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

A comparison of the outcomes of tonsillectomy and expansion sphincter pharyngoplasty operations in patients with obstructive sleep apnea

OBJECTIVE

To compare the efficacy of tonsillectomy and expansion sphincter pharyngoplasty (ESP) in the surgical treatment of obstructive sleep apnea (OSA).

METHODS

OSA patients with Friedman grade III-IV tonsil hypertrophy diagnosed with polysomnography were separated into two groups according to the surgery performed, as the classic tonsillectomy group (Group 1) and the ESP group (Group 2). The primary endpoint of the study was to determine the Apnea-Hypopnea Index (AHI) value.

RESULTS

Group 1 comprised 24 patients with median preoperative AHI of 19.7 and postoperative AHI of median 11.8 (p = .0001). Group 2 comprised 29 patients with median preoperative AHI of 25.1 and postoperative AHI of median 16.3 (p = .0001). Nine (37.5%) of the 24 patients in Group 1 accepted as cure (79.1%). Eight (27.5%) of the 29 patients in Group 2 accepted as cure (72.4%).

CONCLUSION

There was no superiority of ESP over tonsillectomy in patients with lateral pharyngeal obstruction.

Predictors of Success of Pharyngeal Surgery in the Treatment of Obstructive Sleep Apnea: A Narrative Review

(1) Background: This narrative review aims to explore the predictors of success for pharyngeal surgery in the treatment of obstructive sleep apnea (OSA). An extensive literature search was conducted, identifying relevant studies published up to June 2023, utilizing various databases and key search terms related to OSA, surgical interventions, and predictors of success. The review encompasses both retrospective and prospective studies, case series, and cohort studies to provide a broad understanding of the topic; (2) Methods: Review of English scientific literature on phenotypes of OSA related to predictors of success of pharyngeal surgery; (3) Results: Of 75 articles, 21 were included, in these the following were determined to be factors for surgical success: body mass index (BMI) (8 articles), apnea/hypopnea index (AHI) (8 articles), cephalometry (8 articles), palatine tonsil size (7 articles), Modified Mallampati score (2 articles), genioglossus electromyography (2 articles), Friedman score or upper airway anatomy (3 articles), nasopharyngolaryngoscopy (2 articles), drug-induced sleep endoscopy (DISE) (1 article), oral cavity anatomy (1 article) and oxygen desaturation index (ODI) (1 article); (4) Conclusions: The lack of standardized protocols for the indication of pharyngeal surgery is a reality, however identifying known predictors of surgical success may facilitate homogenizing indications.

Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome

OBJECTIVES

To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome.

DESIGN

A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data.

METHODS

The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results.

RESULTS

Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion.

CONCLUSION

Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

Evaluation of a nasopharyngeal stent in patients with obstructive sleep-related breathing disorders

Objective

This study was performed to evaluate the therapeutic effect and diagnostic value of a novel nasopharyngeal stent (Naśtent; Corinium Medical Equipment Ltd., Cirencester, UK). The Naśtent is designed to stent palatal collapse in patients with sleep-related breathing disorders.

Methods

The study was conducted from 2018 to 2019. Patients who did not qualify for continuous positive airway pressure therapy underwent split-night examination with an inserted Naśtent for the first half of the night. The next morning, drug-induced sleep endoscopy (DISE) was performed.

Results

Of the 122 enrolled patients, 21 were excluded because of Naśtent intolerance (n = 14) or technically invalid examinations (n = 7). Among the remaining 101 patients, in correlation with DISE, the apnea–hypopnea index was significantly reduced in patients with palatal obstructions, mainly in those with anteroposterior collapse patterns. The Naśtent did not influence retrolingual or multilevel obstructions. Using a 40% reduction of the apnea–hypopnea index by the Naśtent as a cut-off value, 85.7% of soft palate obstructions were detected compared with DISE.

Conclusions

The Naśtent is a viable tool to reduce palatal obstructions, although it is not readily tolerated. It may also be helpful for diagnosis of sleep-related breathing disorders when DISE is unavailable.

OSAS and upper pharynx surgery: Does basilingual collapsus always rhyme with failure?

OBJECTIVE

Drug-induced-sedation endoscopy (DISE) has proved superior to awake clinical examination for diagnosis of upper-airway obstruction sites and surgical planning. Our question is: does multilevel obstruction on DISE systematically entail failure for surgery limited to the upper pharynx?

MATERIAL & METHODS

We conducted a retrospective single-center study in patients with obstructive sleep apnea syndrome (OSAS) treated by single-level surgery of the upper pharynx (tonsillectomy with or without pharyngoplasty). Preoperative assessment included polysomnography (PSG) and DISE. Surgical efficacy was assessed on postoperative PSG. Treatment response was defined by postoperative apnea-hypopnea index (AHI) <20 events/h with 50% reduction, and cure by AHI <10 (patients with preoperative AHI ≤10 being excluded). Efficacy was compared between groups without (group A) and with basilingual or laryngeal collapsus on DISE (group B).

