Operative Techniques in Otolaryngology (2012) 23, 11-18

Drug-induced sleep endoscopy in adults with

sleep-disordered breathing: Technique and the VOTE
Classification system
W. Hohenhorst, MD,a M.J.L. Ravesloot, MD,b E.J. Kezirian, MD, MPH,c
N. de Vries, MD, PhDb

From the aENT Department, Facial Plastic and Interventional Sleep Medicine, Kliniken St. Antonius, Wuppertal, Germany;
b
Department of Otolaryngology–Head and Neck Surgery, Sint Lucas Andreas Ziekenhuis, Amsterdam, the Netherlands; and
c
Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, California.

KEYWORDS Drug-induced sleep endoscopy (DISE) offers an unique evaluation of the upper airway. After phar-
Obstructive sleep macologic induction of unconscious sedation, it is possible to evaluate endoscopically the structures
apnea; contributing to upper airway obstruction in sleep disordered breathing. The authors describe DISE
Drug-induced sleep techniques and the VOTE classification system for reporting of DISE findings. The VOTE classification
endoscopy; focuses on the primary structures that contribute to upper airway obstruction and represents a common
Surgery; language to describe the patterns of obstruction during DISE. The latter can facilitate the scientific
Propofol; evaluation of DISE, including its role in directing treatment.
Midazolam © 2012 Elsevier Inc. All rights reserved.

Assessment of the site(s) of obstruction is critical to successful requires pharmacologic induction of sedation and flexible
surgical treatment of snoring and obstructive sleep apnea. Multiple fiber optic endoscopy to visualize upper airway obstruc-
evaluation techniques have been developed to examine an indi- tion and/or snoring.1
vidual’s pattern of upper airway obstruction; each with important We have previously renamed the technique DISE to
strengths and weaknesses. Obstructive sleep apnea (OSA) surgical reflect the 3 key features of this method of assessment: (1)
evaluation techniques are commonly performed during wakeful- the use of various pharmacologic agents to achieve seda-
ness and include largely static observations rather than dynamic tion; (2) the goal of reproducing upper airway behavior
assessments. As such, they may not be ideal methods to assess the similar to that which occurs during natural sleep; and (3)
upper airway during breathing and sleep. The variety and com- endoscopic upper airway evaluation. Other terms referenced
plexity of vibrations and collapse events in the upper airway in the literature include sleep endoscopy, sleep nasendos-
during sleep depend on multiple factors. Sleep stages, muscle copy, somnoendoscopy, somnoscopy, sedated endoscopy,
tone, body position, head and neck position, and lung volumes are and propofol sleep endoscopy.
some of the variables that affect upper airway collapsibility. Although DISE is performed widely, research concern-
Drug-induced sleep endoscopy (DISE) has been per- ing the technique is remarkably limited. Several studies
formed for decades, in many leading centers in Europe as have examined its safety, feasibility, validity, and reliabi-
well as selected centers in other parts of the world. lity.2-6 Various studies have examined the association be-
Introduced by Croft and Pringle in 1991, the evaluation tween DISE findings and outcomes of palate surgery7-10 and
mandible repositioning appliances.11,12
More importantly, essential clinically relevant questions
Address reprint requests and correspondence: E.J. Kezirian, MD,
MPH, Department of Otolaryngology–Head and Neck Surgery, University
remain unanswered. The diversity of classification systems,
of California, San Francisco, CA. ranging from the simple to the complex, has prevented the
E-mail address: [email protected]. comparison of results across studies and centers.
1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2011.06.001
12 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

