Drug-induced Sleep Endoscopy Research Articles

Patterns of Pharyngeal Obstruction and Collapse in Obese and Nonobese Children on Drug-Induced Sleep Endoscopy.

(1) Compare proportions of collapse, obstruction, or mixed instances on drug-induced sleep endoscopy findings of obese and nonobese children with obstructive sleep disordered breathing. (2) Determine the frequency of collapse in general between both groups. Retrospective case-control study. Tertiary pediatric center. Obese (body mass index >95 percentile) children presenting with obstructive sleep disordered breathing (>33 on the pediatric sleep questionnaire) were identified from a prospectively kept surgical database. Only those who had undergone drug-induced sleep endoscopy were eligible. Age and sex pair-matched nonobese children were identified. Only nonsyndromic, neurologically normal, surgically naïve patients were included. The frequency of obstructive, collapse, and mixed pharyngeal patterns was documented in both groups. A comparison of proportions was then undertaken (χ2 test). Over a 5-year period, 73 consecutive children with obesity were identified (40 males; mean of 8.5 ± 3.0 years, 2.8-13.1). They were matched with 73 nonobese children (8.4 ± 3.0 years, 2.6-14.1). The obese group exhibited significantly more pharyngeal collapses (62:47) (p = .0021 odds ratio [OR] 3.358, 95% confidence interval [CI] 1.52-7.42). The proportion of pharyngeal findings on drug-induced sleep endoscopy was significantly different (p = .000129) between the 2 groups; obese (61 mixed: 3 obstruction: 9 collapse) and nonobese (48 mixed: 22 obstruction: 4 collapse). The predominance of hypopharyngeal collapse in children with obesity may explain the likelihood of failure of surgery directed at obstructive findings. This may also strengthen the case for drug-induced sleep endoscopy in this group at the initial surgery to guide it rather than after the failure of adenotonsillectomy.

Safety and Feasibility of Hypnosis-Induced Sleep Endoscopy in Obstructive Sleep Apnea Patients.

Hypnosis was never used in sleep endoscopy assessment of obstructive sleep apnea syndrome (OSAS). The aim of the study was to assess the feasibility, safety, and patient satisfaction of hypnosis-induced sleep endoscopy (HISE). From January to July 2021, 24 adults with moderate-to-severe OSAS at the polysomnography were included in the HISE protocol. The following outcomes were evaluated by the otolaryngologist and the hypnotherapist: safety, feasibility, and performance. The patient outcomes were assessed through a patient-reported outcome questionnaire assessing hypnosis acceptance, stress, anxiety, nasofibroscopy examination pain, and discomfort. Twenty-three patients completed the evaluations (16 males). The mean age of patients was 50.8years. The nasofibroscopy was well-tolerated with low levels of stress during the HISE. Otolaryngologist adequately completed the VOTE scoring in 22 patients (95.7%). Hypnosis was ineffective in one patient because he felt pain during the nasofibroscopy procedure due to an important septal deviation. The hypnotherapist reported adequate satisfaction outcomes, with better results for trance compliance compared to other steps. There were no adverse effects or complications. The percentage of snoring was negatively associated with the level of consciousness during hypnosis (p = 0.012). The easiness of nasofibroscopy was positively associated with the levels of muscle relaxation (p = 0.036) and consciousness (P = 0.002). HISE is an effective alternative approach for the work-up of OSAS. Future controlled studies are needed to compare HISE with drug-induced sleep endoscopy and assess the cost-effective outcomes of both approaches.

Drug-Induced sleep endoscopy in children: NAVOTEL scoring system development.

