C H A P T E R 6 

Drug-Induced Sleep
Endoscopy (DISE)

Madeline J.L. Ravesloot, MD, PhD, MSc

Linda Benoist, MD
J. Peter van Maanen, MD
Nico de Vries, MD, PhD

or endoscopy room, and the sedation can be administrated

1  Introduction by either an anesthesiologist or nurse anesthetist.5 Pulse
Drug-induced sleep endoscopy (DISE) was introduced by oximetry, heart rate, and blood pressure are closely monitored
Croft and Pringle in 1991 and over time has increased in throughout the procedure, and it must be possible to
popularity and is applied worldwide.1,2 The evaluation requires administer oxygen if needed. Patients should remain nil per
pharmacologic induction of sedation and flexible fiber-optic os before the procedure to reduce the risk of regurgitation
endoscopy to visualize upper airway obstruction and/or and aspiration. Administration of atropine or other anticho-
snoring. As opposed to most surgical evaluation techniques, linergic agents 30 minutes before starting the procedure can
DISE not only uniquely offers a dynamic evaluation of the be considered to reduce salivation.
upper airway during conditions that ideally mimic natural A topical anesthetic, with or without a decongestant, can
sleep, but also enables visualization of specific structures be administered to one or both nostrils at least 20 minutes
that contribute to upper airway obstruction. before starting the procedure, being careful not to overanes-
thetize the pharynx, as the risk of aspiration and coughing
increases, in addition to a potential interaction with the
2  Indications upper airway and breathing control.2
Home sleep apnea testing or polysomnography (PSG) must Commonly, the procedure is commenced with the patient
be performed before DISE. Assessment of the site(s) of in a supine position on an operating table or in a bed. The
obstruction is paramount to surgical success, and possibly position should attempt to mimic sleeping habits at home
by applying a jaw thrust during DISE, one may predict the (e.g. one or two pillows, with or without dentures). To gain
likelihood that a mandibular advancement device (MAD) added value, the body position should be easily changeable,
would be effective.3 Hence DISE is employed as a diagnostic should one want to visualize potential consequences of another
tool for patients with habitual snoring, as well as those with position. The lights should be dimmed and the room quiet
obstructive sleep apnea (OSA) when surgery or MAD therapy to minimize awaking stimuli. It is practical to be able to
is being considered as a treatment option by the patient and view the film of the flexible endoscopy on a screen and
physician. Furthermore DISE can be applied to improve record it. With the addition of a microphone, acoustic and
understanding of the anatomic basis for surgical, MAD, or visual signals can be recorded simultaneously.
continuous positive airway pressure (CPAP) failure and to
evaluate additional conservative medical or surgical treatment
alternatives.4 DISE is not necessary if CPAP, weight loss, or
5  Anesthesia
positional therapy is being considered, as visualization of the Drugs commonly used for DISE are propofol and/or mid-
level of obstruction is not mandatory for these treatment azolam. Some use propofol only; others use midazolam only.
modalities. Others start with midazolam and continue with propofol.
Propofol has a rapid onset of action; is metabolized quickly,
giving a fast recovery phase; and has a low incidence of
3  Contraindications postoperative nausea, vomiting, and headache. Propofol has
A high American Society of Anesthesiologists score and the benefit of possessing a rapid onset of action and recovery
propofol or midazolam allergies (albeit rare) are considered period, with minimal side effects.6 In addition, it allows
contraindications. As a result of the negative influence on for standardization and reproducibility between different
treatment success, severe OSA and severe obesity are relative operators.
contraindications. A computerized target-controlled infusion system for
propofol can be helpful, as well as a bispectral index score
system for monitoring the depth of sedation, respectively;
4  Technique neither are compulsory.
There are no standardized protocols concerning DISE Anesthetic depth is of key importance. The target
technique. The procedure can be carried out in the operating depth of sedation is the transition from consciousness to
35
36 Section B Diagnosis

