Drug-Induced Sleep Endoscopy: Clinical Application and Surgical Outcomes

The visualization of the level and pattern of apnea and hypopnea events is of pivotal importance in the diagnosis and therapeutic decision-making for sleep-disordered breathing (SDB). There are numerous techniques available to assess upper airway obstruction, which include imaging, acoustic analysis, pressure transducer recording, and endoscopic evaluation. Drug-induced sleep endoscopy (DISE) is a diagnostic tool that allows the dynamic, three-dimensional evaluation of the patterns of vibration and collapse of the upper airway of SDB patients. DISE may change the initial surgical planning in a high percentage of cases. A universally accepted and methodologically standardized DISE could provide significant insight into its role to improve surgical outcomes. However, up to now the ideal DISE protocol remains an open question

Dental caries status in adults with sleep apnea-hypopnea syndrome

A study is made of dental caries in a group of adults with sleep apnea-hypopnea syndrome (SAHS), establishing comparisons with healthy individuals corresponding to the same population. A case-control series was analyzed, including patients with recentl

Xerostomia in patients with sleep apnea-hypopnea syndrome : a prospective case-control study

To describe the characteristics of xerostomia (dry mouth) in the population with sleep apnea-hypopnea syndrome (SAHS) and contrast its prevalence versus that found in healthy subjects, and to compare the frequency of xerostomia in SAHS patients with and without continuous positive airway pressure (CPAP) treatment. A prospective comparative study was made between adults recently diagnosed with SAHS in a public hospital (n=60) and healthy individuals (n=54). The presence of xerostomia was assessed on waking up and during the day, using a frequency scale from 0 (?never?) to 3 (?always?). The prevalence of xerostomia on waking up in the SAHS group was 45%, versus 20.4% among the controls. During the rest of the day the prevalence of the symptom decreased in both the SAHS group (21.7%) and among the controls (9.3%). Multiple binary logistic regression analysis found body mass index (BMI) to be correlated to the association SAHS-xerostomia on waking up (p=0.007). Patients with moderate SAHS had a greater frequency of xerostomia than those with mild SAHS (p=0.022). The frequency of xerostomia on waking up was significantly greater in patients using CPAP than in those without such treatment (57.1% versus 16.7%, respectively) (p=0.008). The frequency of xerostomia was greater in patients with SAHS, particularly on waking up and in those receiving CPAP. The symptom was more prevalent in individuals with moderate to severe SAHS than in those with mild SAHS, and was significantly influenced by BMI

Drug-Induced Sleep Endoscopy: Technique, Indications, Tips and Pitfalls

Drug-induced sleep endoscopy (DISE) is a diagnostic tool to assess the upper airway of snorers and obstructive sleep apnea patients in conditions that mimic natural sleep. Although DISE appears simple and similar to awake endoscopy, there are many aspects that need to be standardized in order to obtain reliable and reproducible information. In this article, we will recommend how to reliably perform DISE, its indications, and how to obtain and interpret the information of the upper airway

Optimizing Mandibular Advancement Maneuvers during Sleep Endoscopy with a Titratable Positioner: DISE-SAM Protocol

Mandibular advancement devices (MAD) are an effective alternative treatment to CPAP. Different maneuvers were performed during drug sleep-induced endoscopy (DISE) to mimic the effect of MAD. Using the Selector Avance Mandibular (SAM) device, we aimed to identify MAD candidates during DISE using a titratable, reproducible, and measurable maneuver. This DISE-SAM protocol may help to find the relationship between the severity of the respiratory disorder and the degree of response and determine the advancement required to improve the collapsibility of the upper airway. Explorations were performed in 161 patients (132 males; 29 females) with a mean age of 46.81 (SD = 11.42) years, BMI of 27.90 (SD = 4.19) kg/m2, and a mean AHI of 26.51 (SD = 21.23). The results showed no relationship between severity and MAD recommendation. Furthermore, there was a weak positive relationship between the advancement required to obtain a response and the disease severity. Using the DISE-SAM protocol, the response and the range of mandibular protrusion were assessed, avoiding the interexaminer bias of the jaw thrust maneuver. We suggest prescribing MAD as a single, alternative, or multiple treatment approaches following the SAM recommendations in a personalized design

Barbed suture pharyngoplasty in velopharyngeal complete concentric collapse: a multicentric study

Abstract Background Studies have shown that complete concentric circular collapse (CCC) at the velum is a frequent finding in drug-induced sleep endoscopy, implying a worse prognosis for surgical outcomes in the treatment of obstructive sleep apnea syndrome (OSAS). Our group evaluated the results of pharyngoplasties with barbed sutures for this indication. We selected 48 patients with OSAS and CCC who underwent pharyngoplasty with barbed sutures in 8 tertiary centers. The outcome results were measured by polygraphy or polysomnography and Epworth Symptoms Scale (ESS) at least 6 months after surgery. Results Apnea Hypopnea Index (AHI) improved from 34.9/h [21.2] to 12.7/h [10.6]. The success rate according to Sher's criteria was 86.7%, the cure rate was 23.9%, and an AHI < 10 occurred in 42.2% of the cases. The oxygen desaturation index improved from 32.5/h [29.9] to 12.5/h SD [11.6], and the ESS improved from 10.2 [5.2] to 6 [3.5]. Conclusions Pharyngoplasty with barbed sutures seems to be a good alternative for patients with OSAS and CCC findings in drug-induced sleep endoscopy

