Clinical Analysis of Drug-Induced Sleep Endoscopy for the OSA Patient
Dina Golbin DO, Brandon Musgrave MD, Eric Succar MD, Kathleen Yaremchuk MD
Department of Otolaryngology/Head and Neck Surgery, Department of Sleep Medicine
Henry Ford Health System, Detroit, Michigan
Introduction
Results
Surgical treatment for obstructive sleep apnea (OSA) is an option
for patients who are unable to tolerate CPAP therapy.
Uvulopalatopharyngoplasty (UPPP) with or without
tonsillectomy is commonly used for treating OSA, however
surgical success, as measured by an AHI decrease of 50% and
<15, has been inconsistent.1 The surgery typically does not
require an extended hospital stay and patients are able to return to
work in approximately two weeks. Major complications rates for
this procedure are acceptable, but the reported long-term success
rates of 50% for UPPP remain low.2
40 patients underwent UPPP with or without tonsillectomy based
on clinical evaluation. These patients showed a significant
reduction in AHI -20.1 (p=0.001) and a complication rate of 3%
(p=0.001). There was no significant change in ESS -2.2
(p=0.734). 64 patients underwent DISE. Based on the findings at
the time of DISE, a UPPP, tonsillectomy, TORS lingual
tonsillectomy and epiglottectomy may have been performed
(DISE + UPPP/T, n=25; DISE + UPPP/T + TORS, n=39). These
patients showed a significant reduction in AHI of -21.4 (p=0.001)
and a complication rate of 34.7% (p=0.001). There was no
significant difference in the change of ESS +0.1 (p=0.734), AHI
(p=0.092) between the two groups (see Figure 1).
Drug-induced sleep endoscopy (DISE) is used to identify areas
of upper airway obstruction (Velum, Oropharyngeal, Tongue,
Epiglottis). During drug induced sleep, a flexible
nasolaryngoscope is used in the operating room to identify areas
of upper airway collapse while the patient is receiving propofol
intravenously.3 If the base of tongue and/or epiglottis are noted to
be involved, transoral robot-assisted surgery (TORS) with base of
tongue reduction, and/or with epiglottectomy can be performed
to eliminate the area of obstruction in an attempt to improve
outcomes.4
The objective of this study was to determine if performing DISE
and TORS for the surgical treatment of OSA results in improved
outcomes and acceptable complication rates when compared
DISE and traditional UPPP with or without tonsillectomy.
Methods
A retrospective cohort review was performed comparing 40
patients who had previously undergone UPPP or UPPP/
tonsillectomy based on clinical evaluation with 64 patients who
had DISE and UPPP, UPPP/tonsillectomy and/or TORS base of
tongue resection or epiglottectomy. The variables included
polysomnography results, Epworth Sleepiness Scale results,
BMI, sex, length of stay, hospital charges, readmissions, ED
visits and major complications. Patients were evaluated for
success based on an AHI decrease of 50% and an AHI <15.
Patients were also evaluated to determine if patients undergoing
DISE decreased a stage in the obstructive sleep apnea
classification from severe to moderate, moderate to mild or mild
to normal.
Categorical variables were compared using a Chi-squared test,
continuous variables were compared using a Student’s ttest. AHI and ESS were examined using analysis of variance for
repeated measures. Significance was indicated by a p-value less
than 0.05. All statistics were implemented using SAS version
9.2.
Major complications, occurring within 30 days of surgery, were
classified as reintubation, hemorrhage and death. The DISE group
was noted to have a significantly greater number of major
complications by 31.7% (p=0.001). Minor complications
(including dehydration, pain intolerance, atelectasis, arrhythmia,
etc.) were also evaluated and included in the total complication
rate for each group. Of the major complications, post-operative
hemorrhage in the DISE group was noted to be significant
(p=0.023) (Figure 3). Death, while not statistically significant
between the two groups, occurred in the DISE group and thought
to be due to respiratory failure associated with sedation. A pain
protocol collaborated with the anesthesia pain service was
immediately initiated and no further deaths occurred.
