Evaluation of the Patient with Facial Palsy: A Multidisciplinary Approach.

This article aims to provide an overview of the management of facial palsy within a multidisciplinary team setting and discusses considerations used to develop patient-specific management plans. The national landscape of facial function services is also discussed including suggestions on what may enable a more equitable and sustainable service for the future.

Enhancing paranasal sinus disease detection with AutoML: efficient AI development and evaluation via magnetic resonance imaging.

PURPOSE: Artificial intelligence (AI) in the form of automated machine learning (AutoML) offers a new potential breakthrough to overcome the barrier of entry for non-technically trained physicians. A Clinical Decision Support System (CDSS) for screening purposes using AutoML could be beneficial to ease the clinical burden in the radiological workflow for paranasal sinus diseases. METHODS: The main target of this work was the usage of automated evaluation of model performance and the feasibility of the Vertex AI image classification model on the Google Cloud AutoML platform to be trained to automatically classify the presence or absence of sinonasal disease. The dataset is a consensus labelled Open Access Series of Imaging Studies (OASIS-3) MRI head dataset by three specialised head and neck consultant radiologists. A total of 1313 unique non-TSE T2w MRI head sessions were used from the OASIS-3 repository. RESULTS: The best-performing image classification model achieved a precision of 0.928. Demonstrating the feasibility and high performance of the Vertex AI image classification model to automatically detect the presence or absence of sinonasal disease on MRI. CONCLUSION: AutoML allows for potential deployment to optimise diagnostic radiology workflows and lay the foundation for further AI research in radiology and otolaryngology. The usage of AutoML could serve as a formal requirement for a feasibility study.

Artificial intelligence chatbots as sources of patient education material for obstructive sleep apnoea: ChatGPT versus Google Bard.

PURPOSE: To perform the first head-to-head comparative evaluation of patient education material for obstructive sleep apnoea generated by two artificial intelligence chatbots, ChatGPT and its primary rival Google Bard. METHODS: Fifty frequently asked questions on obstructive sleep apnoea in English were extracted from the patient information webpages of four major sleep organizations and categorized as input prompts. ChatGPT and Google Bard responses were selected and independently rated using the Patient Education Materials Assessment Tool-Printable (PEMAT-P) Auto-Scoring Form by two otolaryngologists, with a Fellowship of the Royal College of Surgeons (FRCS) and a special interest in sleep medicine and surgery. Responses were subjectively screened for any incorrect or dangerous information as a secondary outcome. The Flesch-Kincaid Calculator was used to evaluate the readability of responses for both ChatGPT and Google Bard. RESULTS: A total of 46 questions were curated and categorized into three domains: condition (n = 14), investigation (n = 9) and treatment (n = 23). Understandability scores for ChatGPT versus Google Bard on the various domains were as follows: condition 90.86% vs.76.32% (p < 0.001); investigation 89.94% vs. 71.67% (p < 0.001); treatment 90.78% vs.73.74% (p < 0.001). Actionability scores for ChatGPT versus Google Bard on the various domains were as follows: condition 77.14% vs. 51.43% (p < 0.001); investigation 72.22% vs. 54.44% (p = 0.05); treatment 73.04% vs. 54.78% (p = 0.002). The mean Flesch-Kincaid Grade Level for ChatGPT was 9.0 and Google Bard was 5.9. No incorrect or dangerous information was identified in any of the generated responses from both ChatGPT and Google Bard. CONCLUSION: Evaluation of ChatGPT and Google Bard patient education material for OSA indicates the former to offer superior information across several domains.

Performance of artificial intelligence chatbots in sleep medicine certification board exams: ChatGPT versus Google Bard.

PURPOSE: To conduct a comparative performance evaluation of GPT-3.5, GPT-4 and Google Bard in self-assessment questions at the level of the American Sleep Medicine Certification Board Exam. METHODS: A total of 301 text-based single-best-answer multiple choice questions with four answer options each, across 10 categories, were included in the study and transcribed as inputs for GPT-3.5, GPT-4 and Google Bard. The first output responses generated were selected and matched for answer accuracy against the gold-standard answer provided by the American Academy of Sleep Medicine for each question. A global score of 80% and above is required by human sleep medicine specialists to pass each exam category. RESULTS: GPT-4 successfully achieved the pass mark of 80% or above in five of the 10 exam categories, including the Normal Sleep and Variants Self-Assessment Exam (2021), Circadian Rhythm Sleep-Wake Disorders Self-Assessment Exam (2021), Insomnia Self-Assessment Exam (2022), Parasomnias Self-Assessment Exam (2022) and the Sleep-Related Movements Self-Assessment Exam (2023). GPT-4 demonstrated superior performance in all exam categories and achieved a higher overall score of 68.1% when compared against both GPT-3.5 (46.8%) and Google Bard (45.5%), which was statistically significant (p value < 0.001). There was no significant difference in the overall score performance between GPT-3.5 and Google Bard. CONCLUSIONS: Otolaryngologists and sleep medicine physicians have a crucial role through agile and robust research to ensure the next generation AI chatbots are built safely and responsibly.

