Clinical Application of Pediatric Sleep Endoscopy: An International Survey.

OBJECTIVES: To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE. METHODS: A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations. RESULTS: A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral. CONCLUSION: Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

The effect of drug-induced sleep endoscopy on surgical outcomes for obstructive sleep apnea: a systematic review.

PURPOSE: Drug-induced sleep endoscopy (DISE) is the most widespread diagnostic tool for upper-airway endoscopic evaluation of snoring and obstructive sleep apnea (OSA). However, a consensus on the effectiveness of DISE on surgical outcomes is still lacking. This study aimed to quantify the effect of DISE on surgical outcomes and to compare DISE with awake examination using the Müller Maneuver (MM). METHODS: This systematic review was performed according to the PRISMA guidelines. Published studies from the last 30 years were retrieved from the Cochrane Library, MEDLINE, SCOPUS, and PubMed databases. Studies comparing DISE with awake examination, or MM were included. Surgical success rate was defined according to Sher's criteria, achieving a postoperative apnoea-hypopnea index (AHI) value < 20 events per hour and a 50% improvement from preoperative AHI. Outcomes are presented in terms of surgical success, pre- and postoperative AHI, Epworth sleepiness score (ESS), oxygen desaturation index (ODI) and lowest oxygen saturation (LOS). RESULTS: This review included 8 studies comprising 880 patients. DISE group showed a higher LOS increase, ODI decrease, ESS decrease than non-DISE group (6.83 ± 3.7 versus 3.68 ± 2.9, p<0.001; 19.6 ± 11.2 versus 12.6 ± 10.4, p<0.001; 6.72 ± 4.1 versus 3.69 ± 3.1, p<0.001). Differences in surgical success rate were significant only between DISE and MM (64.04% versus 52.48%, p = 0.016). AHI decrease resulted higher in non-DISE than in DISE group (39.92 ± 24.7 versus 30.53 ± 21.7, p<0.001). CONCLUSION: Results of this systematic review suggest that the evidence is mixed regarding a positive effect of DISE on surgical outcomes.

Care for Patients with Type-2 Chronic Rhinosinusitis.

In the last 20 years, growing interest in chronic rhinosinusitis (CRS) has become evident in medical literature; nevertheless, it is still difficult to identify the real prevalence of the disease. Epidemiological studies are few and focused on heterogeneous populations and diagnostic methods. Recent research has contributed to identifying CRS as a disease characterized by heterogeneous clinical scenarios, high impact on quality of life, and elevated social costs. Patient stratification with phenotypes and identification of the pathobiological mechanism at the origin of the disease (endotype) and its comorbidities are pivotal in the diagnostic process, and they should be addressed in order to properly tailor treatment. A multidisciplinary approach, shared diagnostic and therapeutic data, and follow-up processes are therefore necessary. Oncological multidisciplinary boards offer models to imitate in accordance with the principles of precision medicine: tracing a diagnostic pathway with the purpose of identifying the patient's immunological profile, monitoring therapeutical processes, abstaining from having only a single specialist involved in treatment, and placing the patient at the center of the therapeutic plan. Awareness and participation from the patient's perspective are fundamental steps to optimize the clinical course, improve quality of life, and reduce the socioeconomic burden.

3D 4K exoscope in snore surgery simulation: pre-clinical experience.

PURPOSE: The application of 3D exoscopic technology is spreading worldwide, in several surgical scenarios. In this study, we present the first-time use of the exoscopic system (VITOM® and Versacrane™) in a cadaver simulation of transoral Snore Surgery. METHODS: All participants (n = 14) were asked to perform 2 exercises that simulate tasks required in Snore Surgery, they were then administered a questionnaire assessing their evaluation of the applied exoscopic technology. Participants were divided into groups according to age and experience. RESULTS: Mean zooming and focusing time was higher in young surgeons than in seniors, and similar results were obtained for mean procedural times. The responses to the questionnaire showed that in the vast majority (86%), the exoscopic technology was well rated. CONCLUSION: The exoscope can be considered a useful tool, thanks to its magnifying power and high-definition images, as well as for its indirect ability to enhance staff involvement in the procedure and for educational purposes.

Barbed pharyngoplasty for the treatment of obstructive sleep apnea: the surgical learning curve.

BACKGROUND: Barbed snore surgery (BSS) was recently introduced for the management of obstructive sleep apnea (OSA) with optimistic clinical outcomes associated with a low complication rate. The purpose of the present study was to describe the surgical learning curve of the BSS to determine the effect of surgeon experience on surgical procedure time and complication rates. METHODS: Patients who underwent tonsillectomy with barbed lateral pharyngoplasty were divided in two different groups based on surgeon experience. Operative time, intraoperative blood loss, intra- and post-operative complications, and hospitalization time were compared. RESULTS: A total of 144 consecutive patients (F: 27; mean age: 47.5 years, SD 9.7) were included. All procedures were successfully completed in 37.0 min (IQR 29.0-47.0). Senior surgeons completed the procedure in 33.0 min (IQR 27.0-41.0), while junior surgeons needed 52.0 min (IQR 36.5-64.5) (p < .05). No intra-operative complications were observed, and intra-operative blood loss was minimal in both groups. No difference was measured in terms of hospitalization time. Only one post-operative bleeding resolved with conservative treatment was detected in both groups. Junior surgeons showed a positive trend in the reduction of operative time (r = - 2.32, 95% CI: - 2.74 to - 1.90; p < .05). CONCLUSIONS: The findings suggest that BSS may be safely performed by inexperienced surgeons with no increased risk of intra- and post-operative complications. The surgical LC is short and the junior surgeon can reach the ability of senior surgeons after a few number of procedures with a progressive reduction of the operative time.

