Drug induced sleep endoscopy: its role in evaluation of the upper airway obstruction and patient selection for surgical and non-surgical treatment

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.

Health-Related Quality of Life and Sleep Quality after 12 Months of Treatment in Nonsevere Obstructive Sleep Apnea: A Randomized Clinical Trial with Continuous Positive Airway Pressure and Mandibular Advancement Splints

“…CPAP treatment effectively reduces the number of pharyngeal soft tissue collapses, which cause the breathing cessations, by creating a pneumatic splint in the upper airways, regardless of OSA severity [ 18 ]. By comparison, the efficacy of the MAS treatment is harder to predict without using less accessible procedures such as remotely controlled mandibular protrusion during sleep [ 19 ] or drug-induced sleep endoscopy [ 20 , 21 ], especially in moderate and severe OSA [ 22 , 23 ]. However, better compliance with MAS treatment makes the overall effectiveness of the two treatments comparable [ 24 ] and they are probably equally effective at preventing negative health outcomes associated with OSA [ 25 – 27 ].…”

Drug‐Induced Sleep Endoscopy Upper Airway Collapse Patterns and Maxillomandibular Advancement

“…To improve DISE methods and its modalities, large observational cohort studies on DISE and treatment outcomes are imperative. As such, more insight into the diversity of the general OSA population could be gained, but more importantly, could lead to a high level of personalized treatment workup for a given patient.…”

Drug-Induced Sleep Endoscopy: A Guide for Treatment Selection

“…However, if a patient refuses to undergo CPAP and wants an operation, OSA surgery with tonsillectomy and soft palate surgery, which can sustain the lateral wall of the pharynx, such as suspension lateral pharyngoplasty, relocation pharyngoplasty, expansion sphincter pharyngoplasty, zpharyngoplasty, and barbed reposition pharyngoplasty can be performed as an alternative treatment. DISE may show obstruction of the laryngeal inlet caused by posterior retraction of the epiglottis, and surgical laser wedge resection can be performed to open the laryngeal inlet [24]. However, as a recent European position paper on DISE indicated, further investigations are required to evaluate in detail whether or not certain DISE findings are related to treatment outcomes [25].…”