Special article
Drug-induced Sleep Endoscopy in Children
Exploración videoendoscópica bajo sueño inducido en niños
a Servicio de Otorrinolaringología, Hospital General Universitario de Catalunya y Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain
b Servicio de Otorrinolaringología, Hospital Universitario de Burgos, Burgos, Spain
c Servicio de Otorrinolaringología, HospitalUniversitario Dr. Peset, Valencia, Spain
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class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Drug-induced sleep endoscopy (DISE) is a widely used technique that has been validated in adults with respiratory sleep disorders (obstructive sleep apnoea—hypopnoea syndrome [OSAHS] and primary snorers).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In adults DISE basically makes it possible to discover the primary sites of upper airway (UAW) collapse, and therefore to rationalise indications for surgery.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The same technique in the paediatric population was introduced by Croft et al. in 1990, when they presented their experience in 15 children.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Different studies have emerged after the above-mentioned publication, and they suggest and confirm the usefulness of DISE as a valid tool for the evaluation of sites of UAW obstruction which cause paediatric OSAHS, especially in cases that persist following adenotonsillectomy.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a> Nevertheless, its exact role in the diagnostic algorithm of paediatric OSAHS is still not perfectly defined. Further prospective studies are required to evaluate the results obtained following specific treatment directed by DISE findings.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7–9</span></a> One of the advantages of DISE is that sedation takes place in the operating theatre, and that suitable surgery can take place following this sedation without discontinuity.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10,11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The anatomical level of the cause of UAW obstruction in children with OSAHS is routinely evaluated based on the findings of physical examination and nasopharyngoscopy. Given that these examinations are performed when the child is awake, the information obtained is restricted to static observations, rather than dynamic observations in a real situation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> It is usually difficult to perform an endoscopy with a child who is awake, especially in children with some form of neurological disorder. Endoscopic findings when awake may differ notably from those when the patient is asleep due to differences in muscle tone, airway reflexes and other changes that arise with sleep.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Indications</span><p id="par0020" class="elsevierStylePara elsevierViewall">UAW collapse is a dynamic state, and endoscopic evaluation of this in real time may supply valuable information in addition to polysomnography (PSG) and clinical examination. DISE seems to be an effective technique for diagnosis of the location of the obstruction and surgical planning in children.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,11,13</span></a> In a review of the literature, Ramji et al. state that DISE makes it possible to evaluate the UAW dynamically, and that it may help to make a better selection of the surgical technique to be used, avoiding unnecessary aggressive actions while foreseeing and preventing cases of persistence.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The basic indication would be those children with OSAHS that is not solely explained by adenotonsillar hypertrophy. This includes those children with OSAHS and normal adenotonsillar size, cases that persist after adenotonsillectomy and children with additional comorbidities, where other sites or causes of obstruction are suspected, as well as adenotonsillar hypertrophy.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10,13–16</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Sedation Technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">The technique has to achieve an optimum balance of sleep-inducing anaesthesia without causing significant obstruction of the UAW, over and above the obstruction due to the respiratory pathology under study. Although the child has to be sufficiently sedated to tolerate the procedure, he must breathe spontaneously without central apnoea due to the drugs used in sedation. It is recommended that paediatric DISE should only be performed when personnel with sufficient experience are present and there is equipment to manage a difficult airway.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The degree of sedation may be a confusion factor for the DISE results, as excessive sedation reduces the muscle tone of the UAW and increases the critical pressure for closure of the pharynx.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The great majority of authors usually perform DISE in an operating theatre. Complete cardiopulmonary monitoring is applied and anaesthesia is generally induced by the inhalation of sevofluorane to enable endovenous access placement.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12,17</span></a> Once intravenous access has been achieved the sevofluorane is ceased and intravenous propofol is administered in a bolus of 1−2 mg, followed by the continuous administration in infusion according to bodyweight (6−10 mg/kg/h) to obtain the desired level of sedation and maintain spontaneous respiration.