The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Surgical Planning After Sleep Versus Awake Techniques in Patients With Obstructive Sleep Apnea Enrique Fern andez-Juli an, MD, PhD; Miguel Angel Garcıa-Perez, PhD; Javier Garcıa-Callejo, MD, PhD; Felipe Ferrer, MD, PhD; Francisco Martı, MD, PhD; Jaime Marco, MD, PhD Objective/Hypothesis: This study examined correlations between surgical recommendations based on either druginduced sleep endoscopy (DISE) or common awake examination methods in patients with obstructive sleep apnea syndrome (OSAS). Study Design: Prospective, blinded, clinical trial at a university hospital. Methods: An otorhinolaryngologist designed surgical plans for patients with OSAS after clinical examination, lateral cephalometry, the M€ uller maneuver, and Friedman staging. A second otorhinolaryngologist blinded to the previous plans made surgical recommendations after DISE. A third person tested agreement between the two sets of plans using Cohen’s kappa statistic and the chi-squared test. Results: One hundred and sixty-two patients (15 females, 147 males) completed the protocol. Good correlation was observed between DISE and Friedman staging regarding recommendations for isolated oropharyngeal or multilevel surgery (kappa 5 0.61). Correlations between DISE and clinical examination, lateral cephalometry, and the M€ uller maneuver regarding surgical procedures on specific structures contributing to upper airway obstruction ranged from fair for velum/tonsil surgery (k 5 0.41–0.60) to poor (k 5 0.01–0.20) for tongue-base, lateral pharyngeal wall, and epiglottal surgery. The most informative value was DISE versus clinical evaluation, lateral cephalometry, and the M€ uller maneuver, which changed surgical recommendations concerning the structures contributing to hypopharyngeal or laryngeal obstruction in > 40% of patients. Conclusions: Our results indicate that DISE provides more information about the anatomical locations and pattern of obstruction, particularly regarding the specific structures contributing to hypopharyngeal and laryngeal obstruction. DISE changes surgical decision making compared to awake evaluation methods. Key Words: Drug-induced sleep endoscopy, clinical examination, lateral cephalometry, M€ uller maneuver, Friedman staging system, surgical planning. Level of Evidence: 4. Laryngoscope, 00:000–000, 2014
INTRODUCTION Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of total or partial obstruction of the upper airway during sleep, usually associated with daytime sleepiness and neurocognitive and cardiovascular consequences.1,2 The gold standard treatment for OSAS is continuous positive airway pressure. However, some patients do not use these devices, or they use them insufficiently. Alternative and well-studied options are surgery, oral appliances, and weight loss. The results of isolated uvulopalatopharyngoplasty (UPPP)3 and multilevel operative therapy4 have been
From the Otorhinolaryngology Department (E.F-J., J.G-C., F.F., J.M.); the Department of Anesthesiology (F.M.), Hospital Clınico Universitario, Spain; and the Institute of Health Research INCLIVA and Department of Genetics (M.A.G-P.), University of Valencia, Valencia, Spain. Editor’s Note: This Manuscript was accepted for publication December 30, 2013. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Enrique Fern andez-Juli an, MD, Department of Otorhinolaryngology, Hospital Clınico Universitario, Avda, ~ ez 17, 46010 Valencia, Spain. E-mail: [email protected] Blasco Ib an DOI: 10.1002/lary.24577
Laryngoscope 00: Month 2014
disappointing in many circumstances. This situation may stem from many factors. Airway obstruction during sleep is not a completely anatomical problem, and surgery designed to achieve only anatomical modification is thus insufficient. Failure to identify the anatomical regions of upper airway obstruction (oropharynx, hypopharynx, or larynx) and specific structures (soft palate, tonsils, lateral pharyngeal walls, tongue base, and/or epiglottis) contributing to this obstruction are other factors. Identifying the anatomical locations and the pattern of obstruction and integrating this anatomy into proper surgical technique are essential for improving effectiveness and minimizing morbidity. Several authors have shown that improper selection criteria can explain the failure rate of surgery for OSAS.5,6 A variety of methods can be used to assess the anatomical locations of upper airway obstruction, but none can be considered a standard diagnostic method. Clinical examination (CE), lateral cephalometry (LC), and the M€ uller maneuver (MM) are applied during wakefulness to discover anatomical features of the skeleton and pharynx that may contribute to structural vulnerability and OSAS pathophysiology. Fujita7 developed a system for the classification of type I (oropharyngeal), type II (oropharyngeal and hypopharyngeal), and type III (hypopharyngeal) OSAS.
