What are the criteria for performing Drug-Induced Sleep Endoscopy (DISE) and what to look for?

From the Guidelines

Performing Drug-Induced Sleep Endoscopy (DISE) is recommended for patients with obstructive sleep apnea (OSA) who have failed or are intolerant to conventional treatments, such as continuous positive airway pressure (CPAP) therapy, or when surgically modifiable sites of airway obstruction are suspected 1. The criteria for performing DISE include:

• Patients with persistent OSA symptoms despite CPAP therapy
• Patients who are unable to tolerate CPAP therapy
• Patients with anatomical abnormalities that may be contributing to OSA, such as a large tongue or narrow airway
• Patients who are being considered for upper airway surgery

During DISE, the patient is given a sedative to induce sleep, and the procedure involves inserting a flexible endoscope through the nose to visualize the upper airway during sleep. The following are looked for during DISE:

• Collapse or obstruction of the airway at the level of the velopharynx, oropharynx, or hypopharynx
• Movement or vibration of the soft tissues, such as the uvula or soft palate
• Presence of anatomical abnormalities, such as a large tongue or narrow airway
• Effectiveness of different mandibular positions or oral appliances on airway patency

The information gathered during DISE can help guide treatment decisions, such as the selection of upper airway surgery or the use of oral appliances, and is particularly useful when CPAP is not desired, adherence is poor, or surgically modifiable sites of airway obstruction are suspected 1.

From the Research

Criteria for Performing Drug-Induced Sleep Endoscopy (DISE)

• DISE is used to identify locations and patterns of residual collapse in patients with obstructive sleep apnea (OSA) who have an incomplete response to oral appliance therapy (OAT) 2
• The procedure is indicated for patients with OSA who are unable to accept or tolerate continuous positive airway pressure therapy 3
• DISE can be used to evaluate the dynamic upper airway collapse during sleep and improve treatment options selection for patients with OSA 3

What to Look for During DISE

• The procedure involves evaluating the upper airway for collapse at different levels, including the palate, tonsils, lateral pharyngeal wall, tongue base, and epiglottis 4
• The VOTE classification system can be used to score DISE videos and identify locations of collapse 2
• A new DISE classification system, termed Palate, Tonsils, Lateral pharyngeal wall, Tongue base, Epiglottis, has been introduced to better differentiate between clinically relevant tonsillar and lateral pharyngeal wall collapse 4
• The choice of sedative agent may affect the patterns of collapse, especially at the tongue base 4

Interpretation of DISE Findings

• DISE findings can aid in the identification of patients who will respond well to oral appliance therapy 4
• The procedure can help identify residual anatomical locations of collapse, which may direct additional medical and surgical treatment options to augment OAT effectiveness 2
• Therapeutic decisions changed in 43.69% of patients after DISE, with changes at uvular and palatal sites being more frequent in adults and at the tonsils in children 5