Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography Test-retest reliability of drug-induced sleep endoscopy Reliability of drug-induced sedation endoscopy: interobserver agreement Validation of sleep nasendoscopy for assessment of snoring with bispectral index monitoring Does arousal frequency predict daytime function? Changes in site of obstruction in obstructive sleep apnea patients according to sleep position: a DISE study. Sleep endoscopy versus modified Mallampati score in sleep apnea and snoring. Sleep nasendoscopy: what benefit to the management of snorers? Endoscopic examination of obstructive sleep apnea syndrome patients during drug-induced sleep. Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders. A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Observer variation in drug-induced sleep endoscopy: experienced versus nonexperienced ear, nose, and throat surgeons. Interrater reliability of drug-induced sleep endoscopy.
The purpose of the present study was to compare pharyngeal and polysomnographical findings during drug-induced sleep endoscopy ( DISE ) performed with either propofol or midazolam as a single sedative agent . It is prospect i ve , non-r and omized , double-blinded case series study . Sixteen patients with sleep disordered breathing were se date d first with propofol and after full wake up with midazolam . Simultaneous polysomnography ( PSG )  was performed . We compared the zones of obstruction and vibration found with both drugs using the VOTE classification . Simultaneous PSG findings are also compared . There were 15 men and one woman ; the mean age was 42.7 years old , mean body mass index 26.9 kg/m2 .  Average DISE duration was 20 min with Propofol and 14.3 min with Midazolam . The induced sleep stage obtained was N2 with both drugs . Outpatient physical exam did not correlate with drug-induced sleep findings . There was a good correlation between DISE results with both drugs in all the areas of collapse except the velum ( p < 0.005 ) . Using a continuous perfusion , there is a good agreement in the findings observed in DISE performed with propofol and midazolam and PSG Objective : To determine the test-retest reliability of drug-induced sleep endoscopy ( DISE ) . Methods : Prospect i ve cohort study . Patients with OSA underwent two separate DISE examinations . The following outcomes were measured : a global assessment of obstruction at the palate and /or hypopharynx ; the degree of obstruction at the palate and hypopharynx ; and the contribution of individual structures ( palate , tonsils , tongue , epiglottis , and lateral pharyngeal walls ) to obstruction . Results : Thirty-two patients underwent two separate DISE examinations . The preoperative sleep study apnea-hypopnea index was 40.7 ± 21.1 , and the lowest oxygen saturation was 79.8 ± 17.4 percent . Point estimates for the intraclass correlation coefficient analogs related to palatal obstruction ranged from 0.41 to 0.89 ; related to the hypopharyngeal airway , the point estimates ranged from 0.57 to 0.84 . Conclusion : The test-retest reliability of DISE appears good , especially in the evaluation of the hypopharyngeal airway . Larger studies can generate more precise confidence interval estimates and test the generalizability of these findings Purpose Several studies have demonstrated the validity , reliability , and safety of drug-induced sedation endoscopy ( DISE ) in assessing the collapse of the upper airway ( UA ) in patients with obstructive sleep apnea hypoapnea syndrome ( OSAHS ) . The aim of this study was to assess the interobserver agreement on DISE and on therapeutic decision between an expert observer and an observer in training . Methods This was a cross-sectional study . Thirty-one DISE videos performed in our service were r and omly selected . Videos belonged to patients with OSAHS who wanted alternative treatments to CPAP .  The videos were review ed by an ENT experienced on DISE and a second observer in formation . Each observer independently assessed the presence of collapse of the UA according to a modified VOTE classification and proposed an alternative treatment to CPAP . Interobserver agreement kappa values were calculated . Results In assessing the presence of collapse at different levels of the upper airway , the percentage of agreement was 80 % at the level of the soft palate ( kappa = 0.1667 ) , 89.29 % in the oropharynx ( k = 0.7742 ) , 80.65 % at the tongue base ( k = 0.5571 ) , and 74.17 % at the epiglottis ( k = 0.4768 ) . When degree and configuration of the collapse was evaluated , the interrater agreement was moderate to good , except at the level of the