ndez-Julia n et al.: Surgical Planning: DISE Versus Awake Techniques Ferna
1
Later, Friedman et al.8 instituted the Friedman staging system (FSS), which is based on tonsil size, palate position in relation to the tongue, and body mass index (BMI). They suggested that the FSS could be helpful in predicting UPPP outcomes (80.6%, 37.9%, and 8.1% success rates in patients with stage I, stage II, and stage III OSAS, respectively).8 The FSS is used widely to select patients for palatal surgery and to confirm the presence of multilevel obstruction, thereby identifying patients who could benefit from multilevel surgery. These evaluation methods are subjective and limited because they are performed in the awake state when increased muscle tone can confound the results. Therefore, correlation with an objective test performed during sleep to determine the anatomical locations of obstruction is needed. In 1991, Croft and Pringle9 described sleep nasendoscopy, a more realistic method of tridimensional evaluation of the upper airway during pharmacologically induced sleep. This technique is also known as druginduced sleep endoscopy (DISE). To date, many descriptions of the diagnostic findings of DISE have been published. However, relatively few studies10 has shown that DISE versus awake techniques provides more clinical information to assess airway function and collapse, and assists in surgical planning for OSAS patients. The purpose of this study was to determine the correlation between surgical recommendations for anatomical locations of upper airway obstruction based on commonly used awake-examination methods (CE, LC, MM, and FS) and those based on DISE in OSAS patients.
MATERIALS AND METHODS This blinded prospective study included patients with moderate to severe OSAS diagnosed by full attended nocturnal polysomnography at the Clinical University Hospital of Valencia between October 2011 and April 2013. The study was approved by the hospital’s research foundation, and patients provided written informed consent before participating in the study. An otorhinolaryngologist designed surgical plans after evaluation of patients in the waking state. A second otorhinolaryngologist blinded to the previous conclusions designed surgical plans after DISE. Both otorhinolaryngologists specialize in the management of OSAS patients and all surgical planning, followed a standardized departmental protocol. Techniques applied included UPPP/tonsillectomy, tongue-base suspension, tongue-base radiofrequency, lingual tonsillectomy, hyoid suspension, and partial epiglottidectomy, as there was obstruction due to hypertrophic soft palate/tonsils, anteroposterior tongue-base prolapse, hypertrophic tongue base, hypertrophic lingual tonsils, collapse of the lateral pharyngeal walls/epiglottis, or floppy epiglottis, respectively. A third person compared the two surgical plans and treatment recommendations.
Clinical Examination An elongated or hypertrophic soft palate or hypertrophic palatine tonsils extending beyond the anterior pillars were defined as oropharyngeal obstruction. Hypopharyngeal obstruction was defined as a hypertrophic tongue base or lingual tonsils, preventing visualization of the entire larynx—including the arytenoids—by supine fiber-optic nasopharyngoscopy. Apposi-
Laryngoscope 00: Month 2014
2
tion of the epiglottis to the posterior pharyngeal wall was defined as laryngeal obstruction.
Lateral Cephalometry On LC, oropharyngeal, hypopharyngeal, and laryngeal obstruction were defined as increased distance between the posterior nasal spine and uvula or elongated soft palate (PNS– U > 40 mm), narrow posterior airway space (PAS < 10 mm), and reduced distance between the epiglottis apex and lower pharyngeal wall (EA–LPW < 6 mm), respectively.11
M€ uller Maneuver The MM was carried out while the patient was awake in dorsal decubitus. Oropharyngeal obstruction was defined as apposition of the soft palate to the posterior pharyngeal wall or midline contact between the palatine tonsils leading to > 50% obstruction. Hypopharyngeal obstruction was defined as anteroposterior tongue-base prolapse leading to > 50% retrolingual obstruction or midline contact between the lateral pharyngeal walls. Posterior displacement of the entire epiglottis toward the glottic inlet was defined as laryngeal obstruction.12
Friedman Staging The FSS was used to classify OSAS as stage I, stage II, or stage III. Oropharyngeal surgery (UPPP) alone was indicated for patients with stage I OSAS, and multilevel surgery was indicated for those with stage II/III OSAS.8
Drug-induced Sleep Endoscopy DISE was performed in an operating room with the patient in the supine position. Oxygen saturation and cardiac rhythm were monitored, and propofol (Diprivan; AstraZeneca International PLC, London, UK) was administered with the aid of target-controlled infusion (TCI) by a pump (Diprifusor TCI system, AstraZeneca International PLC). Oropharyngeal obstruction was defined as anteroposterior or concentric collapse of the soft palate or lateral collapse of the palatine tonsils. Hypopharyngeal obstruction was defined as anteroposterior tongue-base prolapse or midline contact between the lateral pharyngeal walls. Laryngeal obstruction was defined as prolapse of the arytenoids or epiglottis toward the glottic inlet during aspiration, sometimes secondary to tongue base pressure.
