep Apnea, Central; Sleep Apnea, Obstructive; Treatment Outcome
PubMed: 32768459
DOI: 10.1016/j.chest.2020.06.078 -
Journal of Clinical Periodontology Jun 2023To evaluate (1) whether periodontitis has an influence on the prevalence/incidence of respiratory diseases (chronic obstructive pulmonary disease [COPD], asthma,... (Meta-Analysis)
Meta-Analysis Review
AIM
To evaluate (1) whether periodontitis has an influence on the prevalence/incidence of respiratory diseases (chronic obstructive pulmonary disease [COPD], asthma, community-acquired pneumonia [CAP], obstructive sleep apnoea [OSA] and COVID-19), and (2) what is the impact of periodontal therapy on the onset or progression of respiratory diseases.
MATERIALS AND METHODS
An electronic search was performed on Pubmed, Cochrane Library and Scopus databases up to October 2021, to identify studies answering the PECOS and PICOS questions.
RESULTS
Seventy-five articles were selected. Meta-analyses identified statistically significant associations of periodontitis with COPD (n = 12, odds ratio [OR] = 1.28, 95% confidence interval [CI] [1.16; 1.42], p < .001), and OSA (n = 6, OR = 1.65, 95% CI [1.21; 2.25], p = .001), but not for asthma (n = 9, OR = 1.53, 95% CI [0.82; 2.86], p = .181). For acute conditions, two studies were found for CAP, while for COVID-19, significant associations were found for the need of assisted ventilation (n = 2, OR = 6.24, 95% CI [2.78; 13.99], p < .001) and COVID-related mortality (n = 3, OR = 2.26, 95% CI [1.36, 3.77], p = .002). Only four intervention studies were found, showing positive effects of periodontal treatment on COPD, asthma and CAP.
CONCLUSIONS
A positive association between periodontitis and COPD, OSA and COVID-19 complications has been found, while there is a lack of intervention studies.
Topics: Humans; COVID-19; Pulmonary Disease, Chronic Obstructive; Asthma; Periodontitis; Pneumonia; Sleep Apnea, Obstructive
PubMed: 36606394
DOI: 10.1111/jcpe.13767 -
PloS One 2020This systematic review and meta-analysis examines the associations of allergic rhinitis with sleep duration and sleep impairment. Observational studies published before... (Meta-Analysis)
Meta-Analysis
This systematic review and meta-analysis examines the associations of allergic rhinitis with sleep duration and sleep impairment. Observational studies published before August 2019 were obtained through English language literature searches in the PubMed, Embase, and CINAHL databases. Mean differences and odds ratios with 95% confidence intervals were extracted and used for meta-analysis. Heterogeneity was confirmed by the I2-heterogeneity test. Subgroup analysis was conducted to evaluate the influence of study design. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to determine the level of evidence. In total, 2544 records were identified through database searches; 914 duplicate records were excluded, 1452 records were removed after screening of titles and abstracts, 151 records were excluded after full-text screening, and 27 articles were included in the final meta-analyses. A total of 240,706,026 patients (19,444,043 with allergic rhinitis) were considered. No significant difference in sleep duration between the allergic rhinitis and the control groups was found. Patients with allergic rhinitis presented with significantly higher sleep quality scores, sleep disturbances scores, and sleep latency scores; more frequent use of sleep medications; and lower sleep efficiency as measured by the Pittsburgh Sleep Quality Index and polysomnography. Meta-analyses for adjusted odds ratios showed that allergic rhinitis was also associated with higher risks of nocturnal dysfunctions, including insomnia, nocturnal enuresis, restless sleep, sleep-disordered breathing, obstructive sleep apnea, and snoring. Meta-analysis for adjusted odds ratio also showed that allergic rhinitis was associated with daytime dysfunction, including difficulty waking up, daytime sleepiness, morning headache, and the use of sleep medications. The overall quality of evidence ranged from low to very low, indicating that caution is required when interpreting these results. This study demonstrates that there is a significant association of AR with sleep characteristics.