Pediatric drug-induced sleep endoscopy (DISE) lacks a universal and easy-to-use scoring system. The velum, oropharynx, tongue, epiglottis (VOTE) scoring system is widely used but needs to be completed in pediatrics. The main objective of this study was to investigate the distribution of obstructive sites in DISE and to propose an appropriate pediatric scoring system. The secondary objective was to evaluate the changes in surgical management induced by the proposed scoring system. A single-center prospective 5-year study was conducted from March 2016 to December 2021, including 99 children with a mean age of 7.2 years (±3.7), with pathological preoperative sleep recordings and undergoing DISE. The distribution of all upper airway obstructive sites was studied. Adenoids (A) were the most frequent obstructive site (63% of patients), and the nasal cavities (N) and the larynx (L) were other frequent obstructive sites. These sites are not explored by the VOTE scoring system, leading to the creation of the nose, adenoids, velum, oropharynx, tongue, epiglottis, larynx (NAVOTEL) scoring system. NAVOTEL was significantly correlated with the severity of obstructive sleep apnea-hypopnea syndrome (OSAS) (ρ = 0.2; p = 0.04) and highlighted obstructive sites in 6/9 patients with VOTE = 0. Of these patients, 4 had a complete obstructive site, and 3 had a multisite obstruction. VOTE indicated 8 additional surgical actions; NAVOTEL indicated 50 other actions compared to clinical examination. The NAVOTEL scoring system was exhaustive regarding surgical indications for OSAS. The NAVOTEL scoring system is exhaustive in pediatric DISE and correlated to OSAS severity. It should be preferred in pediatric DISE.

The Effect of Tonsillectomy and Adenoidectomy on Upper Airway Obstruction Patterns in Children with Obstructive Sleep Apnea

Introduction Alterations in upper airway flow dynamics and sites of airway obstruction immediately after tonsillectomy and adenoidectomy (TA) have not been assessed. Identification of the changes in airway obstruction patterns after TA potentially improves the surgical management of children with obstructive sleep apnea (OSA). Objective To evaluate the effect of TA on upper airway obstruction patterns detected with drug-induced sleep endoscopy (DISE). Methods The medical records of patients who underwent pre-TA DISE during the induction of anesthesia and post-TA DISE at the end of TA were reviewed. Data pertaining to polysomnography and DISE findings were analyzed. Results Twenty-seven patients (15 male and 12 females aged between 2 and 18 years old) were identified. All patients had obstruction at multiple sites of the upper airway. Prior to TA, airway obstruction was at the level of the velum in 27 patients, of the oropharynx/lateral walls in 27, of the tongue in 7, and of the epiglottis in 4. After TA, airway obstruction was at the level of the velum in 24 patients, of the oropharynx/lateral walls in 16, of the tongue in 6, and of the epiglottis in 4. The degree of obstruction at the levels of the velum and oropharynx/lateral walls after TA was significantly decreased. Conclusions Drug-induced sleep endoscopy performed prior to TA revealed that most of the sites of airway obstruction persisted after TA in OSA children with multiple sites of airway obstruction. Further studies in larger group of children with OSA are needed to establish the value of DISE findings in predicting residual OSA after TA, surgical planning, determining the need for post TA sleep study, and counseling caregivers.

Multilevel Airway Obstruction Phenotypes in Adult OSA.

To describe multilevel phenotypes of airway obstruction identified on drug-induced sleep endoscopy (DISE)inadults. Retrospective chart review. Tertiary care center. Video recordings of DISEon adult patients were retrospectively scored. A cross-correlation matrix was created to detect significant correlations between DISE findings at anatomical subsites. Three multilevel phenotypes resulted from the matrix: complete collapse at the tongue base with complete collapse at the epiglottis (T2-E2), complete circumferential obstruction at the velum with complete lateral pharyngeal wall collapse at the oropharynx (V2C-O2LPW), and incomplete collapse at the velum with complete collapse due to tonsillar hypertrophy (V0/1-O2T). The mean difference (MD) and 95% confidence interval (CI) were calculated for demographic and polysomnogram metrics of each phenotype compared to all other subjects. Phenotype 1 (T2-E2) (n = 88) had older ages (MD 5.784 years, CI [1.992, 9.576]), lower body mass index (BMI) (MD -1.666 kg/m2, CI [02.570, -0.762]), and smaller neck circumferences (MD-0.448 in., CI [-9.14, -0.009]) than the other phenotypes. Phenotype 2 (V2C-O2LPW) (n = 25) had higher BMIs (MD 2.813 kg/m2, CI [1.362, 4.263]), higher neck circumference (MD 0.714 in., CI [0.004, 1.424]), and higher apnea-hypopnea index(MD 8.252, CI [0.463, 16.041]). Phenotype 3 (V0/1-O2T) (n = 20) had younger ages (MD -17.697, CI [-25.215, -11.179]). Three distinct multilevel phenotypes of obstruction were identified on DISE, suggesting different anatomic subsites collapse in a nonrandom pattern. The phenotypes appear to represent distinct patient groups and their identification may have implications in terms of pathophysiology and treatment modalities.