Statistical Analysis The data were recorded and analyzed using the Statistical Package for Social Sciences (SPSS; SPSS Inc., Chicago, IL). The chi-squared test and Cohen’s kappa statistic were used to test agreement in surgical predictions based on DISE and other evaluation techniques. The strength of agreement was classified as excellent (k 5 0.93–1.00), very good (k 5 0.81–0.92), good (k 5 0.61–0.80), fair (k 5 0.41–0.60), slight (k 5 0.21–0.40), or poor (k 5 0.01–0.20).13 Ninety-five percent confidence intervals (CIs) were calculated for all kappa values to indicate the reliability of estimates. Statistical significance was accepted at P < 0.05.
RESULTS Between October 2011 and April 2013, 184 patients were enrolled in the study. The MM could not be performed in 12 patients, four patients rejected DISE, and
ndez-Julia n et al.: Surgical Planning: DISE Versus Awake Techniques Ferna
According to the FSS, patients were classified as having stage I (n 5 31, 19.1%), stage II (n 5 109, 67.3%), and stage III (n 5 22, 13.6%) OSAS. DISE and FSS predicted isolated oropharyngeal surgery in 28.4% (n 5 46) and 19.1% (n 5 31) of patients and multilevel surgery in 71.6% (n 5 116) and 80.9% (n 5 131) of patients, respectively. The Pearson chi-squared test showed significant relationships between surgical predictions of isolated oropharyngeal and multilevel surgery based on DISE and FSS (P < 0.0001). These predictions also showed good agreement (k 5 0.613; 95% CI, 0.473–0.753). The most informative value was DISE vs CE, LC, and MM, which changed surgical recommendations concerning structures contributing to hypopharyngeal or laryngeal obstruction in > 40% of patients. Fig. 1. Distribution of specific structures contributing to upper airway obstruction. CE 5 clinical examination; DISE 5 drug-induced €ller sleep endoscopy; LC 5 lateral cephalometry; MM 5 Mu maneuver.
sedation failed in six patients. A total of 162 patients (15 females and 147 males) completed the protocol. The mean age was 46.3 6 6.4 years, mean BMI was 28.1 6 3.2 kg/m2, and mean apnea-hypopnea index was 32.1 6 18.2/h. None of our patients had morbid obesity. All techniques showed that retropalatal and retrolingual were the most common anatomical locations of obstruction. CE and LC were unable to detect obstruction caused by the lateral pharyngeal walls (Fig. 1). Pearson’s chi-squared test showed a significant relationship between surgical plans based on DISE and those based on awake techniques (CE, LC, and MM) for velum/tonsil surgery (P < 0.0001). However, no significant relationship between plans was found for surgery involving the tongue base, lateral pharyngeal walls, or epiglottis. Agreement between plans based on DISE and awake techniques was fair (k 5 0.41–0.60) for velum/ tonsil surgery but poor (k 5 0.01–0.20) for tongue base, lateral pharyngeal wall, and epiglottal surgery (Table I).
DISCUSSION The aim of our study was to compare DISE versus awake techniques in a group of OSAS patients who were not morbidly obesity because several studies suggest that a high BMI is a marker of poorer outcomes.4,14–17 On polysomnography, apnea is divided into so-called obstructive sleep apnea (no airflow despite expenditure of ventilatory effort) and central sleep apnea (absence of both airflow and ventilatory effort). In standard OSAS patients such as ours, few central sleep apneas (CSA) are observed in polysomnograms and are appropriately ignored because they are of no clinical significance. Nevertheless, hypocapnic patients with primary CSA or Cheyne Stokes, and hypercapnic patients with neuromuscular disorders or obesity hypoventilation syndrome (OHS), often exhibit CSA. It is important to distinguish among OSAS, OHS, and OSAS/OHS because treatments can differ. Upper airway collapse in OSAS patients results from the interaction of static (craniofacial framework and upper airway soft-tissue mass) and dynamic (neuromuscular tone and airflow) forces. The literature on upper airway obstruction in these patients usually refers to oropharyngeal or hypopharyngeal segments, and some
TABLE I. Correlations of Surgical Predictions Based on DISE and Awake Techniques for Specific Structures. Pearson v2 test (DISE vs. indicated awake technique) Surgical Prediction
Velum/tonsils
Tongue base
Technique
n
Technique
DISE
126 (77.8%)
CE
112 (69.1%)
0.436
0.283–0.588
45/h. Therefore, the findings of this study cannot be safely extrapolated to the general population of OSAS patients. Finally, the reliability of DISE exam is good but needs to be improved to reach the level of excellence expected of most gold standard tests used in clinical practice. Further, we emphasize the need for more objective, quantitative descriptors, as well as well-designed research to establish DISE as a justified diagnostic tool in sleep medicine. Our next goal is to explore if DISE versus awake techniques allow us to improve the surgical outcomes of OSAS patients.