Based on the DISE findings, and combining these find- Table 1 Pharmacologic properties of midazolam and
ings with those of poly(somno)graphy and clinical assess- propofol
ment, a mandibular repositioning appliance (MRA) or 1 of
the many different forms of surgery can be selected. Midazolam Propofol
Benzodiazepine derivative 2-6 Disopropylphenol
Large therapeutic range Small therapeutic range
Active metabolites No accumulation
Indications (accumulation)
Functional half-life 45 min Functional half-life 4-6 min
DISE is indicated when surgery or MRA therapy is being Elimination half-life 150 min Elimination half-life 55 min
considered as a treatment option by the patient and physi- Central muscle relaxation Central breathing depression
cian. Consequently DISE is not necessary if continuous Paradoxal reaction in 1% Hypopharyngeal reflex
positive airway pressure, weight loss, or positional therapy depression
is being considered, as visualization of the level of obstruc-
tion is not mandatory for these treatment modalities. A high
American Society of Anesthesiologists (ASA) score (ⱖ3) readily available in case reversal of the benzodiazepine
and propofol or midazolam allergies (albeit rare) are con- effect should be necessary.
sidered contraindications, owing to the high risk. Because of When propofol is the drug of choice, in an operating
a higher procedure-associated risk and lesser effects on theater or in a clinic setting propofol (1.5 mg/kg or contin-
treatment decisions, markedly severe OSA (such as an ap- uous infusion) is administered. Propofol, an ultra-short-
nea-hypopnea index (AHI) ⬎70 events/h) and severe obe- acting hypnotic, enables greater control of the depth of
sity are relative contraindications. sedation, albeit limited by a smaller therapeutic/diagnostic
Prior to DISE, polysomnography must be performed. range. The pharmacologic properties of both drugs are
The results of these examinations are mandatory and at the shown in Table 1. Depending on the organization of the
basis of performing of DISE. examination, a combined procedure may be useful: com-
mence by administrating midazolam intravenously (3-4 mg)
followed by propofol (30-50 mg or continuous infusion),
Technique titrated individually.12
Subjects with an AHI below 30, or to be more accurate
Patients should have basic cardiorespiratory monitoring patients with a supine AHI below 30 and with good health
(pulse oximetry, blood pressure, electrocardiogram), and it (ASA I or II) can undergo midazolam-induced sleep endos-
must be possible to administer oxygen if needed. A com- copy in the clinic. Midazolam is administered by the ear,
puterized target-controlled infusion system for propofol (not nose and throat surgeon (presence of an anesthetist not
available in the United States) can be helpful, as well as a obligatory) or by an anesthetist. Sleep is induced by giving
bispectral index score system for monitoring the depth of midazolam intravenously, slowly titrated up to 0.07 mg/kg
sedation, respectively; neither are compulsory. per patient, followed by a saline flush.13,14 If insufficient, a
Patients should remain nil per os before the DISE, to bolus of 1-2.5 mg is given (a maximum of 7.5 mg per
prevent regurgitation and aspiration. To reduce salivation, patient). Patients who are extremely nervous or who habit-
atropine or other anticholinergic agents can be administered ually use antidepressants or sedatives may need an extra
30 minutes before starting the procedure. bolus.
A topical anesthetic, with or without a decongestant, Previous studies reported that propofol did not change
should be administered to 1 or both nostrils at least 20 the respiratory pattern nor significantly influence the AHI,
minutes before starting the procedure, being careful not to but did interfere with the sleep architecture, specifically,
overanesthetize the pharynx, as the risk of aspiration and reduction in rapid eye movement (REM) sleep in patients
coughing increases. undergoing propofol-induced sleep endoscopy.15 Respira-
The patient should lie in a supine position on an operat- tory and somnological parameters did not change signifi-
ing table or in a bed. The position should attempt to mimic cantly during diazepam-induced sleep endoscopy in com-
sleeping habits at home (eg, 1 or 2 pillows, with or without parison with natural sleep either, except for a small increase
dentures). To gain added value, the body position should be in the apnea index and a minor change in the duration of the
easily changeable, should one want to visualize potential longest apnea and REM sleep.15,16
consequences of another position. It is practical to be able to Anesthetic depth is of key importance. The target depth
view the film of the flexible endoscopy on a screen and of sedation is the transition from consciousness to uncon-
record it. With the help of a microphone, acoustic and visual sciousness (loss of response to verbal stimulation). Because
signals can be recorded simultaneously. The lights should individuals have differential susceptibilities to propofol, the
be dimmed and the room quiet to minimize awaking stimuli. required dosage can vary widely. Slow stepwise induction is
Drugs commonly used for DISE are propofol and/or required to avoid oversedation. Deeper levels of sedation
midazolam. Some use propofol only; others use midazolam are associated with progressive decreases in upper airway
only. Others start with midazolam and continue with propo- dilator muscle tone and neuromuscular reflex activation that
fol.12 If midazolam is used, a flumazenil injection should be both increase airway collapsibility, and the transition to
Hohenhorst et al Drug-Induced Sleep Endoscopy in Adults 13

