A Campanini

European position paper on drug-induced sedation endoscopy (DISE)

BackgroundAlthough drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting.MethodsThe authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique.ResultsA proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system.ConclusionsAlthough consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.

Surgery vs ventilation in adult severe obstructive sleep apnea syndrome

BACKGROUND AND PURPOSE Management of severe obstructive sleep apnea-hypopnea syndrome (OSAHS) is challenging and needs multidisciplinary cooperation. Ventilation is considered the gold standard of treatment in severe OSAHS. The aim of the study was to compare the therapeutical efficacy of a type of surgery (maxillomandibular advancement [MMA]) vs a ventilatory treatment modality (autotitrating positive airway pressure [APAP]). MATERIALS AND METHODS At the ENT Department of Forlì Hospital (University of Pavia), in strict cooperation with the Sleep Lab of the University of Bologna, a prospective randomized controlled trial was designed and performed. After fully informing them, 50 consecutive patients who have severe OSAHS were enrolled and randomized into a conservative (APAP) or surgical (MMA) section. Demographic, biometric, polysomnogram (PSG) and Epworth Sleepiness Scale profiles of the 2 groups were statistically not significantly different. RESULTS One year after surgery or continuous APAP treatment, both groups showed a remarkable improvement of mean Apnea-Hypopnea Index (AHI) and Epworth Sleepiness Scale levels; the degree of improvement was not statistically different. CONCLUSIONS Given the relatively small sample of subjects studied and the relatively brief follow-up, MMA proved to be a valuable alternative therapeutical tool in our adult and severe OSAHS patient group, with a success rate not inferior to APAP.

The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients.

The main pathological event of obstructive sleep apnea hypopnea syndrome (OSAHS) is the apneic collapse of the upper airways (UA). Frequently, UA collapse occurs at the same time at different section levels. Identifying the site and the dynamic pattern of obstruction is mandatory in therapeutical decision-making, and in particular if a surgical therapy option is taken into account. Nowadays, awake fiberoptic nasopharyngeal endoscopy represents the first level diagnostic technique to be performed in such patients, but recently, the drug-induced sleep endoscopy (DISE) has been introduced to overcome the limits of the awake nasopharyngeal endoscopy. Whatever diagnostic tool we decide to use, one of the main problems encountered is the standardization of the description of the sites and dynamic patterns of UA collapses. In this paper, the authors describe the NOHL classification, which could be applied during awake and sleep endoscopy, and allows a simple, quick, and effective evaluation of grade and patterns of UA collapse, suggesting its application, especially in therapeutical decision-making and in the analysis of surgical outcomes.

Sleep-related stridor due to dystonic vocal cord motion and neurogenic tachypnea/tachycardia in multiple system atrophy.

Sleep‐disordered breathing and sleep‐related motor phenomena are part of the clinical spectrum of multiple system atrophy (MSA). Stridor has been attributed to denervation of laryngeal muscles or instead to dystonic vocal cord motion. We studied 3 patients with nocturnal stridor in the setting of MSA. All patients underwent nocturnal videopolysomnography (VPSG) with breathing and heart rate, O2 saturation and intra‐esophageal pressure recordings, and simultaneous EMG recordings of the posterior cricoarytenoid, cricothyroid, and thyroarytenoid muscles and continuous vocal cord motion evaluation by means of fiberoptic laryngoscopy. VPSG/EMG and fiberoptic laryngoscopy documented normal vocal cord motion without denervation during wake and stridor only during sleep when hyperactivation of vocal cords adductors appeared in the absence of significant O2 desaturation. All patients had tachycardia and tachypnea and paradoxical breathing during sleep, erratic intercostalis and diaphragmatic EMG activity and Rem sleep behavior disorder. One of the patients had restless legs syndrome with periodic limb movement during sleep and excessive fragmentary hypnic myoclonus. In conclusion, our patients with MSA had nocturnal stridor due to sleep‐related laryngeal dystonia. Stridor was associated with other abnormal sleep‐related respiratory and motor disorders, suggesting an impairment of homeostatic brainstem integration in MSA.

Combined transoral robotic tongue base surgery and palate surgery in obstructive sleep apnea‐hypopnea syndrome: Expansion sphincter pharyngoplasty versus uvulopalatopharyngoplasty

Transoral robotic surgery (TORS) for obstructive sleep apnea‐hypopnea syndrome is a relatively young technique principally devised for managing apneas in the tongue base (TB) area and supraglottic larynx. This procedure is included in the so‐called “multilevel surgery” often including a palatal and nasal surgery.

