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Sleep Apnea Syndromes: HELP
Articles by Giovanni D'agostino
Based on 9 articles published since 2010
(Why 9 articles?)
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Between 2010 and 2020, G. D'Agostino wrote the following 9 articles about Sleep Apnea Syndromes.
 
+ Citations + Abstracts
1 Review Laryngopharyngeal reflux in obstructive sleep apnoea patients: Literature review and meta-analysis. 2018

Magliulo, Giuseppe / Iannella, Giannicola / Polimeni, Antonella / De Vincentiis, Marco / Meccariello, Giuseppe / Gulotta, Giampiero / Pasquariello, Benedetta / Montevecchi, Filippo / De Vito, Andrea / D'Agostino, Giovanni / Gobbi, Riccardo / Cammaroto, Giovanni / Vicini, Claudio. ·Department of 'Organi di Senso', University "Sapienza", Rome, Italy. Electronic address: giuseppemagliuloorl@yahoo.com. · Department of 'Organi di Senso', University "Sapienza", Rome, Italy. · Department of Oral and Maxillo Facial Sciences, University "Sapienza", Rome, Italy. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy; Department ENT & Audiology, University of Ferrara, Ferrara, Italy. ·Am J Otolaryngol · Pubmed #30224217.

ABSTRACT: PURPOSE: Laryngopharyngeal reflux (LPR) is a frequent condition in Obstructive Sleep Apnoea (OSA) patients and different studies have been published in the last years about this topic. A review of the published literature regarding LPR in OSA patients has been reported. A meta-analysis to evaluate the incidence of LPR in OSA patients and correlate LPR positivity with OSA patients' characteristics has been performed. METHODS: A comprehensive review of the English language literature about LPR in OSA patients was performed using the most important electronic databases (PubMed, EMBASE, the Cochrane Library etc.). A total of 10 papers studying LPR in OSA were assessed and considered eligible for the meta-analysis. RESULTS: The data analysis regarding 870 identified OSA patients showed that 394 patients were LPR +, while 476 were LPR-. The meta-analysis showed no statistical difference regarding the AHI value between LPR + patients and LPR- patients (p = 0,3). Mean BMI was more higher in LPR + patients than in the patients without LPR, showing a significant statistical difference (p = 0.001). CONCLUSION: Current international literature demonstrates a high incidence of LPR (45.2%) in OSA patients. The severity of AHI in OSA patients would not seem to correlate with the presence of laryngopharyngeal reflux. The OSA patients with LPR showed a higher BMI compared with LPR- patients.

2 Review Tongue reduction for OSAHS: TORSs vs coblations, technologies vs techniques, apples vs oranges. 2017

Cammaroto, Giovanni / Montevecchi, Filippo / D'Agostino, Giovanni / Zeccardo, Ermelinda / Bellini, Chiara / Galletti, Bruno / Shams, Medhat / Negm, Hesham / Vicini, Claudio. ·Department of Otolaryngology, University of Messina, Via Consolare Valeria 1, 98100, Messina, Italy. giovanni.cammaroto@hotmail.com. · ENT and Oral Surgery Unit, Department of Special Surgery, Ospedale Morgagni Pierantoni, Forlì, Italy. · Department of Otolaryngology, University of Messina, Via Consolare Valeria 1, 98100, Messina, Italy. · Department of Otolaryngolgy, Head and Neck Surgery, Hamad Medical Corporation, Rumailah Hospital, Doha, Qatar. · Department of Otorhinolaryngology, Faculty of Medicine, University of Cairo, Cairo, Egypt. ·Eur Arch Otorhinolaryngol · Pubmed #27221388.

ABSTRACT: Coblation tongue surgery and Trans-oral robotic surgery (TORS) proved to be the most published therapeutical options for the treatment of patients affected by obstructive sleep apneas (OSAHS). A systematic review of the literature and an analysis of the data are presented. The mean rates of failure were 34.4 and 38.5 %, respectively in TORS and Coblation groups. Complications occurred in 21.3 % of the patients treated with TORS and in 8.4 % of the patients treated with Coblation surgery. TORS seems to give slightly better results, allowing a wider surgical view and a measurable, more consistent removal of lingual tissue. However, the higher rate of minor complication and the significant costs of TORS must also be considered. Moreover, both technologies may be applied to a wide range of surgical techniques, each of them with different effectiveness.