unconscious sedation may be a closer approximation to

natural sleep. Previous research using propofol has shown
that the transition to unconsciousness is associated with
changes in upper airway collapsibility (passive critical clos-
ing pressure), Bispectral Index Score readings (based on
frontal EEG activity), and genioglossus muscle tone; nor-
mals have decreases in genioglossus tone to 10% of maxi-
mum awake activity, which is one-half to one-third of the
level in normals but greater than during REM sleep in
normals and OSA.17 While unconscious sedation under
propofol may not a perfect simulation of natural sleep,
pharyngeal dilator muscle activity appears to lie somewhere
between NREM and REM sleep.
Once the patient has reached a satisfactory level of se-
dation, a flexible endoscope (eg, 3.5 mm) lubricated and
coated with anticondense is introduced into the nasal cavity.
The nasal passage, nasopharynx, velum, tongue base, epi-
glottis, and larynx are observed. The levels of snoring Figure 2 Jaw thrust, or Esmarch maneuver, a gentle advance-
and/or obstruction are assessed. ment of the mandible by up to approximately 5 mm.
During the DISE, maneuvers such as a chin lift (a manual
closure of the mouth) (Figure 1) or a jaw thrust (or Esmarch
maneuver) (Figure 2) should be performed, with reassess- In patients with an insufficient effect of an MRA, DISE
ment of the airway after each maneuver. A jaw thrust is a can be performed without the device both in and out, to
gentle advancement of the mandible by up to approximately assess obstruction site(s) and surgical alternatives.
5 mm, mimicking the effect of a mandibular repositioning
appliance. It is thought that, using DISE, one can predict the
likelihood that an appliance would be effective by examin- VOTE Classification
ing the changes in the airway.12 Although the effects during
sedation may not be identical to those of natural sleep, the The complex interplay of upper airway structures cannot be
distance of protrusion can be measured and can inform explained fully by simple examination of individual struc-
decisions about the necessary degree of mandibular reposi- tures and their relationship to the airway during DISE.
tioning with an appliance. There is a wide range of systems, ranging from overly
simplistic to overly complex. Some exclude the epiglottis;
others try to group multiple structures together in various
combinations.18-20
There is no universally used DISE scoring system—
hence one is needed.
We therefore recently proposed the VOTE Classification
system for reporting DISE findings, with a focus on the
primary structures that contribute to upper airway obstruc-
tion, either alone or in combination: the velum, oropharyn-
geal lateral walls (including the tonsils), tongue, and epi-
glottis.21
The VOTE Classification may be an oversimplification
that overlooks some interactions, but we believe it is a
foundation for further study of pharyngeal obstruction in
OSA and for assessment of the response of upper airway
structures to directed interventions. DISE is a qualitative,
not quantitative assessment of vibration and obstruction
events. It is not possible to assess exact percentages of
obstruction, and the 3 (a) none, (b) partial, (c) complete,
cutoff points are most realistic and best for clinical use. For
quantitative measurements, polysomnography and Pcrit
measurements are more suitable. DISE is neither intended
for, nor possible to calculate, the rate (or grade) of obstruc-
tive events per night.
The shared use of the VOTE Classification can facilitate
Figure 1 Chin lift, a manual closure of the mouth. the scientific evaluation of DISE in individual centers and,
14 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