Upper airway assessment in obstructive sleep apnea patients: can computed tomography with lateral cephalometry replace drug-induced sleep endoscopy (DISE)?

ObjectiveTo evaluate the association between results from drug-induced sleep endoscopy (DISE) and computed tomography with lateral cephalometry (CTLC) of the pharynx in obstructive sleep apnea (OSA) patients, regarding the same anatomic level, in order to understand if CTLC could replace DISE in selected patients. Study designCross-sectional. SettingTertiary hospital. MethodsA total of 71 patients who attended the Sleep Medicine Consultation in the Otorhinolaryngology Department of Hospital CUF Tejo between 1.6.2019 and 30.9.2021, performed a polysomnographic sleep study and were elected to undergo DISE and CTLC of the pharynx for diagnostic purposes were selected. Obstructions at the same anatomic levels – tongue base, epiglottis and velum - were compared in both exams. ResultsPatients with reduction of epiglottis-pharynx space on CTLC had also a complete obstruction at epiglottis level on the VOTE classification of DISE (p = 0,027). Reduction of velum-pharynx space or tongue base-pharynx space were not related to complete obstruction of the velum (P = 0,623) or the tongue base (p = 0,594) found in DISE. Those with two or more space reductions had a tendency to multilevel obstruction observed in DISE (p = 0.089). ConclusionWhen evaluating the obstruction level(s) of an OSA patient, efforts should be made to perform DISE, since CTLC measures, though regarding at the same structures, don´t correlate completely with obstructions observed in DISE.

Drug-Induced Sleep Endoscopy Findings and Hypoglossal Nerve Stimulation Therapy Outcomes.

Hypoglossal-nerve stimulation (HGNS) is an established second-line therapy for patients with obstructive sleep apnea (OSA). Existing studies investigating the effect of preoperative drug-induced sleep endoscopic (DISE) findings on HGNS outcomes have mainly focused on the apnea/hypopnea index (AHI) among polysomnography (PSG) parameters, and have less frequently tested other PSG parameters such as the apnea index (AI), hypopnea index (HI), oxygen desaturation index (ODI), snoring index, and arousal index, or patient-reported excessive daytime sleepiness. The aim of this study was to investigate the correlation between DISE findings and the above-mentioned metrics after HGNS therapy. We only included patients with DISE findings providing detailed information about the degree of the anteroposterior velar (APV), oropharyngeal lateral wall (OPLW), or tongue-base (BT) obstruction based on the velum, oropharynx, base of tongue, and epiglottis (VOTE) classification. The data of 25 patients (9 female (36%)) were retrospectively evaluated. The mean age at the date of implantation was 54.52 ± 9.61 years, and the mean BMI was 29.99 ± 3.97 kg/m2. Spearman's rho correlation coefficients were calculated. Significant correlations were found between the degree of APV obstruction and postoperative HI (r = -0.5, p < 0.05), and between the degree of OPLW obstruction and postoperative snoring index (r = 0.42, p < 0.05). BT obstruction was strongly correlated with postoperative metrics such as AHI (r = -0.57, p < 0.01), AI (r = -0.5, p < 0.05), ODI (r = -0.57, p < 0.01), ∆ AHI (r = 0.58, p < 0.01), ∆ AI (r = 0.54, p < 0.01) and ∆ ODI (r = 0.54, p < 0.01). No significant correlation was found between DISE findings and postoperative Epworth Sleepiness Scale values. These findings suggest that preoperative DISE findings, especially the degree of BT obstruction, are important for predicting an HGNS therapy outcome.

Swallowing evaluation in patients who underwent Partial CO2 LASER Epiglottectomy for Sleep Apnea treatment

ObjectiveTo evaluate swallowing in patients who underwent CO2 LASER Partial Epiglottectomy (CO2-LPE) for Obstructive Sleep Apnea Syndrome and to assess the risk of aspiration with this technique. Material & MethodsChart review of adult patients who underwent CO2-LPE between 2016 and 2020, in a secondary care hospital. Patients underwent surgery for OSAS, in accordance to Drug Induced Sleep Endoscopy findings and an objective swallowing evaluation was done at least 6 months after surgery. Eating Assessment Tool (EAT-10) questionnaire was applied and Volume-Viscosity Swallow Test (V-VST) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) were performed. Dysphagia was classified according to Dysphagia Outcome Severity Scale (DOSS). ResultsEight patients were included in the study. The mean time between surgery and the swallowing evaluation was 50 (±13,2) months. Only 3 patients presented ≥ 3 points on EAT-10 questionnaire. Two patients presented signs of decreased efficacy of swallowing (piecemeal deglutition) but none had a decrease in safety, according to V-VST. Although 50% of the patients presented some pharyngeal residue on FEES, it was classified as trace to mild in most of the cases. No evidence of penetration or aspiration was identified (DOSS ≥ 6 in all patients). ConclusionThe CO2-LPE is a potential treatment for OSAS patients with epiglottic collapse and no evidence of swallowing safety compromise was found.

