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Sadiq I, El-Hakim H. Patterns of Pharyngeal Obstruction and Collapse in Obese and Nonobese Children on Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg 2023; 169:1041-1047. [PMID: 37087678 DOI: 10.1002/ohn.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/15/2023] [Accepted: 03/25/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE (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. STUDY DESIGN Retrospective case-control study. SETTING Tertiary pediatric center. METHODS 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). RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Ibrahim Sadiq
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hamdy El-Hakim
- Divisions of Otolayngology Head & Neck Surgery and Pediatric Surgery, Department of Surgery, Univeristy of Alberta, Edmonton, Alberta, Canada
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2
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Lackey TG, Duffy JR, Green KK. A Protocol for Propofol-Infusion Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg 2023; 168:234-240. [PMID: 35349363 DOI: 10.1177/01945998221088760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/03/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to outline a protocol utilizing propofol infusion without an initial bolus during drug-induced sleep endoscopy (DISE). We define normative values for final propofol infusion rate (Pfinal ) during DISE and sedation depth values at Pfinal . STUDY DESIGN Retrospective chart review. SETTING Tertiary academic hospital. METHODS A review of patients with obstructive sleep apnea who underwent DISE between 2016 and 2020 was performed. The following patient data were recorded: demographics; DISE procedure details, including Pfinal , time to Pfinal , frequency and cadence of infusion rate changes, depth of sedation as measured by Bispectral Index and SedLine values, and hemodynamics; and polysomnography details including apnea-hypopnea index severity and minimum oxygen saturation. A mixed linear model adjusted for age and body mass index was performed for the analysis of effects on Pfinal . Pearson correlation coefficients determined the strength of association between depth of sedation measured and pattern of collapse on DISE and Pfinal . RESULTS There were 246 patients who met inclusion criteria. Pfinal resembled a normal distribution (mean ± SD, 156.44 ± 26.69 mcg/kg/min; median, 150 mcg/kg/min). Analysis demonstrated that Pfinal was influenced by male sex, current smoker status, time to Pfinal , and number of propofol dose changes (P < .05). Depth of sedation categories measured differently between Bispectral Index and SedLine (55-65 vs 45-55, P < .001). The pattern including severity of collapse on DISE was not associated with Pfinal (P > .05). No patients required intra- or postoperative respiratory support beyond oxygen via nasal canula. CONCLUSION We describe a propofol slow-infusion DISE protocol that demonstrates safe and reproducible outcomes.
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Affiliation(s)
- Taylor G Lackey
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado Denver, Aurora, Colorado, USA
| | - James R Duffy
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado Denver, Aurora, Colorado, USA
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado Denver, Aurora, Colorado, USA
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3
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Viana A, Estevão D, Zhao C. The clinical application progress and potential of drug-induced sleep endoscopy in obstructive sleep apnea. Ann Med 2022; 54:2909-2920. [PMID: 36269026 PMCID: PMC9590429 DOI: 10.1080/07853890.2022.2134586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: Obstructive sleep apnoea (OSA) is characterized by nocturnal repetitive upper airway (UA) collapse. For sleep physicians, the recognition of UA collapse characteristics is critical for understanding OSA mechanisms and developing individualized treatment plans. Drug-induced sleep endoscopy (DISE) is an exam during simulated sleep that allows the dynamic assessment of the UA of individuals with OSA. The initial recognition of DISE was to locate the sites of UA obstruction and direct the surgical selection of OSA since it was introduced in the 1990s. After approximately 30 years of studies, based on advances in endoscopic operative techniques and innovative treatments of OSA, DISE had been performed to explore mechanisms and comprehensive treatments related to UA collapse. Methods: This article reviewed contemporary DISE advances, including indications and contraindications, technique of induced sleep, endoscopic operation, UA characteristics classification.Results and Conclusions: Precise selection based on the association between collapse patterns and treatment modalities, such as continuous positive airway pressure, oral appliance, positional therapy, robotic surgery and neurostimulator implanting, is the future research prospect based on DISE.Key messagesDISE provides sleep physicians with valuable information about the upper airway collapse characteristics and dynamic changes during sleep.The studies based on DISE findings improve the selectivity and efficiency of treatment modalities, including classical therapies such as continuous positive airway pressure, oral appliance, positional therapy, and innovative therapies such as neurostimulator implanting and robotic surgery, promote the advancement of OSA precision medicine.
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Affiliation(s)
- Alonço Viana
- Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcilio Dias Naval Hospital, Rio de Janeiro, Brazil
| | - Débora Estevão
- Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Glória D'Or Hospital - Rede D'Or São Luiz, Rio de Janeiro, Brazil
| | - Chen Zhao
- Department of Otorhinolaryngology, the First Hospital of China Medical University, Shenyang, China
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4
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Rusetsky YY, Latysheva EN, Kalugina MS, Spiranskaya OA, Malyavina US, Averbukh VM, Dzhafarova MZ. [Features of sleependoscopy in children]. Vestn Otorinolaringol 2021; 86:58-62. [PMID: 34783475 DOI: 10.17116/otorino20218605158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the technique and determine the indications for sleep endoscopy in children. MATERIAL AND METHODS This study included 35 children, the average age of 5 years 1 month ± 3 years 4 months (from 1 year 6 months to 14 years 5 months). All children underwent standard polysomnography and sleep endoscopy. RESULTS According to polysomnography, severe obstructive sleep apnea (OSA) was diagnosed in 21 children, moderate - in 8 children and mild - in 6 children. Sleep endoscopy revealed that in most cases in unoperated children (about 70%), adenoids and palatine tonsils were the cause of obstruction. In the group of children, who previously underwent surgery for OSA, the causes of residual apnea more often were soft palate and palatine tonsils. In 5 of 8 children, tonsils pharyngoscopy size did not exceed the 1st degree. In 1 child after adenotonsillectomy, the hypertrophic tori tubarii were the cause of obstruction. Another rare cause of upper airway obstruction, lingual tonsil hypertrophy, was found in 2 primary patients. CONCLUSION Sleep endoscopy is a safe and useful method that makes it possible to determine the level of obstruction in children and to plan the optimal amount of surgical treatment.
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Affiliation(s)
- Yu Yu Rusetsky
- National Medical Research Center for Children's Health, Moscow, Russia
| | - E N Latysheva
- National Medical Research Center for Children's Health, Moscow, Russia
| | - M S Kalugina
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O A Spiranskaya
- National Medical Research Center for Children's Health, Moscow, Russia
| | - U S Malyavina
- National Medical Research Center for Children's Health, Moscow, Russia
| | - V M Averbukh
- National Medical Research Center for Otorhinolaryngology of the Federal Medical and Biological Agency of Russia, Moscow, Russia
| | - M Z Dzhafarova
- National Medical Research Center for Otorhinolaryngology of the Federal Medical and Biological Agency of Russia, Moscow, Russia
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5
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The Use of Middle Latency Auditory Evoked Potentials (MLAEP) as Methodology for Evaluating Sedation Level in Propofol-Drug Induced Sleep Endoscopy (DISE) Procedure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042070. [PMID: 33672569 PMCID: PMC7924024 DOI: 10.3390/ijerph18042070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/04/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022]
Abstract
To analyze the middle latency auditory evoked potential index (MLAEPi), compared to the standard bispectral index (BIS), as a method for evaluating the sedation level in drug-induced sleep endoscopy (DISE). In this controlled clinical study on a sample of 99 obstructive sleep apnea (OSA) or snoring patients, we compared the MLAEPi with the BIS after propofol infusion during the standard DISE technique in order to define the MLAEPi values within the observational window of the procedure. The DISE procedure was divided into eight steps, and we collected both MLAEPi and BIS data values from the same patient in every step. The MLAEPi showed a faster response than the BIS after propofol infusion during DISE. Therefore, the clinical use of the MLAEPi in evaluating the sedation level seems to be a good alternative to the current technological standards.