Clinical Outcomes and Complications Associated with TORS for OSAHS: A Benchmark for Evaluating an Emerging Surgical Technology in a Targeted Application for Benign Disease

Background: The aim of this study was to create benchmarks for evaluating clinical outcomes and complications of transoral robotic surgeries (TORS) in a multicenter setting. Methods: 243 TORS for obstructive sleep apnea/hypopnea syndrome (OSAHS) operations, carried out between 2008 and 2012, were analyzed at 7 different centers. The average hospitalization was 3.5 days. The mean patient age was 50 ± 12 years, the average BMI at the time of the procedure was 28.53 ± 3.87 and the majority of the patients were men (81%). Results: The mean preoperative and postoperative apnea/hypopnea index was 43.0 ± 22.6 and 17.9 ± 18.4, respectively (p < 0.001). The mean preoperative and postoperative Epworth Sleepiness Scale score was 12.34 ± 5.19 and 5.7 ± 3.49, respectively (p < 0.001). The mean pre- and postoperative lowest O2 saturation was 79.5 ± 8.77 and 83.9 ± 6.38%, respectively (p < 0.001). Conclusions: Patients undergoing TORS as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation of success with minimal long-term morbidity.

Hyoidthyroidpexia as a treatment in multilevel surgery for obstructive sleep apnea

Conclusion. This type of surgery is effective in patients with obstructive sleep apnea syndrome (OSAS), but may not be effective in obese patients or those with a preoperative apnea hypopnea index (AHI)>35. For these reasons, the careful study and selection of patients is fundamental in the surgical treatment of OSAS. Objectives. Evaluation of the efficacy of hyoid surgery combined with oropharynx and nose surgery in the treatment of OSAS. Subjects and methods. A total of 109 OSAS patients underwent hyoidthyroidpexia as a treatment in multilevel surgery. Before surgery all patients were treated with continuous positive airway pressure (CPAP) therapy for at least 6 months and underwent preoperative and postoperative polysomnography. The preoperative examination was composed of upper airways endoscopy, lateral cephalometric radiograph, calculation of body mass index (BMI), and subjective analysis of daytime sleepiness. Results. In all, 67/109 patients (61.5%) with postoperative AHI<20 were defined as ‘responders’, while the other 42 patients (38.5%) were defined as ‘non-responders’. The correlation between preoperative BMI and postoperative AHI revealed that non-responders had a much higher average BMI compared with responders. Moreover, when analyzing median preoperative and postoperative AHI, it emerged that non-responders had a much higher preoperative AHI compared with responders.

Diagnostic Accuracy of Obstructive Airway Adult Test for Diagnosis of Obstructive Sleep Apnea.

Rationale. The gold standard for the diagnosis of Obstructive Sleep Apnea (OSA) is polysomnography, whose access is however reduced by costs and limited availability, so that additional diagnostic tests are needed. Objectives. To analyze the diagnostic accuracy of the Obstructive Airway Adult Test (OAAT) compared to polysomnography for the diagnosis of OSA in adult patients. Methods. Ninety patients affected by OSA verified with polysomnography (AHI ≥ 5) and ten healthy patients, randomly selected, were included and all were interviewed by one blind examiner with OAAT questions. Measurements and Main Results. The Spearman rho, evaluated to measure the correlation between OAAT and polysomnography, was 0.72 (p < 0.01). The area under the ROC curve (95% CI) was the parameter to evaluate the accuracy of the OAAT: it was 0.91 (0.81–1.00) for the diagnosis of OSA (AHI ≥ 5), 0.90 (0.82–0.98) for moderate OSA (AHI ≥ 15), and 0.84 (0.76–0.92) for severe OSA (AHI ≥ 30). Conclusions. The OAAT has shown a high correlation with polysomnography and also a high diagnostic accuracy for the diagnosis of OSA. It has also been shown to be able to discriminate among the different degrees of severity of OSA. Additional large studies aiming to validate this questionnaire as a screening or diagnostic test are needed.

Drug-Induced Sedation Endoscopy (DISE)

In this chapter, the authors review the history of drug-induced sedation endoscopy (DISE), and important literature contributions to date regarding its utility in diagnosis of OSA, particularly with regard to assessment of surgical candidacy. Each author also describes his or her own institutional experience, technique, and relevant findings regarding DISE.

Atypical Forms and Differential Diagnosis

In the area of benign paroxysmal positioning vertigo (BPPV) a typical form is usually explained by a cupulo or canalithiasis model in one of the semicircular canals. Atypical BPPV is more frequently associated with peripheral disease, but in some cases CNS structural abnormalities must be ruled out. Among the atypical features there are very frequent recurrences, and unexpected unresponsiveness to therapy must be taken into account. In this paper we describe the many possible clinical features of an atypical PPV, the real pathology of atypical forms and the most suitable therapeutic approach.