Drug‐Induced Sleep Endoscopy Informs Management of Obstructive Sleep Apnea after Incomplete Mandibular Advancement Device Response

Abstract

Objectives: (1) Understand that half of obstructive sleep apnea (OSA) patients failing positive airway pressure (PAP) attempt mandibular advancement device (MAD) therapy but still suffer from residual disease. (2) Describe how drug-induced sleep endoscopy (DISE) evaluates anatomical patterns of obstruction under conditions that mimic sleep and aids management in patients with incomplete response to MAD. Methods: A review of 35 consecutive adult OSA patients, with continuous positive airway pressure intolerance and incomplete response to MAD therapy (apnea-hypopnea index [AHI] >15 or AHI >5 with persistent subjective symptoms), who underwent DISE with and without the MAD between 12/2010 and 8/2013. Data collected included demographics, body mass index (BMI), Epworth Sleepiness Score (ESS), polysomnography data, and management decisions after DISE. Each DISE video was retrospectively scored using the VOTE classification system by the same blinded reviewer (R.J.S.). Results: All patients had multilevel airway obstruction during baseline DISE. 32 (91.4%) obstructed in the velopharynx despite MAD use. 26 (74.3%) patients were recommended to undergo targeted surgery based on DISE findings with 21 (60%) completing it. Nineteen (54.3%) underwent additional medical therapy such as MAD or PAP adjustment. Twelve (34.3%) were treated with surgical and medical therapy. Subjective and objective outcomes were significantly improved in 15 patients with outcome data currently available (mean AHI 39.3 to 10.7, P < .01; ESS 11.2 to 6.25, P < .01). Conclusions: In patients with incomplete response to MAD therapy, DISE with and without the MAD provides informs management decisions regarding additional medical or surgical options to augment the effectiveness of the MAD.