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Abstract
PURPOSE OF REVIEW The purpose of this article is to highlight recent advances in the burgeoning field of drug-induced sleep endoscopy (DISE). RECENT FINDINGS One of the first studies to investigate the correlation of DISE findings and natural sleep endoscopy found good agreement in clinically significant obstruction. Previous studies have shown good agreement of DISE findings with the use of different sedative agents implying that the choice of sedative may not be crucial. However, recent studies show variable patterns of collapse, especially at the tongue base, with the use of different sedative agents. A universally accepted classification scheme for drug-induced sleep endoscopy is lacking. A new DISE classification system, termed Palate, Tonsils, Lateral pharyngeal wall, Tongue base, Epiglottis, was introduced this year with the noted advantage of being able to better differentiate between clinically relevant tonsillar and lateral pharyngeal wall collapse. Despite recent advances in the field, there remains no general consensus that DISE findings predict surgical success but may aid in the identification of patients who will respond well to oral appliance therapy. SUMMARY Drug-induced sleep endoscopy is a structure-based evaluation of the upper airway that more closely resembles the natural sleep state compared with awake evaluation.
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7
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Lai CC, Lin PW, Lin HC, Friedman M, Salapatas AM, Chen JP, Chang HW, Juang SE, Wu SC, Lin MC. Computer-Assisted Quantitative Analysis of Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea/Hypopnea Syndrome. Otolaryngol Head Neck Surg 2020; 163:1274-1280. [PMID: 32600112 DOI: 10.1177/0194599820933206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To use computer-assisted quantitative measurements of upper airway changes during drug-induced sleep endoscopy (DISE) and to correlate these parameters with disease severities and physiologic changes in patients with obstructive sleep apnea/hypopnea syndrome (OSA). DESIGN A retrospective study. SETTING Tertiary academic medical center. PATIENTS AND METHODS A total of 170 patients who failed continuous positive airway pressure therapy and then underwent upper airway surgery were enrolled. All patients received polysomnography and DISE preoperatively. We used ImageJ 1.48v to obtain maximal and minimal measurements, including cross-sectional areas and anterior-posterior and lateral diameters at 4 anatomic levels (retropalatal, oropharyngeal, retroglossal, and retroepiglottic) under DISE, and then computed the percentage changes. We analyzed the clinical values of DISE changes by computer-assisted analysis in patients with OSA and any correlations between these changes and polysomnography parameters. RESULTS The percentage changes of upper airway showed significant collapses at all 4 anatomic levels (all P < .0001). We also found that the changes at retropalatal levels were significantly greater and that retroglossal levels were significantly smaller, while the changes of anterior-posterior diameters at retroglossal levels showed a significant positive association with apnea-hypopnea index and desaturation index. However, there were no statistically significant correlations between upper airway changes and obesity. CONCLUSION Computer-assisted quantitative analysis could evaluate upper airway changes of OSA in an objective way and may help identify the sites of obstruction during DISE more accurately. Upper airway showed multilevel collapse with independent significant changes in patients with OSA, with the retropalatal and retroglossal levels playing important roles in particular.
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Affiliation(s)
- Chi-Chih Lai
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Wen Lin
- Division of Glaucoma, Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Sleep Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsin-Ching Lin
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Sleep Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Robotic Surgery Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Michael Friedman
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.,Department of Otolaryngology, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Anna M Salapatas
- Department of Otolaryngology, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Ju-Pin Chen
- Department of Anesthesiology, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Hsueh-Wen Chang
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Sin-Ei Juang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Sleep Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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8
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A New Technological Advancement of the Drug-Induced Sleep Endoscopy (DISE) Procedure: The "All in One Glance" Strategy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124261. [PMID: 32549340 PMCID: PMC7345775 DOI: 10.3390/ijerph17124261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/17/2022]
Abstract
To illustrate a new technological advance in the standard drug-induced sleep endoscopy (DISE) model, a new machine was used, the Experimental 5 Video Stream System (5VsEs), which is capable of simultaneously visualizing all the decisional parameters on a single monitor, and recording and storing them in a single uneditable video. The DISE procedure was performed on 48 obstructive sleep apnea (OSA) or snoring patients. The parameters simultaneously recorded on a single monitor are (1) the pharmacokinetics and pharmacodynamics of propofol (through the target controlled infusion (TCI) pump monitor), (2) the endoscopic upper airway view, (3) the polygraphic pattern, and (4) the level of sedation (through the bispectral index (BIS) value). In parallel to the BIS recording, the middle latency auditory evoked potential (MLAEP) was also recorded and provided. Recorded videos from the 5VsEs machine were re-evaluated six months later by the same clinician and a second clinician to evaluate the concordance of the therapeutic indications between the two. After the six-month period, the same operator confirmed all their clinical decisions for 45 out of 48 videos. Three videos were no longer evaluable for technical reasons, so were excluded from further analysis. The comparison between the two operators showed a complete adherence in 98% of cases. The 5VsEs machine provides a multiparametric evaluation setting, defined as an “all in one glance” strategy, which allows a faster and more effective interpretation of all the simultaneous parameters during the DISE procedure, improving the diagnostic accuracy, and providing a more accurate post-analysis, as well as legal and research advantages.
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Santos-Gorjón P, Sánchez-jara Sánchez JL, Martín-Hernández G, Morales-Martín AC, Intraprendente-Martini JF, Chaves-Araújo R, Racines-Alava EA, León-Ramos AM. Endoscopia del sueño mediante sedación inducida por fármacos o somnoscopia. REVISTA ORL 2020. [DOI: 10.14201/orl.22175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción y objetivos: La somnoscopia es una herramienta diagnóstica para valorar las posibles obstrucciones de la vía aérea superior responsables del síndrome de apnea-hipopnea del sueño (SAHS). Nuestro objetivo de es mostrar nuestra experiencia con somnoscopia o DISE (endoscopia mediante sedación inducida por fármacos) en candidatos a cirugía por una patología obstructiva de vía aerodigestiva superior. Material y métodos Presentamos un estudio retrospectivo de 17 pacientes de los que se excluyen finalmente 2. La edad de los pacientes varió de 34 a 72 años. Se practica polisomnografía previa y el IAH medio fue 7,32±8,71. Discusión y conclusión: La DISE es una técnica segura, reproducible y aplicable en cualquier servicio de ORL. Así mismo, permite individualizar el tratamiento quirúrgico y probablemente evitar cirugías innecesarias.
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10
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Vroegop AV, Vanderveken OM, Verbraecken JA. Drug-Induced Sleep Endoscopy: Evaluation of a Selection Tool for Treatment Modalities for Obstructive Sleep Apnea. Respiration 2020; 99:451-457. [PMID: 32036366 DOI: 10.1159/000505584] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/20/2019] [Indexed: 11/19/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a very common disorder with important day and nighttime symptoms and long-term effects on health. Different treatment modalities such as positive airway pressure (PAP), oral appliance therapy using custom-made, titratable mandibular advancement devices (MAD), different types of surgery and positional therapy have been introduced over the years, with patient preference and adherence to therapy being key elements in improving treatment outcomes. Several patient selection tools to improve treatment outcomes have been introduced and evaluated over the years. Drug-induced sleep endoscopy (DISE) is a procedure that provides real-time upper airway evaluation of the sites of flutter and upper airway collapse. This review focuses on the indications and contraindications for DISE, methods of sedation and evaluation, add-on maneuvers, and the results on patient selection and treatment outcomes. A PICO approach was used to clarify the aims of this review. DISE has the advantage of being easily accessible in most ENT practices and being 3-dimensional, dynamic, site specific, safe and it is valuable in selecting patients for upper airway surgery and oral appliance therapy. There is a strong interest for further standardization and exploration of the predictive value of this evolving technique.
