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World Journal of Otorhinolaryngology-Head and Neck Surgery (2021) 7, 221e227

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.keaipublishing.com/WJOHNS; www.wjent.org

Review Article

Pediatric drug-induced sleep endoscopy: An

updated review of the literature
Jill M. Arganbright a,b,*, Jason C. Lee c, Robert A. Weatherly a,b

a
Children’s Mercy Kansas City, Division of Otolaryngology, Kansas City, MO, USA
b
University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
c
University of Kansas Medical Center, Department of Otolaryngology, Kansas City, KS, USA
Available online 29 June 2021

KEYWORDS Abstract The field of drug-induced sleep endoscopy (DISE) has grown considerably over the
Drug-induced sleep last 10w15 years, to now include its use in pediatric patients. In this review article, we outline
endoscopy; our approach to the use of this technology in Children with Airway Obstruction, most specif-
Pediatric obstructive ically in the management of children with airway obstruction and known or suspected adeno-
sleep apnea; tonsillar enlargement.
Adenotonsillectomy Copyright ª 2021 Chinese Medical Association. Publishing services by Elsevier B.V. on behalf of
in children KeAi Communications Co. Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction most significant contributor to OSA for otherwise healthy

children.2 The American Academy of Pediatrics considers
Obstructive sleep apnea (OSA) has a prevalence of 1%w4% adenotonsillectomy (AT) to be first-line treatment for pe-
for children in the United States.1 Sequelae from pediatric diatric OSA.4 However, a recent meta-analysis reported
OSA can include daytime somnolence, poor school perfor- residual obstructive symptoms in 33.7% of children post AT.5
mance, behavioral and neurocognitive problems, cardio- For patients with persistent obstructive symptoms following
vascular complications, enuresis, growth retardation,2 and AT, overnight polysomnography (PSG) is often considered
an overall significantly reduced quality of life.3 Adeno- the next step in evaluation. While PSG findings are helpful
tonsillar hypertrophy has been widely recognized as the in determining the presence and severity of OSA, they do
not identify the specific location/anatomic cause of the
obstruction. Awake flexible endoscopy can be useful in
assessing for certain anatomic causes of obstruction
* Corresponding author. Children’s Mercy Kansas City, Division of including lingual tonsil hypertrophy and adenoid re-growth;
Otolaryngology, Kansas City, MO, USA. however, these awake exams have not been shown to be
E-mail address: [email protected] (J.M. Arganbright). representative of the patient’s airway while asleep. An
Peer review under responsibility of Chinese Medical Association. article by Lee et al reported that awake flexible endoscopy
findings did not correlate to a similar scope with the patient
asleep when assessing base of tongue collapse.6 Chen et al7
demonstrated that patterns of obstruction at the level of
Production and Hosting by Elsevier on behalf of KeAi
the lateral pharyngeal wall significantly differed in awake

https://doi.org/10.1016/j.wjorl.2021.05.002
2095-8811/Copyright ª 2021 Chinese Medical Association. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 25891081, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.wjorl.2021.05.002 by Chile National Provision, Wiley Online Library on [21/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
222 J.M. Arganbright et al.