Topics: Adolescent; Adult; Aged; Child; Child, Preschool; Humans; Middle Aged; Observational Studies as Topic; Polysomnography; Quality of Life; Rhinitis, Allergic; Sleep; Sleep Apnea Syndromes; Sleep Apnea, Obstructive; Sleep Wake Disorders; Snoring; Young Adult
PubMed: 32053609
DOI: 10.1371/journal.pone.0228533 -
Sleep Medicine Reviews Feb 2017Obstructive sleep apnea (OSA) is one of the common sleep breathing disorders in adults, characterised by frequent episodes of upper airway collapse during sleep.... (Meta-Analysis)
Meta-Analysis Review
Obstructive sleep apnea (OSA) is one of the common sleep breathing disorders in adults, characterised by frequent episodes of upper airway collapse during sleep. Craniofacial disharmony is an important risk factor for OSA. Overnight polysomnography (PSG) study is considered to be the most reliable confirmatory investigation for OSA diagnosis, whereas the precise localization of site of obstruction to the airflow cannot be detected. Identifying the cause of OSA in a particular ethnic population/individual subject helps to understand the etiological factors and effective management of OSA. The objective of the meta-analysis is to elucidate altered craniofacial anatomy on lateral cephalograms in adult subjects with established OSA. Significant weighted mean difference with insignificant heterogeneity was found for the following parameters: anterior lower facial height (ALFH: 2.48 mm), position of hyoid bone (Go-H: 5.45 mm, S-H: 6.89 mm, GoGn-H: 11.84°, GoGn-H: 7.22 mm, N-S-H: 2.14°), and pharyngeal airway space (PNS-Phw: -1.55 mm, pharyngeal space: -495.74 mm and oro-pharyngeal area: -151.15 mm). Significant weighted mean difference with significant heterogeneity was found for the following parameters: cranial base (SN: -2.25 mm, S-N-Ba: -1.45°), position and length of mandible (SNB: -1.49° and Go-Me: -5.66 mm) respectively, maxillary length (ANS-PNS: -1.76 mm), tongue area (T: 366.51 mm), soft palate area (UV: 125.02 mm), and upper airway length (UAL: 5.39 mm). This meta-analysis supports the relationship between craniofacial disharmony and obstructive sleep apnea. There is a strong evidence for reduced pharyngeal airway space, inferiorly placed hyoid bone and increased anterior facial heights in adult OSA patients compared to control subjects. The cephalometric analysis provides insight into anatomical basis of the etiology of OSA that can influence making a choice of appropriate therapy.
Topics: Cephalometry; Craniofacial Abnormalities; Humans; Pharynx; Polysomnography; Sleep Apnea, Obstructive
PubMed: 27039222
DOI: 10.1016/j.smrv.2016.01.007 -
The Cochrane Database of Systematic... Nov 2020Obstructive sleep apnoea (OSA) is a syndrome characterised by episodes of apnoea (complete cessation of breathing) or hypopnoea (insufficient breathing) during sleep.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Obstructive sleep apnoea (OSA) is a syndrome characterised by episodes of apnoea (complete cessation of breathing) or hypopnoea (insufficient breathing) during sleep. Classical symptoms of the disease - such as snoring, unsatisfactory rest and daytime sleepiness - are experienced mainly by men; women report more unspecific symptoms such as low energy or fatigue, tiredness, initial insomnia and morning headaches. OSA is associated with an increased risk of occupational injuries, metabolic diseases, cardiovascular diseases, mortality, and being involved in traffic accidents. Continuous positive airway pressure (CPAP) - delivered by a machine which uses a hose and mask or nosepiece to deliver constant and steady air pressure- is considered the first treatment option for most people with OSA. However, adherence to treatment is often suboptimal. Myofunctional therapy could be an alternative for many patients. Myofunctional therapy consists of combinations of oropharyngeal exercises - i.e. mouth and throat exercises. These combinations typically include both isotonic and isometric exercises involving several muscles and areas of the mouth, pharynx and upper respiratory tract, to work on functions such as speaking, breathing, blowing, sucking, chewing and swallowing.
OBJECTIVES
To evaluate the benefits and harms of myofunctional therapy (oropharyngeal exercises) for the treatment of obstructive sleep apnoea.
SEARCH METHODS
We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 1 May 2020). We found other trials at web-based clinical trials registers.
SELECTION CRITERIA
We included RCTs that recruited adults and children with a diagnosis of OSA.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We assessed our confidence in the evidence by using GRADE recommendations. Primary outcomes were daytime sleepiness, morbidity and mortality.
