Clinical Focus

  • Sleep Surgery
  • Sleep Medicine
  • Biodesign
  • Otolaryngology

Academic Appointments

Boards, Advisory Committees, Professional Organizations

  • Fellow, American Academy of Sleep Medicine (2011 - Present)
  • Member, American Academy of Otolaryngology (2010 - Present)
  • Member, American Brochoesophagological Association (2013 - Present)

Professional Education

  • Fellowship:Stanford University School of Medicine (2008) CA
  • Medical Education:Universidade Federal Do Parana (1995) Brazil
  • Board Certification: Sleep Medicine, American Board of Psychiatry and Neurology (2009)
  • Fellowship:University of Miami Hospital and Clinics (2001) FL
  • Residency:University of Miami (2007) FL
  • Residency:Universidade Federal Do Parana (1999) Brazil
  • Board Certification: Psychiatry, American Board of Psychiatry and Neurology (2008)

Community and International Work

  • Guest lecturer - Biodesign


    Medtech in LATAM



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Pre-operative evaluation and selection of potential candidates for OSA Surgery.
Sleep MRI.
Innovative approaches for management of OSA.


2013-14 Courses


Journal Articles

  • Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope Camacho, M., Certal, V., Brietzke, S. E., Holty, J. C., Guilleminault, C., Capasso, R. 2014; 124 (3): 803-811


    To systematically review outcomes for polysomnography, sleepiness, and mortality in patients who undergo tracheostomy for the treatment of adult obstructive sleep apnea (OSA).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.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.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 < 0.0001). Mean AHI decreased from 92.0 ± 34.8 to 17.3 ± 20.5/h and an AHI mean difference -79.82 (95% CI, -63.74 to -95.90; P < 0.0001) compared with preoperative status was observed. Postsurgically, there was a development of central apneas; however, the central AI demonstrated near normalization to a mean of 2.1 ± 3.5/h after 14 weeks. ODI decreased from 78.2 ± 25.8/h to 20.8 ± 25.5/h. Four studies demonstrated a statistically significant improvement in subjective sleepiness posttracheostomy. Postoperative statistically significant reductions in overall and in cardiovascular mortality compared with untreated historical cohorts was reported.Tracheostomies significantly decrease apnea index, oxygen desaturation index, sleepiness, and mortality in OSA subjects.NA. Laryngoscope, 124:803-811, 2014.

    View details for DOI 10.1002/lary.24433

    View details for PubMedID 24549987

  • "Unattended sleep studies in Pediatric OSA: A systematic review and meta-analysis" The Laryngoscope Certal, V., Camacho, M., Winck, J. C., Capasso, R., Azevedo, I., Costa-Pereira, A. 2014


    Objective: 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). Data Sources: Four medical databases were searched for eligible studies. Review Methods: 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 QUADAS 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). Results: 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 (DOR) 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 cut-off 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%). Conclusions: 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.

    View details for DOI 10.1002/lary.24662

    View details for PubMedID 24596029

  • Management of obstructive sleep apnea in adults. Annals of internal medicine Capasso, R., Kezirian, E., Jacobowitz, O., Weaver, E. M. 2014; 160 (5): 367

    View details for DOI 10.7326/L14-5005

    View details for PubMedID 24589933

  • Reviewing the Systematic Reviews in OSA Surgery OTOLARYNGOLOGY-HEAD AND NECK SURGERY Certal, V., Nishino, N., Camacho, M., Capasso, R. 2013; 149 (6): 817-829


    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.

    View details for DOI 10.1177/0194599813509959

    View details for Web of Science ID 000327245700005

    View details for PubMedID 24154748

  • Comprehensive review of surgeries for obstructive sleep apnea syndrome BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY Camacho, M., Certal, V., Capasso, R. 2013; 79 (6): 780-788
  • Improved sleep MRI at 3 tesla in patients with obstructive sleep apnea. Journal of magnetic resonance imaging Shin, L. K., Holbrook, A. B., Capasso, R., Kushida, C. A., Powell, N. B., Fischbein, N. J., Pauly, K. B. 2013; 38 (5): 1261-1266