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,17</span></a> This is so because, unlike adults, sedation in TCI mode with propofol is not available for children under the age of 7 years.</p><p id="par0040" class="elsevierStylePara elsevierViewall">To date the majority of authors have used propofol (a hypnotic with a transitory effect) as the sedating agent, in association or not with Fentanyl (an opiate analgesic).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,10,12,13</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> Nevertheless, another sedative has recently been introduced which has suitable characteristics for this examination: dexmedetomidine (a powerful and selective alpha 2-adrenergic agonist).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,14,19</span></a> Some authors have shown that propofol may cause excessive hypotonia and muscle relaxation which interferes with the dynamic of altered airways.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,18,19</span></a> Although there may be certain preferences for one sedative or the other, according to different authors both of them permit reliable findings respecting the collapse of the UAW. However, dexmedetomidine seems to achieve superior haemodynamic stability.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A study by Hsu compares remifentanil with dexmedetomidine. According to this author, dexmedetomidine does not cause clinically significant respiratory depression, and it reduces, instead of increasing, the sleep apnoea—hypopnoea index (AHI), and it brings about a certain similarity with natural sleep.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Once a rhythmic pattern of breathing has been achieved, the fibre-optic endoscope is inserted nasally. Some authors use topical nasal anaesthesia with a vasoconstrictor<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,19</span></a> and others do not.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13,17</span></a> One argument for avoiding its use stems from experimental studies in healthy volunteers. These showed that the application of local anaesthetics on the nasal mucosa may trigger a significant increase in episodes of apnoea, central as well as obstructive, of the same magnitude as those which occur due to complete nasal obstruction.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The activation of nasal receptors during nasal respiration has a direct positive effect on spontaneous ventilation, leading to a suitable resting respiratory frequency and ventilation per minute.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">It is recommendable for images to be recorded by a digital video camera for subsequent analysis. Endoscopy is performed with the child supine and the neck in a neutral position, without displacing the jaw.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11,19</span></a> The diameter of the fibre-optic endoscope used varies from 3.4 mm<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,13</span></a> to 2.7 mm.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Determining the right moment to start the examination may be based on the lack of a response to verbal stimulation in a normal tone of voice<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> or by the use of a bispectral electroencephalograph monitor (BIS) that detects the depth of anaesthesia. The BIS levels at which consciousness is lost vary between individuals, although they stand at around 70–50.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> According to the European consensus document the “observation window”, i.e., the ideal time for evaluation of the UAW, is after the first cycle of snoring and obstruction. This is particularly valid when propofol is used, to prevent possible initial exaggeration. If BIS is available, the correct moment in terms of sedation depth is said to occur when its values stand at from 50 to 70.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Classification Systems</span><p id="par0065" class="elsevierStylePara elsevierViewall">In DISE performed in adults, the classification system that is probably the most widely used is the VOTE system proposed by Kezirian.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Some authors also use this system for the paediatric population<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>: this classification assesses the degree of collapse in four structures: the soft palate, the pharyngeal side walls, the base of the tongue and the epiglottis. If there is no collapse or vibration the corresponding score is 0, 1 corresponds to partial collapse or vibration, 2 if it is complete and X if the structure is not correctly visualised. The collapse mode must also be described: whether it is anteroposterior, concentric, circular or lateral.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the characteristics of the paediatric UAW, many authors have added three additional structures: the lower conchas, adenoid occupation of the rhinopharynx and the possibility of laryngomalacia.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12,14,19</span></a> Lower concha hypertrophy is diagnosed if the said structure obstructs more than 50% of the nasal cavity. Adenoid hypertrophy is diagnosed if the adenoids obstruct more than 25% of the nasopharynx. Laringomalacia is diagnosed if redundant mucosa covers the arytenoids with a prolapse towards the glottis during inspiration.