tongue base where the agreement was weak for both degree and configuration of collapse ( k = 0.34 and 0.38 , respectively ) . Interobserver agreement was moderate when the indication of alternative treatments to CPAP is valued based on the findings of DISE . Conclusions Overall , DISE is a reliable technique even when assessing interobserver agreement between an experienced observer and one in training ; however , tongue base is the level of the upper airway that presents the greatest difficulties when assessing the collapse with DISE . Therefore , it is important to develop learning curves for this technique in order to obtain more reliable results Bispectral  index ( BIS ) monitor is a neurophysiological monitoring device which continually analyses a patient ’s electroencephalogram during sedation and general anaesthesia to assess the level of consciousness and depth of anaesthesia . BIS monitoring , whilst performing sleep nasendoscopy ( using midazolam and propofol ) , has helped vali date depth of sedation and allowed comparison with levels of sedation of control patients during natural sleep . A prospect i ve study of 30 patients with snoring undergoing sleep nasendoscopy with BIS monitoring was conducted .  BIS monitoring was recorded throughout the procedure and assessment of snoring was made at the appropriate level of sedation and snoring . BIS values were compared with control patients . The 30 patients undergoing sleep  nasendoscopy had average BIS values ranging from 50.72 to 61.2 . Similar results were seen with BIS and oxygen saturation in the control group . BIS monitoring provides an adjunct to the assessment of sleep nasendoscopy in determining the level of sedation required for snoring assessment . Comparable BIS values and oxygen saturation levels were obtained between controls and patients during sedation-induced sleep , thus validating the role of sleep nasendoscopy Patients with the sleep apnoea/hypopnoea syndrome ( SAHS ) have impaired daytime function with demonstrable sleepiness and impaired cognition . The hypothesis that brief arousals from sleep cause these daytime impairments was tested . One hundred and fifty patients with sleep disordered breathing were studied prospect ively , comparing  overnight polysomnography  with daytime measures of objective sleepiness , psychological well-being and cognitive performance . Significant , but weak ( r2<0.1 ) , relationships were seen between several nocturnal measures ( apnoea/hypopnoea index , arousals and desaturation variables ) and daytime measures of quality of life , well-being , subjective sleepiness , symptoms and cognitive performance . The only significant relationship between nocturnal variables and objective sleepiness was a very weak correlation ( r2<0.05 ) between the lowest oxygen saturation and mean maintenance of wakefulness test ( MWT ) result . The MWT was better correlated with daytime function than the multiple sleep latency test . This study shows a lack of strong relationships between conventional nocturnal measures and daytime function in patients with sleep disordered breathing OBJECTIVES /HYPOTHESIS This study aim ed to evaluate changes in obstruction site in obstructive sleep apnea ( OSA ) patients according to sleep position . STUDY DESIGN Prospect i ve case series . METHODS Eighty-five patients who had undergone level 1 sleep study and drug-induced sleep endoscopy in the supine and lateral positions were included . Obstruction sites were classified as soft palate ( SP ) , tongue base ( TB ) , lateral wall ( LW ) , and larynx ( LX ) . Subgroup analysis was performed according to lateral apnea-hypopnea index ( AHI ) : those with an AHI of ≥ 10 ( lateral obstructors , LO ) and those with an AHI of < 10 ( lateral nonobstructors , LNO ) . RESULTS Prevalence in obstruction site of SP , TB , and LX decreased significantly after change from supine to lateral position ( P < 0.05 ) . However , the prevalence of LW obstruction was not affected by position change . LW collapse in moderate OSA decreased ( from 66.7 % to 35.9 % ) after change to lateral sleep , whereas it persisted in severe OSA patients ( 81.6%-89.5 % ) . In the lateral position , persistent obstruction at the LW was observed more frequently in the LO group compared to the LNO group ( 83.3 % vs. 33.3 % ) . CONCLUSION When sleep posture is changed from supine to lateral , obstruction due to structures such as tongue base and larynx improves dramatically . Obstruction in lateral position is mostly due to obstruction at the oropharyngeal LWs . Therefore , position dependency is mostly determined by LW collapsibility . Evaluating the changes of the upper airway according to sleep position can further characterize the upper airway collapsibility and can be used for tailored treatment planning OBJECTIVES /HYPOTHESIS The aim of this study is to quantify the correlation between a large tongue classified by the modified Mallampati score ( MMS ) and obstruction at the tongue base observed during sleep endoscopy in patients with socially unacceptable snoring ( SUS ) and obstructive sleep apnea syndrome ( OSAS ) . STUDY DESIGN Prospect i ve . METHODS One hundred twenty-seven patients with obstructive sleep apnea and SUS underwent sleep endoscopy .  