DISE with CPAP: a useful procedure to evaluate upper airway collapsibility.

PURPOSE: Drug-induced sleep endoscopy (DISE) is commonly performed in patients suffering obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) intolerance. We aimed to evaluate the effects of adding CPAP to DISE to provide understanding of the reason of its failure and better guidance in future therapeutic decisions. METHODS: A retrospective observational descriptive study was conducted on CPAP-intolerant patients with moderate-severe OSA. DISE was used to evaluate upper airway collapsibility, and CPAP was tested to better describe anatomical sites of obstruction and to measure the opening pharyngeal pressure. RESULTS: Sample size consisted of 38 patients with a mean age of 49 ± 9 years. Mean BMI was 28.4 ± 2.4 kg/m2, mean apnea-hypopnea index (AHI) was 35.4 events per hour ± 20.1, and mean saturation under 90% (TSat90) was 14.5%. In DISE we found a collapse at Velum in 92% of patients, at Oropharyngeal level in 89%, at tongue in 42%, and at epiglottis in 36%. In the subgroup of patients with clinical failure with CPAP, we observed 100% of epiglottic collapse and 50% of tongue obstruction. In this specific population, we recommended personalized surgery and myofunctional therapy. CONCLUSION: DISE-CPAP is a useful tool to select the treatment that better fits to each patient taking care all information available. It improves our ability to prescribe a multilevel treatment with an exhaustive topographic evaluation of upper airway collapsibility that complements CPAP classic titration, and it can be helpful to distinguish better candidates for surgery, myofunctional therapy or CPAP.

Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients.

BACKGROUND: Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE. METHODS: This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator. RESULTS: In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue. CONCLUSIONS: The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.

Palatopharyngeal Arch Staging System (PASS): Consensus about Oropharyngeal Evaluation.

Intraoral examinations are essential in the evaluation of the upper airway in patients with obstructive sleep apnea (OSA). The morphology of the anatomic structures of the soft palate, the tonsillar fossae, and the palatoglossus and palatopharyngeal muscles is an important determinant of the size and collapsibility of the velum and oropharynx. The Palatopharyngeal Arch Staging System (PASS) is a systematic way to explore the oropharynx and report anatomic variations in the visible part of the palatopharyngeal muscle. In this prospective study, 30 sleep surgeons evaluated the reliability of the PASS using a selection of 23 videos of oropharyngeal examinations of healthy patients. The corresponding score on the PASS scale was graded for each examination. For internal structure and internal agreement, the Cronbach and Krippendorff alpha values were 0.96 and 0.46, which corresponded to a nearly perfect interrelationship and a moderate agreement, respectively. These findings suggest that the PASS is a valuable tool for evaluating the position of the palatopharyngeus muscle during oropharyngeal examinations and may be useful for creating a common language for sleep surgeons when evaluating the palatopharyngeal muscle.

Optimizing Mandibular Advancement Maneuvers during Sleep Endoscopy with a Titratable Positioner: DISE-SAM Protocol.

Mandibular advancement devices (MAD) are an effective alternative treatment to CPAP. Different maneuvers were performed during drug sleep-induced endoscopy (DISE) to mimic the effect of MAD. Using the Selector Avance Mandibular (SAM) device, we aimed to identify MAD candidates during DISE using a titratable, reproducible, and measurable maneuver. This DISE-SAM protocol may help to find the relationship between the severity of the respiratory disorder and the degree of response and determine the advancement required to improve the collapsibility of the upper airway. Explorations were performed in 161 patients (132 males; 29 females) with a mean age of 46.81 (SD = 11.42) years, BMI of 27.90 (SD = 4.19) kg/m2, and a mean AHI of 26.51 (SD = 21.23). The results showed no relationship between severity and MAD recommendation. Furthermore, there was a weak positive relationship between the advancement required to obtain a response and the disease severity. Using the DISE-SAM protocol, the response and the range of mandibular protrusion were assessed, avoiding the interexaminer bias of the jaw thrust maneuver. We suggest prescribing MAD as a single, alternative, or multiple treatment approaches following the SAM recommendations in a personalized design.

Drug Induced Sleep Endoscopy Versus Awake Endoscopy in Retrolingual Obstruction Assessment in Obstructive Sleep Apnea Patients: A Comparative Study.