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In the nasopharynx, the normal soft palate opening is oval and remains constantly open horizontally during the entire respiratory cycle: inspiration and expiration. However, adenoid hypertrophy or growth, hypotonia or hypoplasia of the medial facial third may obstruct the opening and reduce nasal airflow. We will see that the palate collapses over the adenoids or posterior nasopharynx and narrowness will be seen that may cause obstruction at the level of the soft palate and pharynx. When the obstruction is partial the anterior edge of the palate and uvula may be seen to be flapping.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The normal oropharyngeal opening has the shape of an hourglass, the waist of which corresponds to the indentation of the lateral pharyngeal wall and tonsils. The narrow central part is subject to the dynamic of the respiratory cycle, and it narrows during inspiration and expands during expiration, remaining sufficiently wide to permit air exchange without obstructions. In children with tonsillar hypertrophy there is a total central collapse of the whole oropharyngeal opening, exacerbated by the medialisation of the pharyngeal side walls during inspiration. In some children with small tonsils in the soft palate, or tonsils located deeply in the tonsillar fossa, medialisation of the pharyngeal side wall leads to a similar obstruction or central closure. In children with hypotonia due to a deficit in neurological development, there may be a circumferential collapse with obstruction of the pharyngeal opening at the level of the oropharynx, due to the collapse of the pharyngeal tissues.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,19</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The normal geometry of the airways at the level of the base of the tongue is a complex that involves the base of the tongue, the sulci and the epiglottis. The rear third of the tongue and pharyngeal wall narrow towards the base of the epiglottis. During non-obstructive inspiration there may be retroflexion of the epiglottis with flexing of the lateral edges of the same, which occasional converge, towards the posterior wall of the pharynx. The flow of air passes through the space under and around the edges of the epiglottis. In children with lingual tonsil hypertrophy there is occupation of the whole sulcus by exacerbated lymphoid tissue with prolapse of the epiglottis against the posterior wall of the pharynx during inspiration. A similar pattern is observed in children with a retruded jaw, although only with a moderate amount of lingual tonsil. In cases with micrognathia or retrognathia, the base of the tongue is displaced posteriorly by the hyperdeveloped jaw.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In the most severe cases, the base of the tongue, with or without lingual tonsil hypertrophy, will be closer to the posterior pharynx wall, obstructing the airway and covering the epiglottis. In children with hypotonia due to neurological development alteration, there is circumferential collapse with obstruction of the pharynx opening at the level of the epiglottis concurrent with collapse of the prominent base of the tongue.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,19</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The normal supraglottis remains widely open during the whole respiratory cycle. Supraglottal obstruction occurs with dragging of the prominent mucosa folds in the accessory cartilage above the arytenoids in the laryngeal introitus.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,19,27</span></a> The dynamic of this process is similar to that of cases of paediatric laryngomalacia, although there is no epiglottis curl and this is present solely during sleep in these older children. This has been termed “hidden or late-onset laryngomalacia”.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,19,27–29</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Chan has recently published a work that shows the degree of obstruction in these locations.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The authors (EEM) use this classification, adding evaluation of nasal obstruction in the nasal conchas or septum.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Adenoids: Posterior View From Nasal Cavity</span><p id="par0110" class="elsevierStylePara elsevierViewall">0 = absence of adenoids.</p><p id="par0115" class="elsevierStylePara elsevierViewall">1 = 0%–50% choanal obstruction.</p><p id="par0120" class="elsevierStylePara elsevierViewall">2 = 50%–99% choanal obstruction.</p><p id="par0125" class="elsevierStylePara elsevierViewall">3 = complete choanal obstruction.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Soft Palate: Inferior View From Nasopharynx; Evaluation of Anteroposterior Obstruction</span><p id="par0130" class="elsevierStylePara elsevierViewall">0 = no obstruction (complete view of the base of the tongue and/or larynx).</p><p id="par0135" class="elsevierStylePara elsevierViewall">1 = 0%–50% anteroposterior collapse (partial view of the base of the tongue/larynx).</p><p id="par0140" class="elsevierStylePara elsevierViewall">2 = 50%–99% anteroposterior collapse (no view of the base of the tongue/larynx, but no collapse against the posterior pharynx wall).</p><p id="par0145" class="elsevierStylePara elsevierViewall">3 = complete collapse against the posterior pharynx wall.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pharynx Side Walls: Inferior View From the Soft Palate; Evaluation of the Obstruction of Side Walls/palate Tonsils</span><p id="par0150" class="elsevierStylePara elsevierViewall">0 = no obstruction.</p><p id="par0155" class="elsevierStylePara elsevierViewall">1 = 0%–50% lateral obstruction.</p><p id="par0160" class="elsevierStylePara elsevierViewall">2 = 50%–99% lateral obstruction.</p><p id="par0165" class="elsevierStylePara elsevierViewall">3 =  complete obstruction.