RESULTS

We analyzed 63 patients, with mean preoperative AHI 33.8±17.9 events/h. The two groups (A, n=36; B, n=27) were clinically comparable. Postoperative PSG took place at a mean 8.5 ± 11.5 months. The success rate was 66.7% in group A (mean reduction in AHI, 57.3±36.2%) and 59.3% in group B (mean reduction, 53.9±39.2%). Cure rates were respectively 48.5% and 48.1%. There was no statistically significant difference between the two groups (P>0.1).

CONCLUSIONS

Oropharyngeal surgery can alleviate associated obstructive sites found on DISE in the lower pharynx, and step-by-step treatment shows efficacy equal to that of single-step multilevel surgery.

[Progress of diagnosis and treatment of upper respiratory obstruction in patients with Treacher Collins syndrome]

Objective

To summarize the progress of diagnosis and treatment of upper respiratory obstruction in patients with Treacher Collins syndrome (TCS).

Methods

The domestic and abroad literature about the diagnosis and treatment of upper respiratory obstruction in patients with TCS was extensively reviewed and analyzed.

Results

TCS is an autosomal-dominant craniofacial developmental syndrome. It is often accompanied by midface and/or mandibular hypoplasia, soft tissue hypertrophy, and other respiratory tissue developmental abnormalities, which can lead to different degrees of upper respiratory obstruction symptoms. Respiratory obstruction in patients with TCS is affected by many factors, and the obstructive degree are different. Early detection of the causes and obstructive sites and adopted targeted treatments can relieve the symptoms of respiratory obstruction and avoid severe complications.

Conclusion

Due to the low incidence of TCS, there is still a lack of high-quality research evidence to guide clinical treatment. Large-scale and prospective clinical studies are needed to provide new ideas for the treatment and prevention of upper respiratory obstruction.

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.

Adult sleep apnea and tonsil hypertrophy: should pharyngoplasty be associated with tonsillectomy?

PURPOSE

Velopharyngoplasty and palatine tonsillectomy are at the very heart of the surgical treatment of obstructive sleep apnea syndrome (OSAS) care. In cases of major tonsil hypertrophy, we evaluated the relevance of associating soft palate surgery with palatine tonsillectomy, independent of the soft palate length.

METHODS

We conducted a retrospective single-center study in OSAS patients with grade III or IV tonsils treated with tonsillectomy. Preoperative assessment included an upper airway examination performed while the patient was awake, a polysomnography and a drug-induced sedation endoscopy (DISE). Surgical efficacy was assessed on postoperative polysomnography. Success was considered when the postoperative apnea-hypopnea index (AHI) was less than 20 events/h with a 50% reduction. We compared palatine tonsillectomy efficacy alone (group A) and associated with soft palate surgery (group B).

RESULTS

We analyzed 33 patients who had undergone surgery between December 2006 and May 2018. Their preoperative mean BMI and mean AHI were 27.3 ± 7.5 kg/m² and 38.6 ± 21.4 events/h, respectively. The two groups (A, n = 18 and B, n = 15) were clinically comparable. The success rate was 72.2% in group A and 60% in group B. There was no statistically significant difference between the two groups (p > 0.1).

CONCLUSIONS

According to this study, in our institution, in cases of major tonsillar hypertrophy, simultaneous soft palate surgery had no significant impact on the success rate, regardless of soft palate length. Associating soft palate surgery with palatine tonsillectomy does not seem mandatory to increase the success rate.

LEVEL OF EVIDENCE

III. Retrospective comparative study.

Drug-induced sleep endoscopy-directed adenotonsillectomy in pediatric obstructive sleep apnea with small tonsils

The study aims to examine drug-induced sleep endoscopy (DISE) in the decision-making process of pediatric obstructive sleep apnea (OSA) patients with small tonsils. This was a retrospective study of children who underwent awake flexible endoscopy, DISE, and adenoidectomy with/without tonsillectomy at the Shanghai Children’s Medical Center between 03/2015 and 12/2016. Tonsillectomy was performed for tonsillar obstruction found by DISE. Adenoidectomy was performed for all children. Cardio-pulmonary coupling (CPC) and oximetry were observed before/after surgery. The study included 126 children: 56 (44.4%) with grade 2 tonsils and 70 (55.6%) with grade 1. Mean age was 5.7±3.2 (range, 2.8–10.4) years and mean BMI of 15.7±5.5 kg/m². Unexpectedly, DISE showed tonsillar obstruction in 57 (45.2%) children, including 44 (78.6%) with grade 2 tonsils and 13 (18.6%) with grade 1. Therefore, DISE-directed tonsillectomy was performed for 57 patients. There was an improvement in respiratory disturbance index (RDI) and oxygen saturation nadir in the DISE (P = 0.0007, P = 0.037) and control (P = 0.001, P = 0.023) groups 6 months after surgery, but RDI improvement was better in the DISE group compared with controls 1 year after surgery (P = 0.042). DISE is a good way to determine the necessity of tonsillectomy in pediatric OSA patients with small tonsils.

Is epiglottis surgery necessary for obstructive sleep apnea patients with epiglottis obstruction?