CONCLUSION Our results indicate that DISE provides more information about the anatomical locations and pattern of obstruction, particularly regarding the specific structures contributing to hypopharyngeal and laryngeal obstruction. DISE changes surgical decision-making compared to awake evaluation methods.
BIBLIOGRAPHY 1. Kim HC, Young T, Matthews CG, Weber SM, Woodward AR, Palta M. Sleep-disordered breathing and neuropsychological deficits: a population-based study. Am J Respir Crit Care Med 1997;156:1813– 1819. 2. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19–25. 3. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19:156–177. 4. Fernandez-Julian E, Munoz N, Achiques MT, Garcia-Perez MA, Orts M, Marco J. Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 2009;140:917–923. 5. Den Herder C, Van Tinteren H, de Vries N. Sleep endoscopy versus modified Mallampati score in sleep apnea and snoring. Laryngoscope 2005; 115:735–739. 6. Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol 2008;265:1397–1402. 7. Fujita S. Surgical treatment of obstructive sleep apnea: UPP and lingualplasty (laser midline glossectomy). In: Guilleminault C, Partinen M, eds. Obstructive Sleep Apnea Syndrome: Clinical Research and Treatment. New York, NY: Raven Press; 1990:129–151. 8. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep disordered breathing. Otolaryngol Head Neck Surg 2002;127:13–21. 9. Croft CB, Pringle M. Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnea. Clin Otolaryngol 1991;16:504–509.
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10. Gillespie MB, Reddy RP, White DR, Discolo CM, Overdyk FJ, Nguyen SA. A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Laryngoscope 2013;123:277–282. 11. Riley R, Guilleminault C, Powell N, Simmons FB. Palatopharyngoplasty failure, cephalometric roentgenograms, and obstructive sleep apnea. Otolaryngol Head Neck Surg 1985;93:240–244. 12. Sher AE, Thorpy MJ, Shptintzen RJ, Spielman AJ, Burack B, McGregor PA. Predictive value of M€ uller maneuver in selection of patients for uvulopalatopharyngoplasty. Laryngoscope 1985;95:1483–1487. 13. Byrt T. How good is that agreement [letter]? Epidemiology 1996;7:561. 14. Gislason T, Lindholm CE, Almqvist M, et al. Uvulopalatopharyngoplasty in the sleep apnea syndrome. Predictors of results. Arch Otolaryngol Head Neck Surg 1988;114:45–51. 15. Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993;108:117–125. 16. Larsson LH, Carlsson-Nordlander B, Svanborg E. Four-year follow-up after uvulopalatopharyngoplasty in 50 unselected patients with obstructive sleep apnea syndrome. Laryngoscope 1994;104:1362–1368. 17. Vicente E, Marin JM, Carrizo S, Naya MJ. Tongue-base suspension in conjunction with uvulopalatopharyngoplsty for treatment of severe obstructive sleep apnea: long-term follow-up results. Laryngoscope 2006;116: 1223–1227. 18. Troell RJ, Riley RW, Powell NB, Li K. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngol Clin North Am 1998;31:979–1012. 19. Pringle MB, Croft CB. A comparison of sleep nasendoscopy and the Muller maneuver. Clin Otolaryngol Allied Sci 1991;16:559–562. 20. Eckert DJ, Malhotra A, Lo YL, White DP, Jordan AS. The influence of obstructive sleep apnea and gender on genioglossus activity during rapid eye movement sleep. Chest 2009;135:957–964. 