Sleep Endoscopy

Educational Objectives

The goal of this program is to improve the management of obstructive sleep apnea (OSA) with sleep endoscopy. After hearing and assimilating this program, the clinician will be better able to:

1. Compare efficiency in identification of hypopharyngeal collapse using drug-induced sedation endoscopy vs the Müller maneuver.
2. Optimize use of upper airway stimulation in patients with OSA.

Summary

Introduction: obstructive sleep apnea (OSA) is a prevalent problem that decreases the quality of life; the risk for mortality increases significantly with the increase in the apnea-hypopnea index (AHI); as the severity of OSA increases, the risk for mild cognitive impairment (MCI) and dementia increases

Treatment of OSA: there are multiple treatment modalities, ie, surgical and nonsurgical; positional therapy is useful for patients with mild OSA and, at times, for moderate and severe OSA in combination with other treatments; oral appliances can be used (requires referral to dentists; can be fitted at the office to improve patient compliance); one should document the exact reason for the continuous positive airway pressure (CPAP) therapy failure; referral to a pulmonologist may be required for cases that are not true failures; the compliance with CPAP is poor (50% in randomized controlled trial); the treatment goal is to improve the quality of life and to reduce the AHI to the point that reduces the risks

Evaluation: inaccurate identification of the level of obstruction leads to surgical failure; thorough history and physical examination are important; the risk for hypopharyngeal collapse increases as the tongue position classification increases; a patient with occlusion problems may be a candidate for certain surgeries, eg, maxillomandibular advancement (MMA) surgery

Drug-induced sleep endoscopy (DISE): the success rate from surgical management of OSA has been poor (same treatment for all patients [with different levels of obstruction]); stratifying by the site of obstruction may improve results; DISE enables better identification of higher hypopharyngeal collapse compared with Müller maneuver (Soares et al [2013])

Key points: one should consider CPAP therapy before DISE and should perform DISE when surgical management is considered; the goal is to reproduce natural sleep; avoid oversedation; good communication with the anesthesia team is essential; technique — keep the stimulation to a minimum; try to keep the scope on the high portion to obtain a bird’s eye view; the velum, oropharynx, tongue, and epiglottis (VOTE) classification and the nose, oropharynx, hypopharynx, and larynx (NOHL) classification can be used; one should look for the patterns of collapse, ie, partial or complete collapse, and determine the predominant one

Significance of DISE: a nonrandomized multicenter study by Pang et al (2020) found that DISE may not significantly affect surgical success in OSA; however, in a recent study, DISE seems to be more useful for patients with severe OSA (with higher AHI); a systematic review (Sigaard et al [2023]) indicated that even though DISE appears to change surgical management, it does not necessarily increase the success rate and may potentially lead to unnecessary procedures in some patients

Surgical procedures for OSA: there is a wide variety of procedures, ie, excision procedures, MMAs, and nerve stimulation; each procedure has its location depending on the anatomic dynamic view; excision ablation or soft-tissue rearrangement includes pharyngoplasty, radiofrequency ablation (RFA), and tongue base reduction (TBR)

Multilevel surgeries: these have the best outcomes, eg, TBR with uvulopalatopharyngoplasty (UPPP; success rate ≈45%); hyoid suspension (HS) when combined with other procedures, eg, UPPP or RFA, has a success rate of ≈55%; UPPP may result in several long-term issues; TBRs may cause dysgeusia or bleeding complications

Upper airway stimulation (UAS): patients prefer UAS as they can be discharged home on the same day, and as it has no significant adverse effects; they are performed now in patients with higher AHI; it is indicated for patients with a body mass index (BMI) of ≤40 (higher BMI may reduce its benefit, leading to poor outcomes in some patients); patients without circumferential collapse are considered good candidates for UAS; using VOTE classification helps to prognosticate patient outcomes, eg, patients without lateral oropharyngeal collapse have better outcomes compared with those having significant lateral collapse (≈57% success rate); patients who have a complete tongue-base obstruction anteroposteriorly have the best outcomes

Choosing the surgical procedure: referral to a sleep medicine physician may be required for some patients; factors, eg, DISE findings, patient factors, the surgeon’s expertise, the technologies available, patient preferences, and the long-term effects of the procedure, help in deciding the surgical procedure to be performed; an anterioposterior (AP) collapse may be miscategorized as a velum and circumferential collapse in an under- or oversedated patient; they can be managed with UAS, a pharyngoplasty, or TBR; circumferential and lateral collapse without tongue base collapse can be managed with pharyngoplasty and HS (for the lateral part in the hypopharynx), MMA (for patients with high AHI), and tonsillectomy with lateral pharyngoplasty and HS; a significant AP collapse at the level of velum and a lateral collapse at the level of the epiglottis can be managed with UAS; the base of the tongue is protracted anteriorly and pulls the epiglottis; other options include a partial epiglottic resection or MMA

Single procedures: isolated HS can be performed for patients with a relatively lower AHI and an independent collapse of the epiglottis from the base of the tongue; sleep endoscopy is repeated in patients who have had a sphincter pharyngoplasty (with a significant reduction in AHI) but are symptomatic with moderate OSA; if pharyngoplasty converts the circumferential collapse to AP collapse, UAS can be performed; if they continue to have circumferential collapse and significant lateral collapse at the oropharyngeal level, consider MMA, CPAP, or oral appliances

Key points: DISE can be performed for UAS; people who have significant issues with insomnia tend to be much less compliant with UAS; ansa cervicalis stimulation is being developed as patients with lateral pharyngeal wall collapse do not have good outcomes with UAS

Conclusion: multilevel procedures are more appropriate for patients with higher AHIs; for patients with lower AHIs, DISE with a single-level procedure for the predominant collapse is preferred; a standard DISE technique, consistency, and involvement of patients in decision-making are important

Readings

Ong AA, Murphey AW, Nguyen SA, et al. Efficacy of Upper Airway Stimulation on Collapse Patterns Observed during Drug-Induced Sedation Endoscopy. Otolaryngol Head Neck Surg. 2016;154(5):970-977. doi:10.1177/0194599816636835; Pang KP, Baptista PM, Olszewska E, et al. Does drug-induced sleep endoscopy affect surgical outcome? A multicenter study of 326 obstructive sleep apnea patients. Laryngoscope. 2020;130(2):551-555. doi:10.1002/lary.27987; Qiao M, Xie Y, Wolff A, Kwon J. Long term adherence to continuous positive Airway pressure in mild obstructive sleep apnea. BMC Pulm Med. 2023;23(1):320. Published 2023 Sep 1. doi:10.1186/s12890-023-02612-3; Sigaard RK, Bertelsen JB, Ovesen T. Does DISE increase the success rate of surgery for obstructive sleep apnea in children? A systematic review of DISE directed treatment of children with OSAS. Am J Otolaryngol. 2023;44(6):103992. doi:10.1016/j.amjoto.2023.103992; Soares D, Folbe AJ, Yoo G, et al. Drug-induced sleep endoscopy vs awake Müller's maneuver in the diagnosis of severe upper airway obstruction. Otolaryngol Head Neck Surg. 2013;148(1):151-156. doi:10.1177/0194599812460505; Song SA, Wei JM, Buttram J, et al. Hyoid surgery alone for obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2016;126(7):1702-1708. doi:10.1002/lary.25847.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Gomez-Rivera was recorded at the Texas Association of Otolaryngology 3rd Annual Conference, held on November 4, 2023, in Georgetown, TX, and presented by Texas Association of Otolaryngology-Head and Neck. For information on upcoming CME activities from this presenter, please visit www.taohns.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OT572002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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