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Affiliation(s)
- Anneclaire V Vroegop
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium, .,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium, .,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium,
| | - Olivier M Vanderveken
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan A Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonary Medicine, Antwerp University Hospital, Edegem, Belgium
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11
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Surgical ablation of lingual tonsils in the treatment of obstructive sleep apnea. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 136:19-23. [PMID: 30503688 DOI: 10.1016/j.anorl.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS The retrolingual space is one of the potential sites of obstruction identified in patients with obstructive sleep apnea syndrome (OSAS). Hypertrophied lingual tonsils (LT) can obstruct the airway at this level. The goal of this study was to measure the tolerance and efficacy of lingual tonsillectomy in patients with OSAS. STUDY DESIGN A retrospective chart review was conducted recruiting all patients with OSAS confirmed on sleep recording, who either had failed or refused medical treatment and who underwent lingual tonsillectomy. MATERIALS AND METHODS Diagnosis of LT hypertrophy was made by full ENT clinical examination using a flexible endoscopy, completed by MRI and followed by drug-induced sleep endoscopy. The surgical intervention was carried out endoscopically by diode laser or coblation. The primary endpoint to measure efficacy was drop in apnea-hypopnea index (AHI) on sleep recording at 6 months. Secondary endpoints comprised reduced snoring and Epworth Sleepiness Scale (ESS) and postoperative symptom tolerance. RESULTS Eleven patients aged 44.3±12.6 years were included. AHI dropped from 29.5±21.7/h to 11.6±9.6/h: i.e., by 60% (P=0.005). Five patients had AHI<10/h: i.e., cure rate of 45%. ESS dropped from 13±3.4 to 8.1±4.9 (P=0.012). No complications were observed. CONCLUSIONS LT ablation seemed effective in OSAS with retrolingual obstruction in failure of medical treatment. LEVEL OF EVIDENCE 4.
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12
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De Vito A, Carrasco Llatas M, Ravesloot MJ, Kotecha B, De Vries N, Hamans E, Maurer J, Bosi M, Blumen M, Heiser C, Herzog M, Montevecchi F, Corso RM, Braghiroli A, Gobbi R, Vroegop A, Vonk PE, Hohenhorst W, Piccin O, Sorrenti G, Vanderveken OM, Vicini C. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol 2018; 43:1541-1552. [PMID: 30133943 DOI: 10.1111/coa.13213] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/14/2018] [Accepted: 08/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The first edition of the European position paper (EPP) on drug-induced sleep endoscopy (DISE) was published in 2014 with the aim to standardise the procedure, to provide an in-depth insight into the main aspects of this technique and to have a basis for future research. Since 2014, new studies have been published concerning new sedative agents or new insights into the pattern/levels of the obstruction depending on the depth of sedation. Therefore, an enlarged group of European experts in the field of sleep breathing disorders (SBD), including the most of the first DISE EPP main authors, has decided to publish an update of the European position paper on DISE, in order to include new evidence and to find a common language useful for reporting the findings of this endoscopic evaluation in adult population affected by SBD. METHODS The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centres in order to provide an update regarding the standardisation of the DISE procedure and an in-depth insight into the main aspects of this technique. RESULTS After the first European Position Consensus Meeting on DISE and its update, consensus was confirmed for indications, required preliminary examinations, where to perform DISE, technical equipment required, staffing, local anaesthesia, nasal decongestion, other medications, patient positioning, basics and special diagnostic manoeuvres, drugs and observation windows. So far, no consensus could be reached on a scoring and classification system. However, regarding this aim, the idea of an essential classification, such as VOTE with the possibility of its graded implementation of information and descriptions, seems to be the best way to reach a universal consensus on DISE classification at this stage. A common DISE language is mandatory, and attempts to come to a generally accepted system should be pursued.
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Affiliation(s)
- Andrea De Vito
- Head and Neck Department, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,ENT Unit, Santa Maria delle Croci Hospital, Ravenna AUSL of Romagna, Romagna, Italy
| | | | - Madeline J Ravesloot
- Department of Otorhinolaryngology and Head and Neck Surgery, OLVG, Amsterdam, The Netherlands.,Medisch Centrum Jan van Goyen, Amsterdam, The Netherlands
| | - Bhik Kotecha
- Royal National Throat Nose & Ear Hospital, UCLH, London, UK
| | - Nico De Vries
- Department of Otolaryngology, OLVG Hospital and ACTA, Amsterdam, Netherlands.,Department of Otorhinolaryngology and Head and Neck Surgery, Multidisciplinary Sleep Disorders Center, University of Antwerp, Antwerp, Belgium.,Department of Oral Kinesiology, Academic Centre for Dentistry, MOVE Inst., Amsterdam, The Netherlands
| | - Evert Hamans
- Department of Otorhinolaryngology, Head and Neck Surgery, Jan Palfijn Hospital, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerpen, Belgium
| | - Joachim Maurer
- Sleep Disorders Centre, Department of Otorhinolaryngology, Head and Neck Surgery, University Medicine Mannheim, Mannheim, Germany
| | - Marcello Bosi
- Pulmonary Operative Unit, Department of Thoracic Diseases, Morgagni-Pierantoni Hospital, AUSL of Romagna, Forlì, Italy
| | - Marc Blumen
- Service ORL, Hopital Foch, Suresnes France and Centre Medical Veille Sommeil, Paris, France
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universitat Munchen, Munich, Germany
| | - Michael Herzog
- Department of Otorhinolaryngology, Head and Neck Surgery, Carl Thiem Klinikum, Cottbus, Germany
| | - Filippo Montevecchi
- Head and Neck Department, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, AUSL of Romagna, Forlì, Italy
| | | | - Alberto Braghiroli
- Sleep Lab. Pulmonary Rehabilitation Dept. Istituti Clinici Scientifici Maugeri, SPA SB, IRCCS, Veruno, Italy
| | - Riccardo Gobbi
- Head and Neck Department, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Anneclaire Vroegop
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Patty Elisabeth Vonk
- Department of Otorhinolaryngology and Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
| | | | - Ottavio Piccin
- Department of Otolaryngology, Head and Neck Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giovanni Sorrenti
- Department of Otolaryngology, Head and Neck Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp- Department ENT, Head and Neck Surgery, Antwerp University Hospital - Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium
| | - Claudio Vicini
- Head and Neck Department, AUSL of Romagna, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,ENT Unit, Infermi Hospital, AUSL of Romagna, Faenza, Italy.,ENT Unit, Santa Maria delle Croci Hospital, Ravenna, Italy.,AUSL of Romagna, Romagna, Italy.,ENT Clinic, University of Ferrara, Ferrara, Italy
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13
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Viana A, Zhao C, Rosa T, Couto A, Neves DD, Araújo-Melo MH, Capasso R. The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings. Laryngoscope 2018; 129:506-513. [PMID: 30194726 DOI: 10.1002/lary.27298] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients. STUDY DESIGN Case series prospective study. METHODS Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016. RESULTS Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O2 nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value. CONCLUSION Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O2 levels, and lower BIS index values. Propofol resulted in an O2 nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation. LEVEL OF EVIDENCE 4 Laryngoscope, 129:506-513, 2019.