Patients were classified into four specific groups according to their MMS . After intravenous administration of midazolam , obstructive events in the upper airway were classified . The level of obstruction was expressed as palatal ( 2 ) , palatal and to a lesser degree base of the tongue/laryngeal level ( 2 ) , tongue base/laryngeal level and to a lesser degree palatal ( 3 ) , and tongue base/laryngeal level ( 3 ) . The degree of correlation between the level of obstruction and the MMS was analyzed by means of Spearman 's rank-order correlation . RESULTS No linear association between the level of obstruction and MMS could be found . A large tongue ( MMS 3 or 4 ) does not predict obstruction at the base of the tongue . Patients classified as MMS 1 or 2 did not frequently show obstruction at the base of the tongue ( 9 of 38 , 23,6 % ) . The majority of the population showed retropalatal obstruction . A large tongue ( MMS 3 or 4 ) was often accompanied by retropalatal obstruction , 76 % of the cases ( 64 of 89 ) . CONCLUSIONS No positive correlation exists between a large tongue and obstruction at tongue base level . In both groups , retropalatal obstruction occurred more often than retrolingual obstruction .  Sleep endoscopy provides qualitative insight into important changes during sleep in patients with SUS and OSAS . In addition , anatomic aberrations are clearly visualized in a dynamic setting . Classification of the size of the tongue , as assessed by the MMS , may be of great importance as well It has been proposed that sleep nasendoscopy ( SN ) will improve the success rate of the uvulopalatopharyngoplasty operation by identifying those patients with palatal snoring . The aim of this study was to test the efficacy of SN in the management of snorers who do not have obstructive sleep apnoea . This study compared a group of 26 snorers managed without SN ( group A ) to a group of 27 snorers managed with SN ( group B ) . The post-operative results of group A were 61 per cent cured , 27 per cent better and 8 per cent unchanged . Group B results were 76 per cent cured , 19 per cent better and 5 per cent unchanged . However , if patients with only palatal snoring had surgery , the results for group B would have been 94 per cent cured , 6 per cent better and 0 per cent unchanged ( 95 per cent C.I. of difference + 0.14 , + 0.54 , p = 0.017 ) . The results confirm the predictive power of SN in identifying success following  uvulopalatopharyngoplasty .  A simple grading system is suggested to aid in treatment planning . Patients are divided into three categories on SN : palatal snorers , mixed snorers and non-palatal ( tongue base ) snorers . It is proposed that uvulopalatopharyngoplasty may cure palatal snorers but mixed snorers will need additional therapies to eliminate their snoring although uvulopalatopharyngoplasty may improve the symptoms Sixty patients diagnosed with obstructive sleep apnea syndrome ( OSAS ) underwent uvulopalatopharyngoplasty ( UPPP ) .  The effects of surgery were studied based on endoscopic findings during drug-induced sleep and determination of the apnea-hypopnea index ( AHI ) before and after the operation . Changes in the form of the airway during sleep in the recumbent position were observed , and the role of upper airway endoscopy in the diagnosis and surgical treatment of OSAS was determined . The site of airway obstruction during sleep induced by i.v . injection of 10 mg of diazepam was classified into five types , and changes in AHI and the site of airway obstruction were compared before and after surgery . Changes in airway morphology during sleep in the supine and recumbent positions were also compared before surgery . The postoperative improvement rate was 74.4 % for the soft palatal type of obstruction , 76.2 % for the tonsillar type , 53.3 % for the circumferential palatal type and 34.0 % for the mixed type . Treatment produced excellent or good effects for the soft palatal and tonsillar types of obstruction . However , many patients with the circumferential palatal