Table 6.1  Drug Dosage 7  Scoring System

Drug Dosage Various scoring systems, such as the VOTE classification
Midazolam Propofol and Nose, Oropharynx, Hypopharynx, and Larynx (NOHL),
are applied in clinical practice and in the literature to
Midazolam BOLUS TECHNIQUE
Starting dose: report DISE findings, complicating scientific evaluation
0.03 mg/kg of DISE in different centers and, just as importantly, the
Observation 2–5 min collection of data across multiple centers.2,14–20 Application
If required, increase of a universal scoring system would be of great benefit to
at a rate of
0.015–0.03 mg/kg
compare results across studies and increase our knowledge
and find supporting evidence whether DISE is indeed
Propofol TCI:
Starting dose: beneficial to the outcomes of existing and novel treatments
1.5–3.0 µg/kg for snoring and OSA. A scoring and classification system
If required, increase at should include primary structures that contribute to upper
a rate of airway obstruction, the degree (severity), and configuration
0.2–0.5 µg/kg
of upper airway obstruction (anteroposterior, circumferential,
CONTINUOUS PUMP or lateral).2
Delivering dose:
50–100 mL/hr
BOLUS TECHNIQUE
Starting dose: 8  Validity
30–50 mg or 1 mg/
kg In studies, propofol did not change the respiratory pattern
If required, increase at or significantly influence the Apnea/Hypopnea Index (AHI),
a rate of 10–20 mg
but it did interfere with the sleep architecture, specifically,
Propofol and Single bolus before TCI: reduction in rapid eye movement (REM) sleep in patients
Midazolam administration of Starting dose: undergoing propofol-induced sleep endoscopy.21 Respiratory
propofol: single 1.5–3.0 µg/kg
starting dose: If required, increase at and somnologic parameters did not change significantly during
0.05 mg/kg or a rate of diazepam-induced sleep endoscopy in comparison with natural
1.5 mg 0.2–0.5 µg/kg sleep either, except for a small increase in the apnea index
and a minor change in the duration of the longest apnea and
Used with permission from De Vito A et al.: European position paper on REM sleep.7,21
drug-induced sedation endoscopy (DISE). Schlaf Atmung
2014;18(3):453–65. Anesthetic depth is of key importance. The target depth
of sedation is the transition from consciousness to uncon-
sciousness (loss of response to verbal stimulation). Because
individuals have differential susceptibilities to propofol, the
unconsciousness (loss of response to verbal stimulation). required dosage can vary widely. Slow stepwise induction is
Because individuals have different susceptibilities to propofol, required to avoid oversedation. Deeper levels of sedation
the required dosage can vary widely. Detailed suggestions are associated with progressive decreases in upper airway
for drug dosages are reported in the European position paper dilator muscle tone and neuromuscular reflex activation that
on DISE (Table 6.1).2 both increase airway collapsibility, and the transition to
Once the patient has reached a satisfactory level of seda- unconscious sedation may be a closer approximation to natural
tion, a flexible endoscope (e.g. 3.5 mm) lubricated and coated sleep. Previous research using propofol has shown that the
with anticondensation solution is introduced into the nasal transition to unconsciousness is associated with changes in
cavity. The nasal passage, nasopharynx, velum, tongue base, upper airway collapsibility (passive critical closing pressure),
epiglottis, and larynx are observed. The levels of snoring Bispectral Index Score readings (based on frontal electro-
and/or obstruction is assessed.7 encephalogram activity), and genioglossus muscle tone;
normals have decreases in genioglossus tone to 10% of
maximum awake activity, which is one-half to one-third of
6  Additional Maneuvers the level in normals but greater than during REM sleep in
Several studies have demonstrated the utility of a jaw thrust normals and OSA.7
in predicting oral appliance outcomes.3,8,9 A jaw thrust or Although unconscious sedation under propofol may not
Esmarch maneuver is a gentle advancement of the mandible be a perfect simulation of natural sleep, pharyngeal dilator
by up to approximately 5 mm. In patients with an insufficient muscle activity appears to lie somewhere between non-REM
benefit of MAD treatment, DISE can be performed with and REM sleep.
or without the device in situ to evaluate reasons for failure
and assess surgical alternatives.4 A more sophisticated and
effective method to titrate MAD and predict treatment
outcome is use of a simulation bite.10
9  Insights From the Literature
Recent studies suggest that change of head position and/ The reliability of test-retest and the intraobserver and
or tilting the patient into alternative sleeping positions is of interobserver variability in DISE scoring are moderate to
added value, especially in position-dependent patients with fair.20,22–24 Not surprisingly, interobserver agreement is higher
OSA with residual disease despite positional therapy.11–13 in ear/nose/throat surgeons who are experienced with DISE.25
 CHAPTER 6  Drug-Induced Sleep Endoscopy (DISE) 37