Complication
No
p-value p-value
DISE
DISE
per
between
(n=64)
(n=40)
group
groups
Change in AHI
(apnea/hypopnea per hour)
-20.1
Change in ESS
-2.2
Major Complication Rate
(%)
-21.4
0.001
0.092
0.1
0.734
p-value
8 (12.5%)
3 (4.7%)
2 (3.1%)
34.70%
0.023
0.288
0.113
0.001
0.732
Conclusion
3
34.7
0.001
Other factors were evaluated between the two groups, including
AHI severity, cure, BMI, sex, age, average total cost, length of
stay, readmission, and visits to the Emergency Department in the
30 days after surgery (Figure 2). The average total charges for the
DISE group was the only factor noted to be statistically
significant, greater by $14,708.
Population
No DISE
DISE
p-value
Mild OSA (AHI 5-15)
0 (0/0)
0 (0/0)
-
68.8 (11/16)
0.233
60.6 (20/33)
0.579
52.6% (30/57)
0.472
Moderate OSA (AHI 15-30) 86.7 (13/15)
68.8 (11/16)
Cure (AHI decrease by 50% and <15) 60% (24/40)
BMI <30
66.7 (4/6)
38.9 (7/18)
0.357
30 ≤ BMI < 40
50.0 (6/12)
48.8 (21/43)
0.943
BMI ≥ 40
33.3 (1/3)
60.0 (3/5)
> 0.999
Females
81.8 (9/11)
58.8 (10/17)
0.25
Males
51.7 (15/29)
42.9 (21/43)
0.448
Age
50.4
49.0
1.00
Average Total Cost
$24,576
$39,284
0.001
Length of stay
1.33 days
1.86 days
0.469
Readmission
1 (2.5%)
5 (7.8%)
0.402
ED Visits
DISE (n=64)
Figure 3. Comparison of pre and post-DISE major complication rates broken down
Figure 1. Comparison of pre and post-DISE ESS, AHI and Major Complication Rate
Severe OSA (AHI >30)
Bleeding
Reintubation
Death
Total
No DISE
(n=40)
2 (5%)
0
0
3%
4 (10.3%)
15 (23.4%)
0.085
Figure 2. Comparison of pre and post-DISE AHI, BMI, sex. Age, overall cost, length of stay,
readmission, emergency department visits
There was no statistically significant difference in surgical
success (50% decrease and AHI <15), ESS, or decrease in AHI
between the group whose treatment was based on clinical
judgment (no DISE) compared to the DISE group with or without
TORS. Patients who had DISE and TORS for OSA demonstrated
an increase in the rate of major complications, LOS, and charges.
It is thought that DISE and TORS allows improved identification
of areas of obstruction in the upper airway and would result in
improved outcomes for surgical treatment of obstructive sleep
apnea. However, clinical results have not been reported to
support this conclusion.
This retrospective study demonstrates that DISE in combination
with other procedures, including TORS, did not provide an
advantage over clinically based recommendations for success in
surgical procedures performed for OSA. The significant increase
in costs ($14,708 more than UPPP), complication rates (34.7%),
and length of stay (1.86 days) associated with DISE and TORS
warrant further investigation to determine if these procedures add
benefit in the treatment of patients with obstructive sleep apnea.
References
1. Värendh M, Berg S, Andersson M . Long-term follow-up of patients operated
with Uvulopalatopharyngoplasty from 1985 to 1991. Respir Med. 2012 Dec;106(12):178893.
2. Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomic abnormalities in
obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngology Head Neck
Surgery 1981; 89: 923-934.
3. Hohenhorst W, Ravesloot MJL, Kezirian EJ, DeVries N,. Drug Induced Sleep Endoscopy
in Adults with sleep-disordered breathing: Technique and the VOTE Classification system
Operative Techniques in Otolaryngology-Head and Neck Surgery. 2012 ; 23(1): 11-18.
4. Lee JM, Weinstein GS, O'Malley BW Jr, Thaler ER. Transoral robot-assisted lingual
tonsillectomy and uvulopalatopharyngoplasty for obstructive sleep apnea.Ann Otol Rhinol
Laryngol. 2012 Oct;121(10):635-9.