just as importantly, the collection of data across multiple Table 2 The VOTE Classification
centers and comparison of results across studies. Our expe-
rience suggests that a focus on structures enables examina- Direction
tion of 2 central questions: treatment selection and the
association between DISE findings and treatment out- Level A-P Lateral Concentric
comes—for surgery, mandibular repositioning appliances, Velum
or combined therapy. The VOTE Classification represents a Oropharynx
common language to describe the patterns of obstruction
during DISE and may ultimately direct treatment interven- Tongue base
tions (Table 2).
The most common and well-known sites of obstruction Epiglottis
and vibration are located in the soft palate, the lateral pha-
ryngeal walls, including tonsils and the base of tongue. Degree of obstruction: (0) no obstruction (no vibration, ⬍50%);
(1) partial obstruction (vibration 50-75%); (2) complete obstruction
Obstruction at epiglottic level occurs less often but has (collapse, ⬎75%); (x) not visualized.
clinical significance. Previous large series of DISE in pa-
tients with OSA reported a majority of multilevel obstruc-
tion, a retropalatinal as well as retrolingual obstruction in a
large percentage of cases.1,13,18,19 In general, an unilevel gions of pharyngeal upper airway obstruction: the palatal/
obstruction is more common in patients with mild OSA, velopharyngeal and hypopharyngeal/retrolingual regions.
while in severe OSA, a multilevel obstruction is more char- However, there are 2 major limitations of a region-based
acteristic, being the very reason for the severity of the classification. First, there is substantial anatomical overlap
OSA.3,22 The subsequent surgical treatment with different, between these regions, including the extension of the lateral
site-specific procedures will not be discussed here. pharyngeal walls throughout the length of the pharynx and
For many years, surgical evaluation techniques have fo- the physical overlap of the tongue and soft palate. Second,
cused on categorizing patients first according to the Fujita a region-based approach may not direct surgical treatment
classification system that encompasses the 2 primary re- adequately. For example, in patients with hypopharyngeal/

Figure 3 Velum obstruction. (A) No obstruction; (B) total anteroposterior (AP) obstruction; (C) partial AP obstruction; (D) concentric
obstruction.
Hohenhorst et al Drug-Induced Sleep Endoscopy in Adults 15

Figure 4 Oropharynx and tonsil obstruction. (A) No obstruction; (B) complete lateral collapse; (C) partial obstruction by tonsils; (D)
complete obstruction by kissing tonsils; (E) kissing tonsils view in the oral cavity.

retrolingual obstruction, the oropharyngeal lateral walls, tions may play a critical role in procedure selection and
tongue, and epiglottis can each play a more prominent role. improvement of outcomes.
Because surgical procedures may exert differential effects Expert opinion suggests that surgical success rates are lower
on these structures and their contribution to upper airway in concentric obstruction. Concentric obstruction is usually
obstruction, distinguishing between the structural contribu- related to higher body mass index and in particular to increased
16 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

Figure 5 Tongue base obstruction. (A) Partial AP obstruction; (B) complete AP obstruction; (C) hypertrophic lingual tonsils; (D) patient
with tongue base obstruction whilst performing a chinlift.

