He did acknowledge the ability of DISE to predict success with upper-airway stimulation, although patients with palatal complete concentric collapse were not included in the pivotal Stimulation Treatment for Apnea Reduction (STAR) trial of the procedure because of poor results in such patients in a retrospective review.
Dr. Steward added, “There are several studies that show that the variation in the level of sedation and which agents you use result in different results of sleep endoscopy, at least in terms of our scoring, predominantly in the degree of obstruction.”
Stacey Ishman, MD, MPH, surgical director of the Upper Airway Center and associate professor of otolaryngology-head and neck surgery and pulmonary medicine at Cincinnati Children’s Hospital Medical Center, said cine MRI, a technique involving the review of more than 100 MRI images over a short span of time, and DISE are two reasonable alternatives to awake flexible endoscopy for evaluating the airway in children.
She said advantages of cine MRI include the fact that there is no radiation used and that several points of obstruction can be evaluated at the same time, making it easier to identify primary and secondary sites of obstruction.
Dr. Ishman said assessment of the size of the lingual tonsils and the adenoids is another asset. “One of the things you like it for is to quantify the size of the lingual tonsils,” she said. “What it helps me do is figure out the appropriate amount of OR time.” On the other hand, she said, it’s not very helpful for evaluation of the larynx and the nasal cavity and isn’t widely available.
Dr. Ishman said the use of DISE in children is evolving. “Persistent sleep apnea is the most common indication, but it’s also more commonly being done to look at kids who don’t have an obvious area of obstruction, [i.e.,] if they have small tonsils or no significant adenoids,” she said. “It also can be use in children with significant co-morbidities like obesity or Down Syndrome who have a very high likelihood of persistent sleep apnea after their tonsils come out.”
It can also be helpful in detecting sleep state-dependent laryngomalacia, although it can be difficult to tell whom to suspect for this condition, she said. One review involving 358 children with sleep-disordered breathing by a Canadian group found the condition was present in about 4% of children (Laryngoscope. 2010;120:1662-1666).
Dr. Ishman said the adult scoring systems used for DISE don’t include several factors that are relevant to evaluating children, and that the field needs a standardized scoring system for pediatric DISE.