endoscopy compared to when the patient was asleep. The change significantly following AT, such that the results of
evolution of induced sleep endoscopy has allowed providers the pre-procedure DISE are low yield as the airway dy-
to assess anatomical sites causing airway obstruction namics will be greatly changed following AT.13 Other situ-
exclusively during sleep. ations where DISE can be helpful in surgically naı̈ve patients
Sleep endoscopy was initially pioneered by Croft and include children with severe symptoms of sleep-disordered
Pringle in 1989 and further developed in the 1990s.8 It was breathing (SDB) or those with OSA and small tonsils/ade-
named “drug-induced sleep endoscopy” (DISE) in 2005 by noids on exam. Miller et al showed that small tonsils (1þ)
Kezirian and Hohenhorst.2,9 The DISE technique involves an were not obstructive in most cases during DISE, and
evaluation of the upper airway using a flexible endoscope therefore additional sites of obstruction should be consid-
while patients are in a pharmacologically induced sleep-like ered in lieu of proceeding with AT.17 A study by Richter et
state. The scope is passed through the nares to examine the al18 highlighted the importance of identifying patients with
nasopharynx, oropharynx, larynx, and in some cases the sleep-state dependent laryngomalacia. This disease entity
trachea. The procedure has been shown to be safe, with is difficult to identify on awake laryngoscopy alone.19 In a
test-retest reliability and moderate-substantial inter-rater meta-analysis by Camacho et al,20 48/62 (77.4%) of children
reliability.10 The goal of the DISE exam is to identify the diagnosed with sleep-state laryngomalacia had failed prior
site(s) of obstruction best to target surgically for the AT. Lastly, children who are being evaluated for hypoglossal
management of pediatric OSA. Controversy remains, how- nerve stimulator (HNS) treatment currently require DISE
ever, as to how well DISE simulates physiologic sleep and, evaluation to be completed to determine candidacy for this
by extension, its utility in improving OSA.11 DISE has clas- procedure. Caloway et al21 2019 published data from 20
sically been used to assess patients with persistent OSA patients undergoing HNS in the current ongoing pediatric
after AT. More recently, DISE is being used for certain sur- clinical trial. Circumferential collapse at the level of the
gically naı̈ve patients, further expanding the indications for velopharynx was considered a criterion for exclusion from
and utility of DISE. DISE and its impact on treatment of the study.
pediatric OSA is a very active area of ongoing research.
The goal of this review article is to summarize the cur-
rent literature on pediatric DISE, specifically examining the Anesthetic protocols
following areas of interest: indications for DISE, anesthetic
protocols, comparison of DISE to other diagnostic modal- In an ideal setting, the anesthetic for DISE should simulate a
ities, DISE scoring systems, the use of DISE in surgically natural sleep state while allowing for spontaneous venti-
naı̈ve patients, and DISE-directed surgical outcomes. lation.22 The anesthetic should not cause artificial respira-
tory depression, cardiovascular effects, or airway collapse
beyond what is occurring in natural sleep. It should be
Indications for DISE repeatable, have a quick onset, be short in duration, and
not result in excessive airway secretions.23 While no
As the role of DISE continues to be studied, indications for medication or combination of medications meets all these
the procedure have expanded: ① persistent OSA after criteria precisely, there is an extensive, ongoing effort to
AT,② prior to AT for patient at high risk for persistent OSA find a protocol that most closely aligns with these ideals.
(i.e. obesity, Down syndrome, craniofacial anomalies, During the DISE procedure, most children require some
neurologic impairment),③ significant symptoms of SDB or type of inhalational anesthetic agent before intravenous
OSA with small tonsils and adenoids,④ occult or sleep-state (IV) line insertion. Topical anesthetic of the nasal passage is
dependent laryngomalacia,⑤ evaluation for candidacy for avoided as it has been reported to potentially exaggerate
hypoglossal nerve stimulator procedure. The most well- findings associated with laryngomalacia, reduce upper
studied indication for DISE is for a child with persistent OSA airway reflexes, and impair the arousal response resulting
following AT. A 2016 systematic review revealed that at in increased sleep apnea severity.2,24 Also, decongestants
least one site of obstruction was identified in 100% of are to be avoided to prevent altering the accuracy of the
children who underwent DISE (n Z 162).2,12 Wilcox et al2 in inferior turbinate evaluation.24
2017 summarized studies using DISE to identify sites of Beyond that, controversy remains as to which general
obstruction in children with persistent OSA after AT; they anesthetic agent should be used. While nearly all anes-
found eight studies reporting that sites were identified in thetics affect upper airway muscle tone to varying degrees,
89%w100% of non-control patients. In 2017, Friedman et it is important to acknowledge that excessive sedation can
al13 surveyed pediatric otolaryngologists; they found strong produce an exaggeration of collapse and create false pos-
agreement from responders in performing DISE for such itives in the areas causing obstruction during sleep.22,23
patients with residual OSA following AT regardless of This highlights the importance of being mindful and inten-
comorbidities. Additionally, a plethora of recent literature tional about the anesthetic protocol used for DISE.
has explored the role of DISE in surgically naı̈ve patients. Currently, multiple anesthetic protocols have been pro-
Studies have shown a benefit in performing DISE prior to AT posed (Table 1), but none have been universally accepted.
in patients who have a relatively high risk of persistent OSA The most common anesthetic agents used in pediatric DISE
following AT, including those with obesity, Down syndrome, are propofol, midazolam, dexmedetomidine (DEX), keta-
craniofacial anomalies, and neurologic impairment.14e16 mine, and inhalational agents (i.e. sevoflurane).23
DISE in these patients can be useful in guiding management For adults, propofol is the anesthetic most frequently
should residual disease persist following AT.16 However, used for DISE and is titrated to a bispectral index between
opponents of this algorithm argue that airway dynamics 50 and 75.9 For pediatric DISE, propofol has historically
 25891081, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.wjorl.2021.05.002 by Chile National Provision, Wiley Online Library on [21/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Pediatric drug-induced sleep endoscopy 223

Table 1 Features of commonly used anesthetics for pediatric DISE.