neck circumference. One of the biggest advantages of DISE is related to the velum can occur with collapse in an antero-
the individual analysis, which allows patient-specific and site- posterior or concentric configuration, but rarely in a lateral
specific therapies according to location and amount. Although configuration (Figure 3A-D).
we have the impression that surgical success rates in pa-
tients selected by DISE are better than average, this has to Oropharyngeal lateral walls including tonsils. The oropharyn-
be confirmed in more studies.12,23 geal lateral walls include 2 structures: the tonsils and the
As opposed to most surgical evaluation techniques, DISE lateral pharyngeal wall tissues that include musculature and
not only uniquely offers a dynamic evaluation of the upper the adjacent parapharyngeal fat pads. Both structures col-
airway during conditions that ideally mimic natural sleep lapse in a lateral configuration, although this may occur in
but also enables visualization of specific structures that combination with collapse of other structures, with a result-
contribute to upper airway obstruction. This structure-based ing concentric pattern. In the presence of lateral wall col-
characterization is the foundation of DISE and must be the lapse, it can be difficult (but certainly not impossible) to
core of any classification system. The recording and report- determine whether the tonsils or lateral walls are playing a
ing of structure-specific findings will enable comparison of significant role, reflecting potential subtypes; importantly,
data across centers and procedures. the distinction can have important implications for treat-
ment selection and outcomes. While the VOTE Classifica-
The structures of the VOTE acronym tion is largely based on DISE findings alone, the examina-
tion of tonsil size and lateral pharyngeal wall tissues during
Our experience with over 7500 DISE examinations sug- routine oral cavity examination can be invaluable in making
gests that a selected group of structures contribute to upper a determination of potential contributions of each structure.
airway narrowing and/or obstruction in sleep disorded Obstruction related to the oropharynx can occur with col-
breathing, individually or in combination. The VOTE Clas- lapse in a lateral or concentric configuration, but not in an
sification (Table 2) evaluates these structures and the degree anteroposterior configuration (Figure 4A-E).
of airway narrowing.
Tongue base. Tongue base obstruction is a common DISE
Velum. Velopharyngeal obstruction occurs at the level of finding, and it results in anteroposterior narrowing of the
soft palate, uvula, or lateral pharyngeal wall tissue at the upper airway. In natural sleep, there is a reduction in muscle
level of the velopharynx. Because these 3 structures are not tone of the tongue, especially during non-REM and REM
entirely distinct entities— both anatomically and on sleep that is more pronounced in OSA patients compared to
DISE—we have grouped them together. Airway closure healthy individuals. Airway closure related to the base of
Hohenhorst et al Drug-Induced Sleep Endoscopy in Adults 17

Figure 6 Epiglottis obstruction. (A) Anteroposterior; (B) lateral.

tongue occurs with collapse in an anteroposterior direction examination already. If indicated, they are noted separately.
(Figure 5A-D). We do not mean to minimize their potential role but believe
the VOTE Classification reflects patterns seen in the large
Epiglottis. Epiglottic collapse occurs in 1 of 2 configura- majority of patients.
tions, anteroposterior (Figure 6A) or lateral (Figure 6B), but
not concentric. Anteroposterior collapse can result with
Degree of airway narrowing
folding of the epiglottis with what appears to be decreased
structural rigidity of the epiglottis or with an apparent pos-
The VOTE Classification involves a qualitative assess-
terior displacement of the entire epiglottis against the pos-
ment of the degree of airway narrowing, divided into the
terior pharyngeal wall, with normal epiglottic structural
following:
integrity. The second pattern, a lateral folding or involution,
is consistent with a central vertically oriented crease of None (typically with no vibration of the involved structure
decreased rigidity of the epiglottis. The epiglottis may be and less than 50% airway narrowing compared to di-
underrecognized as a factor in patients with sleep-disor- mensions during nonapneic state)
dered breathing, and a substantial proportion of patients Partial (vibration, 50-75% narrowing), or
with OSA do demonstrate a significant epiglottic contribu- Complete (obstruction, greater than 75% narrowing, and no
tion to airway obstruction during DISE.3,7,19 DISE may airflow). We recognize that differentiating between the
provide a unique assessment of the epiglottis, as its apparent 3 categories is not always clear, although the evaluation
role has not been demonstrated as clearly demonstrated with of degree of obstruction has been demonstrated as hav-
other evaluation techniques (Fujita, Mallampati/Friedman). ing moderate reliability.7 At 1 level in the upper airway,
a partial collapse (vibration, snoring) might be present,
while at the other level a complete collapse might be
Other structures
detected.
Although less common, airway obstruction in sleep-dis- The VOTE Classification differs slightly from what we
ordered breathing can be related to other structures. In rare independently have developed for use in our practice, as it
cases collapse above the VOTE level, for example, by reflects the most fundamental aspects of the DISE evalua-
massive nasal polyps, adenoid hypertrophy or nasopharyn- tion.5,18 The VOTE Classification does not exclude addition
geal neoplasms, or below the VOTE level, for example, of center-specific assessments. DISE has the advantage of
vocal cord level, in postradiation edema or vocal cord pa- permitting certain maneuvers, ranging from manual closure
ralysis, can be visualized. This is usually detected by awake of the mouth only (Figure 1), to the Esmarch/jaw thrust
18 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

(Figure 2). It goes without saying that multiple, separate References

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