Bhik Kotecha

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.

Is sleep nasendoscopy a valuable adjunct to clinical examination in the evaluation of upper airway obstruction

The objective of the study is to assess the correlation between outpatient department (OPD) assessment and sleep nasendoscopy (SNE) in treatment planning for sleep related breathing disorders. The study design includes a blinded, cohort study comparing the treatment prediction based on OPD clinical evaluation with SNE in consecutive, adult patients by a single clinician with a specialist interest in snoring related disorders. Patients with moderate to severe obstructive sleep apnoea and those who had undergone previous treatment were excluded. The study was conducted in Royal National Throat, Nose and Ear Hospital, London and Queen’s Hospital, Romford. Ninety-four patients were recruited as participants for the study. The main outcome measures include site of obstruction and treatment planning. The results show no significant correlation between the two groups with SNE recommending less surgical intervention and a choice of surgical and non-surgical management in greater number of patients. In conclusion, even in experienced hands, clinical prediction is significantly modified by SNE findings. The addition of SNE to the diagnostic pathway, to assess the three-dimensional dynamic anatomy of the upper airway, provides a valuable adjunct to the OPD assessment of upper airway collapse. This affords the clinician a greater accuracy of diagnosis and the patient a more focussed management strategy with increased choice of modality of treatment.

Role of surgery in adult obstructive sleep apnoea

A surgical approach to treatment of obstructive sleep apnoea (OSA) remains an area of intense debate, both within and without the surgical community itself. Continuous positive airway pressure (CPAP) therapy remains the gold standard for the treatment of OSA, however surgery may be indicated to facilitate CPAP and/or improve compliance in cases where CPAP is poorly tolerated. This article summarises the current range of surgical treatment options together with the evidence base for their intervention in otolaryngology, maxillofacial and bariatric surgery. The continued evolution of technology has brought new surgical techniques to the fore and it seems likely their utilisation together with a multi-level surgical approach to the airway will continue to influence forthcoming research in OSA. Patient selection and precise evaluation will remain crucial in ensuring that when surgery is indicated, the correct procedure or procedures are performed at the correct anatomical level.

Sleep-related adductor laryngeal dystonia causing sleep apnea: a sleep-related breathing disorder diagnosed with sleep endoscopy and treated with botulinum toxin.

Obstructive sleep apnea syndrome (OSAS) is a chronic condition, characterized by recurrent episodes of upper airway collapse during sleep, which affects up to 5% of adults in the Western population. The muscle tone of the human body ordinarily relaxes during sleep, thus causing airway obstruction and leading to sleep apnea. We report a case of a 68‐years old male in which dystonic closure of the larynx during sleep caused OSAS. The sleep endoscopy was crucial in establishing the diagnosis of laryngeal dystonia. A botulinum toxin injection in the vocal cord improved the OSAS. These findings define a novel sleep‐related breathing disorder.

Multilevel radiofrequency ablation to the soft palate and tongue base: tips and pitfalls

The objective of the study is to increase awareness and understanding of the techniques and safety measures to minimise complications and improve patient outcomes. Literature review using MedLine and keywords snoring; obstructive sleep apnoea; radiofrequency ablation; electrosurgery; palate; tongue base was conducted. There is no accepted gold standard technique for radiofrequency ablation; to date, there is no published literature regarding common tips and pitfalls in radiofrequency application specifically for superficial applications and second-stage surgery. Surgery for snoring and obstructive sleep apnoea is typically multilevel. Pre-operative patient assessment and selection are critical to ensure good outcomes. Radiofrequency is generally safe and efficacious in this subset of patients. However, as with all surgery, it is operator-dependent. In particular, we emphasise the methodology for second-stage surgery, optimising visualisation and avoiding ulceration/fistulation of the soft palate, which are previously undescribed in the literature.

Otorhinolaryngological aspects of sleep-related breathing disorders.

Snoring and obstructive sleep apnoea (OSA) are disorders within a wide spectrum of sleep-related breathing disorders (SRBD). Given the obesity epidemic, these conditions will become increasingly prevalent and continue to serve as a large economic burden. A thorough clinical evaluation and appropriate investigations will allow stratification of patients into appropriate treatment groups. A multidisciplinary team is required to manage these patients. Patient selection is critical in ensuring successful surgical and non-surgical outcomes. A wide range of options are available and further long term prospective studies, with standardised data capture and outcome goals, are required to evaluate the most appropriate techniques and long term success rates.