The role of ANCA in the management of cocaine-induced midline destructive lesions or ENT pseudo-granulomatosis with polyangiitis: a London multicentre case series.

OBJECTIVE: In this multicentric study involving three London hospitals, we compared ANCA-positive and ANCA-negative cocaine-induced midline destructive lesions (CIMDL) patients to assess how presence of antineutrophil cytoplasmic antibodies (ANCA) may correlate with disease severity. Our secondary aims are to better classify etiology centered around ANCA positivity and, consequently, better disease management. METHODS: A retrospective review was performed to identify patients with CIMDL seen between January 2019 and December 2022. Population data including age, sex, presentation, endoscopic findings, duration of cocaine use and active use of cocaine, type of treatment, laboratory (including ANCA serology), radiological, and histological findings were collected. RESULTS: Forty CIMDL patients (25 male, median age of 42 years) were identified. The majority of them (72.5%) presented with either a septal perforation, a saddle nose deformity (22.5%), and/or a palatal fistula (20.0%). ANCA was positive in 71.1% of cases (66.7% p-ANCA). No statistically significant differences in the general characteristics, type of treatment, laboratory results, radiological or histological findings were observed when comparing ANCA-positive and ANCA-negative CIMDL patients or when comparing p-ANCA and c-ANCA patients. Similarly, no statistically significant difference was obtained when comparing the pattern of distribution of lesions between the two groups. CONCLUSIONS: A large percentage of CIMDL patients showed positive ANCA test (71.1%) and in the majority of the cases a p-ANCA pattern specifically targeting PR3 (p-ANCA, PR3 + MPO-). However, ANCA positivity or presence of a specific ANCA pattern was not associated with more severe presentation or more aggressive disease. Given its similarities to granulomatosis with polyangiitis (GPA), we recommend the use of the term "cocaine-induced ENT pseudo-GPA" instead of CIMDL. LEVEL OF EVIDENCE: IV Laryngoscope, 2023.

International Multicenter Study of Clinical Outcomes of Sinonasal Melanoma Shows Survival Benefit for Patients Treated with Immune Checkpoint Inhibitors and Potential Improvements to the Current TNM Staging System.

Objectives Sinonasal mucosal melanoma (SNMM) is an extremely rare and challenging sinonasal malignancy with a poor prognosis. Standard treatment involves complete surgical resection, but the role of adjuvant therapy remains unclear. Crucially, our understanding of its clinical presentation, course, and optimal treatment remains limited, and few advancements in improving its management have been made in the recent past. Methods We conducted an international multicenter retrospective analysis of 505 SNMM cases from 11 institutions across the United States, United Kingdom, Ireland, and continental Europe. Data on clinical presentation, diagnosis, treatment, and clinical outcomes were assessed. Results One-, three-, and five-year recurrence-free and overall survival were 61.4, 30.6, and 22.0%, and 77.6, 49.2, and 38.3%, respectively. Compared with disease confined to the nasal cavity, sinus involvement confers significantly worse survival; based on this, further stratifying the T3 stage was highly prognostic ( p < 0.001) with implications for a potential modification to the current TNM staging system. There was a statistically significant survival benefit for patients who received adjuvant radiotherapy, compared with those who underwent surgery alone (hazard ratio [HR] = 0.74, 95% confidence interval [CI]: 0.57-0.96, p = 0.021). Immune checkpoint blockade for the management of recurrent or persistent disease, with or without distant metastasis, conferred longer survival (HR = 0.50, 95% CI: 0.25-1.00, p = 0.036). Conclusions We present findings from the largest cohort of SNMM reported to date. We demonstrate the potential utility of further stratifying the T3 stage by sinus involvement and present promising data on the benefit of immune checkpoint inhibitors for recurrent, persistent, or metastatic disease with implications for future clinical trials in this field.

Litigation in Septorhinoplasty Surgery: A Pan-Specialty Review of National Health Service (the United Kingdom) Data.

