Does drug-induced sleep endoscopy change the surgical decision in surgically naïve non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study

Abstract

BackgroundAdenotonsillectomy is the most commonly performed operation for pediatric snoring/sleep disordered breathing (S/SDB). However, 20–40% of patients will fail to improve. Drug-induced sleep endoscopy (DISE) may provide a more individualized surgical plan and limit unsuccessful surgeries. The aim of this study was to assess the impact of DISE on surgical decision-making in surgically naïve children with S/SDB.MethodsA retrospective observational cohort study was undertaken at the Stollery Children’s Hospital. Patients 3–17 years of age who underwent DISE-directed surgery for S/SDB between January 2009 and December 2015 were eligible. We excluded other indications for tonsillectomy and syndromic children. The primary outcome was the level of agreement between a DISE-based surgical decision and the reference standard based on the American Academy of Pediatrics (AAP) guidelines via un-weighted Cohen’s kappa. Secondary outcomes included the frequency and type of alternate surgical targets identified by DISE. The agreement on tonsil size between in-office physical assessment and DISE was also calculated. The effectiveness of DISE-directed surgery on postoperative S/SDB was not investigated.ResultsFive hundred fifty-eight patients were included. DISE changed the surgical plan in 35% of patients. Agreement between DISE-based and AAP clinical practice guidelines-based management was low (κ = 0.354 +/- 0.021 [95% CI 0.312–0.395]). An alternate diagnosis or surgical target was identified by DISE in 54% of patients. There was moderate agreement on tonsil size (κ = 0.44 [0.33–0.55]) between DISE and in-office clinical assessment.ConclusionsThis is a first phase diagnostic study, which demonstrates that DISE affects decision-making in surgically naïve children with S/SDB in up to 35% of patients. It has utility in individualizing first stage surgical treatments as well as identifying alternate targets for further surgical or medical therapy, while potentially limiting unsuccessful surgeries. Further studies to examine the effect of DISE on surgical outcomes are required.

An updated review of pediatric drug‐induced sleep endoscopy

“…They found a significant improvement in both oAHI and oxygen saturation nadir ( p < 0.001) with the most frequently performed surgeries being adenoidectomy (41%), supraglottoplasty (38%), tonsillectomy (27%), lingual tonsillectomy (13%), nasal surgery (9%), and palatoplasty (5%) . Gazzaz et al recently demonstrated that DISE affects decision‐making in surgically naïve children with snoring and sleep‐disordered breathing in up to 35% of children . This finding is in agreement with Hybaskova et al who found that the surgical plan was changed in 60.8% of patients with obstructive sleep apnea undergoing DISE which often allowed the surgeon to address multiple levels of airway obstruction…”

The Impact of Drug-induced Sleep Endoscopy on Therapeutic Decisions in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

“…A total of 1247 patients were included (69.21% males). Children were recruited in three studies [10-12].…”

“…In children, two studies revealed the changed sites of airway collapse [10-11]. Tonsillectomy was the most frequently changed procedure, with an 88.3% change rate.…”

The efficacy of drug induced sleep endoscopy using multimodality monitoring system

“…Various body positions and situations such as lateral sleep position, head turning, mandibular pull up, mouth opening, or continuous positive airway pressure (CPAP) titration can be applied [5–7]. These simulations provide crucial information for decision making [3, 8, 9]. However, the conventional single channel DISE system usually records flexible endoscopic images only.…”