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Base of the Tongue: Inferior View From the Oropharynx; Evaluation of Anteroposterior Obstruction</span><p id="par0170" class="elsevierStylePara elsevierViewall">0 = no obstruction (complete view of sulcus).</p><p id="par0175" class="elsevierStylePara elsevierViewall">1 = 0%–50% obstruction (sulcus not visible).</p><p id="par0180" class="elsevierStylePara elsevierViewall">2 = 50%–99% obstruction (epiglottis does not make contact with the posterior pharynx wall).</p><p id="par0185" class="elsevierStylePara elsevierViewall">3 = complete obstruction (epiglottis against posterior pharynx wall).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Supraglottis: Inferior View With Base of Tongue (if It Obstructs) Moved Aside, With or Without Jaw Protrusion</span><p id="par0190" class="elsevierStylePara elsevierViewall">0 = no obstruction (complete view of vocal cords).</p><p id="par0195" class="elsevierStylePara elsevierViewall">1 = 0%–50% obstruction (vocal cords partially hidden but more than 50% visible).</p><p id="par0200" class="elsevierStylePara elsevierViewall">2 = 50%–99% obstruction (>50% vocal cords hidden).</p><p id="par0205" class="elsevierStylePara elsevierViewall">3 = complete obstruction (glottal opening not visible).</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0210" class="elsevierStylePara elsevierViewall">An interesting datum offered by performing DISE in children refers to tonsillar hypertrophy, in comparison with the usual examination in the surgery. Tonsillar hypertrophy is one of the most common findings in children with OSAHS. Tonsil size is classified based on the percentage of the lateral dimension of the oropharynx that they occupy, measuring between the anterior pillars. If the majority of the hypertrophic tonsil is located in the area between the anterior pillar and oropharyngeal side wall and occupies a small proportion of the area between the pillars, it may be graded as I or II in a physical examination. The classification scales do not take into account anteroposterior obstruction or its superoinferior dimension. An increase in the size of a tonsil in all directions may contribute to UAW obstruction during sleep.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Ulualp et al. evaluated dynamic obstruction of the airway due to palatine tonsils and pharyngeal side walls during DISE. Complete obstruction at the level of the oropharyngeal side walls was observed in children with Brodsky grades I and II (complete oropharyngeal obstruction in 50% of tonsils in Brodsky grade I and 64% in grade II). Although it is not possible to separate the contribution of the tonsils from that of the pharyngeal side walls when evaluating the collapse of the oropharyngeal side walls, the results supply evidence that complete obstruction of the UAW may occur due to grade I tonsils and that therefore, exeresis of the same may resolve the problem.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Rates of OSAHS persistence in the paediatric population after adenotonsillectomy stand at from 10% to 20%<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a> and even above 30% in a meta-analysis by Friedman et al. with more than 1000 children.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> When cases at higher risk are considered, such as obese children, those with Down syndrome, cerebral palsy or craniofacial malformations, this figures may be higher than 70% of cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,11,19</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Most especially in groups with a risk of persistent OSAHS, many of the causes of UAW collapse go beyond adenotonsillar hypertrophy, so that it is necessary to seek other causes of the obstruction.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,10,12,16</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Persistent cases may be treated with continuous positive nasal pressure (CPAP), although its levels of compliance and acceptation may be low, and complications may arise which, even though they are not serious, may have long-term repercussions (facial hypoplasia of the middle third of the face due to long usage and the continuous pressure of the mask) or they may lead to an increase in the percentage of dysadaptation.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> This is why it is necessary to seek other levels of obstruction that can be corrected surgically.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,12,19</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">In 2012 Durr published his results of using DISE in 13 patients with persistent OSAHS. Their ages ranged from 3 to 15 years, with an average of 7.8 years. 85% of the patients had comorbidities. In the majority, 11 cases, the obstruction was located in more than one level of the UAW. Only two cases had an obstruction at a single location, the base of the tongue in both cases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The most frequent causes of obstruction in cases where OSAHS persisted after adenotonsillectomy were: obstruction at the base of the tongue in 11 cases (85%), of which 10 cases were due to lingual tonsil hypertrophy. Growth of the adenoids was present in 69% of cases, and lower concha hypertrophy was present in 54%. In 15% of cases there was obstruction in the oropharyngeal side walls, both due to tonsil growth. According to the comorbidities that were present, the three cases of cerebral palsy had obstruction at the base of the tongue and adenoids, while the obese cases were more likely to have tonsil and adenoid obstruction.