ABSTRACT: The aim of this study is to evaluate the correlation of retrolingual obstruction determined by drug induced sleep endoscopy (DISE) and awake endoscopy evaluation of Muller maneuver (MM) and lingual tonsil hypertrophy (LTH) in patients with obstructive sleep apnea.A prospective cohort of 100 patients with obstructive sleep apnea who underwent DISE was assessed. The inclusion criteria were age between 18 and 70 years, and apnea-hypopnea index higher than 5. Friedman staging, LTH and MM were determined by awake endoscopy, as other physical findings. The authors evaluated the correlation of retrolingual obstruction determined by DISE using velum oropharynx tongue, epiglottis (VOTE) and nose, oropharynx, hypopharynx, larynx (NOHL) classification.When retrolingual MM was assessed, significant changes between awake and DISE were observed ( P = 0.000). Conversely, Friedman stage had no significant changes to DISE retrolingual findings ( P = 0.868). Analyzing LTH and DISE retrolingual findings according to NOHL and VOTE, if a cutoff value was established at 50%, DISE findings differ from awake: NOHL ( P <0.001) and VOTE ( P = 0.004). Nevertheless, if a restrictive cutoff at 75% was attached, DISE findings were similar to awake: NOHL ( P = 0.124) and VOTE ( P = 0.123).This study demonstrates that awake endoscopy determining LTH and Friedman stage is a mild predictor of collapse at retrolingual level, showing significant correlation to DISE only when severe retrolingual collapse is present. Our findings suggest that in-office awake endoscopy may have certain predictive value to select surgical patients.

One-Stage Multilevel Surgery for Treatment of Obstructive Sleep Apnea Syndrome.

We report the results of one-stage multilevel upper airway surgery for patients who could not tolerate continuous positive airway pressure (CPAP). Patients treated with multilevel surgery at a University Hospital in 2015-2019 were identified from a prospectively maintained database. The inclusion criteria were aged 18-70 years, body mass index (BMI) < 35 kg/m2, apnea-hypopnea index (AHI) > 20, and lingual tonsil hypertrophy grade 3 or 4. Drug-induced sleep endoscopy was performed before surgery in all patients. Multilevel surgery was performed in one stage and included expansion sphincter pharyngoplasty (ESP), coblation tongue base reduction (CTBR), and partial epiglottectomy (PE) as required. The outcome measures were postoperative AHI, time percentage oxygen saturation < 90%, and Epworth Sleepiness Scale (ESS) score. A total of 24 patients were included: median age 49.1 years, average BMI 27.26 kg/m2, and 90% men. Ten patients received ESP plus CTBR plus PE, eight received ESP plus CTBR, and six received ESP plus PE. The mean preoperative AHI was 33.01 at baseline and improved to 17.7 ± 13 after surgery (p < 0.05). The ESS score decreased from 11 ± 5.11 to 7.9 ± 4.94 (p < 0.05). The surgical success rate according to Sher's criteria was 82.3%. The median follow-up was 23.3 months (range 12-36). These findings suggest that multilevel surgery is a safe and successful treatment of OSAHS.

Nasal Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study.

OBJECTIVE: The aim of this study is to evaluate the effects of nasal surgery in the upper airway (UA) collapse using drug induced sleep endoscopy (DISE) in a group of patients with obstructive sleep apnea hypopnea syndrome (OSAHS). METHODS: Prospective cohort of patients treated with nasal surgery between 2015 and 2016. All patients were diagnosed with mild to severe OSAHS. The inclusion criteria were age between 18 and 70 years, apnea-hypopnea index (AHI) higher than 15, and septal deviation. All patients had a DISE performed before surgery and 3 months after. The DISE findings were evaluated through the NOHL scale. RESULTS: Thirty-four patients were included. Surgical success with subjective and objective improvement in nasal obstructions was achieved in all cases. The pattern of UA obstruction did change significantly following nasal surgery (P < 0.05). Before nasal surgery, 74% of the patients demonstrated multilevel obstruction. After nasal surgery, only 50% patients showed multilevel collapse (P < 0.05). Among patients with single-level collapse, the oropharynx was the most common location of obstruction. It became more frequent after nasal surgery was done (41% vs 21%, P < 0.05). Significant improvement was shown in hypopharyngeal collapse. Postoperative AHI decreased from a mean of 26.7 to 19 events/h, but this change was not significant. CONCLUSION: Nasal surgery may improve hypopharyngeal collapses observed during DISE in patients with OSAHS. Thus, an improvement in nasal obstruction may also modify the surgical plan based on UA functional findings in OSAHS patients.

Faringoplastia de expansión: utilidad de la somnoscopia (DISE) / Expansion sphincter pharyngoplasty: Usefulness of DISE

Objetivos: El objetivo de este estudio es presentar las indicaciones y resultados de la faringoplastia de expansión como tratamiento del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS). En segundo lugar, comparar los hallazgos de la somnoscopia (drug-induced sleep endoscopy -DISE-) antes y después de la cirugía. Material y métodos: El diseño del estudio fue una cohorte prospectiva de pacientes tratados quirúrgicamente de 2015 a 2016. Todos los pacientes fueron diagnosticados de SAHOS leve a grave y no toleraban la CPAP. Todos tenían DISE y polisomnografía previa a la cirugía, y posterior a la misma. Los criterios de inclusión fueron la edad, entre 18 años y 70 años, amígdalas pequeñas (tamaños 1 y 2), estadio clínico de Friedman II y III, y colapso lateral mayoritario en la DISE preoperatoria. Se les realizó únicamente cirugía del paladar, usando la técnica de faringoplastia de expansión. Resultados: Se incluyeron 17 pacientes, el 52,94% eran pacientes con SAHOS grave. La edad media fue de 42 años, el índice de masa corporal media fue de 28. La tasa de éxito quirúrgico según los criterios de Sher fue del 82,35%. El 41,17% presentó un índice de apnea-hipopnea postoperatoria inferior a 10. El 75% de los pacientes lograron no tener que usar la CPAP. Conclusión: La faringoplastia de expansión es una técnica segura como tratamiento del SAHOS en pacientes con amígdalas pequeñas, grado Friedman I y II y colapso de paredes laterales en somnoscopia, en ausencia de colapso multinivel. La DISE postoperatoria demostró la mejoría del colapso lateral obtenida con la expansión