21. Woodson BT, Wooten MR. Comparison of upper airway evaluations during wakefulness and sleep. Laryngoscope 1994;104:821–828. 22. Pepin JL, Levy P, Veale D, Ferretti G. Evaluation of the upper airway in sleep apnea syndrome. Sleep 1992;15(suppl 6):S50– S55. 23. Faber CE, Hilberg O, Grymer L. Flextube reflectometry for level diagnosis in patients with obstructive sleep apnea and snoring. Rhinology 2002; 40:122–128. 24. Partinen M, Guilleminault C, Quera-Salva MA, Jamieson A. Obstructive sleep apnea and cephalometric roentgenograms: the role of upper airway abnormalities in the definition of abnormal breathing during sleep. Chest 1988;93:1199–1205. 25. Riley R, Guilleminault C, Herran J, Powell N. Cephalometric analysis and flow-volume loops in obstructive sleep apnea patients. Sleep 1983;6:303– 311. 26. George JR, Chung S, Nielsen I, Goldberg AN, Miller A, Kezirian EJ. Comparison of drug-induced sleep endoscopy and lateral cephalometry in obstructive sleep apnea. Laryngoscope 2012;122:2600–2605. 27. Woodson BT, Naganuma H. Comparison of methods of airway evaluation in obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 1999; 120:460–463. 28. Terris DJ, Hanasono MM, Liu YC. Reliability of the Muller maneuver and its association with sleep-disordered breathing. Laryngoscope 2000;110: 1819–1823. 29. Petri N, Suadicani P, Wildschiodtz G, Bjorn-Jorgensen J. Predictive value of Muller maneuver, cephalometry and clinical features for the outcome of uvulopalatopharyngoplasty: evaluation of predictive factors using discriminate analysis in 30 sleep apnea patients. Acta Otolaryngol 1994; 114:565–571. 30. Doghramji K, Jabourian ZH, Pilla M, Farole A, Lindholm RN. Predictors of outcome for uvulopalatopharyngoplasty. Laryngoscope 1995;105:311–314. 31. Katsantonis GP, Maas CS, Walsh JK. The predictive efficacy of the Muller maneuver in uvulopalatopharyngoplasty. Laryngoscope 1989;99:677–680. 32. Rabelo FAW, Braga A, Kupper DS et al. Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls. Otolaryngol Head Neck Surg 2010;142:218–224. 33. Camilleri AE, Ramamurthy L, Jones P. Sleep nasendoscopy: what benefit to the management of snorers? J Laryngol Otol 1995;109:1163–1165. 34. Li W, Ni D, Jiang H, Zhang L. Predictive value of sleep nasendoscopy and the Muller maneuver in uvulopalatopharyngoplasty for the obstructive sleep apnea syndrome. Lin Chuang Er Bi Yan Hou Ke Za Zhi 2003;17:145–146. 35. Hessel NS, de Vries N. Results of uvulopalatopharyngoplasty after diagnostic workup with polysomnography and sleep endoscopy: a report of 136 snoring patients. Eur Arch Otorhinolaryngol 2003;260:91–95. 36. Eichler C, Sommer JU, Stuk BA, Hormann K, Maurer JT. Does druginduced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea? Sleep Breath 2013;17:63–68. 37. Kezirian EJ. Nonresponders to Pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy. Laryngoscope 2011; 121:1320–1326. 38. Martin SE, Marshall I, Douglas NJ. The effect of posture on airway caliber with the sleep-apnea/hypopnea syndrome. Am J Respir Crit Care Med 1995;152:721–724.
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5
Rhinological and Otological Society, Inc.