Anesthetic agent Features
Propofol  Used for adult DISE
 In pediatric DISE, criticized for its potential to cause excessive
dose-dependent muscle relaxation and airway collapse
Midazolam  A commonly used benzodiazepine
 Causes central apnea and peripheral muscle relaxation
DEX  It is a preferred medication for pediatric DISE due to its minimal effect on the airway
 Studies have shown it to be less likely than propofol to cause upper airway obstruction
 It replicates only non-REM sleep
 It has been criticized for not providing adequate sedation as a single agent
Ketamine  It has minimal to no effect on airway patency and
minimal effects on central respiratory drive
 Causes hypersalivation, which can make DISE more difficult
Inhalational agents  Causes dose-dependent obstruction at various sites in the upper airway
DISE: drug-induced sleep endoscopy; DEX: dexmedetomidine; REM: rapid eye movement.

been criticized for its potential to cause excessive dose- Comparison of DISE to alternative diagnostic
dependent muscle relaxation and airway collapse; howev- modalities
er, in 2020, Kirkham et al16 retrospectively compared DISE
findings for children sedated with propofol versus DEX and
DISE has several advantages, including the ability to obtain
did not find a significant difference in the degree of upper
a three-dimensional view of the airway and to concurrently
airway obstruction. Midazolam is a commonly used benzo-
offer surgical intervention in the same operative setting.
diazepine for DISE but may cause both central apnea and
Allowing for concurrent surgical intervention limits the
peripheral muscle relaxation and obstruction.23 DEX is
need for multiple anesthetics and is more convenient for
currently considered the preferred medication for pediatric
the families. One limitation of DISE is the ability to assess
DISE due to its minimal effect on the airway. Unfortunately,
only one site of obstruction at a time.2 A second disad-
it replicates only nonerapid eye movement (REM) sleep and
vantage is the scope’s presence in the airway during the
has been criticized for not providing adequate sedation as a
exam; some argue that the scope itself can stent open the
single agent.25,26 Ketamine has minimal to no effect on the
airway during the exam, thereby changing the obstructive
airway patency and minimal effects on central respiratory
pattern.28 Despite these limitations, many providers and
drive. However, ketamine does cause hypersalivation which
families feel the benefits outweigh these disadvantages and
can make DISE more difficult. Lastly, inhalational agents
consider pairing the diagnostic DISE with a plan for thera-
cause dose-dependent obstruction at various sites in the
peutic intervention in the same operative setting.2,13
upper airway.22
In addition to DISE, several other modalities have been
Differences in anesthetic protocols make direct com-
used to identify sites of obstruction for pediatric patients
parison of DISE results difficult. For example, a head-to-
with OSA (Table 2). Cine magnetic resonance imaging (MR)
head comparison of propofol and DEX showed significant
is a procedure completed with the child sedated while
differences in upper airway scoring with DISE.27 A univer-
spontaneously ventilated. The main advantage of cine MR is
sally accepted anesthesia protocol is critically important
the ability to assess multiple levels of obstruction simul-
but still not agreed upon as of the date of the publication of
taneously; some feel this ability provides a better overall
this manuscript.
assessment of the airway.2 In contrast to DISE, MR allows

Table 2 Summary of advantages and disadvantages for imaging modalities assessing for sites of obstruction for patients with
OSA.
Items Advantages Disadvantages
DISE Can perform surgical interventions at the same Visualize one site at a time, scope stents the
time, 3-D view airway, difficult for OR planning
Cine MR Image multiple sites simultaneously, Expensive, requires second anesthetic to
distinguish lingual tonsils from BOT perform surgical interventions
MLB Evaluate for SAL Low yield without specific comorbidities
CT 3D reconstructions, can do without sedation Radiation exposure
Cephalometrics Availability of plain film imaging Unknown sensitivity and specificity
Lateral neck films Availability of plain film imaging Patient is awake, sitting upright
OR: operating room; MR: magnetic resonance imaging; BOT: base of tongue; MLB: microlaryngoscopy/bronchoscopy; SAL: synchronous
airway lesions; CT: computerized tomography.
 25891081, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.wjorl.2021.05.002 by Chile National Provision, Wiley Online Library on [21/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
224 J.M. Arganbright et al.