Sneezing during drug-induced sedation endoscopy

Sir, Drug-induced sedation endoscopy remains controversial but has been increasingly shown to serve as a valuable tool in the dynamic evaluation of the upper airway to identify multilevel pathology [1, 2]. The principal criticism has been that this assessment is conducted under sedation and, hence, cannot be extrapolated to reflect true physiological sleep states. However, recent evidence suggests that sedation endoscopy correlates well with mean oxygen saturation, apnoeahypopnoea index and surgical outcomes [3, 4]. Furthermore, the inherent subjectivity in these procedures and the lack of standardisation of not only grading systems but also depth of sedation are being challenged by the development of European guidelines at a recent consensus meeting, the increasing role of bispectral index monitoring alongside strong evidence of good inter-rater reliability [5, 6]. In order to maintain the environment as close to natural physiological states as possible, most clinicians avoid the use of nasal decongestants or local anaesthetic sprays such as xylometazoline and lignocaine with or without phenylephrine. As a corollary to this, using such topical treatments may affect nasal resistance, and a recent systematic review questioned the benefit of using these preparations at all [7]. A perceived benefit for using these preparations is to reduce the sneezing reflex, which can of course obscure dynamic assessment. Stenutation or sneezing is a reflex generating an expulsion of air from the lungs via the nose and mouth. The reflex arc is typically initiated by nasal irritation and, therefore, understandably, can be an issue during flexible endoscopy. However, several other mechanisms have been reported ranging from exposure to bright light, a genetic predisposition, a particularly full stomach and psychogenic and central causes [8]. The common pathway is that of nasal irritation, either chemical or physical, transmitted via branches of the trigeminal nerve to the sneezing centre in the lateral medulla, resulting in an efferent limb outgoing to muscles of the diaphragm, larynx and face. We have noted no significant difference in the use of topical treatments in the production of the sneezing reflex in keeping with the recent Cochrane review and avoid its use in sedation endoscopy [7]. Interestingly, there have been recent reports that anaesthetic agents themselves can lead to the sneezing cycles. This is of particular relevance to druginduced sedation endoscopy as this evidence relates to the effects of propofol leading to sneezing episodes during sedation ophthalmological procedures [8–10]. It is thought that propofol temporarily suppresses the inhibitory neurones in the sneezing centre, thereby leading to an increased sensitivity to stimulation [8–10]. Morely et al. furthermore suggest that propofol-based intravenous sedation induces sneezing in one out of six patients with male gender, deep sedation and, significantly, for our drug-induced sedation endoscopy protocols, concurrent use of midazolam, all increase the risk of sneezing [10]. A possible solution has been suggested with the introduction of an opioid effectively reducing sneezing, although, of course, in aiming to maintain as close to normal physiological states, this would be ideally avoided in sedation endoscopy [11]. This novel information regarding propofol provides an interesting angle regarding drug-induced sedation endoscopy. In our aim to provide standardisation with depth of sedation, grading systems and protocols for the procedure, it is worth bearing in mind the sneezing reflex and its impact on sedation endoscopy. Further thought and studies are required to J. S. Virk ENT Department, Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, Essex, UK

Long-term safety and efficacy of radiofrequency ablation in the treatment of sleep disordered breathing: a meta-analysis

Radiofrequency ablation (RFA) is used in the treatment of sleep disordered breathing (SDB), particularly in the alleviation of snoring. The literature provides evidence that the short-term results are promising; however, the long-term efficacy is a matter of contention. In this article, we present the results of a literature search of studies that use RFA in the treatment of SDB which have a follow-up time of greater than a year. RFA was found to be a safe technique with minimal morbidity. The overall Visual Analogue score from six studies showed the overall mean improvement to be 4.3 (confidence intervals 3.4–5.12). Apnea Hypopnea Index (AHI), improved significantly in five of the studies analysed. Epworth Sleepiness Score (ESS), improved significantly in six of the studies analysed. In conclusion, the evidence suggests that RFA for SDB results in a significant improvement in follow-up times of at least a year. Since RFA can be applied in a clinic setting and leads to minimal disruption to daily life, this treatment option can be considered for those unwilling to participate in the more traditional surgical options for SDB.

Evaluation of upper airway obstruction in snoring patients using digital video stroboscopy

Stroboscopy is routinely used in voice disorder clinics but its use in studying the mechanisms of upper airway obstruction in patients who snore has not yet been described. This study combines the use of stroboscopy during sleep nasendoscopy to evaluate the oscillations and vibrations observed during snoring in slow motion. In addition, we utilised the multi-dimensional voice programme simultaneously to study some of the acoustic parameters of snoring whilst visualising the dynamics of the upper airway. Forty-five patients with primary snoring or mild obstructive sleep apnoea were recruited at two different centres and underwent sleep nasendoscopy. The simultaneous use of acoustic analysis was included to ascertain whether sound analysis alone could replace the need for using the sedation endoscopy in these patients. The use of a stroboscopic light source indeed enhanced the visualisation during the procedure and some subtle aspects of the mechanisms of upper airway obstruction, such as vibrations of the posterior pharyngeal wall and mucosal waves were identified. Most of the patients in this study exhibited multilevel obstruction and thus acoustic analysis alone would not be sufficient in accurately locating the site of upper airway obstruction in snorers.

Does dictating the letter to the GP in front of a follow-up patient improve satisfaction with the consult? A randomised controlled trial.

Various studies have shown that receiving a copy of the letter to the General Practitioner (GP) improves patient satisfaction with the consult. We aimed to establish whether dictating the letter to the GP in front of a listening patient does likewise. Follow-up patients have shorter allotted consultation times. This may contribute to dissatisfaction, hence the choice of our target group. One hundred consecutive follow-up patients who met the eligibility criteria were randomised to listen to the GP letter or not. Immediately after the consult, they were asked to fill in a questionnaire which, in addition to enquiring about various aspects of the consult asked them to quantify their overall satisfaction by means of a ten-point graded visual analogue score. Forty-nine patients received dictation. The mean age and sex distribution of the two groups were matched. The median overall satisfaction in the dictation and non-dictation groups were ten and eight, respectively, this was statistically significant. There was no significant difference between patients’ rating of whether the consult had addressed their ailment adequately, explanation(s) given or the length of consult. Sixty-one percent of patients in the non-dictation group would like to have listened to the dictation, whilst all patients in the dictation group found it useful. This study is the first of its kind in the ENT population. Dictating a letter to the GP in front of a listening patient led to a statistically significant improvement in satisfaction independent of possible confounding aspects of the consult.