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Affiliation(s)
- Alonço Viana
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital (HNMD), Rio de Janeiro, Brazil.,Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A
| | - Chen Zhao
- Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A.,Department of Otorhinolaryngology, First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Talita Rosa
- Department of Neurology, University of California, San Francisco, California, U.S.A
| | - Arnaldo Couto
- Department of Pharmacy, West Zone Rio de Janeiro State University (UEZO), Rio de Janeiro, Brazil
| | - Denise Duprat Neves
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Cardiopulmonary, Rio de Janeiro, Brazil
| | - Maria Helena Araújo-Melo
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Robson Capasso
- Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A
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14
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Lechner M, Wilkins D, Kotecha B. A review on drug-induced sedation endoscopy - Technique, grading systems and controversies. Sleep Med Rev 2018; 41:141-148. [PMID: 29627276 DOI: 10.1016/j.smrv.2018.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 12/19/2017] [Accepted: 02/07/2018] [Indexed: 12/19/2022]
Abstract
Sleep disordered breathing (SDB) comprises a spectrum of disorders, ranging from simple snoring to severe obstructive sleep apnoea (OSA), with a significant burden to health care systems in high income countries. If left untreated, OSA has significant cumulative, long-term health consequences. In the 1990s drug induced sedation endoscopy (DISE) has been developed to become a primary tool in the diagnosis and management of OSA. It allows meticulous endoscopic evaluation of the airway and identifies areas of collapse, thereby informing both on the selection of surgical techniques, where efficacy depends entirely on success at relieving obstruction at a certain level and on the usefulness of conservative measures, such as mandibular advancement splints. This article provides a review of the literature on DISE, covering different grading systems and techniques, explaining different rationales and discussing controversies.
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Affiliation(s)
- Matt Lechner
- Royal National Throat, Nose & Ear Hospital, Gray's Inn Road, London, UK
| | - Dominic Wilkins
- Royal National Throat, Nose & Ear Hospital, Gray's Inn Road, London, UK
| | - Bhik Kotecha
- Royal National Throat, Nose & Ear Hospital, Gray's Inn Road, London, UK.
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15
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Kotecha B, De Vito A. Drug induced sleep endoscopy: its role in evaluation of the upper airway obstruction and patient selection for surgical and non-surgical treatment. J Thorac Dis 2018; 10:S40-S47. [PMID: 29445527 DOI: 10.21037/jtd.2017.10.32] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sleep related breathing disorders cause obstruction of the upper airway which can be alleviated by continuous positive airway pressure (CPAP) therapy, oral devices or surgical intervention. Non-surgical treatment modalities are not always accepted by patients and in order to attain successful surgical outcomes, evaluation of the upper airway is necessary to carefully select the patients who would benefit from surgery. There are numerous techniques available to assess the upper airway obstruction and these include imaging, acoustic analysis, pressure transducer recording and endoscopic evaluation. It is essential to note that the nocturnal obstructive upper airway has limited muscle control compared to the tone of the upper airway lumen during wakefulness. Thus, if one were to attempt to identify the anatomical segments contributing to upper airway obstruction in sleep related breathing disorders; it must be borne in mind that evaluation of the airway must be performed if possible when the patient is awake and asleep albeit during drug induced sleep. This fact as such limits the use of imaging techniques for the purpose. Drug induced sleep endoscopy (DISE) was pioneered at Royal National Throat, Nose and Ear Hospital, London in 1990 and initially introduced as sleep nasendoscopy. The nomenclature and the technique has been modified by various Institutions but the core value of this evaluation technique remains similar and extremely useful for identifying the anatomical segment responsible for obstructing the upper airway during sleep in patients with sleep related breathing disorders. There have been numerous controversies that have surrounded this technique but over the last two decades most of these have been addressed and it now remains in the forefront of methods of evaluating the upper airway obstruction. A variety of sedative agents and different grading systems have been described and efforts to unify various aspects of the technique have been made. This article will look at its usefulness and advantages and will discuss some important contributions made to the field of evaluation of the upper airway using DISE.
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Affiliation(s)
- Bhik Kotecha
- ENT Department, Royal National Throat, Nose & Ear Hospital (UCLH), London, UK.,Department of ENT Surgery, Queens Hospital, Romford, Essex, UK.,Barts and The London School of Medicine and Dentistry, London, UK
| | - Andrea De Vito
- Department of Head and Neck, ENT Unit, GB Morgagni L Pierantoni Hospital, Forlì, Italy
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16
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Dijemeni E, D'Amone G, Gbati I. Drug-induced sedation endoscopy (DISE) classification systems: a systematic review and meta-analysis. Sleep Breath 2017; 21:983-994. [PMID: 28584940 PMCID: PMC5700212 DOI: 10.1007/s11325-017-1521-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/09/2017] [Accepted: 05/23/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Drug-induced sedation endoscopy (DISE) classification systems have been used to assess anatomical findings on upper airway obstruction, and decide and plan surgical treatments and act as a predictor for surgical treatment outcome for obstructive sleep apnoea management. The first objective is to identify if there is a universally accepted DISE grading and classification system for analysing DISE findings. The second objective is to identify if there is one DISE grading and classification treatment planning framework for deciding appropriate surgical treatment for obstructive sleep apnoea (OSA). The third objective is to identify if there is one DISE grading and classification treatment outcome framework for determining the likelihood of success for a given OSA surgical intervention. METHODS A systematic review was performed to identify new and significantly modified DISE classification systems: concept, advantages and disadvantages. RESULTS Fourteen studies proposing a new DISE classification system and three studies proposing a significantly modified DISE classification were identified. None of the studies were based on randomised control trials. CONCLUSION DISE is an objective method for visualising upper airway obstruction. The classification and assessment of clinical findings based on DISE is highly subjective due to the increasing number of DISE classification systems. Hence, this creates a growing divergence in surgical treatment planning and treatment outcome. Further research on a universally accepted objective DISE assessment is critically needed.
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Affiliation(s)
- Esuabom Dijemeni
- Research and Development Department, DISE INNOVATION, 24 Park Central Building, Bow Quarters, 60 Fairfield Road, London, UK.
- Department of Bioengineering, Imperial College London, London, UK.
| | - Gabriele D'Amone
- Research and Development Department, DISE INNOVATION, 24 Park Central Building, Bow Quarters, 60 Fairfield Road, London, UK
- Dyson School of Design Engineering, Imperial College London, London, UK
| | - Israel Gbati
- Research and Development Department, DISE INNOVATION, 24 Park Central Building, Bow Quarters, 60 Fairfield Road, London, UK
- School of Design, Royal College of Art, London, UK
- Department of Mechanical Engineering, Imperial College London, London, UK
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17
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Measurements and status of sleep quality in patients with cancers. Support Care Cancer 2017; 26:405-414. [DOI: 10.1007/s00520-017-3927-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 10/09/2017] [Indexed: 01/04/2023]
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18
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Dijemeni E, Kotecha B. Drug-Induced Sedation Endoscopy (DISE) DATA FUSION system: clinical feasibility study. Eur Arch Otorhinolaryngol 2017; 275:247-260. [PMID: 29043476 PMCID: PMC5754408 DOI: 10.1007/s00405-017-4765-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 10/04/2017] [Indexed: 11/24/2022]
Abstract
Drug-induced sleep endoscopy (DISE) is a diagnostic technique for 3D dynamic anatomical visualisation of upper airway obstruction during sedated sleep. There is a lack of standardised procedure and objective measurement associated with information capture, information management, evaluation of DISE findings, treatment planning, and treatment outcomes. The objective of this study is to present clinical feasibility results using a DISE DATA FUSION system for capturing, merging, displaying and storing anatomical data from an endoscopic imaging system and cardiorespiratory data from an anaesthesiological monitoring system simultaneously in real-time during DISE. This prospective cohort study included 20 patients presenting with symptoms of sleep related breathing disorders undergoing drug-induced sedation endoscopy and had volunteered for DISE DATA FUSION system to be used during their DISE assessment. The DISE DATA FUSION system was used to capture, merge, display, and store anatomical changes from an endoscopic imaging system and cardiorespiratory changes from an anaesthesiological monitoring system simultaneously in real time during drug-induced sedation endoscopy assessment. In all 20 patients, anatomical obstructions at different levels of the pharyngeal lumen (soft palate, velum, tonsils, oropharynx lateral wall, base of tongue, and epiglottis) with a different obstruction configuration and severity were captured simultaneously in real time with its associated cardiorespiratory parameters. Furthermore, a composite video consisting of an anatomical image, blood oxygen level, pulse rate, blood pressure, and timestamp was created for every obstructive event. Our system provides a useful and better way of capturing, merging, visualising, and storing anatomical data/physiological data simultaneously during DISE in real time. Furthermore, it enhances the understanding of the impact of the anatomical severity due to the simultaneous display of the cardiovascular parameters at that specific time of anatomical obstruction for optimising surgical decision based on DISE.