Objectives: The aim of this study was first to present the indications and results using expansion sphincter pharyngoplasty to treat obstructive sleep apnoea-hypopnoea syndrome (OSAHS). And second, to compare the findings of drug-induced sleep endoscopy (DISE) before and after the surgery. Material and methods: The study design was a prospective cohort of patients surgically treated between 2015 and 2016. All patients were diagnosed with mild to severe obstructive sleep apnoea and did not tolerate CPAP. All had pre- and post-surgery DISE and polysomnography. The inclusion criteria were age, between 18 years and 70 years, small tonsils (sizes 1 and 2), Friedman II and III clinical stage, and lateral collapse in preoperative DISE. We performed surgery to the palate only, using expansion sphincter pharyngoplasty. Results: Seventeen patients were included, 52.94% had severe OSAHS. Average age was 42 years, average body mass index was 28. The surgical success rate according to Sher criteria was 82.35%. 41.17% had a postoperative apnoea-hypopnoea index of less than 10. Seventy-five percent of the patients had no further need for CPAP. Conclusion: Expansion sphincter pharyngoplasty is a safe technique for treating OSAHS, in patients with small tonsils, Friedman grade I and II and collapse of lateral walls in DISE, in the absence of multilevel collapse. The postoperative DISE showed improvement of the lateral collapse was achieved with the expansion

Prospective multi-center study on expansion sphincter pharyngoplasty.

BACKGROUND AND OBJECTIVE: The aim of this study was to demonstrate the long-term effectiveness of Expansion Sphincter Pharyngoplasty (ESP) as a standalone surgical treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS) patients through a prospective multi-center study. MATERIAL AND METHODS: A prospective non-comparative multicenter study of patients suffering from OSHAS selected after drug-induced sleep endoscopy, with ESP as standing alone procedure was performed. Inclusion criteria were lateral collapse on oropharynx and preoperative AHI between 5 and 70. Minimum follow-up was >12 months. Outcome measures were Epworth sleepiness scale (ESS), AHI, success rate and CPAP need after surgery. RESULTS: A total of 75 ESP were performed. Mean patient age was 46.7 ± 10.5 years. Mean pre-operative and post-operative AHI was 22.1 ± 12.2 and 8.6 ± 6.7, respectively (p < .001). Mean pre-operative and post-operative ESS score was 11.5 ± 4.7 and 4.6 ± 6.6, respectively (p < .001). AHI <5 was obtained in 25 patients (33.3%), and CPAP was not further needed after surgery in a total of 62 patients (82.6%). CONCLUSIONS AND SIGNIFICANCE: In this prospective multi-center study, patients undergoing ESP standing alone for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.

Expansion sphincter pharyngoplasty: Usefulness of DISE. / Faringoplastia de expansión: utilidad de la somnoscopia (DISE).

OBJECTIVES: The aim of this study was first to present the indications and results using expansion sphincter pharyngoplasty to treat obstructive sleep apnoea-hypopnoea syndrome (OSAHS). And second, to compare the findings of drug-induced sleep endoscopy (DISE) before and after the surgery. MATERIAL AND METHODS: The study design was a prospective cohort of patients surgically treated between 2015 and 2016. All patients were diagnosed with mild to severe obstructive sleep apnoea and did not tolerate CPAP. All had pre- and post-surgery DISE and polysomnography. The inclusion criteria were age, between 18 years and 70 years, small tonsils (sizes 1 and 2), Friedman II and III clinical stage, and lateral collapse in preoperative DISE. We performed surgery to the palate only, using expansion sphincter pharyngoplasty. RESULTS: Seventeen patients were included, 52.94% had severe OSAHS. Average age was 42 years, average body mass index was 28. The surgical success rate according to Sher criteria was 82.35%. 41.17% had a postoperative apnoea-hypopnoea index of less than 10. Seventy-five percent of the patients had no further need for CPAP. CONCLUSION: Expansion sphincter pharyngoplasty is a safe technique for treating OSAHS, in patients with small tonsils, Friedman grade I and II and collapse of lateral walls in DISE, in the absence of multilevel collapse. The postoperative DISE showed improvement of the lateral collapse was achieved with the expansion.