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Objective: To determine the interrater reliability of drug- mean (SD) apnea-hypopnea index of 39.6 (24.0).
induced sleep endoscopy (DISE). Three-quarters of the subjects demonstrated multilevel
airway obstruction at the palate and hypopharynx, with
Design: Prospective cohort; blinded comparison. a diversity of individual structures contributing to
obstruction. The interrater reliability for the presence of
Setting: Academic referral center. obstruction at the palate and hypopharynx ( values,
0.76 and 0.79, respectively) was higher than for the
Participants: Subjects with obstructive sleep apnea un- degree of obstruction (weighted values, 0.60 and
able to tolerate positive airway pressure therapy. 0.44). The interrater reliability for the assessment of
primary structures contributing to obstruction at the
Interventions: Drug-induced sleep endoscopy was per-
palate and hypopharynx (0.70 and 0.86) was higher
formed with intravenous propofol infusion to achieve se-
dation, and the videoendoscopy recording was evalu- than for the contributions of individual structures (
ated by 2 independent reviewers. values, 0.42-0.71). The interrater reliability for evalua-
tion of the hypopharyngeal structures was higher than
Main Outcome Measures: The following outcomes for those of the palate region.
were measured: a global assessment of obstruction at the
palate and/or hypopharynx; the degree of obstruction at Conclusion: The interrater reliability of DISE is mod-
the palate and hypopharynx; and the contribution of in- erate to substantial.
dividual structures (palate, tonsils, tongue, epiglottis, and
lateral pharyngeal walls) to obstruction. Trial Registration: clinicaltrials.gov Identifier:
NCT00695214
Results: A total of 108 subjects underwent DISE
examination. Diagnostic sleep studies demonstrated a Arch Otolaryngol Head Neck Surg. 2010;136(4):393-397
A
IRWAY OBSTRUCTION IN namic upper airway behavior during sleep.
obstructive sleep apnea Drug-induced sleep endoscopy (DISE) dif-
(OSA) can occur at many fers and may provide a useful upper air-
levels, and the principal re- way examination. First described as sleep
gions of dynamic obstruc- nasendoscopy in 1991,1 the technique re-
tion are the palate and hypopharynx (ac- quires pharmacologic sedation and fiber-
tually corresponding to the hypopharynx optic visualization of the upper airway to
and the retrolingual portion of the oro- observe directly and characterize the up-
pharynx). Surgical procedures are inher- per airway collapse that occurs during se-
ently directed at specific regions of the up- dation.2 Drug-induced sleep endoscopy has
been shown to be a safe, feasible, and valid
per airway, and by addressing airway
assessment of the upper airway,3-5 and we
obstruction in a targeted fashion, it may
Author Affiliations: have demonstrated moderate to substan-
Departments of be possible to tailor surgical treatment to tial test-retest reliability.6 The objective of
Otolaryngology–Head and Neck a patient’s specific pattern of obstruction— this study was to examine DISE inter-
Surgery (Drs Kezirian and improving surgical results and/or mini- rater reliability.
Goldberg and Ms Ma) and mizing the scope of surgical interven-
Epidemiology and Biostatistics tion. A major goal of surgical assessment
(Dr McCulloch), University of is determining the pattern of obstruc- METHODS
California, San Francisco; and
Department of Medicine,
tion, but upper airway anatomical assess-
Harvard Medical School, ment is limited by the fact that evalua- This prospective cohort study included con-
Boston, Massachusetts tion is often static and performed during secutive subjects seen by the lead author
(Drs White and Malhotra). wakefulness, which may not represent dy- (E.J.K.) in the University of California, San
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 4), APR 2010 WWW.ARCHOTO.COM
393
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 4), APR 2010 WWW.ARCHOTO.COM
394
No. (%)
Reviewer 1, Reviewer 2,
Unblinded Blinded
Analysis (n = 108) (n = 108) % Agreement Value
Analysis 1: Global assessment of level(s) of obstruction
Palate 99 (92) 102 (94) 97 0.79
Hypopharynx 90 (83) 91 (84) 94 0.76
Analysis 2: Degree of obstruction
Palate,%
⬍50 9 (8) 7 (6) 81 0.60 d
50-75 15 (14) 18 (17)
⬎75 84 (78) 83 (77)
Hypopharynx, % c
⬍50 17 (16) 15 (14) 90 0.44 d
50-75 29 (27) 47 (44)
⬎75 62 (57) 46 (43)
Analysis 3: Specific structures
Primary structure contributing to obstruction at level of the palate c
None 9 (8) 7 (6) 83 0.70
Palate 59 (55) 71 (66)
Tonsils b 32 (30) 25 (23)
LPW-velopharynx 8 (7) 5 (4)
Primary structure contributing to obstruction at the level of the hypopharynx c
None 16 (15) 14 (13) 92 0.86
Tongue 60 (56) 63 (59)
Epiglottis 16 (15) 14 (13)
LPW-hypopharynx 16 (15) 17 (16)
Specific structures contributing to obstruction a
Palate 91 (84) 95 (88) 93 0.69
Tonsils b,c 73 (68) 64 (59) 82 0.42
LPW-velopharynx 62 (57) 64 (59) 74 0.47
Tongue c 77 (71) 84 (78) 86 0.64
Epiglottis 31 (29) 32 (30) 88 0.71
LPW-hypopharynx c 27 (25) 47 (44) 78 0.53
based (Analysis 3) method serves 2 major purposes: char- cal treatment is uvulopalatopharyngoplasty with pos-
acterizing the pattern of obstruction and selecting among sible tonsillectomy, regardless of specific contribution
treatment options. This scheme uniquely focuses atten- of the lateral pharyngeal walls at the velopharynx.
tion on the primary structures contributing to obstruc- Although there are alternative palate procedures, it
tion in each region; we posit that treatment of these pri- remains unclear how to identify specific subgroups of
mary structures may be required, at a minimum, to patients who obtain better or worse outcomes, com-
eliminate upper airway obstruction. The interrater reli- pared to uvulopalatopharyngoplasty.
ability—like the test-retest reliability6—is higher for the However, the involvement of specific structures may
identification of primary structures than for the involve- be critical for the hypopharynx, where DISE may in-
ment of individual structures. form decisions if the multiple treatment options exert dif-
According to both reviewers, three-quarters of the ferential effects on the tongue, epiglottis, and/or lateral
subjects in this study demonstrated multilevel obstruc- pharyngeal walls. The 3 structures that most commonly
tion during DISE. Although the upper airway does not contribute to hypopharyngeal airway obstruction are the
consist of 2 regions (palate and hypopharynx) in isola- tongue, epiglottis, and lateral pharyngeal walls, and the
tion, if DISE provides an accurate airway assessment, results for Analysis 3 indicate that there seems to be an
single pharyngeal procedures may be less likely to treat important diversity in the patterns of hypopharyngeal ob-
OSA successfully than combinations—or at least single struction, a diversity that is evaluated with moderate to
procedures that treat both the palate and hypopharynx. substantial interrater reliability. This may prove invalu-
Because surgical procedures are ultimately directed at able if the array of surgical and nonsurgical treatment op-
specific structures, DISE may improve procedure selec- tions to treat the hypopharyngeal airway truly exert dif-
tion and outcomes. This may not be as important for ferential effects on these various structures. For example,
palatal obstruction, for which the most common surgi- the genioglossus advancement and tongue radiofre-
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 4), APR 2010 WWW.ARCHOTO.COM
395
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 4), APR 2010 WWW.ARCHOTO.COM
396
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 4), APR 2010 WWW.ARCHOTO.COM
397