    PURPOSE: To describe a real-time MR imaging platform for synchronous, multi-planar visualization of upper airway collapse in obstructive sleep apnea at 3 Tesla (T) to promote natural sleep with an emphasis on lateral wall visualization. MATERIALS AND METHODS: A real-time imaging platform was configured for sleep MR imaging which used a cartesian, partial k-space gradient-echo sequence with an inherent temporal resolution of 3 independent slices every 2 s. Combinations of axial, mid-sagittal, and coronal scan planes were acquired. The system was tested in five subjects with polysomnography-proven obstructive sleep apnea during sleep, with synchronous acquisition of respiratory effort and combined oral-nasal airflow data. RESULTS: Sleep was initiated and maintained to allow demonstration of sleep-induced, upper airway collapse as illustrated in two subjects when using a real-time, sleep MR imaging platform at 3T. Lateral wall collapse could not be visualized on mid-sagittal imaging alone and was best characterized on multiplanar coronal and axial imaging planes. CONCLUSION: Our dedicated sleep MR imaging platform permitted an acoustic environment of constant "white noise" which was conducive to sleep onset and sleep maintenance in obstructive sleep apnea patients at 3T. Apneic episodes, specifically the lateral walls, were more accurately characterized with synchronous, multiplanar acquisitions. J. Magn. Reson. Imaging 2013;. © 2013 Wiley Periodicals, Inc.

    View details for DOI 10.1002/jmri.24029

    View details for PubMedID 23390078

  • Phase of nasal cycle during sleep tends to be associated with sleep stage LARYNGOSCOPE Kimura, A., Chiba, S., Capasso, R., Yagi, T., Ando, Y., Watanabe, S., Moriyama, H. 2013; 123 (8): 2050-2055


    BACKGROUND AND OBJECTIVES: The phenomena of periodic cycles of vascular engorgement on the nasal cavity mucosa that alternate between right and left sides are termed the "nasal cycle." The physiologic mechanisms underlying this cycle have not been entirely clarified, even more so during sleep. In this study, we measured the periodic patterns of the normal nasal cycle, not only during wakefulness but also during sleep. STUDY DESIGN: CASE SERIES METHODS: Our team utilized a method for functional rhinologic assessment, the portable rhinoflowmeter (Rhinocycle, Rhinometrics, Lynge, Denmark), measuring airflow independently through each nostril during 24 hours on 20 healthy subjects aged 20 to 56 years, and without any nasal pathology or diagnosed medical, psychiatric, or sleep disorders. In addition, a nocturnal polysomnogram was simultaneously performed during sleep. RESULTS: Nineteen of 20 subjects showed a detectable nasal cycle, and 16 of 19 subjects presented a change of the cyclic phase during sleep. The mean nasal cycle duration was 234.2±282.4 minutes (median, 164.1 minutes), although variation was considerable. The mean cycle duration time during sleep was significantly longer than that in wakefulness (P <0.005). The reversal of cyclic phase during sleep tended to be associated with REM sleep (68.8%) and postural changes (18.8%). It never occurred in slow-wave sleep. CONCLUSIONS: Nasal cycle duration during sleep is longer than in wakefulness. Changes in laterality of nasal cycle frequently coincide with switches in posture, tend to occur in REM sleep, never occur in slow-wave sleep, and may be absent in subjects with severe nasal septal deviations. LEVEL OF EVIDENCE: 4. Laryngoscope, 2012.

    View details for DOI 10.1002/lary.23986

    View details for Web of Science ID 000322004400039

    View details for PubMedID 23576311

  • Snoring exclusively during nasal breathing: a newly described respiratory pattern during sleep. Sleep & breathing = Schlaf & Atmung Hsia, J. C., Camacho, M., Capasso, R. 2013


    PURPOSE: The aim of this study is to describe a distinctive respiratory pattern seen in subjects with inferior turbinate hypertrophy, nasal obstruction, and a polysomnogram-proven diagnosis of primary snoring or mild obstructive sleep apnea. These subjects demonstrated increased snoring with purely nasal breathing and alleviation of snoring with oral breathing. The study design is case series with chart review. The setting was a university-based tertiary care hospital. METHODS: A retrospective chart review was performed for patients with complaints of nasal obstruction with associated inferior turbinate hypertrophy and a polysomnogram-proven diagnosis of mild obstructive sleep apnea or primary snoring. Demographic and polysomnography information were collected and analyzed. Snoring and airflow patterns were reviewed. RESULTS: Twenty-five subjects were identified as having met the inclusion and exclusion criteria on polysomnography for either primary snoring or mild obstructive sleep apnea with inferior turbinate hypertrophy and no other significant nasal deformity or abnormality. Seventeen (68 %) of these patients had polysomnograms which demonstrated snoring during nasal breathing and alleviation of snoring with oral breathing. Of the 17 who snored during nasal breathing, ten of the subjects were female and seven of the subjects were male. The mean age was 27 years (range 18 to 68 years). The mean apnea-hypopnea index was 2.3 events/h (range 0 to 9.7 events/h). The mean body mass index was 25 kg/m(2) (range 20 to 43 kg/m(2)). CONCLUSION: Our study describes a newly recognized pattern of snoring in patients with a polysomnogram-proven diagnosis of either primary snoring or mild obstructive sleep apnea. This pattern of breathing demonstrates patients who snore during nasal breathing even with known nasal obstruction present and subsequently have resolution or improvement of the snoring with oral breathing.