Drug-Induced Sleep Endoscopy Differences by Age in Surgically Naive Children With Sleep-Disordered Breathing

Drug-induced sleep endoscopy (DISE) is increasingly used to guide treatment decisions in children with sleep-disordered breathing (SDB). Previous reports of DISE findings in children have typically included a broad age range, but it is unclear how these patterns of obstruction vary with age. To compare patterns of airway obstruction observed during DISE in 3 age groups of surgically naive children with SDB. This cross-sectional analysis of a prospective cohort of surgically naive nonsyndromic children with SDB or obstructive sleep apnea [OSA] at risk for residual disease after adenotonsillectomy (defined as having at least 1 of these criteria: severe OSA, older than 7 years, obesity, or Black race) who were recruited between May 1, 2015, and February 28, 2020, was conducted at a tertiary children's hospital. Data analysis was conducted from September 2021 to February 2022. DISE. DISE findings were rated at 6 anatomic sites using the Sleep Endoscopy Rating Scale (SERS). The association between age and severity of obstruction at each anatomic site and overall were compared using correlation (Kendall τ) and ordinal logistic regression analysis. Data from 288 children (144 girls [50%]; 20 American Indian/Alaska Native [7%], 4 Asian [1%], 19 Black [7%], 93 Hispanic [33%], 2 Middle Eastern [1%], 6 Native Hawaiian/Pacific Islander [2%], and 203 White [70%] individuals; median [IQR] age, 9.2 [7.0-11.7] years) were stratified by participant age into preschool (age 2-5 years; 27 [9%]), younger school-aged (age 5-10 years; 146 [51%]), and older school-aged (age 10-18 years; 115 [40%]). Among these subgroups, the prevalence of multilevel obstruction was 59%, 51%, and 30%, respectively. Increasing age was inversely correlated with obstruction of the nasal airway (τb, -0.19; 95% CI, -0.29 to -0.09), nasopharynx (τb, -0.20; 95% CI, -0.31 to -0.10), velopharynx (τb, -0.16; 95% CI, -0.26 to -0.06), and overall obstruction (SERS total score: τb, -0.24; 95% CI, -0.33 to -0.14). An adjusted analysis demonstrated an inverse association between age and nasopharyngeal obstruction (odds ratio [OR], 0.84; 95% CI, 0.76 to 0.92), SERS total score (OR, 0.83; 95% CI, 0.76 to 0.90), and the number of sites of complete obstruction (OR, 0.87; 95% CI, 0.87 to 0.95). This cross-sectional analysis of data from a prospective cohort study of surgically naive children with SDB found that preschool-aged children had more frequent multilevel obstruction, more severe overall obstruction, and nasopharyngeal obstruction compared with older children. Understanding the most common sites of obstruction and expected changes with age could inform personalized treatment for children with SDB.

Use of drug-induced sleep endoscopy in Germany-an analysis based on claims data.

