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

Surgical failure guided by DISE in patients with obstructive sleep apnea: a systematic review and meta-analysis

OBJECTIVES

The failure rate and risk factors of upper airway surgery with drug induced sleep endoscopy (DISE) remain unknown in the treatment of obstructive sleep apnea (OSA). This review aims to analyze the failure rate of upper airway surgery with DISE and identify obstruction sites for surgical failure.

METHODS

A systematic review was conducted using PubMed, Embase, Web of Science, and Google Scholar until May 20th, 2023. We included studies that used DISE to assess obstructive sites before upper airway surgery and reported surgical failure rates and outcomes in patients with OSA.

RESULTS

25 studies with a total of 1522 patients were included in the systematic review and meta-analysis. Upper airway surgery guided by DISE had a relatively low failure rate of 37% (95% CI 0.31-0.44) in the random effects model (I2 = 85.97%, P < 0.001). According to the velum, oropharynx, tongue base, and epiglottis (VOTE) scoring system, major risk factors for surgical failure included circumferential collapse at the velum, lateral wall collapse and small tonsils at the oropharynx, anterior-posterior lingual collapse and complete collapse at the tongue base. High body mass index and large preoperative apnea hypopnea index were also risk factors for OSA surgical failure.

CONCLUSIONS

Upper airway surgery guided by DISE in patients with OSA had a low failure rate of 37%. DISE can identify obstruction sites associated with surgical failure and guide single-level and multi-level surgeries.

Predictors of surgical outcomes for limited palatal muscle resection in patients with obstructive sleep apnea

OBJECTIVE

Limited palatal muscle resection (LPMR) is a modified palatal surgical technique to correct retropalatal obstruction without complications. This study aims to determine the associated factors affecting the success and cure rate of LPMR in patients with obstructive sleep apnea (OSA), thus guiding patient selection and improving surgical outcome.

METHODS

Thirty-five OSA patients underwent LPMR were enrolled. All patients received routine physical examination, preoperative drug-induced sleep endoscopy (DISE), and polysomnography (PSG). Clinical, polysomnographic, cephalometric variables, and DISE findings were evaluated. These measurements were compared between the surgical success and failure group based on the results of preoperative and postoperative PSG. Furthermore, we compared the cured and non-cured groups in the surgical success group.

RESULTS

Among 35 patients, the overall success rate was 57 % with a cure rate of 31.4 %. Patients with Friedman stage II had a significantly higher success rate (p = 0.032). According to DISE results, tongue base obstruction affected the surgical outcome (p < 0.001). The success rate was 100 % in the no tongue base obstruction during DISE, 72.2 % in the partial obstruction, and 9.1 % in the total obstruction. Tonsil size is also helpful in predicting surgical success rate (p = 0.041). Furthermore, patients with mild AHI were more likely to be surgical cures. when compared with patients with severe AHI (p = 0.044).

CONCLUSION

Patients with larger tonsil size and no tongue base obstruction during DISE may have a higher chance of surgical success with LPMR. The lower AHI may be predictors of surgical cure after LPMR.

Limited Palatal Muscle Resection for the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

Background and Objectives: Limited palatal muscle resection (PMR) is a surgical technique employed to alleviate respiratory disturbances in obstructive sleep apnea (OSA) patients with retropalatal narrowing by reducing soft palate volume and tightening the muscles. Although some previous publications have demonstrated the effectiveness of limited PMR, the overall efficacy and therapeutic role of limited PMR for the treatment of OSA remain uncertain. This study utilized meta-analysis and a systematic literature review to estimate the overall effectiveness of limited PMR in treating OSA. Materials and Methods: Multiple databases, including PubMed, EMBASE, Cochrane Library, and Web of Science, were searched using specific keywords related to OSA and limited PMR. Original articles assessing respiratory disturbances before and after limited PMR in patients with OSA were included. Data from selected articles were collected using standardized forms, including clinicodemographic characteristics, apnea-hypopnea index (AHI), and lowest pulse oximetry values (minimum SpO2). Random effect models were used for analyzing significant heterogeneity. Egger's test and funnel plot were used to identify publication bias. Results: Four studies were included in this meta-analysis for AHI, and three studies were included for minimum SpO2 during sleep. A significant reduction in the AHI and an increase in the minimum SpO2 were shown following limited PMR as the standardized mean difference (95% confidence interval) was 2.591 (1.092-4.090) and 1.217 (0.248-2.186), respectively. No publication bias was found in either analysis. Conclusions: The results of the meta-analysis and systemic review add to the literature that limited PMR can result in a reduction in the AHI and an increase in min SaO2. In OSA patients with suspected retropalatal obstruction, limited PMR may be efficiently performed.

Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement

STUDY OBJECTIVES

(1) To investigate if drug-induced sleep endoscopy (DISE) findings are predictive of surgical response for patients undergoing maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) and (2) to investigate the predictive value of the jaw thrust maneuver during DISE in terms of surgical response to MMA.

METHODS

A retrospective cohort study was conducted in patients with OSA who underwent a baseline polysomnography (PSG) and DISE followed by MMA and a 3- to 6-month follow-up PSG between September 1, 2011, and September 30, 2020.

RESULTS

Sixty-four patients with OSA (50 males [78.1%]; mean ± SD age = 51.7 ± 9.5 years; mean ± SD apnea-hypopnea index = 49.0 ± 20.8 events/h) were included. Thirty-nine patients were responders, and 25 were nonresponders. Adjusting for baseline characteristics and surgical characteristics (eg, age, baseline apnea-hypopnea index, degree of maxillary advancement), patients with complete anteroposterior epiglottic collapse had 0.239 times lower odds for response to MMA (95% confidence interval, 0.059-0.979; P = .047). No significant relationship was found between complete concentric velum collapse and MMA response. There was no statistically significant association between effect of jaw thrust maneuver during DISE on upper airway patency and treatment outcome of MMA.

CONCLUSIONS

This study indicates that DISE is a promising tool to identify patients who will or will not respond to MMA for treating OSA. Patients with complete anteroposterior epiglottic collapse may be less suitable candidates for MMA.

CITATION

Zhou N, Ho J-PTF, de Vries N, Bosschieter PFN, Ravesloot MJL, de Lange J. Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement. J Clin Sleep Med. 2022;18(4):1073-1081.

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

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

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

PURPOSE

Obstructive sleep apnea (OSA) is a common sleep disorder that can be corrected with upper airway surgery. Prior to surgery, drug-induced sleep endoscopy (DISE) is routinely used to evaluate obstruction sites and severity. Evidence suggests that the findings of DISE may relate to the final surgical outcome. Therefore, we evaluated the ability of drug-induced sleep endoscopy to predict the final effect of upper airway surgery and potentially to guide surgical treatment decision-making.

METHODS

A retrospective analysis was conducted on 85 adult patients with OSA (50 men with mean apnea-hypopnea index [AHI] 30 ± 15 events/h) who underwent DISE followed by tonsillectomy, uvulopalatopharyngoplasty (UPPP), or a combination of the two. Surgery outcome was evaluated at follow-up by polysomnography. Success response to surgery was defined as a postoperative value of the AHI< 20 events/h and more than 50% postoperative reduction of AHI.

RESULTS

Of the 85 patients evaluated, 48 (53%) were responders. DISE revealed significant differences between the two groups. Specifically, complete circumferential collapse at the velum and complete anterior-posterior collapse at the tongue base occurred at higher frequencies in nonresponders. In contrast, the presence of grade 3-4 tonsillar hypertrophy and anterior-posterior mild/partial collapse at the velum were positively associated with responders.

CONCLUSIONS

Our results suggest that DISE may help predict the final outcome of tonsillectomy, UPPP, or a combination of the two in adult patients with OSA. The use of DISE shows potential to guide treatment decisions for individual patients with OSA.