3 Article Laryngopharyngeal Reflux Diagnosis in Obstructive Sleep Apnea Patients Using the Pepsin Salivary Test. 2019

Iannella, Giannicola / Vicini, Claudio / Polimeni, Antonella / Greco, Antonio / Gobbi, Riccardo / Montevecchi, Filippo / De Vito, Andrea / Meccariello, Giuseppe / Cammaroto, Giovanni / D'Agostino, Giovanni / Pace, Annalisa / Cascella, Raffaella / Brunori, Marco / Lo Iacono, Cristina Anna Maria / Pelucchi, Stefano / Magliulo, Giuseppe. ·Department of 'Organi di Senso', University "Sapienza", Viale dell'Università 33, 00161 Rome, Italy. giannicola.iannella@uniroma1.it. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. claudio@claudiovicini.com. · Department ENT and Audiology, University of Ferrara, Via Aldo Moro, 8, 44124 Ferrara, Italy. claudio@claudiovicini.com. · Department of Oral and Maxillo Facial Sciences, University "Sapienza", Via Caserta, 6, 00161 Rome, Italy. antonella.polimeni@uniroma1.it. · Department of 'Organi di Senso', University "Sapienza", Viale dell'Università 33, 00161 Rome, Italy. antonio.greco@uniroma1.it. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. dr.riccardogobbi@gmail.com. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. filippomontevecchi72@gmail.com. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. dr.andrea.devito@gmail.com. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. drmeccariello@gmail.com. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. giovanni.cammaroto@hotmail.com. · Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy. giovanni.dagostino77@gmail.com. · Department of 'Organi di Senso', University "Sapienza", Viale dell'Università 33, 00161 Rome, Italy. annalisapace90@gmail.com. · Department of 'Organi di Senso', University "Sapienza", Viale dell'Università 33, 00161 Rome, Italy. raffaellacascella@virgilio.it. · Department of Cardiovascular, Respiratory, Nephrologic, Anaesthesiologic and Geriatric Sciences, Sapienza University, Viale dell'Università 33, 00161 Rome, Italy. marco.brunori@uniroma1.it. · Department of Cardiovascular, Respiratory, Nephrologic, Anaesthesiologic and Geriatric Sciences, Sapienza University, Viale dell'Università 33, 00161 Rome, Italy. cristina.loiacono@uniroma1.it. · Department ENT and Audiology, University of Ferrara, Via Aldo Moro, 8, 44124 Ferrara, Italy. stefano.pelucchi@unife.it. · Department of 'Organi di Senso', University "Sapienza", Viale dell'Università 33, 00161 Rome, Italy. giuseppe.magliulo@uniroma1.it. ·Int J Environ Res Public Health · Pubmed #31185704.

ABSTRACT: BACKGROUND: To investigate the presence of laryngopharyngeal reflux in patients with obstructive sleep apnea (OSA) employing the salivary pepsin concentration method. To compare the results of pepsin concentration with the severity of the pathology. METHODS: Seventy-five OSA patients (44 males, 31 females) were enrolled in the study. For each patient, the AHI (apnea-hypopnea index) and the BMI (body mass index) were initially evaluated. All the patients enrolled were assessed using the reflux symptom index (RSI) and the reflux finding score (RFS) in order to perform a clinical diagnosis of laryngopharyngeal reflux. In all patients a salivary sample was taken to estimate the presence of pepsin and its concentration. RESULTS: The incidence of LPR (laryngopharyngeal reflux) in OSA patients, evaluated using the salivary pepsin concentration test (PEP-test), was found to be 32% of cases. Linear regression testing did not show any correlation between AHI and pepsin concentration in salivary samples ( CONCLUSION: A high number of patients with OSA seem to show positivity for salivary pepsin, correlated to an LPR. There does not appear to be a correlation between the severity of apnea and the grade of salivary pepsin reflux. On the other hand, direct correlation between BMI and the value of pepsin in salivary specimens was observed.

4 Article The aging effect on upper airways collapse of patients with obstructive sleep apnea syndrome. 2018

Vicini, Claudio / De Vito, Andrea / Iannella, Giannicola / Gobbi, Riccardo / Corso, Ruggero Massimo / Montevecchi, Filippo / Polimeni, Antonella / De Vincentiis, Marco / Meccariello, Giuseppe / D'agostino, Giovanni / Cammaroto, Giovanni / Stomeo, Francesco / Magliulo, Giuseppe. ·Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy. · Department ENT and Audiology, University of Ferrara, Ferrara, Italy. · Department of 'Organi di Senso', University "Sapienza", Via Satrico 7, 00183, Rome, Italy. giannicolaiannella@hotmail.it. · Intensive Care Unit, Morgagni-Pierantoni Hospital, Forlì, Italy. · Department of Oral and Maxillo Facial Sciences, University "Sapienza", Rome, Italy. · Department of 'Organi di Senso', University "Sapienza", Via Satrico 7, 00183, Rome, Italy. ·Eur Arch Otorhinolaryngol · Pubmed #30317385.