visualization of the obstruction without instruments in the Cephalometrics can use known measurements and ratios to
airway. Cine MR is also felt to be superior in its ability to determine areas of narrowing and possible obstruction.
assess for glossoptosis and to distinguish lingual tonsillar However, no known published studies identify the sensi-
hypertrophy from base of tongue obstruction.29 The main tivity and specificity of these calculated ratios.32 Lateral
disadvantages of cine MR are the expense of the study and neck radiographs are widely available with relatively low
the fact that surgical interventions would need to be cost, but the ability to identify obstruction may be limited
completed in a separate setting.29 Interestingly, results for by the 2-dimensional result, as well as the fact that the
DISE and cine MR exams have not been found to specifically patient is sitting upright and is awake.
correlate; Clark et al in 2017 evaluated 15 children with
OSA using DISE and cine MR and found discrepancies in the
diagnostic results in 33% of the patients.30 Most of these DISE scoring systems
diagnostic differences were attributed to the fact that the
DISE exam found additional sites of obstruction that were An ideal scoring system would be standardized, validated,
not identified on MR. and universally accepted. A standardized scoring system
Some providers perform tracheoscopy or micro- would allow for objective outcome analysis after DISE be-
laryngoscopy/bronchoscopy (MLB) at the same time as DISE tween clinicians, institutions, and studies.2 Currently, there
to assess for synchronous airway lesions below the level of are several published scoring systems for DISE, but no
the glottis. A survey of pediatric otolaryngology providers in consensus yet among providers.13 A review by Amos et al34
2016 reported that 30% examine trachea/bronchi during found that among 44 DISE studies, 21 different scoring sys-
DISE.13 Bliss et al31 found that only 5% of patients under- tems were used. A study by Tejan et al35 used six different
going DISE had a synchronous airway lesion (SAL) identified scoring systems on the same subset of surgically naı̈ve pe-
with MLB and only a few of these required surgical diatric patients undergoing DISE and concluded that all of
correction. Their study concluded that in most cases con- the scoring systems lacked standardization of anatomic sites
current MLB with DISE is unnecessary but may be consid- and rating scales. The six most common scoring systems used
ered when there is a history of intubation, prematurity, or for pediatric DISE are summarized in Table 3. Each system is
other genetic, neurologic, or craniofacial comorbidities. unique and varies by the anatomic sites, quantification, and
Additionally, they highlight that the improved optics of the characterization of airway obstruction. The VOTE system has
distal chip fiberoptic scopes used for DISE allow for easier been the most widely studied and is used in both adults and
visualization of the subglottis and may be able to identify pediatric patients.36 This system is criticized for pediatric
patients who would benefit from further MLB evaluation.31 DISE due to its omission of the nasopharyngeal and supra-
A study by Quinlan et al32 highlighted new computed glottic sites. The Chan scoring system, published in 2014,37
tomography (CT) technology allowing for “dynamic 3- documents the percentage of obstruction at all sites other
dimensional CT” imaging of the upper airway that does not than lingual tonsils, which are described as present or ab-
require sedation. CT may be less favorable in pediatric sent. This system is similar to VOTE but includes the nasal,
patients, however, due to radiation exposure. Other re- nasopharynx, and supraglottic sites. The Sleep Endoscopy
ports have been published using cephalometrics and lateral Rating Scale (SERS) and the Bachar grading system evaluate
neck films to identify sites of airway obstruction.33 similar sites but add an overall total score of upper airway

