Sleep medicine in otolaryngology units: an international survey.

PURPOSE: No study to date has described the overall landscape of sleep disorders management and training in otolaryngology departments of different countries. The aim of our study was to investigate and compare settings, diagnostic and therapeutic approaches and training programmes. METHODS: An international online survey was developed with the collaboration of the YO-IFOS (Young Otolaryngologists-International Federation of Otorhinolaryngological Societies) to assess the current practice of otolaryngologists in the management of sleep disorders. The survey also included a session dedicated to training. RESULTS: A total of 126 otolaryngologists completed the survey. The larger part of responses was collected from Central/South America and Europe. The majority of responders from South/Central America (97%) declared to be certified as sleep specialist while 49% of Europeans stated the opposite. Of responders 83% perform a drug-induced sleep endoscopy (DISE) before planning a possible surgical intervention. Soft palate and base of tongue interventions were the most common procedure, respectively performed in 94% and 79% of the cases. Residents were allowed to perform soft palate surgery in 77% of the cases. Upper airway stimulation (26% vs 10%), trans-oral robotic surgery (36% vs 11%) and radiofrequency of the base of the tongue (58% vs 25%) were preferred more frequently by European responders. The highest caseloads of soft palate surgery and bi-maxillary advancement were registered in the academic institutions. CONCLUSION: Significant concordance and few interesting divergences in diagnosis and treatment of sleep disorders were observed between nationalities and types of institution. Economic resources might have played a significant role in the therapeutic choice. Trainees' lack of exposure to certain interventions and to a sufficient caseload appeared to be the main burden to overcome.

Patient-reported outcome measure for obstructive sleep apnea: Symptoms, Tiredness, Alertness, Mood and Psychosocial questionnaire: Preliminary results.

Obstructive sleep apnea (OSA) is a common chronic condition that has a significant impact on the biopsychosocial aspects of the patient's life. There is currently no psychometrically validated patient-reported outcome measure to assess the impact of this condition on the health-related quality of life. We designed a novel instrument based on common patient statements, prioritized by patient preference. Sixty-three patients with OSA and 33 participants with no symptoms of sleep-disordered breathing were asked to complete a 20-item initial questionnaire. The acceptability, reliability and validity of the instrument were assessed using known psychometric techniques. The instrument had strong acceptability and was completed within 180 s with no missing data. Five items were removed as they had a high ceiling factor. A further three items were removed as they did not represent the central construct uniquely. The final 12-item instrument had high internal consistency (Cronbach's alpha 0.91), strong test-retest reliability (p = .83) and high discriminant validity when comparing mean total scores of controls (6.88; 95% confidence interval [CI], 4.67-9.08) and those with OSA (31.39; 95% CI, 27.94-34.84) (p < .001). Further studies are planned to help validate this instrument for clinical use.

Introducing a new classification for drug-induced sleep endoscopy (DISE): the PTLTbE system.

PURPOSE: A new classification system is proposed to help the interpretation of drug-induced sleep endoscopy (DISE). The purpose is to create a classification system that improves upon existing systems designed to assess suitability of lateral wall surgery such as expansion pharyngoplasty whilst improving the reliability of the classification. METHODS: A qualitative study into the difficulties trainees had with existing systems was used to identify key issues that needed to be addressed. A visual description of the palate, tonsils, lateral pharyngeal wall, tongue base, epiglottis (PTLTbE) classification was developed. Preliminary data on the inter-rater reliability of PTLTbE were collected. Twenty junior doctors were asked to interpret 5 DISE videos using the PTLTbE classification, and the kappa and percentage agreement were calculated. RESULTS: The Krippendorff alpha ranged between 0.56 and 0.86 for individual DISE videos which compared favourably with the results from those who also completed the VOTE classification (range 0.31 to 0.66). The overall percentage agreement for PTLTbE was 90.1%. CONCLUSIONS: There are a number of advantages of the PTLTbE system over other existing DISE classifications. (1) Tonsillar obstruction is separated from lateral pharyngeal wall collapse. (2) Interobserver reliability is improved, critical to improve communication, patient outcomes and future research. (3) The learning curve to use this system is short. Most doctors did not need to refer to the classification images as an aide-memoire after a few uses of the PTLTbE system. A fuller examination of the reliability of the PTLTbE system is underway along with examination of its use in clinical settings.