There are no severe side effects; emergency situations; VOTE classification system. Oper Tech Otolayngol Head Neck Surg
or indications for endotracheal intubation, tracheotomy, or 2012;23(1):11–18.
8. Battagel JM, Johal A, Kotecha BT. Sleep nasendoscopy as a predictor
need of flumazenil administration described with DISE in of treatment success in snorers using mandibular advancement splints.
the literature.7 In case of oversedation, airway management J Laryngol Otol 2005;119(2):106–12.
with the use of positive pressure or, in rare cases, a laryngeal 9. Johal A, Hector MP, Battagel JM, et al. Impact of sleep nasendoscopy
mask airway may be required. on the outcome of mandibular advancement splint therapy in subjects
with sleep-related breathing disorders. J Laryngol Otol 2007;121(7):
Despite substantial heterogeneity in the literature, 668–75.
multilevel obstruction is a more common observation.22,26–31 10. Vroegop AV, Vanderveken OM, Dieltjens M, et al. Sleep endoscopy
The latter is associated with a higher AHI.27 The presence with simulation bite for prediction of oral appliance treatment outcome.
of multilevel collapse, complete collapse, and base of tongue J Sleep Res 2013;22(3):348–55.
collapse is associated with a higher AHI.27,28 Palatal collapse 11. Lee CH, Kim DK, Kim SY, et al. Changes in site of obstruction in
obstructive sleep apnea patients according to sleep position: A DISE
is observed most frequently.26,28,31 A complete concentric study. Laryngoscope 2015;125(1):248–54.
collapse (CCC), particularly at the palatal level, is associated 12. Safiruddin F, Koutsourelakis I, de Vries N. Upper airway collapse during
with a higher body mass index (BMI).28 drug induced sleep endoscopy: head rotation in supine position compared
Just over 50% of 535 cases included in a recent systematic with lateral head and trunk position. Eur Arch Otorhinolaryngol
2015;272(2):485–8.
review had a different surgical treatment plan after DISE 13. Safiruddin F, Koutsourelakis I, de Vries N. Analysis of the influence of
compared with awake examination.32 The differences are head rotation during drug-induced sleep endoscopy in obstructive sleep
most frequently associated with the hypopharyngeal and apnea. Laryngoscope 2014;124(9):2195–9.
laryngeal structures. This, of course, gives no indication 14. Vicini C, De Vito A, Benazzo M, et al. The nose oropharynx hypopharynx
whether DISE is associated with improved outcomes. Few and larynx (NOHL) classification: a new system of diagnostic standardized
examination for OSAHS patients. Eur Arch Otorhinolaryngol 2012;
studies consider the implications of DISE on surgical success, 269(4):1297–300.
and the studies that have been published are retrospective 15. Pringle MB, Croft CB. A grading system for patients with obstructive
in nature.33,34 sleep apnoea—based on sleep nasendoscopy. Clin Otolaryngol Allied
A CCC has repeatedly been associated with surgical failure Sci 1993;18(6):480–4.
16. Camilleri AE, Ramamurthy L, Jones PH. Sleep nasendoscopy: what
in the literature. Patients with absence of CCC had a sig- benefit to the management of snorers? J Laryngol Otol 1995;109(12):
nificant postoperative improvement in AHI after hypoglossal 1163–5.
nerve stimulation therapy.35 In a retrospective study, the 17. Kezirian E, Hohenhorst W, de Vries N. Drug-induced sleep endoscopy:
presence of CCC was found to predict the occurrence of the VOTE classification. Eur Arch Otorhinolaryngol 2011;268(8):
surgical failure.34 CCC is associated with a high BMI, which 1233–6.
18. Bachar G, Nageris B, Feinmesser R, et al. Novel grading system for
in turn is associated with surgical failure. quantifying upper-airway obstruction on sleep endoscopy. Lung
2012;190(3):313–18.
19. Koo SK, Choi JW, Myung NS, et al. Analysis of obstruction site in
10  Summary obstructive sleep apnea syndrome patients by drug induced sleep
endoscopy. Am J Otolaryngol 2013;34(6):626–30.
DISE is a valid addition to PSG and clinical assessment in 20. Gillespie MB, Reddy RP, White DR, et al. A trial of drug-induced sleep
an awake patient. Correct technique and performance endoscopy in the surgical management of sleep-disordered breathing.