Table 3 Commonly used scoring systems for pediatric drug-induced sleep endoscopy.
Scoring system Details
VOTE  Most studied
 Used in children and adults
 Concise and easy to use
 Evaluates: velum, oropharynx, tongue base, epiglottis
 Criticized in children because it omits the nasopharynx and supraglottis
Chan  Evaluates: nose, adenoid, velum, oropharynx/LPW, tongue base,
lingual tonsils, epiglottis and supraglottis
 Notes whether a jaw thrust or oral airway was required
SERS  Evaluates: nose, nasopharynx, velum, oropharynx/LPW, hypopharynx, larynx
 Uses an overall score for upper airway obstruction
Bachar  Evaluates: nose, nasopharynx, palate and tonsils, tongue base, hypopharynx, and larynx
 Uses an overall score for upper airway obstruction
Boudewyns  Evaluates: adenoids, tonsils, tongue base, palate, epiglottis, and supraglottis
 Describes if obstruction is fixed or dynamic
 Allows for generalized impression of hypotonia present or absent
Fishman  Evaluates: nose, nasopharynx, lateral walls, tongue base, supraglottis
 Rates the degree of obstruction at several levels
 Includes the quality of exam and the level of confidence in the findings
LPW: lateral pharyngeal wall.
 25891081, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.wjorl.2021.05.002 by Chile National Provision, Wiley Online Library on [21/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Pediatric drug-induced sleep endoscopy 225

obstruction.38,39 The Boudewyns scoring system uniquely in the management of pediatric OSA. A prospective study by
characterizes the obstruction as fixed or dynamic and also Hybaskova et al followed 51 pediatric patients with PSG-
allows for a generalized impression as to whether hypotonia confirmed OSA. Based on history, physical exam, and PSG
is present or absent.40 The Fishman system evaluates the findings, a therapeutic plan was designed prior to DISE.
degree of obstruction at several sites but also factors in the Once DISE was performed, the surgical plan was changed in
quality of the exam, the confidence in the findings, and the 60.8% of the patients based on the DISE findings.45 A recent
severity of OSA, and asks the provider to determine the systematic review of pediatric patients with OSA by Sania-
primary site of obstruction at the end of the exam.41 More siaya et al8 reported that DISE findings caused a change in
recently, Williamson et al42 published another scoring system the surgical plan for 30% of the patients. Similarly, Blanc et
that evaluates obstruction at more sites than any of the six al46 reported 31 patients with OSA/hypopnea syndrome and
above systems: nasal airway, adenoid, palate, tonsils and found that DISE caused a change in surgical treatment of
lateral pharyngeal wall, tongue base, lingual tonsils, obstruction sites in 45% of the patients.
vallecula, epiglottis, aryepiglottic folds, and arytenoids. Using DISE to guide surgical decision making is described
Currently, the use of multiple DISE scoring systems has as DISE-directed surgery.47 Several investigators have
created a lack of uniformity in how DISE is reported and examined DISE-directed surgical outcomes in children using
studied. The need for a single universally agreed upon standard objective criteria. Wootten et al assessed 26 pa-
scoring system for DISE is imperative to move the field of tients retrospectively who had persistent OSA after AT.
pediatric sleep surgery forward.2 These patients underwent DISE with DISE-directed surgical
interventions performed in the same setting. The study
reported that 92% of patients experienced subjective
DISE for surgically naı̈ve patients improvement in symptoms as well as a decrease in mean
obstructive apnea-hypopnea index (OAHI) from 7.0  5.8
Traditionally, DISE has been used to assess the airway of events per hour to 3.6  1.8 events per hour. Only one
children who had persistent OSA following AT. However, patient had complete normalization of the OAHI, and the
recent studies have shown utility in performing DISE on study failed to show a statistically significant difference in
surgically naı̈ve patients prior to AT. Gazzaz et al showed the pre- and post-operatively OAHI.47 A recent systematic
DISE affected decision-making in surgically naı̈ve patients review and meta-analysis by Socarras et al demonstrated
with snoring and SDB in up to 35% of children. Additionally, that DISE-directed surgeries led to significant mean re-
an alternate diagnosis or surgical target was identified by ductions in OAHI in children with persistent OSA following
DISE in 54% of the patients.43 Chen et al7 reported DISE AT. However, the authors noted that complete resolution of
findings for patients with OSA and small tonsils and the OSA is rarely observed even with DISE-directed surgery.
concluded that DISE was an effective way to determine the The study highlights that factors such as medical co-mor-
necessity of tonsillectomy. Miller et al reported that for bidities and severe baseline OSA may contribute further to
surgically naı̈ve patients with OSA and small non-obstruc- persistent disease.28 A study by He et al reported 56 pedi-
tive tonsils, DISE was useful in identifying other sites of atric patients with either persistent OSA following AT or
obstruction. The supraglottis was the most common site of infant OSA. These patients underwent DISE-directed sur-
obstruction found and supraglottoplasty was the most gery and had significant improvement in both OAHI and
common procedure performed for this patient cohort.17 oxygen saturation nadir. The most commonly performed
Kirkham et al reported 62 surgically naı̈ve patients with OSA surgical procedures were adenoidectomy (48%), supra-
who were considered high risk for having persistence after glottoplasty (38%), tonsillectomy (27%), lingual tonsillec-
traditional AT. These patients underwent DISE prior to any tomy (13%), nasal surgery (11%), pharyngoplasty (7%), and
surgical intervention. Based on the DISE findings, 42% un- partial midline glossectomy (7%). The study found that
derwent AT, while 58% underwent treatment other than AT, DISE-directed surgery had better results for children with a
including 18% who had multilevel surgery.16 This study lower AHI at baseline.48 Esteller et al49 showed that DISE-
demonstrates the ability of DISE to change the surgical directed surgery led to significant improvement of OAHI in
management for pediatric patients with OSA who are sur- 20 otherwise healthy patients with prior AT. For surgically
gically naı̈ve. With this knowledge, the question then be- naı̈ve patients, DISE-directed surgery has also been shown
comes whether DISE should be completed on all children to decrease OAHI. Kirkham et al5 examined 62 surgically
prior to AT. Collu et al44 aimed to identify specific sub- naı̈ve children at high risk for persistent OSA and found
groups of patients for whom DISE should specifically be significant reductions in OAHI and improvement in oxygen
considered. They concluded that DISE is not as useful for nadir following DISE directed intervention. As more DISE-
“conventional” or classic cases. In this study, “conven- directed data become available in the future, the specific
tional” patients were those with mild to moderate OSA and role of DISE-directed surgery may become more apparent.
larger tonsils; DISE changed the plan in only 4.5% of the
patients.
Future directions
The ability of DISE to change management and In a recent publication by Bergeron et al,50 the authors
DISE-directed surgical outcomes described their institutional experience in performing DISE
in the MR induction room compared to DISE completed in
Multiple studies have attested to the ability of DISE to the traditional operating room. No major complications
change patient management, supporting it as a useful tool occurred, and total time of procedure was similar. There
 25891081, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.wjorl.2021.05.002 by Chile National Provision, Wiley Online Library on [21/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
226 J.M. Arganbright et al.