Success in septorhinoplasty surgery can be difficult to assess due to a lack of objective and measurable outcomes. If patients' expectations are not met, it places surgeons performing septorhinoplasty at risk of litigation which can be stressful and costly. The National Institute of health (NHS) Resolution is a government-funded organization in the United Kingdom that provides expertise to the NHS on resolving patient concerns. Data were requested from NHS Resolution for claims involving septorhinoplasty surgery over a period of 5 years between April 2015 and April 2020. Rhinoplasty claims performed by all specialties were included. Data included the claim status, incident details, alleged injury, damages claimed, and damages paid. A total of 31 claims were identified by the study, equating to a total cost of £1,347,336.10. Of the 31 claims for rhinoplasty or septorhinoplasty, 9 cases were open (29%, £962,361.00) and 22 cases were closed (71%, £384,975.10). The common causes for claims were "intraoperative problems (32%)," "failure to warn-informed consent (19%)," and "foreign body left in situ (13%)." The most common injuries were "cosmetic disfigurement (39%)," "unnecessary pain (29%)," and "additional/ unnecessary operation (29%)." This study highlights the need for improved awareness of clinical negligence claims among surgeons who perform septorhinoplasty. Results are applicable to all specialties who perform the procedure. The study highlights the importance of assessing patients' motives and expectations prior to surgery and emphasizes the need for a well-documented rigorous consent process.

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset.

INTRODUCTION: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for endoscopic sinus surgery (ESS). The aim of this study was to investigate the safety of day-case ESS in England. DESIGN: Secondary analysis of administrative data. METHODS: We extracted data from the Hospital Episodes Statistics database for the 5 years from 1 April 2014 to 31 March 2019. Patients undergoing elective ESS procedures aged ≥17 years were included. Exclusion criteria included malignant neoplasm, complex systemic disease and trans-sphenoidal pituitary surgery. The primary outcome was readmission within 30 days post-discharge. Multilevel, multivariable logistic regression modelling was used to compare outcomes for those operated on as day-cases and those with an overnight stay after adjusting for demographic, frailty, comorbidity and procedural covariates. RESULTS: Data were available for 49 223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/2015 to 78.7% in 2018/2019. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar. CONCLUSIONS: Our data support the view that ESS can safely be performed as day-case surgery in most cases, although it will not be suitable for all patients. There appears to be scope to increase rates of day-case ESS in some hospital trusts in England.

Clinical outcomes, Kadish-INSICA staging and therapeutic targeting of somatostatin receptor 2 in olfactory neuroblastoma.

INTRODUCTION: Olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy. METHODS: We conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763). RESULTS: Dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n = 278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD). CONCLUSIONS: This study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.

Olfactory dysfunction in antineutrophil cytoplasmic antibody-associated vasculitides: A review of the literature.

Olfactory dysfunction (OD) has been described in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAV), but the underlying mechanisms are not completely understood. The causes of altered smell function can generally be divided into conductive, sensorineural or others. To date no specific treatment is available for AAV-related OD and the efficacy of currently available options has not been explored. The aim of this review is to provide an overview of the causes that may lead to OD in patients with AAV. Current available treatments for OD and possible options in patients with AAV presenting with smell impairment are also mentioned.

The Evidence Base for the Benefits of Functional Septorhinoplasty and its Future Post COVID-19.

Ever since the introduction of the concept of Procedures of Limited Clinical Value (PoLCV), procedures such as functional septorhinoplasty have been subject to additional funding restrictions within the British National Health Service. Recent publications have suggested that 10% of Clinical Commissioning Groups in the United Kingdom no longer fund septorhinoplasty surgery irrespective of the indications, including congenital malformations or post-trauma, and despite the strong evidence available in the literature in treating a range of health conditions. Thus, inequity exists across the country. At present functional septorhinoplasty surgery is frequently but incorrectly grouped together with aesthetic rhinoplasty, both of which are deemed to be cosmetic interventions. Moreover, as we exit the peak of the current coronavirus disease 2019 (COVID-19) pandemic, procedures deemed to be of lower clinical priority will potentially be at risk throughout Europe. The purpose of this review is twofold; the first is to put forward the evidence to commissioners in favor of functional septorhinoplasty surgery on patient well-being and mental health; the second is to demonstrate why functional septorhinoplasty surgery is a distinct procedure from aesthetic rhinoplasty and why it ought not to be classified as a procedure of limited clinical value.

The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review.

