Drug-Induced Sedated Endoscopy

History

• 1.

  History of present illness

  • a.

    Presence of common sleep disorders, such as insomnia and restless legs syndrome. Failure to treat these disorders will result in suboptimal outcomes.

  • b.

    Subjective benefit from previous weight loss, positional therapy, oral appliance, or positive airway pressure (PAP) implicates OSA as driving force behind symptomatology.

  • c.

    In-depth review of most recent diagnostic sleep study with attention to positional or stage-related differences. DISE is considered to largely resemble non-REM rapid eye movement sleep.

• 2.

  Past medical history

  • a.

    Prior surgical otolaryngology treatment

  • b.

    Comorbidities associated with OSA: diabetes, hypertension, stroke, myocardial infarction, arrhythmia, depression, obesity

  • c.

    Difficulty with entrance or emergence from anesthesia

Physical Examination

• 1.

  Anterior rhinoscopy

  • a.

    Septal deviation, turbinate hypertrophy, and nasal polyps: These structures can create proximal obstruction, thereby increasing negative pressure in the distal pharynx.

• 2.

  Facial skeleton evaluation

  • a.

    Significant maxillary or mandibular constriction may require skeletal correction.

• 3.

  Neck exam

  • a.

    Inferiorly positioned hyoid bone (greater than two fingerbreadths below mandibular plane) intimates an unfavorably elongated airway; treatment options must be tailored to this phenotype.

Imaging

• None—although DISE findings may be correlated with existing imaging results

Indications

Surgical evaluation for sleep apnea requires synthesis of patient’s OSA symptoms, medical history, physical exam (including awake nasolaryngoscopy), sleep study results, patient preference, and patient expectations. If these elements are favorable for surgical treatment, the DISE can be performed as a planning tool either as a standalone procedure or immediately prior to surgical therapy in the operating room. Common indications include:

• 1.

  To plan a multilevel upper airway surgical plan in patients who have failed medical device therapy and present with concern for multilevel or multifactorial airway collapsibility

• 2.

  To evaluate the upper airway after prior failure of airway reconstructive surgery

• 3.

  To evaluate for anatomic candidacy for hypoglossal nerve stimulation therapy. At present, the Inspire hypoglossal nerve stimulator is the only surgical therapy that requires a priori DISE evaluation for candidacy determination. This requirement is related to indication guidelines from the US Food and Drug Administration.

• 4.

  At the time of staged or adjunctive nasal surgery, DISE to evaluate the rest of the upper airway anatomy should additional surgical considerations be needed in the future

• 5.

  In patients who achieve partial but incomplete results with oral appliance therapy, DISE with and without the oral appliance to evaluate for residual locations of collapse and additional medical or surgical treatment options to further augment the effectiveness of the oral appliance

• 6.

  In patients with persistent apnea-hypopnea index elevation or other evidence of airway obstruction despite CPAP (continuous positive airway pressure) use, DISE with and without the CPAP in place to investigate the reasons for CPAP failure, such as epiglottic collapse or iatrogenic airway obstruction due to the interface impact on the jaw and neck position

• 7.

  In the pediatric population, to evaluate for persistent OSA after adenotonsillectomy and other first-line therapy. DISE is often preferred to in-office awake laryngoscopy for both patient tolerability and visualization of dynamic collapsibility.

Contraindications

• History of drug allergy to sedating agent

• Pregnancy

• Significant nasal obstruction precluding endoscopic examination

Preoperative Preparation

• No food or drink after midnight because the patient is receiving general anesthesia