Methods: The 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.Background: Although 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.Results: A 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.Conclusions: Although 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

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.

A new palatal procedure for snoring/obstructive sleep apnea (OSA) is described. The procedure was named as barbed reposition pharyngoplasty (BRP). The technique is described step by step. The new surgical technique was carried out in ten adult OSA patients with mean age of 53.4 ± 12.4 years (average 30-70) with confirmed retropalatal obstruction. In this pilot study; we assessed the feasibility by calculating the number of cases that failed to be operated and converted to other palatal technique during the same surgical setting, safety was assessed by evaluating both intra-operative and post-operative complications, teachability measured by the learning curve of our team members (the time of surgical procedure). In this study, the technique is proved to be feasible in all cases. There were no significant intra-operative or post-operative complications. Objective clinical improvement was confirmed by polysomnography 6 months post-operative with significant decrease in mean AHI from 43.65 ± 26.83 to 13.57 ± 15.41 (P = 0.007), daytime sleepiness assessed by Epworth Sleepiness Scale from 11.6 ± 4.86 to 4.3 ± 2 (P < 0.01), ODI from 44.7 ± 27.3 to 12.9 ± 16.3 (P = 0.004). Operative time decreased over the course of the study with an initial steep ascent in technical skill acquisition followed by more gradual improvement, and a steady decrease in operative time to as short as 20 min. Our preliminary results suggest that BRP technique is feasible, safe and effective in management of OSA patients. Moreover, it is easy to learn even for not experienced surgeons, less time consuming and with no significant complications.

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.