was a significant cost reduction when DISE was performed in 13. Friedman NR, Parikh SR, Ishman SL, et al. The current state of
the MR induction room. The downside remained that sur- pediatric drug-induced sleep endoscopy. Laryngoscope. 2017;127:
gical interventions could not be incorporated in the MR 266e272. http://www.ncbi.nlm.nih.gov/pubmed/27311407.
setting. 14. Park JS, Chan DK, Parikh SR, Meyer AK, Rosbe KW. Surgical
outcomes and sleep endoscopy for children with sleep-disor-
dered breathing and hypotonia. Int J Pediatr Otorhinolaryngol.
Conclusion 2016;90:99e106.
15. Costa DJ, Mitchell R. Adenotonsillectomy for obstructive sleep
DISE is helpful in its ability to guide the surgical manage- apnea in obese children: a meta-analysis. Otolaryngol Head
Neck Surg. 2009;140:455e460.
ment of pediatric patients with SDB and OSA. Its utility has
16. Kirkham E, Ma CC, Filipek N, et al. Polysomnography outcomes
been shown in managing patients with OSA who have
of sleep endoscopy-directed intervention in surgically naı̈ve
already had AT as well as in certain surgically naı̈ve pa- children at risk for persistent obstructive sleep apnea. Sleep
tients. The field of pediatric sleep surgery ultimately needs Breath. 2020;24:1143e1150.
a universally agreed upon anesthetic protocol and scoring 17. Miller C, Purcell PL, Dahl JP, et al. Clinically small tonsils are
system for DISE. typically not obstructive in children during drug-induced sleep
endoscopy. Laryngoscope. 2017;127:1943e1949.
18. Richter GT, Rutter MJ, deAlarcon A, Orvidas LJ, Thompson DM.
Declaration of competing interest Late-onset laryngomalacia: a variant of disease. Arch Otolar-
yngol Head Neck Surg. 2008;134:75e80.
None. 19. Love H, Slaven JE, Mitchell RM, Bandyopadhyay A. Outcomes of
OSA in surgically naı̈ve young children with and without DISE
identified laryngomalacia. Int J Pediatr Otorhinolaryngol.
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