MAIN RESULTS
We found nine studies eligible for inclusion in this review and nine ongoing studies. The nine included RCTs analysed a total of 347 participants, 69 of them women and 13 children. The adults' mean ages ranged from 46 to 51, daytime sleepiness scores from eight to 14, and severity of the condition from mild to severe OSA. The studies' duration ranged from two to four months. None of the studies assessed accidents, cardiovascular diseases or mortality outcomes. We sought data about adverse events, but none of the included studies reported these. In adults, compared to sham therapy, myofunctional therapy: probably reduces daytime sleepiness (Epworth Sleepiness Scale (ESS), MD (mean difference) -4.52 points, 95% Confidence Interval (CI) -6.67 to -2.36; two studies, 82 participants; moderate-certainty evidence); may increase sleep quality (MD -3.90 points, 95% CI -6.31 to -1.49; one study, 31 participants; low-certainty evidence); may result in a large reduction in Apnoea-Hypopnoea Index (AHI, MD -13.20 points, 95% CI -18.48 to -7.93; two studies, 82 participants; low-certainty evidence); may have little to no effect in reduction of snoring frequency but the evidence is very uncertain (Standardised Mean Difference (SMD) -0.53 points, 95% CI -1.03 to -0.03; two studies, 67 participants; very low-certainty evidence); and probably reduces subjective snoring intensity slightly (MD -1.9 points, 95% CI -3.69 to -0.11 one study, 51 participants; moderate-certainty evidence). Compared to waiting list, myofunctional therapy may: reduce daytime sleepiness (ESS, change from baseline MD -3.00 points, 95% CI -5.47 to -0.53; one study, 25 participants; low-certainty evidence); result in little to no difference in sleep quality (MD -0.70 points, 95% CI -2.01 to 0.61; one study, 25 participants; low-certainty evidence); and reduce AHI (MD -6.20 points, 95% CI -11.94 to -0.46; one study, 25 participants; low-certainty evidence). Compared to CPAP, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.30 points, 95% CI -1.65 to 2.25; one study, 54 participants; low-certainty evidence); and may increase AHI (MD 9.60 points, 95% CI 2.46 to 16.74; one study, 54 participants; low-certainty evidence). Compared to CPAP plus myofunctional therapy, myofunctional therapy alone may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.56 to 2.96; one study, 49 participants; low-certainty evidence) and may increase AHI (MD 10.50 points, 95% CI 3.43 to 17.57; one study, 49 participants; low-certainty evidence). Compared to respiratory exercises plus nasal dilator strip, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.46 to 2.86; one study, 58 participants; low-certainty evidence); probably increases sleep quality slightly (-1.94 points, 95% CI -3.17 to -0.72; two studies, 97 participants; moderate-certainty evidence); and may result in little to no difference in AHI (MD -3.80 points, 95% CI -9.05 to 1.45; one study, 58 participants; low-certainty evidence). Compared to standard medical treatment, myofunctional therapy may reduce daytime sleepiness (MD -6.40 points, 95% CI -9.82 to -2.98; one study, 26 participants; low-certainty evidence) and may increase sleep quality (MD -3.10 points, 95% CI -5.12 to -1.08; one study, 26 participants; low-certainty evidence). In children, compared to nasal washing alone, myofunctional therapy and nasal washing may result in little to no difference in AHI (MD 3.00, 95% CI -0.26 to 6.26; one study, 13 participants; low-certainty evidence).
AUTHORS' CONCLUSIONS
Compared to sham therapy, myofunctional therapy probably reduces daytime sleepiness and may increase sleep quality in the short term. The certainty of the evidence for all comparisons ranges from moderate to very low, mainly due to lack of blinding of the assessors of subjective outcomes, incomplete outcome data and imprecision. More studies are needed. In future studies, outcome assessors should be blinded. New trials should recruit more participants, including more women and children, and have longer treatment and follow-up periods.
Topics: Apnea; Child; Continuous Positive Airway Pressure; Disorders of Excessive Somnolence; Exercise; Female; Humans; Isotonic Contraction; Male; Middle Aged; Myofunctional Therapy; Oropharynx; Randomized Controlled Trials as Topic; Sleep Apnea, Obstructive; Snoring; Therapeutic Irrigation; Waiting Lists
PubMed: 33141943
DOI: 10.1002/14651858.CD013449.pub2