BACKGROUND: The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis diseases and often precedes the diagnosis of ANCA-associated vasculitis by many months. Although treatment for ANCA-associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission. PURPOSE: The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA-associated vasculitis presenting with sinonasal involvement. MATERIALS AND METHODS: A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020. CONCLUSION: Surgical intervention during the active phase of ANCA-associated vasculitis disease can improve the patient's symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.

A Unilateral Mucoperichondrial/Mucoperiosteal Flap Including Inferior Turbinate with Contralateral Underlay Xenograft for a Large Nasal Septal Perforation Repair.

Findings: We describe a septal perforation repair technique aimed for moderate to large perforations, which involves a unilateral transpositional/rotational flap utilizing lateral nasal wall and inferior turbinate (IT) mucosa and a contralateral underlay porcine small intestinal submucosa mesh. Meaning: The addition of IT mucosa as part of the unilateral lateral nasal wall mucoperichondrium/periosteal flap combined with a contralateral acellular matrix underlay optimizes the repair of larger perforations. The underlay acellular matrix acts as a scaffold for the regeneration of healthy mucoperichondrium akin to a tympanoplasty repair and reduces donor site morbidity.

A national survey of functional septorhinoplasty surgery performed in the United Kingdom: a clinician end-user questionnaire to assess current practice and help inform future practice.

PURPOSE: The aim of this national survey is to assess the current practice of functional septorhinoplasty (SRP) surgery in the UK and better inform future practice. METHODS: An ENT-UK approved questionnaire was sent out to all 135 consultant members of the British Society of Facial Plastic Surgery (BSFPS). Data was collected on numbers of functional SRPs performed on the NHS, use of outcome measures, psychology and photography support, antibiotic use, referral base and consenting practice. RESULTS: The response rate was 38.5%, with 52 out of 135 completed. The median number of annual SRP cases per surgeon was 40. Most surgeons (95%) used clinical photography as an outcome measure. However, 27% of the respondents use a subjective outcome measurement and 3% of them use an objective outcome measurement. Only 34% had access to psychology support and 60% receive their referrals from primary care. All surgeons counsel patients for aesthetic change, 15% mention CSF leak and 38% mention olfactory disturbance. The key comment from our respondents was to relabel the rhinoplasty procedure as a functional SRP procedure with the aim to remove it from the Procedures of Limited Clinical Value (PoLCV) list. CONCLUSION: The majority of our respondents perform a large proportion of the SRP surgeries in the UK with each of the respondents performing an average of 40 SRP surgeries per year. There is a need to recatergorise functional septorhinoplasty as a functional operation and recommend functional SRP surgery to be removed from the PoLCV list.

Tumour resection volumes and facial nerve outcomes for vestibular schwannomas.

The objective of this study is to correlate tumour volume relationship with surgical outcomes in subtotal resections and accepted nomenclature through a retrospective study at Charing Cross Hospital, London, a tertiary referral centre. The participants were 16 patients with vestibular schwannoma managed with subtotal resection between 2002 and 2011. The main outcome measures were surgical technique; tumour volume; recurrence and post-operative facial nerve function. Mean pre-operative and post-operative volumes for all patients were 14.7 and 3.7 cm(3) respectively. Tumour volumes do not correlate with diameter (p < 0.05). Mean reduction in volume of these subtotal resections was 75 %. Long term facial nerve outcome was good in the majority of patients: House-Brackmann Grade I/II in 12 (75 %), Grade III/IV in 2 (12.5 %) and Grade V/VI in 2 patients (12.5 %). Notably, two patients with Grade I/II House-Brackmann grading later developed Grade V/VI palsy following adjunctive radiotherapy. Seven of the 16 subtotal resections had subsequent radiotherapy or microsurgery. Mean follow up was 26.5 months. In conclusion, subtotal resections lead to good facial nerve outcomes but may require further treatments. Radiation treatment can worsen facial nerve function. There is no standardised use of tumour volumes or accepted guidelines for resection terminology. We propose the use of tumour volumes to define this further.

An "Uncrimped" SMart Stapes Prosthesis: A Cause of Late Hearing Deterioration in Otosclerosis.