Drug-induced sleep endoscopy (DISE) has recently gained relevance as adiagnostic tool for obstructive sleep apnea (OSA). However, it is unclear to what extent and in which patient cohorts DISE is used in Germany. With introduction of specific coding for this method in 2021 (Operationen- und Prozedurenschluessel, OPS code), usage can now be analyzed based on diagnosis-related groups (DRG) claims data. Aggregated data from all inpatient DISE procedures conducted in German hospitals in 2021 were obtained from the publicly available Institut fuer das Entgeltsystem im Krankenhaus (InEK) database. Patient-relevant information as well as data on hospitals providing the examinations were exported and analyzed. Between January and December 2021, atotal of 2765DISE procedures were conducted and documented using the newly introduced specific code (1-611.01). Most patients were male (75.6%), in the age categories 30-39 (15.2%) and 40-49years (17.2%), and presented with the lowest patient clinical complexity level (PCCL; class0 = 81.88%). Pediatric use was rare (1.8%). Leading main diagnoses of patients were G47.31 (OSA) and J34.2 (deviation of nasal septum). The most common procedures conducted together with DISE were nasal surgery, and the examination was mostly provided in large public hospitals with more than 800beds. Though the OSA prevalence in Germany is high, use of DISE as adiagnostic tool is low and represented only 4.4% of cases with amain diagnosis of OSA in 2021. Since specific coding was only introduced in January 2021, trends cannot yet be identified. Noticeable is the frequent combination of DISE with nasal surgery, which is not obviously related to adiagnosis of OSA. Limitations of the study are mainly related to the underlying data, which are available for the inpatient sector only, and due to potentially limited use of the OPS code, which was introduced recently and might not be known to all hospitals.

High-Definition 3D Exoscope-Assisted Barbed Pharyngoplasty for OSAS and Snoring: Better Than Live

Recently, a high-definition 3D exoscope (VITOM), a new magnification system that provides a 3D image of the surgical field, has been introduced. This study aims to describe the first use of VITOM 3D technology in Barbed Pharyngoplasty (BP) for Obstructive Sleep Apnea (OSA). VITOM 3D technology is used to support visualization during BP in a male patient affected by severe OSA with a circular palatal collapse pattern at drug-induced sleep endoscopy. During the surgical procedure, this approach markedly improves the visualization of the surgical field through anatomic details of the oral cavity, facilitating surgical dissection and enhancing the teaching environment. It allows for a better involvement and more interactions during the surgery, as scrubbed and assistant nurses can see the surgical field and anticipate the surgeon's choice of instrument. VITOM 3D technology, by combining a telescope with a standard endoscope, has been successfully used in various surgical disciplines and could be very useful, especially in teaching hospitals. VITOM 3D can guarantee "a real immersive" surgical experience for all participants in the operating room. Economic and efficacy studies would be conducted to support the use of a VITOM-3D exoscope in common clinical practice.

Drug-induced sleep endoscopy-continuous positive airway pressure (DISE-CPAP), a newer modality to choose the right candidates for CPAP.

Continuous positive airway pressure (CPAP) therapy is recommended for moderate-to-severe obstructive sleep apnea (OSA). We aimed to investigate whether or notcombining drug-induced sleep endoscopy (DISE) with CPAP titration may inform more appropriate pressure settings. A sleep CPAPtitration study and DISE-CPAP treatment were performed on consecutive subjects with moderate-to-severe OSA under controlled sedation using bispectral monitoring. Video recordings of dynamic changes in UA with CPAP pressure ranges of 5 to 25cm were assessed in accordance with the VOTE classification. The 95th percentile (95th PC) pressure of the CPAP titration trial was compared to optimal pressure for alleviating UA blockage. We included 30 subjects (mean age 37.5, 17% women). All showed UA collapse at more than one level, with more than 80% of them collapsing completely at the levels of thevelum and oropharynx. At the velum, 90% of subjects experienced improvement with CPAP. At the oropharynx, 75% of subjects experienced improvement with CPAP. The meanpressureand standard deviation (SD) of the 95th PC of the CPAP titration was 14.3 (3.5) cmH2O, while the pressure required to partially or fully open the airway (best possiblepressure) was 16.1 (3.9) cmH2O; mean (SD) difference, 1.9 (2.2); P ≤ 0.001. The limits of agreement between the CPAP 95th pressure and the ideal pressure were - 6.32 to + 2.52. The palate and lateral pharynx were more affected by CPAP than the hypopharynx. Most of the time, the mean 95th PC CPAP titration pressure was lower than the mean optimal pressure needed to alleviate the collapse.

Transverse Maxillary Deficiency Predicts Increased Upper Airway Collapsibility during Drug-Induced Sleep Endoscopy.

