Drug-induced Sleep Endoscopy Findings Research Articles

Drug-Induced Sleep Endoscopy Findings in Supine vs Nonsupine Body Positions in Positional and Nonpositional Obstructive Sleep Apnea

The anatomic mechanisms underlying positional vs nonpositional obstructive sleep apnea (OSA) are poorly understood and may inform treatment decisions. To examine drug-induced sleep endoscopy (DISE) findings in the supine vs nonsupine body positions in positional and nonpositional obstructive sleep apnea. A cross-sectional study of 65 consecutive eligible adults with OSA undergoing DISE without marked tonsillar hypertrophy, including 39 with positional OSA (POSA) and 26 with nonpositional OSA (N-POSA) was conducted in a sleep surgery practice at a tertiary academic medical center. Drug-induced sleep endoscopy performed in the supine vs nonsupine body position. Drug-induced sleep endoscopy findings were scored separately for the supine and lateral body positions using the VOTE classification (velum, oroparyngeal lateral walls, tongue, epiglotis) and with identification of a single primary structure contributing to airway obstruction. Velum-related obstruction was separated into anteroposterior and lateral components. The 65 study participants had a mean (SD) age of 52.4 (11.7) years, and 55 (84.6) were men. Mean (SD) body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) was 27.2 (3.1), with only 9 (14%) of 65 participants having a BMI greater than 30. The supine body position was associated with greater odds of anteroposterior velum- (odds ratio [OR], 7.28; 95% CI, 3.53-15.01), tongue- (OR, 29.4; 95% CI, 12.1-71.5), and epiglottis-related (OR, 11.0; 95% CI, 1.3-92.7) obstruction in the entire cohort, with similar findings in the POSA and N-POSA subgroups. The supine body position was associated with a lower odds of oropharyngeal lateral wall-related (OR, 0.22; 95% CI, 0.07-0.70) obstruction in the N-POSA subgroup, whereas there was no increase in the overall sample or the POSA subgroup. The oropharyngeal lateral walls were a common primary structure causing obstruction, especially in the lateral body position. In a study population of primarily nonobese adults, DISE findings differed based on body position, generally corresponding to gravitational factors. Treatments that address velum- and tongue-related obstruction successfully may be more effective in the POSA population.

The role of drug-induced sleep endoscopy: predicting and guiding upper airway surgery for adult OSA patients.

Obstructive sleep apnea (OSA) is a common sleep disorder that can be corrected with upper airway surgery. Prior to surgery, drug-induced sleep endoscopy (DISE) is routinely used to evaluate obstruction sites and severity. Evidence suggests that the findings of DISE may relate to the final surgical outcome. Therefore, we evaluated the ability of drug-induced sleep endoscopy to predict the final effect of upper airway surgery and potentially to guide surgical treatment decision-making. A retrospective analysis was conducted on 85 adult patients with OSA (50 men with mean apnea-hypopnea index [AHI] 30 ± 15events/h) who underwent DISE followed by tonsillectomy, uvulopalatopharyngoplasty (UPPP), or a combination of the two. Surgery outcome was evaluated at follow-up by polysomnography. Success response to surgery was defined as a postoperative value of the AHI< 20events/h and more than 50% postoperative reduction of AHI. Of the 85 patients evaluated, 48 (53%) were responders. DISE revealed significant differences between the two groups. Specifically, complete circumferential collapse at the velum and complete anterior-posterior collapse at the tongue base occurred at higher frequencies in nonresponders. In contrast, the presence of grade 3-4 tonsillar hypertrophy and anterior-posterior mild/partial collapse at the velum were positively associated with responders. Our results suggest that DISE may help predict the final outcome of tonsillectomy, UPPP, or a combination of the two in adult patients with OSA. The use of DISE shows potential to guide treatment decisions for individual patients with OSA.

Predicting Success of Oral Appliance Therapy in Treating Obstructive Sleep Apnea Using Drug-Induced Sleep Endoscopy.