The use of drug-induced sleep endoscopy in England and Belgium.

PURPOSE: The purpose of this international survey is to ascertain the current practice of drug-induced sleep endoscopy (DISE) for patients with sleep-disordered breathing (SDB) by Otolaryngologists in the United Kingdom and Belgium. We compare the results with recommendations from the European Position Paper on drug-induced sleep endoscopy. METHODS: An online questionnaire was circulated to Consultant Otolaryngologists, independent practitioners, and trainees across the two countries. Eleven questions were used in total. RESULTS: 181 responses from the UK and 117 responses from Belgium were received, mostly from consultants and independent practitioners. SDB was a common presentation to ENT practice, seen by over 90% of clinicians. The use of DISE varied greatly between the two countries (72.9% Belgium, 26.1% UK). 54.1% of Belgian respondents use DISE on over 50% of their patients, compared to only 32.4% of British clinicians. Attitudes of surgeons towards the diagnostic value of DISE varied; in Belgium, the majority (54%) gave a rating of 3 or more (1 = useless to 5 = essential), with no respondents giving a score of 0 (useless). In the UK only 16% of respondents felt DISE had useful clinical value, with 25 respondents deeming it 'useless'. The majority opt for DISE when non-surgical therapies fail (51.4% UK, 61.3% Belgium). The majority of participants do not use objective measures for depth of sedation (75.7% UK, 66.7% Belgium), with a marked variation on anaesthetic methods. 62.2% of UK clinicians do not use a classification system, whereas in Belgium the majority of clinicians (60.8%) use the VOTE grading system. CONCLUSIONS: Clinicians in Belgium were more favourable to using DISE than in the UK. Differences in its clinical effectiveness were apparent between the two countries. A consensus on patient selection, method of sedation and an effective classification system seemed to be lacking from both countries. Further education is required to raise awareness for the use of DISE.

The role of elastography in evaluating thyroid nodules: a literature review and meta-analysis.

To appraise the literature for studies involving the use of elastography to diagnose thyroid nodule pathology. Two independent reviewers performed a systematic review of the English medical literature for studies involving elastography diagnosing thyroid nodule pathology. Data gleaned from this process was used in a meta-analysis to summarise the results. Thirty-eight studies were used in the meta-analysis totalling 5,942 thyroid nodules examined with elastography. The pooled results were sensitivity = 87.0 % (95 % confidence intervals (CI) = 86.2-87.9 %), specificity = 80.6 % (CI = 79.5-81.6 %), positive predictive value (PPV) = 48.9 % (CI = 47.6-50.2 %), negative predictive value (NPV) = 96.7 % (CI = 96.2-97.1 %), diagnostic accuracy = 81.7 % (CI = 80.7-82.7 %). Subgroup analysis of the data is also presented. Elastography has its limitations in the diagnosis of thyroid nodules; however, its high NPV is increasingly being used as an important investigation and may allow a reduction in the number of hemi-thyroidectomies with benign pathology. Subgroup analysis suggests that elastography techniques where compressive force is performed in a non-user-dependant method results in improved final results.

The quality of snoring treatment information on the internet.

The aim of this study was to assess the quality of information available on the World Wide Web regarding the treatment of snoring. The main data source was from internet searches using the three most popular search engines using the keywords "snoring treatment". First page websites were evaluated using the DISCERN instrument (assessing reliability and information given about treatment choices). Of the 135 websites identified, 16 unique websites were evaluated in the study (the remaining being adverts or repetitions). The websites had an average overall score of 2.37 out of 5 (range 1.19-4) and 37.5 % of the websites evaluated scored less than 2 out of 5 overall, suggesting very poor quality information. Highly ranked websites on popular search engines may not contain the most reliable information. Overall the information on the internet regarding the treatment of snoring is poor and patients should be encouraged to discuss their findings with a medical professional.