presumed, it is a reliable and safe tool to detect and analyze Laryngoscope 2013;123(1):277–82.
the phenomena of the upper airway during sleep visually 21. Rabelo FAW, Braga A, Küpper DS, et al. Propofol-induced sleep:
and acoustically. polysomnographic evaluation of patients with obstructive sleep
apnea and controls. Otolaryngol Head Neck Surg 2010;142(2):
DISE allows for a targeted management of snoring or 218–24.
OSA in suitable individuals eligible for sleep surgery or MAD 22. Kezirian EJ, White DP, Malhotra A, et al. Interrater reliability of drug-
treatment by clarifying the underlying contributing anatomic induced sleep endoscopy. Arch Otolaryngol Head Neck Surg 2010;136(4):
sites. Further research is needed to evaluate the association 393–7.
23. Berry S, Roblin G, Williams A, et al. Validity of sleep nasendoscopy in
between preoperative findings and surgical outcomes. the investigation of sleep related breathing disorders. Laryngoscope
2005;115(3):538–40.
24. Rodriguez-Bruno K, Goldberg AN, McCulloch CE, et al. Test-retest
References reliability of drug-induced sleep endoscopy. Otolaryngol Head Neck
1. Croft CB, Pringle M. Sleep nasendoscopy: a technique of assessment Surg 2009;140(5):646–51.
in snoring and obstructive sleep apnoea. Clin Otolaryngol Allied Sci 25. Vroegop AV, Vanderveken OM, Wouters K, et al. Observer variation in
1991;16(5):504–9. drug-induced sleep endoscopy: experienced versus nonexperienced ear,
2. De Vito A, Carrasco Llatas M, Vanni A, et al. European position paper nose, and throat surgeons. Sleep 2013;36(6):947–53.
on drug-induced sedation endoscopy (DISE). Sleep Breath 2014;18(3): 26. Salamanca F, Costantini F, Bianchi A, et al. Identification of obstructive
453–65. sites and patterns in obstructive sleep apnoea syndrome by sleep
3. Johal A, Battagel JM, Kotecha BT. Sleep nasendoscopy: a diagnostic tool endoscopy in 614 patients. Acta Otorhinolaryngol Ital 2013;33(4):
for predicting treatment success with mandibular advancement splints 261–6.
in obstructive sleep apnoea. Eur J Orthod 2005;27(6):607–14. 27. Vroegop AV, Vanderveken OM, Boudewyns AN, et al. Drug-induced
4. Kent DT, Rogers R, Soose RJ. Drug-induced sedation endoscopy sleep endoscopy in sleep-disordered breathing: report on 1,249 cases.
in the evaluation of osa patients with incomplete oral appliance Laryngoscope 2014;124(3):797–802.
therapy response. Otolaryngol Head Neck Surg 2015;153(2): 28. Ravesloot MJ, de Vries N. One hundred consecutive patients undergoing
302–7. drug-induced sleep endoscopy: results and evaluation. Laryngoscope
5. Benoist L, de Vries N. Organization and logistics of drug-induced sleep 2011;121(12):2710–16.
endoscopy in a training hospital. Eur Arch Otorhinolaryngol 2015; 29. Abdullah VJ, Wing YK, van Hasselt CA. Video sleep nasendoscopy: the
271(9). Hong Kong experience. Otolaryngol Clin North Am 2003;36(3):461–71,
6. Glen JB. The development of ‘Diprifusor’: a TCI system for propofol. vi.
Anaesthesia 1998;53(Suppl. 1):13–21. 30. Bachar G, Feinmesser R, Shpitzer T, et al. Laryngeal and hypopharyngeal
7. Hohenhorst W, Ravesloot MJL, Kezirian EJ, et al. Drug-induced sleep obstruction in sleep disordered breathing patients, evaluated by sleep
endoscopy in adults with sleep-disordered breathing: technique and the endoscopy. Eur Arch Otorhinolaryngol 2008;265(11):1397–402.
38 Section B Diagnosis

31. Hamans E, Meeus O, Boudewyns A, et al. Outcome of sleep endoscopy 34. Koutsourelakis I, Safiruddin F, Ravesloot M, et al. Surgery for obstructive
in obstructive sleep apnoea: the Antwerp experience. B-ENT 2010; sleep apnea: sleep endoscopy determinants of outcome. Laryngoscope
6(2):97–103. 2012;122(11):2587–91.
32. Certal VF, Pratas R, Guimaraes L, et al. Awake examination versus 35. Vanderveken OM, Maurer JT, Hohenhorst W, et al. Evaluation of drug-
DISE for surgical decision making in patients with OSA: a systematic induced sleep endoscopy as a patient selection tool for implanted upper
review. Laryngoscope 2016;126(3):768–74. airway stimulation for obstructive sleep apnea. J Clin Sleep Med
33. Golbin D, Musgrave B, Succar E, et al. Clinical analysis of drug-induced 2013;9(5):433–8.
sleep endoscopy for the OSA patient. Laryngoscope 2016;126(1):249–53.