    View details for PubMedID 23716022

  • Surgical Therapy of Obstructive Sleep Apnea: A Review NEUROTHERAPEUTICS Carvalho, B., Hsia, J., Capasso, R. 2012; 9 (4): 710-716


    Obstructive sleep apnea (OSA) is a disease characterized by intermittent and repetitive narrowing of the airway during sleep. Surgical therapies for the treatment of OSA aim to improve airway patency by addressing selected site(s) of obstruction. Because several areas may each be responsible for the narrowing, different surgical modalities have also been developed. In this review, we give an overview of surgery for each of potential obstruction site(s). As a consequence of the multi-factorial and heterogeneous etiology of OSA, surgical therapies need to be selected and performed specifically for each patient, as there is no perfect surgery that will fit all patients. As with any other treatment modalities for OSA, surgical therapies have variable efficacy, but are a very important tool on OSA management in selected patients and have been shown effectiveness in decreasing the morbidity and mortality associated with the disease.

    View details for DOI 10.1007/s13311-012-0141-x

    View details for Web of Science ID 000310325000004

    View details for PubMedID 22915293

  • The effect of continuous positive airway pressure on middle ear pressure LARYNGOSCOPE Lin, F. Y., Gurgel, R. K., Popelka, G. R., Capasso, R. 2012; 122 (3): 688-690


    While continuous positive airway pressure (CPAP) is commonly used for obstructive sleep apnea treatment, its effect on middle ear pressure is unknown. The purpose of this study was to measure the effect of CPAP on middle ear pressure and describe the correlation between CPAP levels and middle ear pressures.Retrospective review of normal tympanometry values and a prospective cohort evaluation of subjects' tympanometric values while using CPAP at distinct pressure levels.A total of 3,066 tympanograms were evaluated to determine the normal range of middle ear pressures. Ten subjects with no known history of eustachian tube dysfunction or obstructive sleep apnea had standard tympanometry measurements while wearing a CPAP device. Measurements were taken at baseline and with CPAP air pressures of 0, 5, 10, and 15 cm H(2)O.The percentage of normal control patients with middle ear pressures above 40 daPa was 0.03%. In the study population, prior to a swallowing maneuver to open the eustachian tube, average middle ear pressures were 21.67 daPa, 22.63 daPa, 20.42, daPa, and 21.58 daPa with CPAP pressures of 0, 5, 10, and 15 cm H(2) 0, respectively. After swallowing, average middle ear air pressures were 18.83 daPa, 46.75 daPa, 82.17 daPa, and 129.17 daPa with CPAP pressures of 0, 5, 10, and 15 cm H(2)0, respectively. The postswallow Pearson correlation coefficient correlating CPAP and middle ear pressures was 0.783 (P < 0.001).Middle ear air pressure is directly proportional to CPAP air pressure in subjects with normal eustachian tube function. Middle ear pressure reaches supraphysiologic levels at even minimal CPAP levels. Although further investigation is necessary, there may be otologic implications for patients who are chronically CPAP dependent. These findings may also influence the perioperative practice of otologic and skull base surgeons.

    View details for DOI 10.1002/lary.22442

    View details for Web of Science ID 000300680200035

    View details for PubMedID 22252535

  • Sleep medicine clinical and surgical training during otolaryngology residency: a national survey of otolaryngology residency programs. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Shen, T., Shimahara, E., Cheng, J., Capasso, R. 2011; 145 (6): 1043-1048


    The authors sought to assess the otolaryngology residency training experiences in adult sleep medicine and sleep surgery in the United States.Internet survey.US academic otolaryngology residency programs.This Internet survey was emailed to the program directors of 103 US Accreditation Council for Graduate Medical Education (ACGME)-approved otolaryngology residency programs in 2010.A total of 47 program directors responded, representing 46% of programs surveyed. In 59% of these programs, there was at least 1 faculty member with clinical practice dedicated to adult medicine. Most commonly, these clinicians spent less than 50% of their clinical time on adult sleep medicine. While most otolaryngology residents were reported being well trained in commonly performed procedures such as septoplasty and uvulopalatopharyngoplasty (UPPP), the training on hypopharyngeal or multilevel surgeries, such as partial glossectomy, tongue base resection, hyoid or tongue suspension, or geniotubercle advancement, was considered less frequent. The overall exposure to education regarding the interpretation of original data of laboratory-based sleep studies or portable home monitoring devices was infrequent. A significant portion of respondents indicated that they would like to expand their residents' exposure to adult sleep medicine and sleep surgery.This survey provides a starting point to further assess the rigor of sleep medicine/sleep surgery training in US residency programs. Continued assessment and strengthening of the current curriculum are crucial to keep residents up to date with this evolving field. This result calls attention to the importance of bolstering sleep medicine and surgery curriculum to meet the academic requirements of otolaryngology training.