Surgical Planning After Sleep Versus Awake Techniques in Patients With Obstructive Sleep Apnea Enrique Fern andez-Juli an, MD, PhD; Miguel Angel Garcıa-Perez, PhD; Javier Garcıa-Callejo, MD, PhD; Felipe Ferrer, MD, PhD; Francisco Martı, MD, PhD; Jaime Marco, MD, PhD Objective/Hypothesis: This study examined correlations between surgical recommendations based on either druginduced sleep endoscopy (DISE) or common awake examination methods in patients with obstructive sleep apnea syndrome (OSAS). Study Design: Prospective, blinded, clinical trial at a university hospital. Methods: An otorhinolaryngologist designed surgical plans for patients with OSAS after clinical examination, lateral cephalometry, the M€ uller maneuver, and Friedman staging. A second otorhinolaryngologist blinded to the previous plans made surgical recommendations after DISE. A third person tested agreement between the two sets of plans using Cohen’s kappa statistic and the chi-squared test. Results: One hundred and sixty-two patients (15 females, 147 males) completed the protocol. Good correlation was observed between DISE and Friedman staging regarding recommendations for isolated oropharyngeal or multilevel surgery (kappa 5 0.61). Correlations between DISE and clinical examination, lateral cephalometry, and the M€ uller maneuver regarding surgical procedures on specific structures contributing to upper airway obstruction ranged from fair for velum/tonsil surgery (k 5 0.41–0.60) to poor (k 5 0.01–0.20) for tongue-base, lateral pharyngeal wall, and epiglottal surgery. The most informative value was DISE versus clinical evaluation, lateral cephalometry, and the M€ uller maneuver, which changed surgical recommendations concerning the structures contributing to hypopharyngeal or laryngeal obstruction in > 40% of patients. Conclusions: Our results indicate that DISE provides more information about the anatomical locations and pattern of obstruction, particularly regarding the specific structures contributing to hypopharyngeal and laryngeal obstruction. DISE changes surgical decision making compared to awake evaluation methods. Key Words: Drug-induced sleep endoscopy, clinical examination, lateral cephalometry, M€ uller maneuver, Friedman staging system, surgical planning. Level of Evidence: 4. Laryngoscope, 00:000–000, 2014
INTRODUCTION Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of total or partial obstruction of the upper airway during sleep, usually associated with daytime sleepiness and neurocognitive and cardiovascular consequences.1,2 The gold standard treatment for OSAS is continuous positive airway pressure. However, some patients do not use these devices, or they use them insufficiently. Alternative and well-studied options are surgery, oral appliances, and weight loss. The results of isolated uvulopalatopharyngoplasty (UPPP)3 and multilevel operative therapy4 have been
From the Otorhinolaryngology Department (E.F-J., J.G-C., F.F., J.M.); the Department of Anesthesiology (F.M.), Hospital Clınico Universitario, Spain; and the Institute of Health Research INCLIVA and Department of Genetics (M.A.G-P.), University of Valencia, Valencia, Spain. Editor’s Note: This Manuscript was accepted for publication December 30, 2013. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Enrique Fern andez-Juli an, MD, Department of Otorhinolaryngology, Hospital Clınico Universitario, Avda, ~ ez 17, 46010 Valencia, Spain. E-mail: [email protected] Blasco Ib an DOI: 10.1002/lary.24577
Laryngoscope 00: Month 2014
disappointing in many circumstances. This situation may stem from many factors. Airway obstruction during sleep is not a completely anatomical problem, and surgery designed to achieve only anatomical modification is thus insufficient. Failure to identify the anatomical regions of upper airway obstruction (oropharynx, hypopharynx, or larynx) and specific structures (soft palate, tonsils, lateral pharyngeal walls, tongue base, and/or epiglottis) contributing to this obstruction are other factors. Identifying the anatomical locations and the pattern of obstruction and integrating this anatomy into proper surgical technique are essential for improving effectiveness and minimizing morbidity. Several authors have shown that improper selection criteria can explain the failure rate of surgery for OSAS.5,6 A variety of methods can be used to assess the anatomical locations of upper airway obstruction, but none can be considered a standard diagnostic method. Clinical examination (CE), lateral cephalometry (LC), and the M€ uller maneuver (MM) are applied during wakefulness to discover anatomical features of the skeleton and pharynx that may contribute to structural vulnerability and OSAS pathophysiology. Fujita7 developed a system for the classification of type I (oropharyngeal), type II (oropharyngeal and hypopharyngeal), and type III (hypopharyngeal) OSAS.
ndez-Julia n et al.: Surgical Planning: DISE Versus Awake Techniques Ferna
1
Later, Friedman et al.8 instituted the Friedman staging system (FSS), which is based on tonsil size, palate position in relation to the tongue, and body mass index (BMI). They suggested that the FSS could be helpful in predicting UPPP outcomes (80.6%, 37.9%, and 8.1% success rates in patients with stage I, stage II, and stage III OSAS, respectively).8 The FSS is used widely to select patients for palatal surgery and to confirm the presence of multilevel obstruction, thereby identifying patients who could benefit from multilevel surgery. These evaluation methods are subjective and limited because they are performed in the awake state when increased muscle tone can confound the results. Therefore, correlation with an objective test performed during sleep to determine the anatomical locations of obstruction is needed. In 1991, Croft and Pringle9 described sleep nasendoscopy, a more realistic method of tridimensional evaluation of the upper airway during pharmacologically induced sleep. This technique is also known as druginduced sleep endoscopy (DISE). To date, many descriptions of the diagnostic findings of DISE have been published. However, relatively few studies10 has shown that DISE versus awake techniques provides more clinical information to assess airway function and collapse, and assists in surgical planning for OSAS patients. The purpose of this study was to determine the correlation between surgical recommendations for anatomical locations of upper airway obstruction based on commonly used awake-examination methods (CE, LC, MM, and FS) and those based on DISE in OSAS patients.