and mixed types of obstruction showed only some improvement or no change . Good airway morphology was maintained in the recumbent position by patients with the soft palatal type of obstruction . With the circumferential palatal and mixed types of obstruction , improvement can be expected from operations which include surgical treatment of the posterior pharyngeal wall or lateral funiculus , or with midline laser glossectomy . A good operative outcome can be predicted in patients showing improvement of apnea in the recumbent position preoperatively OBJECTIVE To vali date the technique of sleep nasendoscopy using target controlled infusion in symptomatic patients and a control group of asymptomatic individuals . DESIGN Prospect i ve cohort study . SETTING Department of otolaryngology-head and neck surgery and anesthesia in a teaching hospital . PARTICIPANTS Two groups of patients were compared and matched for their body mass index . The first group consisted of 53 patients with a history suggestive of obstructive sleep apnea . The second group consisted of 54 patients with partner-confirmed history of no snoring . These patients were undergoing anesthesia for other reasons . Both groups of patients were free of associated otorhinolaryngologic symptoms . MAIN OUTCOME MEASURE Assessment of production of snoring or obstruction in patients with no documented history of snoring when  sedation was administered as part of general anesthesia using target controlled infusion with propofol . RESULTS AND CONCLUSIONS None of the patients in the asymptomatic group snored or obstructed at any level of propofol , and this was clearly significant on comparison with the symptomatic group ( P < .001 ) . All of the symptomatic patients were induced to become symptomatic ( snoring/obstruction ) OBJECTIVES /HYPOTHESIS To determine the reliability and validity of drug-induced sleep endoscopy ( DISE ) for patients undergoing surgery for sleep-disordered breathing ( SDB ) . STUDY DESIGN Non-r and omized , prospect i ve clinical trial . METHODS Patients with sleep-disordered breathing were evaluated for multi-level upper airway surgery by awake and drug-induced sleep endoscopy to identify levels and degree of airway collapse . The reliability of a drug-induced sleep endoscopy rating index was assessed by comparing scores of three blinded investigators . The validity was assessed by comparison of drug-induced sleep endoscopy index scores from awake and drug-induced sleep endoscopy ; correlation between drug-induced sleep endoscopy scores and Apnea-Hypopnea Index ; and determination whether drug-induced sleep endoscopy affected the original surgical plan . RESULTS Thirty-eight patients ( 22 M , 16 F ) underwent preoperative assessment with awake and drug-induced sleep endoscopy .  Drug-induced sleep endoscopy  was successfully performed in all but one patient ( 97 % ) who became combative during propofol infusion . Using an internal airway grading scale , drug-induced sleep endoscopy demonstrated more severity of collapse than awake endoscopy ( P = 0.0001 ) . The surgical plan was changed after drug-induced sleep endoscopy in 23 ( 62 % ) cases and unchanged in 14 ( 38 % ) . The majority ( 73 % ) had multi-segmental airway collapse with fewer having single-level palatal ( 16 % ) or tongue base ( 11 % ) collapse . Scoring of drug-induced sleep endoscopy videos demonstrated good intrarater ( κ 0.61 ) and interrater ( κ 0.65 ) correlation . CONCLUSIONS Drug-induced sleep endoscopy provides more clinical information to assess airway function and collapse than awake endoscopy alone and assists in the surgical planning . Additional investigation is needed to st and ardize drug-induced sleep endoscopy techniques , training , and interpretation STUDY OBJECTIVE To determine variations in interobserver and intraobserver agreement of drug-induced sleep endoscopy ( DISE ) in a cohort of experienced versus nonexperienced ear , nose , and throat ( ENT ) surgeons . DESIGN Prospect i ve , blinded agreement study . SETTING Ninety-seven ENT surgeons ( 90 nonexperienced with DISE ; seven experienced ) observed six different DISE videos  and were asked to score the upper airway ( UA ) level ( palate , oropharynx , tongue base , hypopharynx , epiglottis ) , direction ( anteroposterior , concentric , lateral ) , and degree of collapse ( none ; partial or complete collapse ) . Findings were collected and analyzed , determining interobserver and intraobserver agreement [ overall agreement ( OA ) , specific agreement ( SA ) ] and kappa values per UA level . MEASUREMENT AND RESULTS In the nonexperienced group , overall interobserver agreement on