To examine the relationship between craniofacial skeletal anatomy and objective measures of pharyngeal collapse obtained during drug-induced sleep endoscopy. We hypothesized that transverse maxillary deficiency and an increased pharyngeal length will be associated with higher levels of pharyngeal collapsibility. Cross-sectional analysis in a prospective cohort. University Hospital. A cross-sectional analysis was conducted in a cohort of consecutive patients from the positive airway pressure(PAP) alternatives clinic who underwent computed tomography (CT) analysis and drug-induced sleep endoscopy for characterization of upper airway collapsibility. PAP titration was used to determine pharyngeal critical pressure (PCRIT ) and pharyngeal opening pressure (PhOP). CT metrics included: Transverse maxillary dimensions (interpremolar and intermolar distances) and pharyngeal length (posterior nasal spine to hyoid distance). The cohort (n = 103) of severe obstructive sleep apnea (Apnea and Hipopnea Index 32.1 ± 21.3 events/h) was predominantly male (71.8%), Caucasian (81.6%), middle-aged (54.4 ± 14.3 years), and obese (body mass index[BMI] = 30.0 ± 4.9 kg/m2 ). Reduced transverse maxillary dimensions were associated with higher PCRIT (intermolar distance: β [95% confidence interval, CI] = -.25 [-0.14, -0.36] cmH2 O/mm; p = .03) and PhOP (Interpremolar distance: β = -.25 [-0.14, -0.36] cmH2 O/mm; p = .02). Longer pharyngeal length was also associated with higher PCRIT (β = .11 [0.08, 0.14] cmH2 O/mm, p = .04) and PhOP (β [95% CI] = .06 [0.03, 0.09] cmH2 O/mm, p = .04). These associations persisted after adjustments for sex, age, height, and BMI. Our results further the concept that skeletal restriction in the transverse dimension and hyoid descent areassociated with elevations in pharyngeal collapsibility during sleep, suggesting a role of transverse deficiency in the pathogenesis of airway obstruction.

Efficacy of high-flow nasal oxygen during drug-induced sleep endoscopy in patients with obstructive sleep apnea.

High-flow nasal oxygenation (HFNO) can provide a low level of continuous positive airway pressure and alveolar recruitment. We aimed to compare the efficacy of pre-oxygenation with HFNO and low-flow nasal oxygenation (LFNO) during drug-induced sleep endoscopy (DISE). In the LFNO group, preoxygenation was performed for 10 min at 3 L·min-1. In the HFNO group, preoxygenation was performed for 10 min at 30 L·min-1 at a fraction of inspired oxygen of 100% using the Optiflow device. From the start of sedative administration to the end of DISE, vital signs were monitored continuously. The primary outcome was the lowest oxygen saturation (SpO2) during DISE. Of 24 patients enrolled, 12 were randomly assigned to the LFNO and 12 to the HFNO groups. Theprevalence of hypoxia events was 75% in the LFNO group and 58% in the HFNO group. The difference in lowest oxygen saturation between the two groups was not significant between the two groups (P=0.665). The lowest SpO2 during all procedures was comparable between the two groups (86.8 ± 6.5% in the LFNO group and 87.2 ± 8.0% in the HFNO group; P=0.912). The findings suggest thatHFNO may not be superior to LFNO as a preoxygenation tool to prevent hypoxia during DISE.

Epiglottopexy for refractory obstructive sleep apnea in children – A single-institution experience

BackgroundRefractory obstructive sleep apnea (OSA) is a common condition in children with medical comorbidities, leading to a significant impact on quality of life. Drug-induced sleep endoscopy (DISE) has become the standard of care in identifying the levels of obstruction in children with refractory OSA. Epiglottopexy has been shown to improve OSA symptoms in adults and healthy children with epiglottic prolapse in a few studies, with minimal long-term complications. The objective of our study was to evaluate the role of epiglottopexy in children with refractory OSA. MethodsA retrospective chart review of children with refractory OSA who were found to have epiglottic prolapse on DISE, and underwent epiglottopexy between January 2018 and November 2021 at a pediatric tertiary care hospital. Results42 patients (age 8.1 ± 5.1 years) met inclusion criteria. Thirty patients (71.4 %) suffered from neurodevelopmental disease or congenital syndrome, and 14 patients (33.3 %) were gastrostomy-tube dependent. All patients had at least one prior surgical procedure to address their OSA. Thirty-six patients (85.7 %) were diagnosed with refractory OSA by polysomnography prior to surgery, with an average apnea-hypopnea index (AHI) of 12.4 ± 9.7/h. Forty patients (95.2 %) required an additional procedure in conjunction with epiglottopexy including lingual tonsillectomy (n = 27, 64.3 %), supraglottoplasty (n = 14, 33.3 %), tonsillectomy with or without revision adenoidectomy (n = 9, 21.4 %) and tongue base suspension (n = 1, 2.4 %). Twenty-one patients had repeated polysomnography; 4 patients were found to have residual severe OSA post-operatively (average AHI 17.4 ± 11.4/h), while the remaining patients demonstrated clinical improvement and a significant reduction in OSA severity, with an average AHI of 1.5 ± 2.2/h. Regression analysis identified pre-operative oxygen nadir <75 % to be associated with residual OSA postoperatively. Following surgery, 7 patients were found to have new-onset or worsening dysphagia, 6 of whom were diagnosed with complex medical comorbidities. ConclusionsEpiglottopexy, as part of multi-level airway surgery, is associated with a significant improvement in the severity of refractory OSA. Dysphagia may complicate the post-operative course, particularly in children with medical comorbidities.