Oral appliance therapy (OAT) can be an effective treatment option for patients with obstructive sleep apnea unable to tolerate continuous positive airway pressure. We hypothesize that drug-induced sleep endoscopy (DISE) can be useful in identifying patients who will benefit from OAT. A retrospective review of all patients who underwent DISE (DISE group) between January 2014 and June 2016 was carried out. We included patients if they received OAT based on recommendations made by DISE findings. A control group was designed by selecting a sample of patients undergoing polysomnography (PSG) with an oral appliance in place who had not undergone prior DISE (no DISE group). The two cohorts were compared to evaluate the hypothesis. A total of 20 patients fit inclusion criteria for the DISE group and 20 patients for the no DISE group. There was no difference between the DISE and no DISE cohorts with respect to mean age, sex, pre-OAT body mass index, post-OAT body mass index, or pre-OAT PSG characteristics including: apneahypopnea index (AHI), oxygen desaturation nadir, or Epworth Sleepiness Scale score. There was a significantly lower treatment AHI (P = .04) and increased number of patients reaching an AHI less than 5 events/h with OAT therapy (P = .04) in the DISE group. Patients showing increased airway dimensions at the level of the velum and/or oropharynx with a jaw thrust may benefit the most from OAT. The use of DISE to identify this subset of patients is helpful in optimizing outcomes with OAT.

Faringoplastia de expansión: utilidad de la somnoscopia (DISE)

ObjectivesThe aim of this study was first to present the indications and results using expansion sphincter pharyngoplasty to treat obstructive sleep apnoea-hypopnoea syndrome (OSAHS). And second, to compare the findings of drug-induced sleep endoscopy (DISE) before and after the surgery. Material and methodsThe study design was a prospective cohort of patients surgically treated between 2015 and 2016. All patients were diagnosed with mild to severe obstructive sleep apnoea and did not tolerate CPAP. All had pre- and post-surgery DISE and polysomnography. The inclusion criteria were age, between 18 years and 70 years, small tonsils (sizes 1 and 2), Friedman II and III clinical stage, and lateral collapse in preoperative DISE. We performed surgery to the palate only, using expansion sphincter pharyngoplasty. ResultsSeventeen patients were included, 52.94% had severe OSAHS. Average age was 42 years, average body mass index was 28. The surgical success rate according to Sher criteria was 82.35%. 41.17% had a postoperative apnoea-hypopnoea index of less than 10. Seventy-five percent of the patients had no further need for CPAP. ConclusionExpansion sphincter pharyngoplasty is a safe technique for treating OSAHS, in patients with small tonsils, Friedman grade I and II and collapse of lateral walls in DISE, in the absence of multilevel collapse. The postoperative DISE showed improvement of the lateral collapse was achieved with the expansion.

The Relationship Between Modified Mallampati Score, Müller's Maneuver and Drug-Induced Sleep Endoscopy Regarding Retrolingual Obstruction.

This study explored the correlation between clinical explorations, including modified Mallampati score and Müller's maneuver, with drug-induced sleep endoscopy (DISE) findings regarding retrolingual obstruction. One hundred forty-two obstructive sleep apnea patients were enrolled in this prospective study. All of the patients received clinical explorations including modified Mallampati scoring and Müller's maneuver in the clinic. Drug-induced sleep endoscopy was further evaluated in the operating room. A significant relationship was noted between modified Mallampati score and retrolingual obstruction during DISE. In contrast, no significant relationship was noted between Müller's maneuver and DISE findings regarding retrolingual obstruction. A significant discrepancy existed between retrolingual airway collapse evaluated by modified Mallampati score and Müller's maneuver. Modified Mallampati score is more correlated with DISE regarding retrolingual obstruction compared to Müller's maneuver. It should therefore be used as an initial evaluation of retrolingual obstruction when DISE is unavailable.