presence of tongue base collapse ( OA = 0.63 ; kappa = 0.33 ) was followed by the agreement on epiglottis ( OA = 0.57 ; kappa = 0.23 ) and oropharynx collapse ( OA = 0.45 ; kappa = 0.09 ) . Low overall interobserver agreement in this group was found for hypopharyngeal collapse ( OA = 0.33 ; kappa = 0.08 ) . A similar ranking was found for degree of collapse . For direction of collapse , high interobserver agreement was found for the palate ( OA = 0.57 ; kappa = 0.16 ) . Among the experienced observers , overall interobserver agreement was highest for presence of tongue base collapse ( OA = 0.93 ; kappa = 0.71 ) , followed by collapse of the palate ( OA = 0.80 ; kappa = 0.51 ) . In this group , lowest agreement was also found for hypopharyngeal collapse ( OA = 0.47 ; kappa = 0.03 ) . Interob-server agreement on direction of collapse was highest for epiglottis collapse ( OA = 0.97 ; kappa = 0.97 ) . Concerning the degree of collapse , highest agreement was found for degree of oropharyngeal collapse ( OA = 0.82 ; kappa = 0.66 ) . Among the experienced observers a statistically significant higher interobserver agreement was obtained for presence , direction , and degree of oropharyngeal collapse , as well as for presence of tongue base collapse and degree of epiglottis collapse . Among the nonexperienced observers , high intraobserver agreement was found in particular for tongue base and epiglottis collapse . Among the experienced observers , high agreement was found for all levels but to a lesser extent for hypopharyngeal collapse . Intraobserver agreement was statistically significantly higher in the experienced group , for all UA levels expect for the hypopharynx . CONCLUSION This study indicates that both interobserver and intraobserver agreement was higher in experienced versus nonexperienced ENT surgeons . Agreement ranged from poor to excellent in both groups . The current results suggest that experience in performing DISE is necessary to obtain reliable observations OBJECTIVE To determine the interrater reliability of drug-induced sleep endoscopy ( DISE ) . DESIGN Prospect i ve cohort ; blinded comparison . SETTING Academic referral center . PARTICIPANTS Subjects with obstructive sleep apnea unable to tolerate positive airway pressure therapy . INTERVENTIONS Drug-induced sleep endoscopy was performed with intravenous propofol infusion to achieve sedation , and the videoendoscopy recording was evaluated by 2 independent review ers . MAIN OUTCOME MEASURES The following outcomes were measured : a global assessment of obstruction at the palate and /or hypopharynx ; the degree of obstruction at the palate and hypopharynx ; and the contribution of individual structures ( palate , tonsils , tongue , epiglottis , and lateral pharyngeal walls ) to obstruction . RESULTS A total of 108 subjects underwent DISE examination . Diagnostic sleep studies demonstrated a mean ( SD ) apnea-hypopnea index of 39.6 ( 24.0 ) . Three-quarters of the subjects demonstrated multilevel airway obstruction at the palate and hypopharynx , with a diversity of individual structures contributing to obstruction . The interrater reliability for the presence of obstruction at the palate and hypopharynx ( kappa values , 0.76 and 0.79 , respectively ) was higher than for the degree of obstruction ( weighted kappa values , 0.60 and 0.44 ) . The interrater reliability for the assessment of primary structures contributing to obstruction at the palate and hypopharynx ( 0.70 and 0.86 ) was higher than for the contributions of individual structures ( kappa values , 0.42 - 0.71 ) . The interrater reliability for evaluation of the hypopharyngeal structures was higher than for those of the palate region . CONCLUSION The interrater reliability of DISE is moderate to substantial . Trial Registration clinical trials.gov Identifier : NCT00695214
Purpose Drug-induced sedation endoscopy ( DISE ) classification systems have been used to assess anatomical findings on upper airway obstruction , and decide and plan surgical treatments and act as a predictor for surgical treatment outcome for obstructive sleep apnoea management .
The first objective is to identify if there is a universally accepted DISE grading and classification system for analysing DISE findings .
The second objective is to identify if there is one  DISE  grading and classification treatment planning framework for deciding appropriate surgical treatment for obstructive sleep apnoea ( OSA ) .
The third objective is to identify if there is one DISE grading and classification treatment outcome framework for determining the likelihood of success for a given OSA surgical intervention .