    View details for DOI 10.1177/0194599811416765

    View details for PubMedID 21791704

  • Caregiver Reports of Sleep Problems in Non-Hispanic White, Hispanic, and African American Patients with Alzheimer Dementia JOURNAL OF CLINICAL SLEEP MEDICINE Ownby, R. L., Saeed, M., Wohlgemuth, W., Capasso, R., Acevedo, A., Peruyera, G., Sevush, S. 2010; 6 (3): 281-289


    Sleep problems are common in persons with dementing illnesses and among the most stressful patient behaviors for caregivers. Although studies have shown differences in sleep across ethnic groups, little information is available on ethnic differences among persons with dementia. The purpose of this study was to investigate possible ethnic differences in sleep problems among patients with Alzheimer dementia.Caregiver reports of 5 sleep- or circadian rhythm-related behavioral problems (behavior disturbance worse in the evening, difficulties falling asleep, frequent awakenings, early awakenings, and excessive daytime sleep) were evaluated in 395 patients who had received a diagnosis of Alzheimer disease after diagnostic evaluation. The average cognitive score of the groups suggested that they could be characterized as having moderately severe impairment. The frequency of sleep problems was then evaluated across subgroups defined by self-reported ethnicity (African American, Hispanic, and non-Hispanic white). As patient and caregiver characteristics may affect caregivers' reports of patients' behaviors, mixed effects regression models were used to adjust for patient and caregiver variables that might affect caregiver reports.Analyses revealed ethnic differences in sleep or circadian rhythm disturbances. African American and Hispanic patients were reported to have more severe sleep disturbances than non-Hispanic whites. After correction for patient and caregiver variables that might have affected caregiver reports, differences between African Americans and others remained.Sleep problems in patients with dementing illnesses are reported by caregivers with differing frequencies across groups of African Americans, Hispanics, and non-Hispanic whites. Clinicians should be aware of these differences in assessing sleep disturbance in patients with dementia as well as the potential effects of patient and caregiver variables on reports of these problems.

    View details for Web of Science ID 000278786300011

    View details for PubMedID 20572423

  • Endoscopic resection of inverted papilloma: University of Miami experience AMERICAN JOURNAL OF RHINOLOGY Kaza, S., Capasso, R., Casiano, R. R. 2003; 17 (4): 185-190


    The aim of this study was to evaluate the efficacy and safety of endoscopically resecting paranasal sinus inverted papillomas at a tertiary medical center.Over a 9-year period, 51 patients with a diagnosis of inverted papilloma underwent endoscopic resection at the University of Miami/Jackson Memorial Medical Center. The study group consisted of 14 women and 37 men with a mean age of 59 years (range, 20-88 years) enrolled in a clinical data base. All of the patients were followed endoscopically at regular intervals on an outpatient basis.Endoscopic evidence of extensive papillomas involving the anterior and posterior ethmoid sinuses and at least one (usually the maxillary) dependent sinus was found in 60% of the cases. Extensive radiological disease (varying degrees of mucoperiosteal thickening or opacification of all five cavities) was evident in 50% of the cases. All but two had unilateral disease. An association with chronic inflammatory polyps (clinically and pathologically) was observed in 25 of 51 patients (49%). Follow-up ranged from 6 to 99 months (mean, 30 months). There have been seven recurrences (14%). Four of these have been managed in the office under topical anesthesia. Three recurrences were managed surgically in the operating room. All of the patients have been free of disease. Complications included an intraoperative CSF leak (three patients); temporary infraorbital hypesthesia (three patients); periorbital ecchymosis, hematoma, or cheek edema (four patients); and orbital symptoms (two patients). Carcinoma was found in four patients (8%) who received postoperative radiotherapy and remain free of disease.The endoscopic approach continues to provide at least equivalent short-term results as compared with external techniques for the removal of paranasal sinus inverted papilloma. The final cavity should allow for adequate postoperative surveillance and potential resection of recurrences in the office setting, without the need for a return to the operating room in most patients. The association of inverted papilloma with chronic inflammatory polyps and tobacco use warrants additional study.

    View details for Web of Science ID 000185068000002

    View details for PubMedID 12962186

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