Drug-induced sleep endoscopy – decisional factor in obstructive sleep apnea treatment

Abstract BACKGROUND. Drug-Induced Sleep Endoscopy (DISE) is a sleep apnea diagnostic procedure which allows direct view the obstruction while inducing sleep using analgosedation with propofol. Many studies highlighted the importance of DISE in finding the level of obstruction and choosing the specific treatment. MATERIAL AND METHODS. We performed DISE under propofol sedation in 27 patients diagnosed with sleep apnea who addressed to our clinic for further investigation and treatment. We assessed the obstruction type and severity using the Fujita scale, VOTE (velum, oropharynx, tongue base, epiglottis) and NOHL (nose, oropharynx, hypopharynx, larynx). Finally, we correlated the DISE findings with the polysomnographic results. RESULTS. We observed significant correlations between the obstruction severity seen at DISE and the polysomnographic results. Further, we could decide the appropriate treatment for our patients, whether surgical or not (continuous positive airway pressure - CPAP). CONCLUSION. Sleep endoscopy represents a very important method in establishing the topographic diagnostic of sleep apnea patients, being useful for the therapeutic decision and the postoperative assessment. We recommend drug-induced sleep endoscopy as elective investigation regarding the diagnostic and treatment of sleep apnea patients.

Test-retest reliability of drug-induced sleep endoscopy using midazolam.

Drug-induced sleep endoscopy (DISE) has been suggested to be a valuable method for determining the obstruction patterns causing sleep-disordered breathing. However, since DISE is not performed throughout the duration of sleep but for less than 1 hour, the reproducibility and reliability of DISE are questionable. Therefore, we aimed to determine the test-retest reliability of DISE using midazolam. Thirty-four patients diagnosed with obstructive sleep apnea were prospectively included in this study. The patients underwent 2 separate DISE examinations that were performed at different days using the same drug and technique. For a more accurate comparison, the depth of sleep and examination time were identically controlled. VOTE classification was used to classify the obstruction findings, and the findings of upper airway obstruction were compared between the 2 tests. There were 30 men and four women; the mean age was 45.4 ± 13.1 years. The mean apnea-hypopnea index was 38.3 ± 22.6, and the lowest oxygen saturation was 77.5% ± 12.4%. The lateral wall of the oropharynx, tongue base, and epiglottis showed very good agreement, and the velum showed good agreement between the first and second DISE examinations. The reliability of DISE is debatable because it observes only a small portion of the total sleep, but this study suggests that DISE is a reliable test because the findings of 2 separate DISE examinations on different days showed a high concordance rate.

Effect of long-term oral appliance therapy on obstruction pattern in patients with obstructive sleep apnea.

Oral appliance therapy is an alternative treatment modality for obstructive sleep apnea (OSA). However, there have been no studies to determine whether changes in the obstructive pattern occur following long-term use of oral devices. Therefore, we examined whether the obstructive pattern changes in patients with OSA who undergo long-term oral appliance therapy using drug-induced sleep endoscopy (DISE). We investigated 156 consecutive patients diagnosed with OSA. Seventy-nine of these patients were found to be eligible for inclusion in this study. All enrolled patients underwent two DISE examinations: before and after oral appliance use. We compared the DISE findings for each patient in terms of degree and configuration of airway obstruction at the levels of the velum, oropharynx, tongue base, and epiglottis. We found that dental problems, as assessed using the average values of overjet and overbite, were significantly decreased after 2years of oral appliance use. Comparisons of the DISE findings revealed that there was significant widening of the upper airway structures following long-term oral appliance therapy, especially in the velum (P = 0.022) and epiglottis (P = 0.001). However, changes in the configuration of upper airway obstruction were not observed in any of the structures of the upper airway. We found evidence possibly indicating decreased obstruction at the levels of the velum and epiglottis after long-term use of oral appliances. We suggest further cohort studies to confirm these findings.

Does drug-induced sleep endoscopy predict surgical success of limited palatal muscle resection in patients with obstructive sleep apnea?

