Phenotypic Labelling Using Drug-Induced Sleep Endoscopy Improves Patient Selection for Mandibular Advancement Device Outcome: A Prospective Study

Abstract

Study Objectives: Mandibular advancement device (MAD) outcome varies between patients. We hypothesized that upper airway collapse sites, patterns, and degrees assessed during baseline drug-induced sleep endoscopy (DISE) affect MAD outcome. Methods: One hundred patients with obstructive sleep apnea (OSA) were included and underwent baseline type 1 polysomnography. MAD was fitted intraorally at fixed 75% maximal protrusion. A total of 72 patients completed 3-month follow-up polysomnography and baseline DISE. Response was defined as apneahypopnea index (AHI) reduction ≥ 50%, deterioration as AHI increases during MAD treatment compared to baseline. Results: Adjusting for baseline AHI and body mass index, patients with tongue base collapse showed 3.69 higher odds (1.27-10.73; P = .0128) for response.Complete concentric collapse at the level of the palate (5.32 [1.21-23.28]; P = .0234) and complete laterolateral oropharyngeal collapse (6.62 [1.14-38.34]; P = .0330) related to deterioration. Results for tongue base collapse and complete concentric collapse at the level of the palate were confirmed in the moderate to severe OSA subgroup. Applying these results to this selected subgroup increased response rate with 54% and decreased deterioration rate with 53%. These results were confirmed using other response and deterioration definitions. Conclusions: Three baseline DISE phenotypes identified during drug-induced sleep were significantly related to MAD treatment outcome: one beneficial, tongue base collapse, and two adverse, complete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse. If confirmed in future prospective studies, these results could guide patient selection for MAD outcome. Clinical Trial Registration: This prospective clinical trial (PROMAD) was registered on Clinicaltrials.gov with identifier: NCT01532050.

Drug‐Induced Sleep Endoscopy Upper Airway Collapse Patterns and Maxillomandibular Advancement

“…The results of the present prospective study, in a population of 14 patients who underwent MAD treatment followed by MMA surgery, show that a complete elimination of CCCp can be achieved by MMA surgery. This is of major importance, as CCCp is considered to be a negative predictive value for MAD treatment, UA surgery, and UA stimulation, and tends to be more difficult to alleviate compared to the other collapse patterns . In addition, when CCCp is present, higher CPAP pressure is needed to reopen the UA …”

“…Previous research states that partial collapse is more favorable to be treated successfully than complete collapse, that anteroposterior collapse is more favorable than concentric collapse, and that unilevel collapse is more favorable than multilevel collapse . Severe laterolateral collapse has been linked to treatment failure in patients receiving MAD therapy or targeted interventions with multilevel surgery such as palatopharyngoplasty and tongue base surgery . A recent study observed 15 patients with CPAP failure and CCCp as a DISE baseline collapse pattern, and all patients underwent a uvulopalatopharyngoplasty with tonsillectomy (TE‐UPPP) .…”

“…This is of major importance, as CCCp is considered to be a negative predictive value for MAD treatment, UA surgery, and UA stimulation, and tends to be more difficult to alleviate compared to the other collapse patterns. 14,15,17,18,23,24 In addition, when CCCp is present, higher CPAP pressure is needed to reopen the UA. 23 The most important finding of this study, which is reported here for the first time, is that the presence of CCCp appears not to be an exclusion criterion for MMA surgery outcome in terms of AHI reduction.…”

“…This can be performed by drug‐induced sleep endoscopy (DISE) mimicking natural sleep . A complete concentric collapse at the level of the palate (CCCp), as observed during DISE, has been a reported predictor for decreased success rate of some specific non‐CPAP treatment options such as UA stimulation, UA surgery, and MAD . Specifically, surgical treatment with UA stimulation, using electrical neurostimulation of the hypoglossal nerve synchronized with ventilation, fails to reduce OSA severity in patients with CCCp .…”

“…13 A complete concentric collapse at the level of the palate (CCCp), as observed during DISE, has been a reported predictor for decreased success rate of some specific non-CPAP treatment options such as UA stimulation, UA surgery, and MAD. [15][16][17][18] Specifically, surgical treatment with UA stimulation, using electrical neurostimulation of the hypoglossal nerve synchronized with ventilation, fails to reduce OSA severity in patients with CCCp. 15,16,19 Consequently, according to the Food and Drug Administration approval statement, CCCp became a formal exclusion criterion for UA stimulation therapy.…”