Does nasal surgery improve multilevel surgical outcome in obstructive sleep apnea:A multicenter study on 735 patients

Objective Does nasal surgery affect multilevel surgical success outcome. Methods Prospective eight country nonrandomized trial of 735 obstructive sleep apnea (OSA) patients, who had multilevel palate and/or tongue surgery, divided into two groups, with or without nose surgery. Results There were 575 patients in nose group, 160 patients in no nose group. The mean age for nose group 44.6 ± 11.4, no nose group 44.2 ± 11.8. Mean preoperative BMI for nose group 27.5 ± 3.6, no nose group 27.5 ± 4.1, mean postoperative BMI nose group 26.3 ± 3.7, no nose group 27.1 ± 3.8 (P = .006). Mean preoperative AHI nose group 32.7 ± 19.4, no nose group 34.3 ± 25.0 (P = .377); and mean postoperative AHI nose group 13.5 ± 10.2, no nose group 17.1 ± 16.0 (P = .001). Mean preoperative ESS nose group was 11.3 ± 4.7, no nose group was 10.4 ± 5.4 (P = .051); and mean postoperative ESS nose group was 5.3 ± 3.2, no nose group was 6.7 ± 2.8 (P = .001). The nose group had higher percentage change (adjusted for age, gender, BMI) in AHI (33.7%, 95% CI 14% to 53.5%) compared to the no nose group (P = .001); the nose group also had more percentage change in ESS (37%, 95% CI 23.6% to 50.3%) compared to the no nose group (P < .001). Change in BMI did not affect AHI nor ESS change (Cohen effect 0.03 and 0.14, respectively). AHI change in both groups were also statistically significant in the mild OSA (P = .008) and the severe OSA (P = .01). Success rate of surgery for the nose group 68.2%, while the no nose group 55.0% (P = .002). Conclusion Combining nose surgery in multilevel surgery improves surgical success. Level of evidence IIC

Is there a relationship between tonsil volume and the success of pharyngeal surgery among adult patients with obstructive sleep apnea?

Objectives: Hypertrophic palatine tonsils play a role in the blockage of the upper airway, one of the known causes of Obstructive Sleep Apnea (OSA). Therefore, it is possible that there is an association between tonsil size and the success of pharyngeal surgery during OSA treatment. The main objective of this study was to evaluate the relationship between tonsil grade and volume, as well as to establish whether a relationship exists between tonsil size and the success rate of pharyngeal surgery (tonsillectomy and pharyngoplasty with barbed sutures). Methods: This retrospective study includes forty-four adult patients who underwent tonsillectomy and pharyngeal surgery with barbed sutures for the treatment of simple snoring and OSA between January 2016 and September 2019. Patients who had been previously tonsillectomized or those for whom tonsil volume measurement was lacking were excluded. All patients underwent a pre-operative physical exploration at the clinic exam room and a sleep study. Prior to surgery a Drug Induced Sleep Endoscopy (DISE) was performed. Tonsil volume was measured intraoperatively using the water displacement method. The same sleep study was repeated six months following surgery. Results: A significant correlation was found between tonsil grade and volume and between such measurements and the blockage observed at the level of the oropharynx during the DISE. Moreover, an association was observed between tonsil volume, but not tonsil grade, and the success of tonsillectomy and pharyngoplasty with barbed sutures. A tonsil volume greater than 6.5 cm3 was linked to success during pharyngeal surgery. Conclusion: A correlation exists between tonsil grade and tonsil volume. A bigger tonsil volume is associated with a greater success rate of oropharyngeal surgery during treatment of OSA. Level of evidence: Level 3, non-randomized cohort study

Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review

Background The purpose of the present study is to review the international literature, using a systematic review, for studies comparing propofol and dexmedetomidine for drug-induced sleep endoscopy (DISE) or sedation in which there is a description of the effect of the agents on the upper airway and associated variables (e.g., vital signs, sedation scores). Methods This is a systematic review through October 4, 2016. PubMed/MEDLINE and four additional databases were accessed for this study. Results Two hundred twenty studies were screened. 79 were downloaded, and 10 met criteria. The majority of the studies identified dexmedetomidine as the preferred pharmacologic agent for DISE due to an overall safer and more stable profile based upon hemodynamic stability. However, propofol provided greater airway obstruction with oxygen desaturations. With either agent, the degree of obstruction in the upper airway lacks some degree of validity as to whether the obstructions accurately represent natural sleep or are simply a drug induced effect. Conclusion Dexmedetomidine and propofol have their advantages and disadvantages during DISE. Generally, dexmedetomidine was preferred and seemed to provide a more stable profile based upon cardiopulmonary status. However, propofol has a quicker onset, has a shorter half-life, and can demonstrate larger degrees of obstruction, which might more accurately reflect what happens during REM sleep. Additional research is recommended