ABSTRACT: PURPOSE: To evaluate, using drug-induced sleep endoscopy (DISE), sites of upper airway obstruction and pattern of collapse in patients over 65 years old affected by obstructive sleep apnea. To compare sites and pattern of collapse of elderly patients with a group of patients younger than 65 years. METHODS: A group of 55 patients aged over 65 years were enrolled in this prospective study. Fifty patients under 65 years old were collected in the control group. Polysomnographic data and clinical parameters such as the daytime sleepiness, and body mass index were evaluated for both groups of patients. All patients underwent DISE examination with VOTE classification. RESULTS: The AHI value increased with aging whereas elderly patients presented a reduction in daytime sleepiness. Elderly patients showed a higher incidence of total collapse in the velum region compared to younger patients (90.9% vs 70%;); the older patients showed a lower degree of total oropharyngeal lateral wall collapse with respect to younger patients, (20% vs 50%). No difference in tongue base collapse emerged between the two subgroups of patients. CONCLUSION: Elderly patients showed a higher incidence of total collapse in the velum and a lower incidence in the oropharyngeal lateral wall compared to younger patients.

5 Article Palatal surgery in a transoral robotic setting (TORS): preliminary results of a retrospective comparison between uvulopalatopharyngoplasty (UPPP), expansion sphincter pharyngoplasty (ESP) and barbed repositioning pharyngoplasty (BRP). 2017

Cammaroto, G / Montevecchi, F / D'Agostino, G / Zeccardo, E / Bellini, C / Meccariello, G / Vicini, C. ·Department of Otolaryngology, University of Messina, Italy. · Department of Special Surgery, ENT and Oral Surgery Unit, Ospedale Morgagni Pierantoni, Forlì, Italy. ·Acta Otorhinolaryngol Ital · Pubmed #28530254.

ABSTRACT: It has become increasingly clear in the past decade that surgical management of obstructive sleep apnoea hypopnoea syndrome (OSAHS) is most successfully managed with multilevel surgery. We evaluated the outcomes of multilevel interventions comparing three different palatal techniques added to TORS: uvulopalatopharyngoplasty (UPPP), a modified expansion sphincter pharyngoplasty (ESP), inspired by the Pang expansion sphincter pharyngoplasty technique and the latest barbed repositioning pharyngoplasty (BRP). Thirty patients were retrospectively evaluated. Ten patients underwent UPPP by Fairbanks, 10 BRP and 10 a modified ESP already described. All patients underwent TORS, tonsillectomy and septo-turbinoplasty. For all cases, the following data were retrieved and revaluated: preoperative and postoperative apnoea-hypopnoea index (AHI), preoperative and postoperative Epworth Sleepiness Scale (ESS), pain visual analogue scale (VAS; 0-10) for the first 5 days postoperatively, palatal operative time for each surgical technique, discharge date and complication types and rate. Both BRP and ESP resulted in better postoperative AHI values and higher surgical success rates in comparison with UPPP. On the other hand, BRP was not more effective than ESP. ESP surgery time was significantly higher than UPPP, while BRP was the quickest procedure. In summary, ESP and BRP seem to be more effective than UPPP in a multilevel surgical robotic setting. However, being quicker, easy to learn and with a low rate of complications, BRP is a safe, effective and promising option for treatment of OSAHS patients.

6 Article The interpretation of compact polysomnography/polygraphy in sleep breathing disorders patients: a validation's study. 2017

Bosi, Marcello / De Vito, Andrea / Bellini, Chiara / D'Agostino, Giovanni / Firinu, Elisabetta / Gobbi, Riccardo / Pacella, Alessandro / Filograna Pignatelli, Giulio / Zeccardo, Ermelinda / Poletti, Venerino / Vicini, Claudio. ·Department of Diseases of the Thorax, GB Morgagni-Pierantoni Hospital, AUSL of Romagna, Forlì, Italy. · Ear-Nose-Throat Unit, Head and Neck Department, Morgagni-Pierantoni Hospital, AUSL of Romagna, 47121, Forlì, Italy. dr.andrea.devito@gmail.com. · Ear-Nose-Throat Unit, Head and Neck Department, Morgagni-Pierantoni Hospital, AUSL of Romagna, 47121, Forlì, Italy. · Oral Medical and Biotechnological Science Department, Obstructive Sleep Breathing Disorders Screening University Center, G. D'Annunzio University, Chieti, Italy. · Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark. · ENT Clinic, University of Ferrara, Ferrara, Italy. ·Eur Arch Otorhinolaryngol · Pubmed #28451755.