Objective Pharyngeal Phenotyping in Obstructive Sleep Apnea With High-Resolution Manometry.

Drug-induced sleep endoscopy (DISE) is a commonly used diagnostic tool for surgical procedural selection in obstructive sleep apnea (OSA), but it is expensive, subjective, and requires sedation. Here we present an initial investigation of high-resolution pharyngeal manometry (HRM) for upper airway phenotyping in OSA, developing a software system that reliably predicts pharyngeal sites of collapse based solely on manometric recordings. Prospective cross-sectional study. An academic sleep medicine and surgery practice. Forty participants underwent simultaneous HRM and DISE. A machine learning algorithm was constructed to estimate pharyngeal level-specific severity of collapse, as determined by an expert DISE reviewer. The primary outcome metrics for each level were model accuracy and F1-score, which balances model precision against recall. During model training, the average F1-score across all categories was 0.86, with an average weighted accuracy of 0.91. Using a holdout test set of 9 participants, a K-nearest neighbor model trained on 31 participants attained an average F1-score of 0.96 and an average accuracy of 0.97. The F1-score for prediction of complete concentric palatal collapse was 0.86. Our findings suggest that HRM may enable objective and dynamic mapping of the pharynx, opening new pathways toward reliable and reproducible assessment of this complex anatomy in sleep.

Relationship between level CPAP titration, anthropometric variables, and drug-induced sleep endoscopy DISE.

Subjects with palatal obstruction alone vs. multilevel obstruction on DISE had better outcomes after palate surgery. We asked ourselves if the therapeutic level positive airway pressure (PAP) titration could predict the level of airway obstruction and its complexity. The aim of this study was to identify possible relationships between therapeutic level of positive airway pressure initial titration and levels of collapse in drug-induced sleep endoscopy (DISE). A secondary objective wasto establish the relationship the other variables and DISE. We analyzed retrospective clinical histories between March 2020 to March 2022 of 37 patients with polysomnography or cardiorespiratory polygraphy studies and PAP initial titration who were taken to drug-induced sleep endoscopy. Sleep study data, anthropometric variables, and patterns of airway collapse during DISE were analyzed with PAP initial titration levels. Most of the patients with complex collapse had concentric velum collapse (p < 0.006). A significant association was found between the apnea-hypopnea index (AHI) and oropharyngeal collapse; (p < 0.0030) and finally we demonstrated relationship between neck circumference and gender with epiglottis collapse (p < 0.046), (p < 0.037), respectively. Our findings show a strong relationship between that complex collapses and concentric velum collapse; patients with greater oropharyngeal collapse have a higher mean AHI. Patients without epiglottic collapse have a higher mean neck circumference. An association between mean pressure initial titration and complex collapse could not be established.

Application of drug-induced sleep endoscopy in predicting the outcomes of velopharyngeal surgery in adult patients with Friedman stage II and III obstructive sleep apnea syndrome.