MATERIALS AND METHODS This blinded prospective study included patients with moderate to severe OSAS diagnosed by full attended nocturnal polysomnography at the Clinical University Hospital of Valencia between October 2011 and April 2013. The study was approved by the hospital’s research foundation, and patients provided written informed consent before participating in the study. An otorhinolaryngologist designed surgical plans after evaluation of patients in the waking state. A second otorhinolaryngologist blinded to the previous conclusions designed surgical plans after DISE. Both otorhinolaryngologists specialize in the management of OSAS patients and all surgical planning, followed a standardized departmental protocol. Techniques applied included UPPP/tonsillectomy, tongue-base suspension, tongue-base radiofrequency, lingual tonsillectomy, hyoid suspension, and partial epiglottidectomy, as there was obstruction due to hypertrophic soft palate/tonsils, anteroposterior tongue-base prolapse, hypertrophic tongue base, hypertrophic lingual tonsils, collapse of the lateral pharyngeal walls/epiglottis, or floppy epiglottis, respectively. A third person compared the two surgical plans and treatment recommendations.
Clinical Examination An elongated or hypertrophic soft palate or hypertrophic palatine tonsils extending beyond the anterior pillars were defined as oropharyngeal obstruction. Hypopharyngeal obstruction was defined as a hypertrophic tongue base or lingual tonsils, preventing visualization of the entire larynx—including the arytenoids—by supine fiber-optic nasopharyngoscopy. Apposi-
Laryngoscope 00: Month 2014
2
tion of the epiglottis to the posterior pharyngeal wall was defined as laryngeal obstruction.
Lateral Cephalometry On LC, oropharyngeal, hypopharyngeal, and laryngeal obstruction were defined as increased distance between the posterior nasal spine and uvula or elongated soft palate (PNS– U > 40 mm), narrow posterior airway space (PAS < 10 mm), and reduced distance between the epiglottis apex and lower pharyngeal wall (EA–LPW < 6 mm), respectively.11
M€ uller Maneuver The MM was carried out while the patient was awake in dorsal decubitus. Oropharyngeal obstruction was defined as apposition of the soft palate to the posterior pharyngeal wall or midline contact between the palatine tonsils leading to > 50% obstruction. Hypopharyngeal obstruction was defined as anteroposterior tongue-base prolapse leading to > 50% retrolingual obstruction or midline contact between the lateral pharyngeal walls. Posterior displacement of the entire epiglottis toward the glottic inlet was defined as laryngeal obstruction.12
Friedman Staging The FSS was used to classify OSAS as stage I, stage II, or stage III. Oropharyngeal surgery (UPPP) alone was indicated for patients with stage I OSAS, and multilevel surgery was indicated for those with stage II/III OSAS.8
Drug-induced Sleep Endoscopy DISE was performed in an operating room with the patient in the supine position. Oxygen saturation and cardiac rhythm were monitored, and propofol (Diprivan; AstraZeneca International PLC, London, UK) was administered with the aid of target-controlled infusion (TCI) by a pump (Diprifusor TCI system, AstraZeneca International PLC). Oropharyngeal obstruction was defined as anteroposterior or concentric collapse of the soft palate or lateral collapse of the palatine tonsils. Hypopharyngeal obstruction was defined as anteroposterior tongue-base prolapse or midline contact between the lateral pharyngeal walls. Laryngeal obstruction was defined as prolapse of the arytenoids or epiglottis toward the glottic inlet during aspiration, sometimes secondary to tongue base pressure.
Statistical Analysis The data were recorded and analyzed using the Statistical Package for Social Sciences (SPSS; SPSS Inc., Chicago, IL). The chi-squared test and Cohen’s kappa statistic were used to test agreement in surgical predictions based on DISE and other evaluation techniques. The strength of agreement was classified as excellent (k 5 0.93–1.00), very good (k 5 0.81–0.92), good (k 5 0.61–0.80), fair (k 5 0.41–0.60), slight (k 5 0.21–0.40), or poor (k 5 0.01–0.20).13 Ninety-five percent confidence intervals (CIs) were calculated for all kappa values to indicate the reliability of estimates. Statistical significance was accepted at P < 0.05.