Statement of Problem. Stapedotomy is the treatment of choice for otosclerosis. Numerous techniques and prosthesis are available to perform this procedure. Success rates of surgery vary from 17% to 80%, and revision surgery carries an increased risk of complications as well as poorer hearing outcomes. Method of Study. Case report. Results. We report the first case of uncrimping of a SMart stapes prosthesis with no lateral displacement as a cause of late failure despite successful crimping and improvement in audiological outcomes after initial surgery. Conclusion. The SMart stapes prosthesis is widely used and has been shown to be safe and provide good hearing outcomes. Displacement of a stapes prosthesis is the commonest cause of failure. Our case shows that deterioration of hearing thresholds can occur from uncrimping of the prosthesis with no displacement. It is important to improve our understanding of stapedotomy failure as revision procedures are associated with poorer outcomes.

Endoscopic management of an internal laryngopyocele presenting with acute airway obstruction.

Statement of Problem. Laryngocele is a rare laryngeal disease, where there is an abnormal dilatation of the saccule of the laryngeal ventricle. It can either be internal or external, and a laryngopyocele is a rare complication of this anomaly. Internal laryngopyoceles can prove difficult to manage, as they often present with airway compromise. Method of Study. Case Report. Results. We present a case of a laryngopyocele that was successfully managed with suspension laryngoscopy and endoscopic marsupialisation and resection. To our knowledge, this is the first such case described in the literature. Conclusions. Surgical drainage of a laryngopyocele via the external approach is well documented in the literature. We feel that endoscopic resection of laryngopyoceles in an emergency situation is a viable alternative and also prevents the associated surgical morbidity.

Impact of long-term nasopharyngeal airway on health-related quality of life of children with obstructive sleep apnea caused by syndromic craniosynostosis.

Obstructive sleep apnea in children with syndromic craniosynostosis is a well-documented entity, and airway management in these group of children is difficult, with well-documented cardiorespiratory and neurodevelopment consequences. Numerous well-documented techniques are available for airway management in this group of children. In our center, the nasopharyngeal airway (NPA) is the first-line treatment. This study aimed to evaluate the improvement in health-related quality of life in this group of children using the Glasgow Children's Benefit Inventory. We conducted a retrospective postal study of 24 patients with craniofacial disorders who had an NPA inserted as part of their airway management. A 79.2% (n = 19) response rate was obtained. Mean (SD) age was 5.8 (4.1) years. Patients were classified into 3 main groups: Crouzon (n = 11), Apert (n = 6), and Pfeiffer (n = 2) syndromes. There was improvement in 3 of the 4 domains, namely, learning (P = 0.006), vitality (P = 0.003), physical (range, -3 to 8; mean, 2; P = 0.005). There was significant improvement in the sleep study parameters; however, no correlation was found between this and the Glasgow Children's Benefit Inventory findings. Parents also preferred an NPA as opposed to a tracheostomy when given a choice. Our study shows that NPA confers significant improvement not only in health-related quality of life but also in severity of obstructive sleep apnea as judged by sleep study parameters. The NPA is also well tolerated by patients and is much preferred by parents for airway management for their children as opposed to having a tracheostomy. We think that this should be considered in other centers as first-line management in children with syndromic craniosynostosis.

Adenotonsillectomy for sleep-disordered breathing in children with syndromic craniosynostosis.

Syndromic craniosynostosis (SCS) is known to be associated with sleep-disordered breathing (SDB) in childhood. Problems can occur at various levels, but midface hypoplasia is a major factor in affected infants.Adenotonsillectomy (AT) has been proven to be efficacious as a first-line treatment of SDB in healthy children. However, its role in the treatment of this issue in those with SCS has not been evaluated. Owing to the multiple possible levels of obstruction in such individuals, AT may have no benefit. This study therefore aimed to evaluate the effectiveness of AT in this group of patients.Twenty-six children with SCS with moderate to severe obstructive sleep apnea (OSA) were treated with AT. The mean age at surgery was 4.5 years (range, 1.6-13.9 y). Seven had severe OSA, 11 had moderate OSA, and 7 had mild OSA preoperatively. Of 25 children, 15 (60%) demonstrated an improvement in sleep severity scores postoperatively.Overall, there was a significant improvement in the mean number of saturation dips greater than 4%/h and in the mean nadir of dips in saturation after the operation. There was no significant difference in mean oxygen saturation, number of pulse rate rises per hour, or percentage time spent less than 90% SaO2.Clinically, there is thought to be some benefit in performing AT in these groups of patients. In children with SCS, in whom the cause of obstruction might be at multiple levels, AT should still to be considered as first-line treatment in the management of OSA/SDB.We acknowledge that some children may still go on to require further airway intervention. Further multicenter trials would be useful to examine more closely the significance of the effects of AT in children with craniofacial disorders experiencing SDB.