ObjectiveThe aims of this study were to determine the associated factors affecting the success rate of limited palatal muscle resection (LPMR), and to investigate whether drug-induced sleep endoscopy (DISE) could predict the therapeutic response to LPMR in patients with obstructive sleep apnea obstructive sleep apnea (OSA). MethodsTwenty-one consecutive OSA patients underwent LPMR were enrolled. All patients received routine ENT examination, preoperative DISE, and polysomnography (PSG). Clinical, polysomnographic, cephalometric variables, and DISE findings were evaluated. The measurements were related to the success or failure of LPMR based on the results of preoperative and postoperative PSG. ResultsThe overall success rate of LPMR was 66.6%. Postoperative AHI and minimal oxygen saturation were significantly decreased after LPMR (p<0.001). Comparison between success and failure groups revealed no significant differences in BMI, Friedman stage, preoperative AHI, minimal oxygen saturation, and all cephalometric parameters. However, the success of LPMR was significantly correlated with site, degree, and configuration of obstruction in DISE. In the velopharynx, complete obstruction (p=0.006) with anterolateral or concentric pattern (p=0.044) had significantly better success rate than partial obstruction with lateral pattern. ConclusionDISE was only predictive method for identifying the success in OSA patients undergoing LPMR. Patients with anteroposterior or concentric total obstruction in the velopharynx might be suitable candidate for LPMR.

Drug-induced sleep endoscopy: from obscure technique to diagnostic tool for assessment of obstructive sleep apnea for surgical interventions.

Provide a practical update on drug-induced sleep endoscopy (DISE) for anesthesia providers, which can also serve as a reference for those preparing to establish a DISE program. New developments in surgical approaches to OSA and the growing global incidence of the condition have stimulated increased interest and demand for drug-induced sleep endoscopy. New techniques include transoral robotic surgery and hypoglossal nerve stimulation. Recent DISE literature has sought to address numerous debates including relevance of DISE findings to those during physiologic sleep and the most appropriate depth and type of sedation for DISE. Propofol and dexmedetomidine have supplanted midazolam as the drugs of choice for DISE. Techniques based on pharmacokinetic models of propofol are superior to empiric dosing with regard to risk of respiratory compromise and the reliability of dexmedetomidine to achieve adequate conditions for a complete DISE exam is questionable. The role of DISE in surgical evaluation and planning for treatment of OSA continues to develop. Numerous questions as to the optimal anesthetic approach remain unanswered. Multicenter studies that employ a standardized approach using EEG assessment, pharmacokinetic-pharmacodynamic modelling, and objectively defined clinical endpoints will be helpful. There may be benefit to undertaking DISE studies in non-OSA patients.

The predictive value of drug-induced sleep endoscopy for CPAP titration in OSA patients.

The aim of this study was to identify possible upper airway obstructions causing a higher continuous positive airway pressure (CPAP) titration level, utilizing drug-induced sleep endoscopy (DISE). A total of 76 patients with obstructive sleep apnea (OSA) underwent CPAP titration and DISE. DISE findings were recorded using the VOTE classification system. Polysomnographic (PSG) data, anthropometric variables, and patterns of airway collapse during DISE were analyzed with CPAP titration levels. A significant association was found between the CPAP titration level and BMI, oxygen desaturation index (ODI), apnea-hypopnea index (AHI), and neck circumference (NC) (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively, by Spearman correlation). Patients with concentric collapse of the velum or lateral oropharyngeal collapse were associated with a significantly higher CPAP titration level (P < 0.001 and P = 0.043, respectively, by nonparametric Mann-Whitney U test; P < 0.001 and P = 0.004, respectively, by Spearman correlation). No significant association was found between the CPAP titration level and any other collapse at the tongue base or epiglottis. By analyzing PSG data, anthropometric variables, and DISE results with CPAP titration levels, we can better understand possible mechanisms resulting in a higher CPAP titration level. We believe that the role of DISE can be expanded as a tool to identify the possible anatomical structures that may be corrected by oral appliance therapy or surgical intervention to improve CPAP compliance.