Long-term safety and efficacy of radiofrequency ablation in the treatment of sleep disordered breathing: a meta-analysis.

Radiofrequency ablation (RFA) is used in the treatment of sleep disordered breathing (SDB), particularly in the alleviation of snoring. The literature provides evidence that the short-term results are promising; however, the long-term efficacy is a matter of contention. In this article, we present the results of a literature search of studies that use RFA in the treatment of SDB which have a follow-up time of greater than a year. RFA was found to be a safe technique with minimal morbidity. The overall Visual Analogue score from six studies showed the overall mean improvement to be 4.3 (confidence intervals 3.4-5.12). Apnea Hypopnea Index (AHI), improved significantly in five of the studies analysed. Epworth Sleepiness Score (ESS), improved significantly in six of the studies analysed. In conclusion, the evidence suggests that RFA for SDB results in a significant improvement in follow-up times of at least a year. Since RFA can be applied in a clinic setting and leads to minimal disruption to daily life, this treatment option can be considered for those unwilling to participate in the more traditional surgical options for SDB.

Guidelines on the surgical management of sleep disorders: A systematic review.

OBJECTIVE: To facilitate the development of U.K. guidelines for sleep surgery and to guide sleep surgeons to existing guidelines relevant to their practice, we provide a systematic review and quality assessment of all existing guidelines on the surgical management of sleep disorders. METHODS: Systematic review using preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations. Medline and Embase databases were searched from inception to April 2018. Publications were included if they described a guideline for the surgical management of sleep disorders. Three assessors used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to evaluate included guidelines. RESULTS: The systematic search revealed 1,161 publications. Twenty-two guidelines from eight countries were included. Fourteen focused on adults, five on children, and three on both. The guidelines discussed nasal, tonsillar, palatal, tongue, hyoid, maxillomandibular, tracheal, bariatric, and multilevel surgeries. The mean overall AGREE II quality score of included guidelines was 3.5 (range = 2 to 5.3; maximum possible score = 7). CONCLUSION: This article provides a summary and quality assessment of all published guidelines on the surgical management of sleep disorders. No U.K. guidelines were identified, and existing guidelines have several shortcomings. This highlights the need for robust U.K. national guidelines on sleep surgery to promote clinical and cost-effective care in this field. Our findings can be used by stakeholders as a foundation for the development of new guidelines and can be used by sleep surgeons to direct them to existing guidelines relevant to their practice, promoting evidence-based clinical care. Laryngoscope, 130:1070-1084, 2020.

Measurement properties of patient-reported outcome measures (PROMs) in adults with obstructive sleep apnea (OSA): A systematic review.

This systematic review summarizes the evidence regarding the quality of patient-reported outcome measures (PROMs) validated in patients with obstructive sleep apnea (OSA). We performed a systematic literature search of all PROMs validated in patients with OSA, and found 22 measures meeting our inclusion criteria. The quality of the studies was assessed using the consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist. The results showed that most of the measurement properties of the PROMs were not, or not adequately, assessed. For many identified PROMs there was no involvement of patients with OSA during their development or before the PROM was tested in patients with OSA. Positive exceptions and the best current candidates for assessing health status in patients with OSA are the sleep apnea quality of life index (SAQLI), Maugeri obstructive sleep apnea syndrome (MOSAS) questionnaire, Quebec sleep questionnaire (QSQ) and the obstructive sleep apnea patient-oriented severity index (OSAPOSI). Even though there is not enough evidence to fully judge the quality of these PROMs as outcome measure, when interpreted with caution, they have the potential to add value to clinical research and clinical practice in evaluating aspects of health status that are important to patients.