ABSTRACT: The Otorhinolaryngologist (ENT) frequently has to deal with OSA or suspicious OSA patients and undergone polysomnography (PSG) or portable monitoring (PM) and should be confident about the quality and consistency of the polysomnographic diagnosis. The main polysomnographic traces compressed in a unique epoch, defined as compact PSG/PM (CP), could represent an efficient tool to confirm the quality of PSG/PM Sleep Breathing Disorders diagnosis. This is a validation's study of a CP interpretation's method, analyzing the learning curve, the level of diagnostic accuracy, and the inter-operator agreement in interpreting the CP pattern between a group of ENT specialists not skilled in PSG/PM scoring, but managing SBD patients during daily practice. Seven ENT specialists have been enrolled in the study. 50 CP traces (ranging from normal to all main SBD patterns) have been showed to each participant for the interpretation and scoring process, before and after a 2-h theoretical-practical interactive lesson, focusing on the recognition of the four main oximetric patterns on CP traces (normal, phasic, prolonged, and overlap patterns). RESULTS: before and after the theoretical-practical interactive lesson, the whole diagnostic accuracy in interpreting the 50 CP has been reported improved from 0.12 to 0.80 (median 0.52) to 0.82-0.96 (median 0.92) (p = 0.006) and the inter-scorers' agreement showed a kappa value increased from of 0.18 to 0.75 (p < 0.0001). A complete clinical diagnostic evaluation is essential in OSA patients and the ENT specialist should be concerned to verify if the patient, suitable for surgical therapy, is affected really by an isolated form of OSA. The CP interpretation allows a checking of the proper nosographic SBD framework and could be significantly important for all ENT specialists not skilled in PSG/PM scoring, but managing SBD patients during daily practice. The data reported in our validation's study showed that the CP interpretation's method is easy to apply, with a rapid learning curve. The level of diagnostic accuracy is high with a high inter-scorer agreement in interpreting the CP patterns.

7 Article The importance of drug-induced sedation endoscopy (D.I.S.E.) techniques in surgical decision making: conventional versus target controlled infusion techniques-a prospective randomized controlled study and a retrospective surgical outcomes analysis. 2017

De Vito, Andrea / Agnoletti, Vanni / Zani, Gianluca / Corso, Ruggero Massimo / D'Agostino, Giovanni / Firinu, Elisabetta / Marchi, Chiara / Hsu, Ying-Shuo / Maitan, Stefano / Vicini, Claudio. ·Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy. dr.andrea.devito@gmail.com. · Anaesthesia and Intensive Care Unit, Emergency Department, M. Bufalini Hospital, Cesena, Italy. · Anesthesia and Intensive Care Unit, Santa Maria delle Croci Hospital, Ravenna, Italy. · Anaesthesia and Intensive Care Unit, Emergency Department, G.B. Morgagni-Pierantoni Hospital, Forlì, Italy. · Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy. · Department of Otolaryngology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China. ·Eur Arch Otorhinolaryngol · Pubmed #28213776.

ABSTRACT: Drug-Induced Sedation Endoscopy (DISE) consists of the direct observation of the upper airways during sedative-induced sleep, allowing the identification of the sites of pharyngeal collapse, which is the main pathological event in Obstructive Sleep Apnea (OSA). The Authors have compared Target Controlled Infusion (TCI) sedation endoscopy (TCI-DISE) technique to conventional DISE (CDISE), performed by a manual bolus injection of sedative agent, to recreate accurately and safely snoring and apnea patterns comparable to natural sleep. The authors conducted a prospective, randomized, long-term study and a retrospective analysis of surgical outcomes. The apnea-event observation and its correlation with pharyngeal collapse patterns is the primary endpoint; secondary endpoints are defined as stability and safety of sedation plan of DISE-TCI technique. From January 2009 to January 2011, OSA patients were included in the study and randomly allocated into two groups: the bolus injection conventional DISE group and the TCI-DISE group. Third endpoint is to compare the surgical outcomes enrolling OSA patients from January 2009 to June 2015. We recorded the complete apnea-event at oropharynx and hypopharynx levels in 15/50 pts in conventional DISE group (30%) and in 99/123 pts in TCI-DISE group (81%) (p < 0.0001). Four pts needed oxygen in conventional DISE group because a severe desaturation occurred during the first bolus of propofol (1 mg/kg) (p = 0.4872 ns). We recorded instability of the sedation plan in 13 patients of conventional DISE group (65%) and 1 patient of the TCI-DISE group (5%) (p = 0.0001). In 37 TCI-DISE group surgical patients we reported a significant reduction of postoperative AHI (from 42.7 ± 20.2 to 11.4 ± 10.3) in comparison with postoperative AHI in 15 C-DISE group surgical patients (from 41.3 ± 23.4 to 20.4 ± 15.5) (p = 0.05). Our results suggest the DISE-TCI technique as first choice in performing sleep-endoscopy because of its increased accuracy, stability and safety. However, it is mandatory an accurate assessment of PSG/PM, which allows us to differentiate OSA patients in whom UA anatomical abnormalities are predominant in comparison with not-anatomical pathophysiologic factors, achieving good surgical patient's selection and outcomes as a consequence.