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Affiliation(s)
- Esuabom Dijemeni
- Department of Bioengineering, Imperial College London, London, UK. .,Research and Development Department, DISE INNOVATION, London, UK.
| | - Bhik Kotecha
- ENT Department, Royal National Throat, Nose and Ear Hospital, 330 Grays Inn Road, London, WC1X 8DA, UK.,Barts and The London School of Medicine and Dentistry, London, E1 2AT, UK
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19
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Vonk P, Ravesloot M, de Vries N. Advances in the Role of Drug-Induced Sleep Endoscopy in Investigating Sleep Apnea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0160-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Is observed upper airway obstruction patterns during drug-induced sedation endoscopy dose-dependent? Sleep Breath 2017; 22:185-186. [PMID: 28791564 DOI: 10.1007/s11325-017-1540-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
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21
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Vanderveken OM. The global and evident need to increase the validity and uniformity when performing drug-induced sleep endoscopy. Sleep Breath 2017; 22:191-192. [PMID: 28791502 DOI: 10.1007/s11325-017-1543-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Olivier M Vanderveken
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium. .,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium. .,Research Group Translational Neuroscience, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
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22
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Gobbi R, Baiardi S, Mondini S, Cerritelli L, Piccin O, Scaramuzzino G, Milano F, Melotti MR, Mordini F, Pirodda A, Cirignotta F, Sorrenti G. Technique and Preliminary Analysis of Drug-Induced Sleep Endoscopy With Online Polygraphic Cardiorespiratory Monitoring in Patients With Obstructive Sleep Apnea Syndrome. JAMA Otolaryngol Head Neck Surg 2017; 143:459-465. [PMID: 28253389 DOI: 10.1001/jamaoto.2016.3964] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Drug-induced sleep endoscopy is a diagnostic technique that allows dynamic evaluation of the upper airway during artificial sleep. The lack of a standardized procedure and the difficulties associated with direct visual detection of obstructive events result in poor intraobserver and interobserver reliability, especially when otolaryngology surgeons not experienced in the technique are involved. Objectives To describe a drug-induced sleep endoscopy technique implemented with simultaneous polygraphic monitoring of cardiorespiratory parameters (DISE-PG) in patients with a diagnosis of obstructive sleep apnea syndrome and discuss the technique's possible advantages compared with the standard procedure. Design, Setting, and Participants This prospective cohort study included 50 consecutive patients with obstructive sleep apnea syndrome who underwent DISE-PG from March 1, 2013, to June 30, 2014. A standard protocol was adopted, and all the procedures were carried out in an operation room by an experienced otolaryngology surgeon under the supervision of an anesthesiologist. Endoscopic and polygraphic obstructive respiratory events were analyzed offline in a double-blind setting and randomized order. Main Outcomes and Measures The feasibility and safety of the DISE-PG technique, as well as its sensitivity in detecting respiratory events compared with that of the standard drug-induced sleep endoscopy procedure. Results All 50 patients (43 men and 7 women; mean [SD] age, 51.1 [12.1] years) underwent DISE-PG without technical problems or patient difficulties regarding the procedure. As expected, polygraphic scoring was more sensitive than endoscopic scoring in identifying obstructive events (mean [SD] total events, 13.3 [6.8] vs 5.3 [3.6]; mean [SD] difference, 8.8 [5.6]; 95% CI, 7.3 to 10.4; Cohen d, -1.5). This difference was most pronounced in patients with a higher apnea-hypopnea index (AHI) at baseline (mean [SD] difference for AHI >30, 27.1% [31.0%]; 95% CI, -36.2% to 90.4%; Cohen d, 0.2; for AH I >40, 76.0% [35.5%]; 95% CI, 4.6% to 147.4%; Cohen d, 0.5; for AHI >50, 92.2% [37.2%]; 95% CI, 17.3% to 167.1%; Cohen d, 0.6) and a high percentage of hypopneas (≥75% of all obstructive events) at baseline (mean [SD] difference, 20.2% [5.4%]; 95% CI, 9.2% to 31.3%; Cohen d, 1.1). No other anthropomorphic or polygraphic features at baseline were associated with the differences between the DISE-PG and baseline home sleep apnea test. Conclusions and Relevance The DISE-PG technique is feasible, safe, and more sensitive at detecting an obstructed breathing pattern than is drug-induced sleep endoscopy alone. The DISE-PG technique could be helpful for accurate comprehension of upper airway obstructive dynamics (ie, degree of obstruction and multilevel pattern) and a nonobstructive breathing pattern (ie, central apneas).
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Affiliation(s)
- Riccardo Gobbi
- Department of Head, Neck and Sensory System, Otorhinolaryngolologic Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Simone Baiardi
- Neurology Unit, Department of Head, Neck and Sensory System, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy3Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Susanna Mondini
- Neurology Unit, Department of Head, Neck and Sensory System, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Luca Cerritelli
- Department of Head, Neck and Sensory System, Otorhinolaryngolologic Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Ottavio Piccin
- Department of Head, Neck and Sensory System, Otorhinolaryngolologic Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | | | - Maria Rita Melotti
- Anesthesia and Intensive Care Unit, Department of Surgical and Anesthesiological Sciences, University of Bologna, Bologna, Italy
| | - Francesco Mordini
- Anesthesia and Intensive Care Unit, Department of Surgical and Anesthesiological Sciences, University of Bologna, Bologna, Italy
| | - Antonio Pirodda
- Department of Head, Neck and Sensory System, Otorhinolaryngolologic Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Fabio Cirignotta
- Neurology Unit, Department of Head, Neck and Sensory System, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy3Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giovanni Sorrenti
- Department of Head, Neck and Sensory System, Otorhinolaryngolologic Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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23
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De Vito A, Agnoletti V, Zani G, Corso RM, D'Agostino G, Firinu E, Marchi C, Hsu YS, Maitan S, Vicini C. The importance of drug-induced sedation endoscopy (D.I.S.E.) techniques in surgical decision making: conventional versus target controlled infusion techniques-a prospective randomized controlled study and a retrospective surgical outcomes analysis. Eur Arch Otorhinolaryngol 2017; 274:2307-2317. [PMID: 28213776 DOI: 10.1007/s00405-016-4447-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/27/2016] [Indexed: 11/29/2022]
Abstract
Drug-Induced Sedation Endoscopy (DISE) consists of the direct observation of the upper airways during sedative-induced sleep, allowing the identification of the sites of pharyngeal collapse, which is the main pathological event in Obstructive Sleep Apnea (OSA). The Authors have compared Target Controlled Infusion (TCI) sedation endoscopy (TCI-DISE) technique to conventional DISE (CDISE), performed by a manual bolus injection of sedative agent, to recreate accurately and safely snoring and apnea patterns comparable to natural sleep. The authors conducted a prospective, randomized, long-term study and a retrospective analysis of surgical outcomes. The apnea-event observation and its correlation with pharyngeal collapse patterns is the primary endpoint; secondary endpoints are defined as stability and safety of sedation plan of DISE-TCI technique. From January 2009 to January 2011, OSA patients were included in the study and randomly allocated into two groups: the bolus injection conventional DISE group and the TCI-DISE group. Third endpoint is to compare the surgical outcomes enrolling OSA patients from January 2009 to June 2015. We recorded the complete apnea-event at oropharynx and hypopharynx levels in 15/50 pts in conventional DISE group (30%) and in 99/123 pts in TCI-DISE group (81%) (p < 0.0001). Four pts needed oxygen in conventional DISE group because a severe desaturation occurred during the first bolus of propofol (1 mg/kg) (p = 0.4872 ns). We recorded instability of the sedation plan in 13 patients of conventional DISE group (65%) and 1 patient of the TCI-DISE group (5%) (p = 0.0001). In 37 TCI-DISE group surgical patients we reported a significant reduction of postoperative AHI (from 42.7 ± 20.2 to 11.4 ± 10.3) in comparison with postoperative AHI in 15 C-DISE group surgical patients (from 41.3 ± 23.4 to 20.4 ± 15.5) (p = 0.05). Our results suggest the DISE-TCI technique as first choice in performing sleep-endoscopy because of its increased accuracy, stability and safety. However, it is mandatory an accurate assessment of PSG/PM, which allows us to differentiate OSA patients in whom UA anatomical abnormalities are predominant in comparison with not-anatomical pathophysiologic factors, achieving good surgical patient's selection and outcomes as a consequence.
