Drug-induced sleep endoscopy: techniques, interpretation and implications.

PURPOSE OF REVIEW: The purpose of this article is to highlight recent advances in the burgeoning field of drug-induced sleep endoscopy (DISE). RECENT FINDINGS: One of the first studies to investigate the correlation of DISE findings and natural sleep endoscopy found good agreement in clinically significant obstruction. Previous studies have shown good agreement of DISE findings with the use of different sedative agents implying that the choice of sedative may not be crucial. However, recent studies show variable patterns of collapse, especially at the tongue base, with the use of different sedative agents. A universally accepted classification scheme for drug-induced sleep endoscopy is lacking. A new DISE classification system, termed Palate, Tonsils, Lateral pharyngeal wall, Tongue base, Epiglottis, was introduced this year with the noted advantage of being able to better differentiate between clinically relevant tonsillar and lateral pharyngeal wall collapse. Despite recent advances in the field, there remains no general consensus that DISE findings predict surgical success but may aid in the identification of patients who will respond well to oral appliance therapy. SUMMARY: Drug-induced sleep endoscopy is a structure-based evaluation of the upper airway that more closely resembles the natural sleep state compared with awake evaluation.

Maxillomandibular Advancement Surgery for Patients Who Are Refractory to Continuous Positive Airway Pressure: Are There Predictors of Success?

PURPOSE: This pilot study was conducted to determine the effectiveness of maxillomandibular advancement (MMA) in the treatment of patients with moderate to severe obstructive sleep apnea (OSA). The predictive value of clinical, radiographic, and treatment-related variables also was investigated in relation to the success or failure of MMA as treatment for OSA. MATERIALS AND METHODS: A retrospective study design was used to assess the outcomes of MMA in patients with moderate to severe OSA (apnea hypopnea index [AHI] >15 events per hour) at the University of Michigan (Ann Arbor, MI). Data collected included clinical, radiographic, and polysomnographic findings. Primary outcomes of interest included the AHI, minimal oxygen saturation, and percentage of time spent with oxygen saturation lower than 88% as measured by polysomnography. RESULTS: Twenty patients met the inclusion criteria for the study (mean age, 48.8 ± 12.3 yr). Mean body mass index decreased from 32.03 ± 5.13 kg/m2 at baseline to 29.75 ± 5.23 kg/m2 at follow-up (P = .001). Mean advancements were 13.5 ± 2.7 mm at point B and 16.1 ± 4.5 mm at the pogonion. A 4.5-fold increase in minimal cross-sectional area and a 2.2-fold increase in airway volume were achieved on average. Patients showed a 68.5% decrease in mean AHI from 49.4 to 15.6 events per hour (P < .001). The percentage of time with oxygen saturation lower than 88% was significantly decreased from 15.4% at baseline to 1.4% after surgery (P = .014). The overall surgical success rate was 55% (11 of 20) based on an AHI of fewer than 15 events per hour. CONCLUSIONS: These preliminary results indicate that MMA surgery might be highly effective for select patients with moderate to severe OSA. Despite large increases in airway dimensions, a surgical success rate of 55% was achieved in the overall sample. Assessment of predictive variables for success and failure are discussed.

Multidisciplinary Alternatives to CPAP Program for CPAP-Intolerant Patients.

ABSTRACT: Continuous positive airway pressure (CPAP) intolerance remains a persistent problem for many obstructive sleep apnea patients. Clinicians and researchers continue to search for other effective treatment modalities given the well-documented sequelae associated with untreated obstructive sleep apnea. A multidisciplinary "Alternatives to CPAP program" (ALT) can facilitate systematic evaluation of non-CPAP therapies appropriate for an individual patient. We review successful strategies and barriers encountered during implementation of an ALT at our institution. Creation of similar programs in private practice and academic settings can help medical, dental, and surgical sleep medicine specialists coordinate evaluation and treatment of CPAP-intolerant patients.