Is the use of drug-induced sleep endoscopy (DISE) and transoral robotic surgery (TORS) for obstructive sleep apnea (OSA) associated with improved outcomes and acceptable complication rates when compared to uvulopalatopharyngoplasty (UPPP) with or without tonsillectomy (±T)?
Background: Surgical OSA treatment is an option for patients who do not tolerate continuous positive airway pressure (CPAP) therapy. Reported long-term success rates for UPPP are low, with approximately 50% of OSA patients cured. DISE and TORS with base-of-tongue reduction, lingual tonsillectomy, and/or partial epiglottectomy are performed to attempt to improve outcomes while maintaining low complication rates.
Explore this issue:January 2016
Study design: Retrospective cohort review on 40 patients who had previously undergone UPPP±T from January 2011 through June 2012 and 64 patients who had DISE, UPPP±T, and possible TORS base-of-tongue resection and/or partial epiglottectomy from May 2012 through December 2014.
Setting: Department of Otolaryngology–Head and Neck Surgery, Department of Sleep Medicine, Henry Ford Hospital, Detroit.
Synopsis: A total of 64 patients met inclusion criteria for the DISE group (25 UPPP alone; 13 UPPP with TORS base-of-tongue reduction; 12 UPPP with TORS partial epiglottectomy; 14 UPPP with TORS base-of-tongue and partial epiglottectomy). The no-DISE group showed a significant reduction in apnea-hypopnea index (AHI) of -20.1 and a 3% complication rate. Patients who had UPPP±T with or without TORS lingual tonsillectomy and partial epiglottectomy showed a significant reduction in AHI of -21.4. The average total charges for the DISE group (greater by $14,708) was the only factor noted to be statistically significant. The DISE group had a significantly greater number of major complications occurring within 30 days of surgery (reintubation, hemorrhage, and death) than the no-DISE group. There was no significant difference among UPPP±T alone, UPPP±T with DISE, and UPPP±T with DISE and TORS in surgical success rate, downgraded OSA classification rate, major complication rate, multiple major complication incidence, ED rate, or body mass index (BMI). Overall, there was no statistically significant difference between the no-DISE group and the DISE group with or without TORS in surgical success, Epworth Sleepiness Scale (ESS), or OSA classification change. One limitation found increased costs due to TORS being the chosen procedure when hypopharyngeal obstruction was noted.
Bottom line: Patients who underwent UPPP±T without DISE did not show a statistically significant difference in outcomes compared with patients who underwent DISE with other procedures, including TORS. The TORS patients had increased total costs and length of stay that were statistically significant.
Citation: Golbin D, Musgrave B, Succar E, Yaremchuk K. Clinical analysis of drug-induced sleep endoscopy for the OSA patient. Laryngoscope; 2016;126:249-253.