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Affiliation(s)
- Andrea De Vito
- Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy.
| | - Vanni Agnoletti
- Anaesthesia and Intensive Care Unit, Emergency Department, M. Bufalini Hospital, Cesena, Italy
| | - Gianluca Zani
- Anesthesia and Intensive Care Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Ruggero Massimo Corso
- Anaesthesia and Intensive Care Unit, Emergency Department, G.B. Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Giovanni D'Agostino
- Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Elisabetta Firinu
- Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Chiara Marchi
- Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Ying-Shuo Hsu
- Department of Otolaryngology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China
| | - Stefano Maitan
- Anaesthesia and Intensive Care Unit, Emergency Department, G.B. Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Claudio Vicini
- Otorhinolaryngology and Oral Surgery Unit, Department of Head and Neck Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
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24
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Gazzaz MJ, Isaac A, Anderson S, Alsufyani N, Alrajhi Y, El-Hakim H. Does drug-induced sleep endoscopy change the surgical decision in surgically naïve non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study. J Otolaryngol Head Neck Surg 2017; 46:12. [PMID: 28193298 PMCID: PMC5307859 DOI: 10.1186/s40463-017-0190-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/08/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Adenotonsillectomy is the most commonly performed operation for pediatric snoring/sleep disordered breathing (S/SDB). However, 20-40% of patients will fail to improve. Drug-induced sleep endoscopy (DISE) may provide a more individualized surgical plan and limit unsuccessful surgeries. The aim of this study was to assess the impact of DISE on surgical decision-making in surgically naïve children with S/SDB. METHODS A retrospective observational cohort study was undertaken at the Stollery Children's Hospital. Patients 3-17 years of age who underwent DISE-directed surgery for S/SDB between January 2009 and December 2015 were eligible. We excluded other indications for tonsillectomy and syndromic children. The primary outcome was the level of agreement between a DISE-based surgical decision and the reference standard based on the American Academy of Pediatrics (AAP) guidelines via un-weighted Cohen's kappa. Secondary outcomes included the frequency and type of alternate surgical targets identified by DISE. The agreement on tonsil size between in-office physical assessment and DISE was also calculated. The effectiveness of DISE-directed surgery on postoperative S/SDB was not investigated. RESULTS Five hundred fifty-eight patients were included. DISE changed the surgical plan in 35% of patients. Agreement between DISE-based and AAP clinical practice guidelines-based management was low (κ = 0.354 +/- 0.021 [95% CI 0.312-0.395]). An alternate diagnosis or surgical target was identified by DISE in 54% of patients. There was moderate agreement on tonsil size (κ = 0.44 [0.33-0.55]) between DISE and in-office clinical assessment. CONCLUSIONS This is a first phase diagnostic study, which demonstrates that DISE affects decision-making in surgically naïve children with S/SDB in up to 35% of patients. It has utility in individualizing first stage surgical treatments as well as identifying alternate targets for further surgical or medical therapy, while potentially limiting unsuccessful surgeries. Further studies to examine the effect of DISE on surgical outcomes are required.
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Affiliation(s)
- Malak Jamal Gazzaz
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, AB Canada
- Division of Otolaryngology - Head and Neck Surgery, Umm Al-Qura University, Makkah, Saudi Arabia
| | - André Isaac
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Scott Anderson
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada
| | - Noura Alsufyani
- Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada
- Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
| | - Yaser Alrajhi
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, AB Canada
- Division of Pediatric Surgery, Department of Surgery, Stollery Children’s Hospital, Edmonton, AB Canada
| | - Hamdy El-Hakim
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, AB Canada
- Division of Pediatric Surgery, Department of Surgery, Stollery Children’s Hospital, Edmonton, AB Canada
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25
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[Drug-induced sedation endoscopy-quo vadis? : Review and outlook]. HNO 2017; 65:125-133. [PMID: 28116457 DOI: 10.1007/s00106-016-0329-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Drug-induced sedation endoscopy (DISE) is a diagnostic procedure which allows evaluation of the collapsibility of the upper airway. According to expert opinion, it is possible to imitate nocturnal collapsibility and perform a realistic investigation of the site of obstruction and vibration. This should enable sufficient and precise therapeutic advice to be given solely on the basis of clinical assessment. OBJECTIVE The current publication critically evaluates the present state of development of DISE and its potential indications. MATERIALS AND METHODS A PubMed literature research was performed using "sleep" and "endoscopy" or "DISE" as keywords. Relevant publications were evaluated. RESULTS The present publication provides a historical summary of the available publications and relates these to other methods for examining obstructive sleep apnea. The present state of DISE in terms of drugs applied, grading systems, and validity is evaluated. Indications for DISE are described and critically discussed on the basis of literature data. CONCLUSION DISE provides deep insights into the genesis of obstructions of the upper airway and snoring. Although its value for diagnosis and treatment of sleep-disordered breathing could not yet be demonstrated for all non-CPAP (continuous positive airway pressure) therapies, DISE could identify predictive parameters some methods. Further potential indications for DISE might be predictive examinations for mandibular advancement devices and respiration-synchronous neurostimulation of the hypoglossal nerve. DISE will thus remain a valuable diagnostic tool for obstructive sleep apnea and rhonchopathy.
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da Cunha Viana A, Mendes DL, de Andrade Lemes LN, Thuler LCS, Neves DD, de Araújo-Melo MH. Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications. Eur Arch Otorhinolaryngol 2016; 274:627-635. [PMID: 27164944 DOI: 10.1007/s00405-016-4081-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
Abstract
Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the pharynx that result in a decrease in oxyhemoglobin saturation. Nasofibrolaryngoscopy under induced sleep is a promising alternative for identifying sites of upper airway obstruction in patients with OSA. This study aimed to compare the obstruction sites screened by drug-induced sleep endoscopy (DISE) using the Nose oropharynx hypopharynx and larynx (NOHL) and Velum oropharynx tongue base epiglottis (VOTE) classifications. We also determined the relationship between OSA severity and the number of obstruction sites and compared the minimum SaO2 levels between DISE and polysomnography (PSG). This was a prospective study in 45 patients with moderate and severe OSA using DISE with target-controlled infusion of propofol bispectral index (BIS) monitoring. The retropalatal region was the most frequent obstruction site, followed by the retrolingual region. Forty-two percent of patients had obstruction in the epiglottis. Concentrically shaped obstructions were more prevalent in both ratings. The relationship between OSA severity and number of obstruction sites was significant for the VOTE classification. Similar minimum SaO2 values were observed in DISE and PSG. The VOTE classification was more comprehensive in the analysis of the epiglottis and pharynx by DISE and the relationship between OSA severity and number of affected sites was also established by VOTE. The use of BIS associated with DISE is a reliable tool for the assessment of OSA patients.