OBJECTIVES/HYPOTHESIS

To examine the effect of epiglottis obstruction during drug-induced sleep endoscopy (DISE) on the surgical results of multilevel sleep surgery without epiglottic intervention.

STUDY DESIGN

Cross-sectional study.

METHODS

This investigation involved patients diagnosed with severe obstructive sleep apnea (OSA) based on preoperative polysomnography (PSG), who underwent DISE followed by multilevel OSA surgery without epiglottic intervention at Kyung Hee Medical Center (Seoul, South Korea) between March 2013 and July 2016. During DISE, obstruction patterns of the upper airway were evaluated using the velum, oropharynx, tongue base, epiglottis classification method. Follow-up PSG was performed 3 months after surgery to determine the success rate of multilevel surgery without epiglottic intervention. A comparison was done between the group with epiglottis obstruction and the group without epiglottis obstruction.

RESULTS

Epiglottis obstruction was observed during DISE in 43.7% of patients. After application of exclusion criteria, 54 subjects were included (27 with and 27 without epiglottis obstruction). DISE revealed an association between epiglottis obstruction and tongue base collapse (P = .02). Comparing pre- and postoperative PSG findings, both groups exhibited improvement postoperatively. The success rate was 44.4% in the epiglottis obstruction group and 40.7% in the non-epiglottis obstruction group (P = .80). There was no difference in surgical success rates between the two groups.

CONCLUSIONS

The prevalence of epiglottis obstruction requiring epiglottic surgery was lower than what was found during DISE. Sleep surgeons may consider staged epiglottic surgery in patients with epiglottis obstruction.

LEVEL OF EVIDENCE

3b Laryngoscope, 129:2658-2662, 2019.

Lingual tonsillectomy with palatal surgery for the treatment of obstructive sleep apnea in adults: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to evaluate effects of lingual tonsillectomy with palatal surgery as a combined procedure for the treatment of obstructive sleep apnea (OSA) in adults.

SEARCH METHODS

Data source: a comprehensive search of MEDLINE, Scopus, Ovid, Web of Science, and the Cochrane Library was performed through November 2017. Manual searches and subject matter expert input were also obtained. This review includes studies assessing efficacy of lingual tonsillectomy with palatal surgery as a combined procedure for the treatment of OSA in adults, who had multilevel obstruction including lingual tonsil hypertrophy, in which apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) were reported.

RESULTS

A total of four studies (107 patients) met our inclusion criteria. Pooled random effects analysis demonstrated a statistically significant improvement of polysomnographic respiratory events postoperatively, with average AHI reduction of 18.51 events per hour, [95% confidence interval (CI) (- 31.72, - 5.31); P = 0.006] and increase in minimal arterial oxygen saturation of 5.26 [95% CI (0.10, 10.42); P = 0.05]. The result also showed that the procedures significantly improved sleepiness resulting in an average Epworth Sleepiness Scale (ESS) reduction of 5.44 [95% CI (- 8.69, - 2.18); P = 0.001].

CONCLUSION

A combination of lingual tonsillectomy with palatal surgery may offer benefits in a selected group of OSA adults, in terms of apnea/hypopnea index, minimal arterial oxygen saturation and Epworth Sleepiness Scale. Data were based on meta-analysis of all case series with 2-6 months' follow-up.

Does Sleep Endoscopy Staging Pattern Correlate With Outcome of Advanced Palatopharyngoplasty for Moderate to Severe Obstructive Sleep Apnea?

STUDY OBJECTIVES

Although drug-induced sleep endoscopy (DISE) is an accepted method to localize upper airway obstruction, it is not known whether all sites identified by DISE must be treated to achieve sufficient apnea-hypopnea index (AHI) improvement. The aim of this study was to compare outcomes for unilevel (upper) versus multilevel DISE collapse patterns in a patient cohort that only underwent modern palatopharyngoplasty. Our hypothesis was that not all tongue base-level obstructions on DISE must be treated.

METHODS

Thirty-eight patients with mean AHI of 45 events/h underwent DISE followed by palatopharyngoplasty. Outcome was measured by polysomnography or home sleep apnea testing.

RESULTS

Eleven patients (29%) had multilevel, complete tongue base obstruction and nineteen (50%) had no obstruction. These two groups were similar in age, body mass index, and AHI; the complete group had smaller tonsils and higher tongue position. The postoperative success rate and AHI in the group without tongue base obstruction were not significantly different from those of the complete group (68%; 17.4 ± 11.0 versus 73%; 15.4 ± 20.5, P > .99). Seventeen patients (45%) had circumferential collapse of velum. The postoperative AHI was higher for patients with circumferential collapse (23.6 ± 15.8 from 55.3 ± 22.1 versus 10.5 ± 9.94 from 36.4 ± 16.7, P < .0001), but both groups had clinically and statistically significant AHI reductions.

CONCLUSIONS

Patients with multilevel obstruction on DISE, treated with palatopharyngoplasty alone, had similar AHI outcome as those with unilevel obstruction. Multilevel surgery may not be needed in some patients with a multilevel obstruction pattern. Circumferential collapse of velum, however, was associated with a higher residual AHI.