8 Article Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life. 2015

Vicini, Claudio / Eesa, Mohamed / Hendawy, Ehsan / Pari, Milena / D'Agostino, Giovanni / AlGhamdi, Saleh / Meccariello, Giuseppe. ·Department of Special Surgery, ENT and Oral Surgery Unit, G.B. Morgagni - L. Pierantoni Hospital, University of Pavia in Forlì, Italy. · Department of Otolaryngology, Head-Neck Surgery, University of Zagazig, Zagazig, Egypt. Electronic address: dr.eesaorl@gmail.com. · Department of Otolaryngology, Head-Neck Surgery, University of Zagazig, Zagazig, Egypt. · King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia. ·Int J Pediatr Otorhinolaryngol · Pubmed #25980687.

ABSTRACT: OBJECTIVES: To compare the results of powered intracapsular tonsillectomy and adenoidectomy (PITA) with that of conventional extracapsular tonsillectomy and adenoidectomy (ECTA) in treatment of pediatric obstructive sleep apnea (OSA) as regard efficacy, complications including postoperative pain and bleeding, and quality of life. METHODS: Four hundred fifty children with adenotonsillar hyperplasia (with age range from 3 to 14 years) underwent tonsillectomy ± adenoidectomy (251 PITA and 199 ECTA) from January 2012 till October 2014 for OSA. Outcome measures included Obstructive Sleep Apnea Survey (OSA-18), the number of cases treated for post tonsillectomy bleeding with particular regard to the number of cases that needed readmission, the need for analgesics, the visual analog scale (VAS) for post-operative pain, the perceived satisfaction assessed by post tonsillectomy quality of life questionnaire (QOL). RESULTS: OSA-18 scores proved that both PITA and ECTA were equally effective in curing upper airway obstructive symptoms as reflected by the targeted questionnaire. Postoperative bleeding was significantly lower in the PITA group (P<0.01). Postoperative pain and number of needed analgesic doses were significantly lower in the PITA group (P=0.01, P<0.01, respectively). Satisfaction and quality of life were significantly higher in the PITA group (P<0.01). CONCLUSION: PITA is proved to be effective in treating pediatric OSA with less morbidity, less complications in terms of postoperative bleeding mainly with better satisfaction and lower incidence of regrowth.

9 Article Swallowing outcome after TORS for sleep apnea: short- and long-term evaluation. 2015

Eesa, Mohamed / Montevecchi, Filippo / Hendawy, Ehsan / D'Agostino, Giovanni / Meccariello, Giuseppe / Vicini, Claudio. ·Department of Otolaryngology, Head-Neck Surgery, University of Zagazig, Zagazig, Egypt, dr.eesaorl@gmail.com. ·Eur Arch Otorhinolaryngol · Pubmed #25557003.

ABSTRACT: The aim of this study was to evaluate outcomes related to swallowing function in patients who underwent transoral robotic surgery (TORS) for sleep apnea on both short- and long-term scales. 78 patients who underwent TORS for sleep apnea between 2011 and 2014 were followed up for an average period of 20 ± 7.12 months (range 7-32 months), then swallowing outcomes determined by MD Anderson Dysphagia Inventory (MDADI) questionnaire, gastrografin fluoroscopy imaging results, nasogastric tube dependence and subjectively by recording the patients' complaints were analyzed and reported. Minimal insignificant short-term impact on swallowing function (4.58 ± 7.03 preoperative MDADI score versus 5.18 ± 8.32 post-operative) (p = 0.56) was registered. Mean time for start of oral feeding was 1.05 ± 0.25 days (average, 1-3). In no case nasogastric tube feeding was required. Only five patients (6 %) showed significant aspiration on gastrografin fluoroscopy examination after 1 week; there was no significant correlation between the volume of tissue removed from both tongue base and epiglottis to the incidence of aspiration as shown by gastrografin fluoroscopy examination (p = 0.72). No long-term swallowing complaint was registered. Patients who underwent TORS tongue base reduction and supraglottoplasty for sleep apnea proved to have a reasonable short-term swallowing outcomes with no long-term sequelae.