This study aimed to evaluate the predictive value of drug-induced sleep endoscopy (DISE) for the outcomes of velopharyngeal surgery in adult patients with Friedman stage II and III obstructive sleep apnea syndrome (OSAS). A total of 39 male OSAS patients with Friedman stage II and III were retrospectively analyzed. Subjects with an apnea-hypopnea index (AHI) > 5 events/h indicated by polysomnography (PSG) and typical symptoms, such as snoring, sleep apnea, and daytime sleepiness, were included in this study. All these patients underwent pre-operative DISE examinations and were treated by velopharyngeal surgery and evaluated by velum, oropharynx, tongue base, and epiglottis (VOTE) scoring system. Clinical, polysomnographic parameters (e.g., hypopnea, apnea, AHI, lowest oxygen saturation, etc.), cephalometric variables, and DISE findings were evaluated. The treatment outcomes were assessed by polysomnography at least 6 months after surgery. All 39 patients showed complete velopharyngeal airway collapses during pre-operative DISE examinations. After surgery, the AHI was significantly improved from 50.2 ± 21.6 to 19.8 ± 19 events/h (P < 0.05). There were 23 responders (59.0%) and 16 non-responders (41.0%). The glossopharyngeal airway collapse degree (GA-CD) was significantly different between responders and non-responders (P < 0.05). The velopharyngeal airway collapse pattern (VA-CP) and GA-CD were independently predictive of treatment outcomes (both P < 0.05). Patients with non-lateral VA-CP and grade II GA-CD (collapse degree > 50%) had a significantly lower surgical success rate than those without (P < 0.05). The VA-CP and GA-CD in DISE examination are valuable for predicting the treatment outcomes of velopharyngeal surgery in patients with Friedman stage II and III OSAS. Patients with lateral VA-CP and grade I GA-CD are appropriate candidates for velopharyngeal surgery.

Development and Internal Validation of a Prediction Model for Surgical Success of Maxillomandibular Advancement for the Treatment of Moderate to Severe Obstructive Sleep Apnea.

Background: Maxillomandibular advancement (MMA) has been shown to be the most effective surgical therapy for obstructive sleep apnea (OSA). Despite high success rates, there are patients who are considered as non-responders to MMA. In order to triage and inform these patients on their expected prognosis of MMA before the surgery, this study aimed to develop, internally validate, and calibrate a prediction model for the presence of surgical success for MMA in patients with OSA. Methods: A retrospective cohort study was conducted that included patients that had undergone MMA for moderate to severe OSA. Baseline clinical, polysomnographic, cephalometric, and drug-induced sleep endoscopy findings were recorded as potential predictors. Presence or absence of surgical success was recorded as outcome. Binary logistic regression analyses were conducted to develop the model. Performance and clinical values of the model were analyzed. Results: One hundred patients were included, of which sixty-seven (67%) patients reached surgical success. Anterior lower face height (ALFH) (OR: 0.93 [0.87−1.00], p = 0.05), superior posterior airway space (SPAS) (OR: 0.76 [0.62−0.92], p < 0.05), age (OR: 0.96 [0.91−1.01], p = 0.13), and a central apnea index (CAI) <5 events/hour sleep (OR: 0.16 [0.03−0.91], p < 0.05) were significant independent predictors in the model (significance level set at p = 0.20). The model showed acceptable discrimination with a shrunken area under the curve of 0.74, and acceptable calibration. The added predictive values for ruling in and out of surgical success were 0.21 and 0.32, respectively. Conclusions: Lower age at surgery, CAI < 5 events/hour, lower ALFH, and smaller SPAS were significant predictors for the surgical success of MMA. The discrimination, calibration, and clinical added values of the model were acceptable.

Supine Pharyngeal Width Is Associated With Complete Concentric Palatal Collapse During Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulator Outcomes.

Hypoglossal nerve stimulation (HNS) implantation in the US requires preoperative drug-induced sleep endoscopy (DISE) screening for complete concentric palatal collapse (CCC) to establish treatment candidacy. We hypothesized that supine pharyngeal width (SPW) in awake patients is associated with CCC and HNS therapy outcomes. Adults with moderate to severe obstructive sleep apnea underwent awake measurement of SPW followed by DISE screening for CCC. Eligible patients electing for HNS implantation underwent postoperative polysomnography per standard of care. SPW was measured in 73 patients. For SPW >20mm, the positive likelihood ratio for absence of CCC was 6.67 with pre- and post-test odds of 6.3 and 42.0, respectively. Postoperative PSG data were available from 31 of 44 (70.5%) patients subsequently implanted with HNS. Patients with SPW >20mm had a greater rate of HNS response than those with SPW ≤20 (62 vs 30%; P < .05). Only SPW and BMI were significantly associated with CCC and HNS response in regression models. In a retrospective cohort study, SPW was significantly associated with CCC and postoperative apnea-hypopnea index following HNS implantation. SPW may be a viable screening tool for HNS candidacy.