RESULTS Between October 2011 and April 2013, 184 patients were enrolled in the study. The MM could not be performed in 12 patients, four patients rejected DISE, and
ndez-Julia n et al.: Surgical Planning: DISE Versus Awake Techniques Ferna
According to the FSS, patients were classified as having stage I (n 5 31, 19.1%), stage II (n 5 109, 67.3%), and stage III (n 5 22, 13.6%) OSAS. DISE and FSS predicted isolated oropharyngeal surgery in 28.4% (n 5 46) and 19.1% (n 5 31) of patients and multilevel surgery in 71.6% (n 5 116) and 80.9% (n 5 131) of patients, respectively. The Pearson chi-squared test showed significant relationships between surgical predictions of isolated oropharyngeal and multilevel surgery based on DISE and FSS (P < 0.0001). These predictions also showed good agreement (k 5 0.613; 95% CI, 0.473–0.753). The most informative value was DISE vs CE, LC, and MM, which changed surgical recommendations concerning structures contributing to hypopharyngeal or laryngeal obstruction in > 40% of patients. Fig. 1. Distribution of specific structures contributing to upper airway obstruction. CE 5 clinical examination; DISE 5 drug-induced €ller sleep endoscopy; LC 5 lateral cephalometry; MM 5 Mu maneuver.
sedation failed in six patients. A total of 162 patients (15 females and 147 males) completed the protocol. The mean age was 46.3 6 6.4 years, mean BMI was 28.1 6 3.2 kg/m2, and mean apnea-hypopnea index was 32.1 6 18.2/h. None of our patients had morbid obesity. All techniques showed that retropalatal and retrolingual were the most common anatomical locations of obstruction. CE and LC were unable to detect obstruction caused by the lateral pharyngeal walls (Fig. 1). Pearson’s chi-squared test showed a significant relationship between surgical plans based on DISE and those based on awake techniques (CE, LC, and MM) for velum/tonsil surgery (P < 0.0001). However, no significant relationship between plans was found for surgery involving the tongue base, lateral pharyngeal walls, or epiglottis. Agreement between plans based on DISE and awake techniques was fair (k 5 0.41–0.60) for velum/ tonsil surgery but poor (k 5 0.01–0.20) for tongue base, lateral pharyngeal wall, and epiglottal surgery (Table I).
DISCUSSION The aim of our study was to compare DISE versus awake techniques in a group of OSAS patients who were not morbidly obesity because several studies suggest that a high BMI is a marker of poorer outcomes.4,14–17 On polysomnography, apnea is divided into so-called obstructive sleep apnea (no airflow despite expenditure of ventilatory effort) and central sleep apnea (absence of both airflow and ventilatory effort). In standard OSAS patients such as ours, few central sleep apneas (CSA) are observed in polysomnograms and are appropriately ignored because they are of no clinical significance. Nevertheless, hypocapnic patients with primary CSA or Cheyne Stokes, and hypercapnic patients with neuromuscular disorders or obesity hypoventilation syndrome (OHS), often exhibit CSA. It is important to distinguish among OSAS, OHS, and OSAS/OHS because treatments can differ. Upper airway collapse in OSAS patients results from the interaction of static (craniofacial framework and upper airway soft-tissue mass) and dynamic (neuromuscular tone and airflow) forces. The literature on upper airway obstruction in these patients usually refers to oropharyngeal or hypopharyngeal segments, and some
TABLE I. Correlations of Surgical Predictions Based on DISE and Awake Techniques for Specific Structures. Pearson v2 test (DISE vs. indicated awake technique) Surgical Prediction
Velum/tonsils
Tongue base
Technique
n
Technique
DISE
126 (77.8%)
CE
112 (69.1%)
0.436
0.283–0.588
45/h. Therefore, the findings of this study cannot be safely extrapolated to the general population of OSAS patients. Finally, the reliability of DISE exam is good but needs to be improved to reach the level of excellence expected of most gold standard tests used in clinical practice. Further, we emphasize the need for more objective, quantitative descriptors, as well as well-designed research to establish DISE as a justified diagnostic tool in sleep medicine. Our next goal is to explore if DISE versus awake techniques allow us to improve the surgical outcomes of OSAS patients.
CONCLUSION Our results indicate that DISE provides more information about the anatomical locations and pattern of obstruction, particularly regarding the specific structures contributing to hypopharyngeal and laryngeal obstruction. DISE changes surgical decision-making compared to awake evaluation methods.
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