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Affiliation(s)
- Alonço da Cunha Viana
- Graduate Program of Neurology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil. .,Otorhinolaryngology Department, Marcílio Dias Naval Hospital, Cezar Zania,138, Lins de Vasconcelos, Rio de Janeiro, 20725-090, Rio de Janeiro, Brazil.
| | - Daniella Leitão Mendes
- Otorhinolaryngology Department, Marcílio Dias Naval Hospital, Cezar Zania,138, Lins de Vasconcelos, Rio de Janeiro, 20725-090, Rio de Janeiro, Brazil
| | | | - Luiz Claudio Santos Thuler
- Graduate Program of Neurology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil.,Clinical Research Coordination at the National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Denise Duprat Neves
- Graduate Program of Neurology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil.,Cardiopulmonary Department, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Maria Helena de Araújo-Melo
- Graduate Program of Neurology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil.,Otorhinolaryngology Department, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
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Kellner P, Herzog B, Plößl S, Rohrmeier C, Kühnel T, Wanzek R, Plontke S, Herzog M. Depth-dependent changes of obstruction patterns under increasing sedation during drug-induced sedation endoscopy: results of a German monocentric clinical trial. Sleep Breath 2016; 20:1035-43. [DOI: 10.1007/s11325-016-1348-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/07/2016] [Accepted: 04/12/2016] [Indexed: 11/25/2022]
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Lo YL, Ni YL, Wang TY, Lin TY, Li HY, White DP, Lin JR, Kuo HP. Bispectral Index in Evaluating Effects of Sedation Depth on Drug-Induced Sleep Endoscopy. J Clin Sleep Med 2015; 11:1011-20. [PMID: 25979098 DOI: 10.5664/jcsm.5016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 03/25/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the effect of sedation depth on drug-induced sleep endoscopy (DISE). METHODS Ninety patients with obstructive sleep apnea (OSA) and 18 snorers underwent polysomnography and DISE under bispectral index (BIS)-guided propofol infusion at two different sedation levels: BIS 65-75 (light sedation) and 50-60 (deep sedation). RESULTS For the patients with OSA, the percentages of velopharynx, oropharynx, hypopharynx, and larynx obstructions under light sedation were 77.8%, 63.3%, 30%, and 33.3%, respectively. Sedation depth was associated with the severity of velopharynx and oropharynx obstruction, oropharynx obstruction pattern, tongue base obstruction, epiglottis anteroposterior prolapse and folding, and arytenoid prolapse. In comparison, OSA severity was associated with the severity of velopharynx obstruction, severity of oropharynx obstruction, and arytenoid prolapse (odds ratio (95% confidence interval); 14.3 (4.7-43.4), 11.7 (4.2-32.9), and 13.2 (2.8-62.3), respectively). A good agreement was noted between similar DISE findings at different times and different observers (kappa value 0.6 to 1, respectively). A high percentage of arytenoid prolapse (46.7% among the patients with OSA under light sedation) was noted. CONCLUSIONS Greater sedative depth increased upper airway collapsibility under DISE assessment. DISE under BIS-guided propofol infusion, and especially a level of 65-75, offers an objective and reproducible method to evaluate upper airway collapsibility. Some findings were induced by drug sedation and need careful interpretation. Specific arytenoid prolapse patterns were noted for which further investigations are warranted. CLINICAL TRIALS REGISTRATION http://www.clinicaltrials.gov, identifier: NCT01100554. COMMENTARY A commentary on this article appears in this issue on page 965.
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Affiliation(s)
- Yu-Lun Lo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan.,Healthcare Center, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yung-Lun Ni
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan.,Department of Chest Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Tsai-Yu Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
| | - Ting-Yu Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
| | - Hsueh-Yu Li
- Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
| | - David P White
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, School of Medicine, Taipei, Taiwan
| | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
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Drug-induced sleep endoscopy and simulated snoring in patients with sleep-disordered breathing: agreement of anatomic changes in the upper airway. Eur Arch Otorhinolaryngol 2015; 272:2541-50. [DOI: 10.1007/s00405-015-3559-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/10/2015] [Indexed: 10/23/2022]
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[Sk2 guidelines"diagnosis and therapy of snoring in adults" : compiled by the sleep medicine working group of the German Society of Otorhinolaryngology, Head and Neck Surgery]. HNO 2014; 61:944-57. [PMID: 24221222 DOI: 10.1007/s00106-013-2775-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
These guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patient's medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not-at least as we currently understand it-a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.
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Sneezing during drug-induced sedation endoscopy. Sleep Breath 2014; 18:451-2. [DOI: 10.1007/s11325-014-1007-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/14/2014] [Indexed: 11/26/2022]
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De Vito A, Carrasco Llatas M, Vanni A, Bosi M, Braghiroli A, Campanini A, de Vries N, Hamans E, Hohenhorst W, Kotecha BT, Maurer J, Montevecchi F, Piccin O, Sorrenti G, Vanderveken OM, Vicini C. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 2014; 18:453-65. [PMID: 24859484 DOI: 10.1007/s11325-014-0989-6] [Citation(s) in RCA: 193] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 04/04/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting. METHODS The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique. RESULTS A proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system. CONCLUSIONS Although consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.
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Affiliation(s)
- Andrea De Vito
- Special Surgery Department, Ear-Nose-Throat Unit, Morgagni-Pierantoni Hospital, Via Forlanini 34, 47121, Forlì, Italy
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Carrasco Llatas M, Dalmau Galofre J, Zerpa Zerpa V, Marcano Acuña M, Mompó Romero L. Drug-induced Sleep Videoendoscopy: Clinical Usefulness and Literature Review. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2014. [DOI: 10.1016/j.otoeng.2014.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stuck BA, Dreher A, Heiser C, Herzog M, Kühnel T, Maurer JT, Pistner H, Sitter H, Steffen A, Verse T. Diagnosis and treatment of snoring in adults-S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery. Sleep Breath 2014; 19:135-48. [PMID: 24729153 DOI: 10.1007/s11325-014-0979-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 02/18/2014] [Accepted: 03/31/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This guideline aims to promote high-quality care by medical specialists for subjects who snore and is designed for everyone involved in the diagnosis and treatment of snoring in an in- or outpatient setting. DISCUSSION To date, a satisfactory definition of snoring is lacking. Snoring is caused by a vibration of soft tissue in the upper airway induced by respiration during sleep. It is triggered by relaxation of the upper airway dilator muscles that occurs during sleep. Multiple risk factors for snoring have been described and snoring is of multifactorial origin. The true incidence of snoring is not clear to date, as the incidence differs throughout literature. Snoring is more likely to appear in middle age, predominantly in males. Diagnostic measures should include a sleep medical history, preferably involving an interview with the bed partner, and may be completed with questionnaires. Clinical examination should include examination of the nose to evaluate the relevant structures for nasal breathing and may be completed with nasal endoscopy. Evaluation of the oropharynx, larynx, and hypopharynx should also be performed. Clinical assessment of the oral cavity should include the size of the tongue, the mucosa of the oral cavity, and the dental status. Furthermore, facial skeletal morphology should be evaluated. In select cases, technical diagnostic measures may be added. Further objective measures should be performed if the medical history and/or clinical examination suggest sleep-disordered breathing, if relevant comorbidities are present, and if the subject requests treatment for snoring. According to current knowledge, snoring is not associated with medical hazard, and generally, there is no medical indication for treatment. Weight reduction should be achieved in every overweight subject who snores. In snorers who snore only in the supine position, positional treatment can be considered. In suitable cases, snoring can be treated successfully with intraoral devices. Minimally invasive surgery of the soft palate can be considered as long as the individual anatomy appears suitable. Treatment selection should be based on individual anatomic findings. After a therapeutic intervention, follow-up visits should take place after an appropriate time frame to assess treatment success and to potentially indicate further intervention.