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Truong presents his experience with 80 children subjected to DISE and subsequent surgery guided by the results obtained in the said examination and during the same anaesthesia. This author separates the cases into two groups: the first group of 39 patients had not been subjected to any previous intervention, while the second group of 41 patients were persistent cases following adenotonsillectomy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In the first group (without previous surgery) the great majority (35/39 cases) were subjected to adenotonsillar surgery and radiofrequency turbinate reduction. In the second group the most frequent intervention was lingual tonsillectomy (32 cases) and/or supraglottoplasty (8 cases). In five second group patients adenotonsillectomy revision was required.</p><p id="par0250" class="elsevierStylePara elsevierViewall">An interesting detail found in this publication refers to obstruction at the level of the base of the tongue. At this level it may be difficult to calibrate tonsil volume when a child is in neutral position. When evaluating the base of the tongue during DISE, a jaw traction manoeuvre may help to differentiate between lingual tonsil hypertrophy and a retruded base of the tongue with no lingual tonsil hypertrophy. Patients with lingual tonsil hypertrophy will respond well to lingual tonsillectomy. On the contrary, collapse of the base of the tongue due to hypotonia or craniofacial anomalies will not respond to the same degree.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Wootten published a series of 26 children with persistent OSAHS after adenotonsillectomy, of which 14 (56%) had Down syndrome. The author showed the successful results of surgical interventions after DISE. He performed 22 lingual tonsillectomies, 16 mid-line posterior glossectomies, revision adenoidectomy in 11 cases, inferior turbinectomy in 7 cases, uvulopalatopharyngoplasty in 2 cases and supraglottoplasty in two others. He shows the results of posterior PSG in 11 of the 26 patients and the average AHI fell from 7 to 3.6/h.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Other sites of obstruction and causes of OSAHS must also be looked for in the children without comorbidities and with little adenotonsillar hypertrophy.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,19</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The factors other than adenotonsillar hypertrophy which are known to contribute to airway obstruction during sleep include craniofacial disproportion such as hypoplasia of the middle third of the face or micrognathia, hypotonia, obesity that causes, among other alterations, an increase in oropharyngeal soft tissues, laryngomalacia and hypertrophy of the lingual tonsil.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,19</span></a> We may also find nasal obstruction, regrowth of adenoid or tonsil hypertrophy or glossoptosis.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,10</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The advantage of discovering these additional sites of obstruction during DISE is that in the majority of cases this examination can be immediately followed by surgical correction.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10,19</span></a> For example, by reducing the lingual tonsil using radiofrequency or by performing a supraglottoplasty if hidden laryngomalacia is found, or by surgery on tonsillar remains or collapsing adenoids.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10,19,35</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">In 2013 Ulualp published the results obtained in 82 patients aged from 1.5 to 17 years (average 6 ± 3.7). Twenty of these cases had a comorbidity. In 67 of the 82 patients obstruction at palate level was observed, in 72 it was due to the side walls of the oropharynx, in 19 at the level of the base of the tongue and in 10 in the supraglottis. Only 29% had an obstruction at a single location, and in these cases the most frequent site was the oropharynx side wall. The others had multiple collapsed zones and in these cases the most frequent association was between the soft palate and the side walls of the oropharynx. The cases with obstruction at the base of the tongue or supraglottis were always in patients with more than one obstruction site. Depending on the severity of OSAHS, in the mild cases the most frequent situation was a single location, while moderate-severe cases tended to have more than one location.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">There are discrepancies in the literature respecting the utility of DISE in clear cases of adenotonsillar hypertrophy in children without previous surgery or associated comorbidities. In a review of the literature, Galluzzi states that in these cases (which we could term conventional) it has limited utility, as adenotonsillar will be performed regardless of DISE.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Our personal data agree that in this group of conventional patients any change of planned surgery due to DISE is minimal, and that therefore here DISE can be omitted.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Nevertheless, a recent publication by Gazzaz states that in up to 35% of these patients, DISE gives rise to a change in the type of surgery. According to this author, the changes are fundamentally aimed at avoiding adenoidectomy or tonsillectomy, instead of performing both reductions.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Boudewyns also supports these findings.