Patterns of Upper Airway Obstruction on Drug-Induced Sleep Endoscopy in Patients with Sleep-Disordered Breathing with AHI

ObjectiveTo describe the patterns of upper airway obstruction in patients with sleep-disordered breathing with apnea-hypopnea index (AHI) <5 using drug-induced sleep endoscopy (DISE).Study DesignRetrospective study.SettingTertiary care center.Subjects and MethodsInclusion of patients with sleep-disordered breathing with AHI <5 on polysomnography who underwent DISE. Patients <18 years of age were excluded. DISE findings were reported with the VOTEL classification system: the level of collapse was described as occurring at the velum, oropharynx, tongue base, epiglottis, and the lingual tonsils. The degree of collapse was reported as complete, partial, or none. The pattern of the obstruction was described as anteroposterior, lateral, or concentric when applicable.ResultsA total of 54 patients with sleep-disordered breathing with AHI <5 underwent DISE. Ages ranged from 19 to 65 years. DISE was performed alone in 7% (n = 4) of patients and in conjunction with surgery in 93% (n = 50) of patients. The velum was the most frequent site of upper airway obstruction (85%, n = 46), followed by base of tongue (63%, n = 34), epiglottis (39%, n = 21), lingual tonsils (35%, n = 19), and oropharynx (31%, n = 17). Eighty-three percent (n = 45) of patients had multiple levels of upper airway obstruction, and 15% (n = 8) had a single level of upper airway obstruction.ConclusionPatients with sleep-disordered breathing with AHI <5 have significant upper airway obstruction as seen on DISE. DISE findings indicate that a majority of these patients have multiple levels of upper airway obstruction, which can lead to significant symptoms.

Effect of physical stress on drug-induced sleep endoscopy for obstructive sleep apnea.

Drug-induced sleep endoscopy (DISE) is a reliable upper airway evaluation tool, widely used to improve surgical results in patients with obstructive sleep apnea (OSA). Several factors, including sleeping position and depth of sedation, affect DISE findings. This study aimed to evaluate the impact of physical stress on DISE findings. Eighty-five patients with OSA underwent two DISE examinations at the same level of sedation. The "first DISE" (control group) was performed after polysomnography, while the "second DISE" (test group) performed immediately after a treadmill stress test. The two groups were compared for changes in degree and configuration of airway obstruction at the levels of the velum, oropharynx, tongue base, and epiglottis. There were several differences in DISE findings between the control and test groups. DISE findings obtained after the stress test revealed significant narrowing of multiple airway structures; upper airway narrowing was observed at the velum (19/48; 39.6%), oropharynx (31/63; 49.2%), and tongue base (9/61; 14.8%). Changes in configuration of upper airway obstruction were observed only at the level of the velum (33/85; 38.8%). Stress exercise test induces changes in the degree and configuration of upper airways narrowing, which causes surgeons to over or underestimate the obstructive pattern, depending on the clinical circumstance. When counseling patients on the likely value of sleep surgery based on DISE findings, stressful physical activity should be included as a contributing factor in treatment planning.

0566 DRUG-INDUCED SLEEP ENDOSCOPY AND SURGICAL OUTCOMES: AN INTERNATIONAL, MULTICENTER COHORT STUDY

Successful surgical management of obstructive sleep apnea (OSA) is based upon determining the pattern of upper airway obstruction and design of a tailored treatment. Drug-Induced sleep endoscopy (DISE) is an evaluation using pharmacologic sedation designed to simulate natural sleep. DISE has shown promise in studies at single institutions or single interventions. The objective of this study was to examine the association between DISE findings and surgical outcomes across multiple institutions and surgical procedures. This was a retrospective cohort study of adults who underwent surgery for obstructive sleep apnea, with preoperative recorded DISE video and both preoperative and postoperative sleep studies. Patients were excluded if they had a history of any prior hypopharyngeal surgery other than tonsillectomy. The preoperative recorded DISE videos were reviewed by 4 reviewers in a blinded fashion using the VOTE Classification. Surgical outcomes were defined by change in the apnea-hypopnea index and the commonly-used definition of surgical response. Multiple linear and logistic regression evaluated potential associations between preoperative DISE findings and surgical outcomes. These analyses were performed for the entire cohort and for subgroups defined by specific DISE findings and surgical interventions. Statistical adjustment was performed for demographic and specific physical examination findings. Fourteen institutions contributed a total of 628 study participants. Two DISE findings were broadly associated with poorer outcomes: complete concentric collapse related to the velum/palate and complete oropharyngeal lateral wall collapse. Soft palate surgery outcomes were better in cases with isolated soft palate obstruction. Multilevel surgery that matched multilevel obstruction on DISE improved outcomes in selected instances. DISE may characterize specific patient subgroups that may not respond well to surgery. DISE may also improve the design of effective surgical treatment plans. This study was supported by grant 118-FP-15 from the American Sleep Medicine Foundation.