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Affiliation(s)
- Boris A Stuck
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany,
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Pilaete K, De Medts J, Delsupehe KG. Drug-induced sleep endoscopy changes snoring management plan very significantly compared to standard clinical evaluation. Eur Arch Otorhinolaryngol 2013; 271:1311-9. [DOI: 10.1007/s00405-013-2795-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
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[Drug-induced sleep videoendoscopy: clinical usefulness and literature review]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013; 65:183-90. [PMID: 24094447 DOI: 10.1016/j.otorri.2013.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 06/17/2013] [Accepted: 06/20/2013] [Indexed: 11/23/2022]
Abstract
Fiberoptic examination of the pharynx under drug-induced sleep is a test that helps to detect the areas of vibration and collapse in patients with sleep-disordered breathing. This article is a review of the available literature on the subject, aimed at helping otolaryngologists to understand the procedure and to resolve some controversies surrounding it.
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Hong SD, Dhong HJ, Kim HY, Sohn JH, Jung YG, Chung SK, Park JY, Kim JK. Change of obstruction level during drug-induced sleep endoscopy according to sedation depth in obstructive sleep apnea. Laryngoscope 2013; 123:2896-9. [PMID: 23918761 DOI: 10.1002/lary.24045] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 12/12/2012] [Accepted: 01/17/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS We evaluated the change in upper airway collapse according to the depth of sedation during drug-induced sleep endoscopy (DISE), as well as characteristics possibly associated with that change. STUDY DESIGN Prospective, single center, observational study. METHODS Twenty-nine patients with upper airway collapse were twice evaluated using DISE according to the depth of sedation, as confirmed by the bispectral index (BIS), which is a measure of the level of consciousness. Changes in the site and degree of obstruction according to the change in sedation depth at the retropalatal and the retroglossal levels were evaluated. The possible contributing factors of this change were explored. RESULTS As DISE sedation deepened, the upper airway became narrower in 37% of patients at the retropalatal level and in 44.8% of patients at the retroglossal level. No clinical, polysomnographic, or cephalometric variables showed any association with the change in the degree of retroglossal airway narrowing, with the exception of mouth breathing during DISE. CONCLUSIONS The degree of upper airway narrowing can be aggravated according to the sedation depth. The monitoring of sedation depth during DISE is critical, especially in patients with mouth breathing.
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Affiliation(s)
- Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
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Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography. Eur Arch Otorhinolaryngol 2013; 271:181-7. [PMID: 23665745 DOI: 10.1007/s00405-013-2548-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
The purpose of the present study was to compare pharyngeal and polysomnographical findings during drug-induced sleep endoscopy (DISE) performed with either propofol or midazolam as a single sedative agent. It is prospective, non-randomized, double-blinded case series study. Sixteen patients with sleep disordered breathing were sedated first with propofol and after full wake up with midazolam. Simultaneous polysomnography (PSG) was performed. We compared the zones of obstruction and vibration found with both drugs using the VOTE classification. Simultaneous PSG findings are also compared. There were 15 men and one woman; the mean age was 42.7 years old, mean body mass index 26.9 kg/m(2). Average DISE duration was 20 min with Propofol and 14.3 min with Midazolam. The induced sleep stage obtained was N2 with both drugs. Outpatient physical exam did not correlate with drug-induced sleep findings. There was a good correlation between DISE results with both drugs in all the areas of collapse except the velum (p < 0.005). Using a continuous perfusion, there is a good agreement in the findings observed in DISE performed with propofol and midazolam and PSG.
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Kotecha B, Kumar G, Sands R, Walden A, Gowers B. Evaluation of upper airway obstruction in snoring patients using digital video stroboscopy. Eur Arch Otorhinolaryngol 2013; 270:2141-7. [PMID: 23392750 DOI: 10.1007/s00405-013-2370-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/17/2013] [Indexed: 10/27/2022]
Abstract
Stroboscopy is routinely used in voice disorder clinics but its use in studying the mechanisms of upper airway obstruction in patients who snore has not yet been described. This study combines the use of stroboscopy during sleep nasendoscopy to evaluate the oscillations and vibrations observed during snoring in slow motion. In addition, we utilised the multi-dimensional voice programme simultaneously to study some of the acoustic parameters of snoring whilst visualising the dynamics of the upper airway. Forty-five patients with primary snoring or mild obstructive sleep apnoea were recruited at two different centres and underwent sleep nasendoscopy. The simultaneous use of acoustic analysis was included to ascertain whether sound analysis alone could replace the need for using the sedation endoscopy in these patients. The use of a stroboscopic light source indeed enhanced the visualisation during the procedure and some subtle aspects of the mechanisms of upper airway obstruction, such as vibrations of the posterior pharyngeal wall and mucosal waves were identified. Most of the patients in this study exhibited multilevel obstruction and thus acoustic analysis alone would not be sufficient in accurately locating the site of upper airway obstruction in snorers.
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Affiliation(s)
- Bhik Kotecha
- ENT Department, Queens Hospital, Rom Valley Way, Romford, Essex, RM7 0AG, UK.
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The Utility of Sleep Endoscopy in Adults with Obstructive Sleep Apnea: A Review of the Literature. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-012-0005-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ozdas T, Ozcan KM, Ozdogan F, Ozcan I, Selcuk A, Cetin MA, Dere H. Investigation of lateral pharyngeal walls in OSAS. Eur Arch Otorhinolaryngol 2012; 270:767-71. [PMID: 23064460 DOI: 10.1007/s00405-012-2212-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 09/26/2012] [Indexed: 01/19/2023]
Abstract
The aim of this study is to investigate the relationship between the site of obstruction detected on Müller's maneuver and the polysomnography findings in patients with obstructive sleep apnea syndrome. This study is a prospective cohort study in a setting of Tertiary referral center. The study was performed on 87 patients (59 males and 28 females) with a mean age of 50 ± 10.34 years (range 20-83 years) who presented with the complaints of snoring, apnea, witnessed apnea and daytime sleepiness. The height and body weight of the enrolled patients were measured and the body mass indexes were calculated. The obstruction degrees of the soft palate and lateral pharyngeal walls at the level of the soft palate and the obstruction degrees of the tongue base and lateral pharyngeal walls at the level of the tongue base were determined using the Müller's maneuver. All patients underwent whole-night polysomnography at our hospital's Sleep Center. The apnea-hypopnea index values of the patients increased as their ages and body mass index values increased. There was a highly statistically significant correlation between apnea-hypopnea index and the obstruction degree of the lateral pharyngeal walls at the level of the tongue base on Müller's maneuver (p < 0.01). We found that the apnea-hypopnea index increased as the obstruction degree of the lateral pharyngeal walls increased on Müller's maneuver. In patients with obstructive sleep apnea syndrome, a high apnea-hypopnea index can be predicted if the obstruction degree of the lateral pharyngeal walls is high at the level of the tongue base on Müller's maneuver.
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Affiliation(s)
- Talih Ozdas
- ENT Clinic, Yenimahalle State Hospital, Ankara, Turkey
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