Andrea De Vito

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.

The importance of nasal resistance in obstructive sleep apnea syndrome: a study with positional rhinomanometry.

The importance of nasal obstruction in the pathogenesis of obstructive sleep apnea syndrome (OSAS) has not yet been totally defined. Numerous studies have reported an association between nasal obstruction and OSAS, but the precise nature of this relationship remains to be clarified. This study was undertaken to evaluate the prevalence of nasal obstruction disorders in a group of OSAS patients. For this purpose, we analyzed the nasal resistance of 36 OSAS patients by performing a traditional basal anterior active rhinomanometry test (AAR) and a positional AAR, with the patient in a supine position. Seven patients had a pathologic nasal resistance in the seated position that increased further in the supine position; 9 patients had normal resistance in the seated position but a pathologic resistance in the supine position. In 20 patients, nasal resistance was normal in both positions. No statistically significant differences in the degree of apnea/hypopnea index (AHI) was found between the 20 patients with normal positional AAR and the 16 with pathologic positional AAR (p = 0.13). Moreover, no statistically significant differences in the degree of AHI was found between the 7 patients with pathologic basal and positional AAR and the 9 patients with normal basal AAR and pathologic positional AAR (p = 0.38).

Tissue engineering of the tympanic membrane using electrospun PEOT/PBT copolymer scaffolds: A morphological in vitro study

Abstract Objective: Tissue engineering has recently been identified as a suitable tool to develop replacements for the tympanic membrane. This study aimed at investigating PEOT/PBT copolymer scaffolds obtained via electrospinning as potential eardrum substitutes using an in vitro approach. Study design: PEOT/PBT copolymer ultrafine fibre meshes were manufactured and characterized for morphology and pore features. The scaffolds were cultured with human mesenchymal stromal cells (MSCs) under a dynamic flow regimen to improve cell infiltration and viability. The expression of basic extracellular matrix molecules was evaluated and compared to that of the human eardrum. Finally, the interaction between human tympanic membrane keratinocytes and the scaffolds was investigated. Results: The electrospun scaffolds had a fibre diameter of 1.9 ± 0.9 μm, thickness of 220 ± 56 μm, and porosity of 80% ± 0.8%. The macroporous meshes were suitable for cell infiltration, since 83.3% of relative void volume was from pores of 3–300-μm size. Over a four week culture, the bioreactor always increased the viability of human MSCs in the scaffolds with respect to traditional multi-well plate cultures. Viability was best at two weeks in culture, so this time-point was selected for further morphological and histochemical analyses. In static cultures, the human MSCs interacted with the top surface of the fibrous scaffold, while in dynamic cultures they infiltrated the mesh up to 240-μm depth. Adherent human MSCs maintained a non-differentiated phenotype, as shown by a very low production of glycosaminoglycans and glycoproteins, which are conversely highly expressed in the eardrum connective tissue layer. Human tympanic membrane keratinocytes adhered to the scaffold surface and were viable after 48 h. Conclusion: Using electrospinning combined with bioreactor culture appeared an efficient approach to develop biohybrid eardrum replacements in vitro, suitable for re-epithelialization in vivo.

A Case of Primary Non-Hodgkin’s Lymphoma of the External Auditory Canal

Lymphomas represent the second most frequent malignant tumor (incidence 2.5%) in the head and neck region. Non-Hodgkin lymphomas (NHLs) present with cervical lymph node involvement, but in 40% extranodal site could be primary involved: nasopharynx, the lacrimal sac, the temporal bone, or the others areas. NHLs of the ear are rarely reported. In this report, we described a patient with primary NHL of the external ear canal who was successfully treated with surgical excision and chemotherapy.

The importance of obstructive sleep apnoea and hypopnea pathophysiology for customized therapy

The objective of this study is to highlight the importance of anatomical and not-anatomical factors’ identification for customized therapy in OSAHS patients. The data sources are: MEDLINE, The Cochrane Library and EMBASE. A systematic review was performed to identify studies that analyze the role of multiple interacting factors involved in the OSAHS pathophysiology. 85 out of 1242 abstracts were selected for full-text review. A variable combinations pathophysiological factors contribute to realize differentiated OSAHS phenotypes: a small pharyngeal airway with a low resistance to collapse (increased critical closing pressure), an inadequate responses of pharyngeal dilator muscles (wakefulness drive to breathe), an unstable ventilator responsiveness to hypercapnia (high loop gain), and an increased propensity to wake related to upper airway obstruction (low arousal threshold). Identifying if the anatomical or not-anatomical factors are predominant in each OSAHS patient represents the current challenge in clinical practice, moreover for the treatment decision-making. In the future, if a reliable and accurate pathophysiological pattern for each OSAHS patient can be identified, a customized therapy will be feasible, with a significant improvement of surgical success in sleep surgery and a better understanding of surgical failure.

The role of compact polysomnography/polygraphy in sleep breathing disorder patients’ management

While managing obstructive sleep apnea (OSA) or suspicious OSA patients, the otorhinolaryngologist frequently has to deal with patients undergoing repeated polysomnography (PSG) or portable monitoring (PM) and, on the other hand, should be confident about the quality and consistency of the polysomnographic diagnosis. The main polysomnographic traces compressed in a unique epoch, defined as compact PSG/PM (CP), which should be reported in all PSG/PM report, could represent an efficient tool to confirm the quality of PSG/PM diagnosis and to recognize the sleep breathing disorders (SBD): OSA, no-OSA SBD and overlap of OSA with no-OSA SBD. In this study, a synthetic and clear guided iconography and an easy decision-making algorithm based on desaturation patterns (phasic, prolonged and overlap desaturation patterns) identifiable on the CP are suggested for a quick check of the quality of PSG/PM diagnosis and to achieve an improvement in the patient’s clinical management.

Phenotyping the pathophysiology of obstructive sleep apnea using polygraphy/polysomnography: a review of the literature

Continuous positive airway pressure (CPAP) is the first-line treatment for the majority of patients affected by obstructive sleep apnea syndrome (OSA). However, long-term compliance with CPAP therapy may result limited and alternatives to CPAP therapy are required to address the increasing need to provide tailored therapeutic options. Understanding the pathophysiological traits (PTs) of OSA patients [upper airway (UA) anatomical collapsibility, loop gain (LG), arousal threshold (AT), and UA gain (UAG)] lies at the heart of the customized OSA treatment. However, sleep research laboratories capable to phenotype OSA patients are sparse and the diagnostic procedures time-consuming, costly, and requiring significant expertise. The question arises whether the use of routine clinical polysomnography or nocturnal portable multi-channel monitoring (PSG/PM) can provide sufficient information to characterize the above traits. The aim of the present review is to deduce if the information obtainable from the clinical PSG/PM analysis, independently of the scope and context of the original studies, is clinically useful to define qualitatively the PTs of individual OSA patients. In summary, it is possible to identify four patterns using PSG/PM that are consistent with an altered UA collapsibility, three that are consistent with altered LG, two with altered AT, and three consistent with flow limitation/UA muscle response. Furthermore, some PSG/PM indexes and patterns, useful for the suitable management of OSA patient, have been discussed. The delivery of this clinical approach to phenotype pathophysiological traits will allow patients to benefit in a wider range of sleep services by facilitating tailored therapeutic options.

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

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.