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In a series by the same author, in which the children are divided into those under the age of 24 months (n = 34) and those over this age (n = 75) without comorbidities or previous treatments, he finds a change of therapeutic strategy in 1/3 of those under the age of 24 months and in 1/4 of those over this age.</p><p id="par0290" class="elsevierStylePara elsevierViewall">It should finally be pointed out that two interesting publications show the validity of the findings obtained using DISE by comparing different observers and levels of polysomnographic severity.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,14</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Fishman presents his results with 28 patients aged from 1 to 18 years (average age 7.65 years) with persistent OSAHS. The author presents the results evaluated by four independent observers and compared with fibre-optic endoscopy performed in the surgery with the patient awake. He describes a good level of agreement between the observers when evaluating the primary site of obstruction, especially in the nasopharynx and supraglottis. There is also a good level of agreement when predicting the degree of obstruction intensity and the level of obstruction that is most responsible for the disease. Additionally, he states that DISE is a better predictor than endoscopy with the patient awake for the severity of OSAHS due to PSG. Although both endoscopic techniques under-value the level of OSAHS severity, there was a strong correlation between the PSG results and the impressions of the four observers respecting OSAHS severity.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">Chan for his part describes his experience with 23 patients with an average age of 2.2 years. 70% of these patients had comorbidities. They are divided into three groups on the basis of findings: the first group contains 9 patients where only one obstruction site was observed, a second group of 7 patients had two or more obstruction sites that were at adjacent levels (adenoids-soft palate-oropharynx or base of tongue—supraglottis), and finally a third group with 7 additional patients who had two or more obstruction sites that were not adjacent. In this third group the AHI was higher than it was in the other two groups.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">The author points out a strong 70% correlation between the four observers in evaluating the obstruction sites, as well as when predicting the severity of OSAHS using polysomnographic criteria, especially in connection with oxygen saturation. Respecting the AHI, the resulting were not statistically significant, although they did show a positive tendency.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">To conclude, although controversial points still exist, DISE seems to be an examination technique that offers necessary information for the correct treatment of an important percentage of paediatric OSAHS patients. Further prospective controlled studies are required to establish the degree of its real importance, although we believe that it is clearly advantageous in cases without clear adenotonsillar hypertrophy, persistent OSAHS after surgery or in patients with comorbidities.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of Interests</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1387871" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1273422" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1387870" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1273423" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Indications" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Sedation Technique" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Classification Systems" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Adenoids: Posterior View From Nasal Cavity" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Soft Palate: Inferior View From Nasopharynx; Evaluation of Anteroposterior Obstruction" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Pharynx Side Walls: Inferior View From the Soft Palate; Evaluation of the Obstruction of Side Walls/palate Tonsils" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Base of the Tongue: Inferior View From the Oropharynx; Evaluation of Anteroposterior Obstruction" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Supraglottis: Inferior View With Base of Tongue (if It Obstructs) Moved Aside, With or Without Jaw Protrusion" ] ] ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-02-20" "fechaAceptado" => "2019-03-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1273422" "palabras" => array:3 [ 0 => "Drug-induced sleep endoscopy" 1 => "DISE" 2 => "Children" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1273423" "palabras" => array:3 [ 0 => "Endoscopia del sueño inducido" 1 => "Niños" 2 => "DISE" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This document is intended as a guide for Spanish ENT specialists who want to perform drug-induced sleep endoscopy. Indications, sedation method and important findings are discussed to unify criteria and methodology.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Este documento pretende ser una guía para los otorrinolaringólogos españoles que deseen realizar endoscopia del sueño inducido por fármacos, normalmente conocida como DISE de sus siglas en inglés Drug-Induced Sleep Endoscopy. Las indicaciones, el método de sedación y la valoración de los hallazgos se comentarán para tratar de unificar metodología y criterios.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Esteller Moré E, Navazo Egía AI, Carrasco Llatas M. Exploración videoendoscópica bajo sueño inducido en niños. 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