Drug-Induced Sleep Endoscopy as a Selection Tool for Surgical Management of Obstructive Sleep Apnoea Syndrome: Our Personal Experience.

Polysomnography proved OSA patients, who are planned for surgery in dept. of ENT AND HEAD& NECK, JSS Hospital, Mysore. A prospective clinical study. 30 Polysomnography proved OSA patients, age between 20 and 60years have been selected for Drug Induced Sleep Endoscopy (DISE) after taking informed consent for proposed surgery. Inj propofol infusion given throughout the DISE procedure and upper airway nasal endoscopy performed for assessment of site of collapse (Retropalatal, Retrolingual, Hypopharyngral), type of collapse (circumferential, lateral) and severity of obstruction, Lowest SpO2, apnoeic episodes and DISE findings were recorded. Out of these thirty patients 90% were male and 10% were female, observed that 66.7% of males and 40.7% of females belonged to 31-40 age group, and BMI of 63.3% of patient population were overweight, 20% were obese and 5% were normal. Mean fall in SpO2 was 90.20±2.77 in normal subjects, 83.05±5.14 in overweight subjects and 68.83±9.11 in obese subjects. Normal subjects had 0.4±0.9 apnoeic episodes, overweight subjects had 0.9±1.6 episodes and obese subjects had 4.0±2 apnoeic episodes. We observed that 40% had retropalatal airway collapse, 23.3% had airway obstruction at the base of the tongue, 20% had airway obstruction with floppy epiglottis, 12% multiple level collapse, 6.7% of patient population had grade 4 enlarged tonsils, 3.3% had lateral pharyngeal wall collapse, and 0% hypopharyngeal collapse. Out of 30, 29 Patients underwent surgery (Expansion sphincter pharyngo plasty-14, Hyoid advancement-4, Uuvulopalatoplasty-10, Epiglottic surgery-6, Zeta pharyngoplasty-2, midline glossectomy-3, Endoscopic septoplasty-5, Inferio turbinoplasty-2, LASSER Assisted lingual tonsillectomy-1), All these 29 patient were followed for 3months, at the end of 3rd month again Each subject was evaluated with a baseline Epworth Sleepiness Scale and LEVEL-3 PSG, the results were impressive with statistically significant. DISE is a dynamic, safe, and easy-to-perform technique that visualizes, the anatomical sites of snoring or apneas for assessment site of collapse (Retropalatal, Retrolingual, Hypopharyngral), type of collapse (Circumferential, Lateral) and severity of obstruction and guides the design of a tailor-made treatment plan for a OSA SURGEON in individual cases, which will improves perioperative outcome.

Interventional Drug-Induced Sleep Endoscopy: A Novel Technique to Guide Surgical Planning for Obstructive Sleep Apnea.

