Drug-Induced Sleep Endoscopy

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Key points

  • Obstructive sleep apnea is a heterogenous disorder characterized by a number of distinct phenotypes of upper airway collapse.

  • Evaluating dynamic pharyngeal collapse in the sleeping patient is clinically challenging.

  • Drug-induced sleep endoscopy is a safe, effective outpatient procedure for reliably assessing upper airway obstruction in the sleeping patient.

  • Although numerous reporting methods exist for drug-induced sleep endoscopy findings, the VOTE (Velum, Oropharynx, Tongue base and Epiglottis)

Introduction: nature of the problem

Obstructive sleep apnea (OSA) is a heterogeneous disorder represented by a wide spectrum of pharyngeal dysfunction. Modern surgical techniques are used to address the various clinical phenotypes. However, assessment of the site, extent, and severity of the obstructive event in the sleeping patient is a clinical challenge.

Early methods of assessment included Mueller’s maneuver (forced inspiration against a closed glottis during awake endoscopy), lateral cephalometry, and computed tomography.

Preoperative Planning

After undergoing thorough clinical assessment including a complete head and neck, and oral–maxillofacial examination suitable candidates can be considered for DISE.

Preparation and patient positioning

The patient should be positioned supine and comfortable in a semidark and silent operating or endoscopy suite. In our practice, we do not provide

Pearls and pitfalls

The relatability of DISE to naturally induced sleep has been discussed in the literature at length. Propofol-induced sleep induces a lower minimum O2 saturation (SaO2) than natural sleep. Propofol-induced sleep also results in a significant change in sleep architecture with an increase in N3 (deep or slow-wave) sleep. Finally, there is also a marked inability to observe rapid eye movement sleep during propofol sedation, a period during which OSA is known to worsen in severity.13

Clinical results in the literature

DISE is used to identify unique OSA phenotypes and thereby tailor treatment strategies. Koutsourelakis and colleagues14 found complete circumferential collapse of the velum was an important independent predictor of upper airway surgery failure. Complete lateral pharyngeal wall collapse has been demonstrated to show a strong association with disease severity, thus indicating a need for more aggressive treatment strategies in this group of patients.15 Furthermore, DISE has been used to

Summary

DISE is a safe and clinically useful tool for targeting surgical therapy, irrespective of the choice of sedation. It can also aid in the optimization of medical therapy, including oral appliances, positional devices, and continuous positive airway pressure. Beyond medical therapy, DISE is used to determine candidacy for upper airway stimulation and demonstrate disease severity in at-risk patients. The value of the procedure continues to evolve and expand, with newer applications such as

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Disclosure: The authors have nothing to disclose.

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