Obstructive sleep apnoea after radiotherapy for head and neck cancer.

OBJECTIVE: The aim of this study is to focus attention on obstructive sleep apnoea hypopnoea syndrome (OSHAS) as a sequela of non-surgical treatments of selected head and neck cancer (HNca), sharing our experience in drug-induced sleep endoscopy (DISE). To the best of our knowledge, this is the first study that documents dynamic anatomical and functional alterations during sleep in irradiated OSAHS patients by DISE. METHODS: A retrospective study of patients affected by OSAHS referring to our department from January 2018 to December 2019 was carried out. Inclusion criteria were: patients who underwent radiation or chemo-radiation for HNca affecting upper airways that presented sleep-related breathing disorders after treatment. RESULTS: 6 patients with moderate to severe OSAHS and a clinical story of previous non-surgical treatment for an HNca were enrolled. DISE showed in all patients typical anatomical alterations observed in irradiated individuals. Four patients were treated with continuous positive airway pressure, while 2 subjects were treated with tailored minimal invasive surgery without post-operative complications. CONCLUSIONS: Our results suggest that minimal invasive surgical treatments can be a good therapeutic option in very selected patients with post-irradiation iatrogenic OSAHS.

Barbed Roman blinds technique for the treatment of obstructive sleep apnea: how we do it?

Retro-palatal obstruction is often involved in the pathogenesis of obstructive sleep apnea syndrome (OSAS), which is currently treated by means of various surgical procedures. The aim of this paper is to describe our preliminary results using a new, minimally invasive and non-resective procedure called the "barbed Roman blinds technique" (BRBT), which was used to treat severe OSAS due to retro-palatal obstruction. The apnea-hypopnea index (AHI), time with <90 % O2 saturation, and Epworth Sleepiness Scale (ESS) of 32 consecutive adult outpatients (mean age 47.3 ± 8.6 years) were compared before and after surgery. The tolerability of the procedure was assessed using a 0-10 visual analog scale (VAS). All of the treated patients experienced a clinical and subjective improvement as documented by the significant differences (P < 0.001) in their pre- and post-BRBT AHI, time with <90 % O2 saturation, and ESS scores. There were no minor or major adverse events, and the good tolerability of the procedure was documented by the short mean hospital stay (1.2 ± 0.5 days) and the mean VAS value of 4.3 ± 0.7. The mean follow-up period was 12.2 ± 2.0 months. The preliminary results indicate that the BRBT is safe and effective, but long-term follow-up and comparative studies of larger case series are needed to confirm these encouraging findings.

Diagnostic Accuracy of Obstructive Airway Adult Test for Diagnosis of Obstructive Sleep Apnea.

RATIONALE: The gold standard for the diagnosis of Obstructive Sleep Apnea (OSA) is polysomnography, whose access is however reduced by costs and limited availability, so that additional diagnostic tests are needed. OBJECTIVES: To analyze the diagnostic accuracy of the Obstructive Airway Adult Test (OAAT) compared to polysomnography for the diagnosis of OSA in adult patients. METHODS: Ninety patients affected by OSA verified with polysomnography (AHI ≥ 5) and ten healthy patients, randomly selected, were included and all were interviewed by one blind examiner with OAAT questions. MEASUREMENTS AND MAIN RESULTS: The Spearman rho, evaluated to measure the correlation between OAAT and polysomnography, was 0.72 (p < 0.01). The area under the ROC curve (95% CI) was the parameter to evaluate the accuracy of the OAAT: it was 0.91 (0.81-1.00) for the diagnosis of OSA (AHI ≥ 5), 0.90 (0.82-0.98) for moderate OSA (AHI ≥ 15), and 0.84 (0.76-0.92) for severe OSA (AHI ≥ 30). CONCLUSIONS: The OAAT has shown a high correlation with polysomnography and also a high diagnostic accuracy for the diagnosis of OSA. It has also been shown to be able to discriminate among the different degrees of severity of OSA. Additional large studies aiming to validate this questionnaire as a screening or diagnostic test are needed.

Should we stop performing uvulopalatopharyngoplasty?

Uvulopalatopharyngoplasty (UPPP) is still one of the most frequently performed procedures for snoring and obstructive sleep apnea syndrome (OSAS) in adults, with unsatisfactory results. In the era of the mini-invasive/conservative surgery, considering the increasing attention to the disregulation of the peripheral neuromuscular control of the upper airway contributing to pharyngeal collapse in OSAS, with the development of sophisticated treatments such as the neural stimulation of the upper-airway, which role should be reserved to a muscular resective procedure such as UPPP? Being aware of the uncertain results and the high postoperative morbidity of UPPP, we believe that we should re-evaluate the role of these procedures involving the resection of palatal/pharyngeal muscles and uvula.