One of the challenges of surgery for obstructive sleep apnea (OSA) is identifying the correct surgical site for each patient. The objective of this study was to use drug-induced sleep endoscopy (DISE) and nasopharyngeal tube (NPT) placement to determine the effect of eliminating palatal collapse on the obstruction seen on other segments of the upper airway. Forty-one OSA patients were enrolled in this prospective study. All patients had a polysomnogram followed by DISE. DISE findings were recorded and compared with and without placement of a NPT. Obstruction was graded with a scale that incorporates location, severity, and interval of obstruction. Most patients (83%) demonstrated multilevel obstruction on initial DISE. With the nasopharyngeal airway in place, many patients with multilevel obstruction had at least a partial improvement (74%) and some a complete resolution (35%) of collapse (p < 0.05). Reduction in collapse was observed at the lateral walls (86%), epiglottis (55%), and tongue base (50%). NPT placement did not significantly alter upper airway morphology of patients with incomplete palatal obstruction or mild OSA. To our knowledge, this is the first study to evaluate the effect of soft palatal stenting on downstream pharyngeal obstruction during DISE. Our study provides evidence that reducing soft palatal collapse can reduce negative pharyngeal pressure and thereby alleviate other sites of upper airway obstruction. Taken together, these findings provide a means to identify appropriate candidates for isolated palatal surgery and better direct a minimally invasive approach to the surgical management of OSA.

Predictors of failure of DISE-directed adenotonsillectomy in children with sleep disordered breathing

BackgroundAdenotonsillectomy (AT) is the most commonly performed procedure for sleep disordered breathing (SDB) in pediatrics. However, 20-40% of patients will have persistent signs and symptoms of SDB after AT. Drug-induced sleep endoscopy (DISE) has the potential to individualize surgical treatments and avoid unnecessary or unsuccessful surgeries. The objective of this study was to determine the predictors of failure of DISE-directed adenoidectomy and/or tonsillectomy in otherwise healthy children with SDB.MethodsWe retrospectively reviewed a prospective database of children who presented with SDB. All patients underwent preoperative pulse oximetry (PO), followed by DISE with T ± A, The variables documented included demographics, ethnicity, co-morbidities, family history, McGill Oximetry Score (MOS) on PO, as well as findings of collapse and or obstruction on DISE and symptom resolution based on modified Pediatric Sleep Questionnaire (PSQ). The primary outcome was the independent predictors of treatment failure based on multivariate binary logistic regression.ResultsThree hundred eighty-two patients satisfied the inclusion criteria. Based on post-operative modified PSQ, SDB resolved in 259 patients (68%), whereas 123 (32%) had persistent symptoms. On bivariate analysis, neuropsychiatric diagnosis (r = 0.286, p = 0.042), history of sleepwalking or enuresis (r = 0.103, p = 0.044), MOS (r = 0.123, p = 0.033), presence of DNS (r = 0.107, p = 0.036), and presence of laryngomalacia (r = 0.122, p = 0.017) all positively correlated with treatment failure. Small tonsil size on DISE correlated with treatment failure (r = −0.180, p < 0.001). Multivariate analysis identified age greater than 7 years (OR = 1.799, [95% CI 1.040–3.139], p = 0.039), obesity (OR = 2.032, [95% CI 1.043–3.997], p = 0.040), chronic rhinitis (OR = 1.334, [95% CI 1.047–1.716], p = 0.025), deviated nasal septum (OR = 1.745, [95% CI 1.062–2.898], p = 0.031) and tonsil size (OR = 0.575, [95% CI 0.429–0.772], p < 0.01) as independent predictors of treatment failure.ConclusionsObese, asthmatic, and children older than seven years are at increased risk of treatment failure after DISE-directed AT. Several DISE findings can independently predict AT failure, including tonsil size, degree of chronic rhinitis, and the presence of a deviated nasal septum, and can be addressed at a second stage. Further research is needed into the role of DISE in surgically naïve patients with SDB, and to compare DISE-directed surgery with the current standard of care.

Multimodality assessment of upper airway obstruction in children with persistent obstructive sleep apnea after adenotonsillectomy.

Children with obstructive sleep apnea (OSA) may have multiple sites of upper airway obstruction (UAO). A wide variety of techniques has been used to evaluate UAO. Our aim was to compare findings of cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) in identifying UAO sites in children with persistent OSA after adenotonsillectomy (AT). Retrospective chart review. The medical records of children who underwent DISE and cine MRI were reviewed. Data pertaining to demographics, past medical history, body mass index, polysomnography, findings of DISE, and cine MRI were obtained. Fifteen children (11 boys, 4 girls; age range, 7-18 years) were identified. Comorbid conditions were Down syndrome in nine patients, cerebral palsy in one, attention deficit hyperactivity disorder in two, and asthma in three. Severity of OSA was moderate in five, and severe in 10. DISE and cine MRI showed the same UAO site in 10 patients: a single site (tongue) in nine and multiple sites (tongue and oropharynx/lateral walls) in one. DISE showed additional UAO sites undetected by cine MRI in three patients. Cine MRI showed additional UAO sites undetected by DISE in one patient. DISE and cine MRI showed different sites of obstruction in one patient. Cine MRI and DISE documented single and multiple sites of UAO in children with persistent OSA after AT. Cine MRI and DISE findings were similar in the majority of the children. Assessment of the sensitivity and specificity of cine MRI and DISE in detecting sites of UAO merits further investigation. 4. Laryngoscope, 127:1224-1230, 2017.

Drug-induced sleep endoscopy in children with Prader-Willi syndrome.

Review drug-induced sleep endoscopy (DISE) findings in children with Prader-Willi syndrome (PWS) and correlate the patterns of airway collapse with apnea-hypopnea index (AHI) and body mass index (BMI). A total of nine children with PWS underwent DISE. DISE findings were recorded using the VOTE classification system. The relationship between different patterns of airway collapse with AHI and BMI was analyzed. The majority of children with PWS were found to have multilevel obstruction (six out of nine children, 66.6%). The velum was the most common site of obstruction (nine out of nine children, 100%). All of the patients had positional obstructive sleep apnea (OSA). Patients with partial or complete anterior-posterior tongue base collapse were associated with a significantly higher AHI (P=0.016) compared to patients with no anterior-posterior tongue base collapse. Apart from tongue base collapse, no other patterns of airway collapse showed a consistent association with AHI in our results. No patterns of airway collapse showed a significant association with BMI in our study. In our study, partial or complete anterior-posterior tongue base collapse was associated with higher AHI values in children with PWS. Therefore, careful attention should be addressed to the management of tongue base collapse. Positional therapy could be a potential treatment for patients with PWS since it may alleviate the severity of tongue base collapse.

A comparison of dexmedetomidine versus propofol during drug‐induced sleep endoscopy in sleep apnea patients

In this study, we compared the effects of propofol and dexmedetomidine on the upper airway collapse pattern and cardiopulmonary parameters of patients with obstructive sleep apnea (OSA) undergoing drug-induced sleep endoscopy (DISE). Prospective, single center, observational study The 50 patients with OSA underwent 30 minutes of DISE on 2 different days, the first time with propofol target-controlled infusion (TCI) and the second time with dexmedetomidine TCI. Both the characteristics of upper airway obstruction and cardiopulmonary parameters in response to the depth of sedation achieved with each drug were evaluated. The results obtained with propofol and dexmedetomidine DISE were in excellent agreement for all sites of obstruction irrespective of the depth of sedation. Although partial or total obstruction at all areas was consistently observed using both drugs, the degree of upper airway narrowing was slightly lower with dexmedetomidine than with propofol. However, the percentage of patients with a greater than 20% change in blood pressure and heart rate compared to baseline was significantly higher in response to propofol than to dexmedetomidine (P = 0.003 and P < 0.001, respectively). Minimal oxygen saturation was significantly lower in DISE with propofol than with dexmedetomidine (P = 0.004). The percentage of patients with oxygen saturation less than 90% or 80% during DISE was significantly higher in response to propofol than to dexmedetomidine (P = 0.032 and P < 0.001, respectively). The DISE findings achieved with propofol and dexmedetomidine were in excellent agreement. However, during DISE, dexmedetomidine provided greater hemodynamic stability and less respiratory depression than propofol. 4. Laryngoscope, 126:763-767, 2016.