Upper airway endoscopy in wakefulness and drug-induced sleep in obstructive sleep apnea

Czech version

Authors: E. Bartáková; R. Salzman
Authors‘ workplace: Klinika otorinolaryngologie a chirurgie hlavy a krku LF UP a FN Olomouc
Published in: Otorinolaryngol Foniatr, 75, 2026, No. 2, pp. 112-126.
Category: Original Article
doi: https://doi.org/10.48095/ccorl2026112

Overview

Introduction: Obstructive sleep apnea (OSA) is defined as recurrent episodes of upper airway (UA) obstruction during sleep. The treatment of choice is positive airway pressure (PAP) therapy. Surgical intervention is indicated for non-obese patients with mild OSA and selected patients with moderate to severe OSA. A key diagnostic challenge in planning surgical treatment is the identification of the site of obstruction. In the awake state, the Müller maneuver (MM) can be used to simulate apnea; however, the current gold standard is drug-induced sleep endoscopy (DISE). Objective: The aim of this study was to compare findings and surgical indications based on the Müller maneuver (in both seated and supine positions) and DISE. Methods: A prospective study was conducted including 31 patients who underwent both the Müller maneuver and DISE at the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Olomouc, between November 2023 and May 2024. Results: A statistically significant difference in findings was observed only in the epiglottic region between seated MM and DISE (P < 0.01). A trend toward statistical significance was also noted in the epiglottic region when comparing supine MM and DISE (P = 0.11), and in the tongue base region between seated MM and DISE (P = 0.08). When comparing surgical indications by target area, the only statistically significant difference was in the recommendation for epiglottopexy based on seated MM compared to DISE (P < 0.01). DISE altered the surgical indication in 20 cases (64.5%) compared to seated MM, and in 17 cases (54.8%) compared to supine MM. Conclusion: Anatomical and functional relationships in the upper airway differ between wakefulness and sleep. The Müller maneuver can enhance diagnostic yield in the awake state, and when performed in the supine position, it may provide a more accurate assessment of obstruction in the epiglottic and tongue base regions in certain patients. However, neither seated nor supine MM is sufficiently reliable for determining surgical indications in these areas. DISE remains the gold standard in the diagnostic algorithm for OSA and can significantly modify the extent of surgical intervention.

Keywords:

obstructive sleep apnea – drug-induced sleep endoscopy – Müller’s maneuver

Sources

1. Senaratna CV, Perret JL, Lodge CJ et al. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev 2017; 34 : 70–81. Doi: 10.1016/j.smrv. 2016.07.002.

2. Tufik S, Santos-Silva R, Taddei JA et al. Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med 2010; 11 (5): 441–446. Doi: 10.1016/j.sleep.2009.10.005.

3. Pretl M, Hobzová M, Honnerová M et al. Indikační kriteria pro léčbu poruch dýchání ve spánku pomocí přetlaku v dýchacích cestách u dospělých. Dokument České společnosti pro výzkum spánku a spánkovou medicínu. 2011 [online]. Dostupné z: https: //www.sleep-society.cz/doc/doporucene-postupy/Indikacni-kriteria-pro-lecbu-PAP-2011.pdf.

4. Wang X, Ouyang Y, Wang Z et al. Obstructive sleep apnea and risk of cardiovascular disease and all-cause mortality: a meta-analysis of prospective cohort studies. Int J Cardiol 2013; 169 (3): 207–214. Doi: 10.1016/j.ijcard.2013.08.088.

5. Koseoglu S, Ikinciogullari A, Cetin MA et al. The clinical efficiency of positive airway pressure treatment. Sci World J 2013; 2013 : 245476. Doi: 10.1155/2013/245476.

6. Betka J, Kubíčková J, Klozar J et al. Poruchy dýchání ve spánku –⁠ chirurgická léčba. In: Chrobok V (ed). Medicína hlavy a krku. Havlíčkův Brod: Tobiáš 2019 : 70–79.

7. De Vito A, Carrasco Llatas M, Ravesloot MJ et al. European position paper on drug-induced sleep endoscopy: 2017 update. Clin Otolaryngol 2018; 43 (6): 1541–1552. Doi: 10.1111/coa.13213.

8. Betka J, Klozar J, Kuchař M et al. Léky navozená spánková endoskopie –⁠ cesta k lepším chirurgickým výsledkům při léčbě syndromu obstrukční spánkové apnoe. Cesk Slov Neurol N 2016; 79/112 (5): 516–520.

9. Masárová M. Příručka pro praxi: endoskopie horních cest dýchacích v léky navozeném spánku (DISE). 2020 [online]. Dostupné z: https: //www.otorinolaryngologie.cz/content/uploads/2020/12/ppp_dise.pdf.

10. Veer V, Zhang H, Mandavia R et al. Introducing a new classification for drug-induced sleep endoscopy (DISE): the PTLTbE system. Sleep Breath 2020; 24 (4): 1685–1693. Doi: 10.1007/s11325-020-02035-y.

11. Betka J, Klozar J, Kuchař M et al. Obstrukční syndrom spánkové apnoe –⁠ srovnání efektivity různých chirurgických přístupů. Otorinolaryngol Foniatr 2014; 63 (1): 3–9.

12. Torre C, Camacho M, Liu SYC et al. Epiglottis collapse in adult obstructive sleep apnea: a systematic review. Laryngoscope 2016; 126 (2): 515–523. Doi: 10.1002/lary.25589.

13. Schoustra E, van Maanen P, den Haan C et al. The role of isolated nasal surgery in obstructive sleep apnea therapy –⁠ a systematic review. Brain Sci 2022; 12 (11): 1446. Doi: 10.3390/brainsc i12111446.

14. Tkadlecová N, Černochová P. Vztah mezi obstrukční spánkovou apnoí a kraniofaciálními anomáliemi u dospělých pacientů. Cesk Stomatol Prakt Zub Lek 2021; 121 (4): 98–107. Doi: 10.51479/cspzl.2021.013.

15. Camacho M, Certal V, Brietzke SE et al. Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 2014; 124 (3): 803–811. Doi: 10.1002/lary.24433.

16. Hybášková J, Jor O, Novák V et al. Možné využití spánkové endoskopie pro zvýšení efektivity léčby (operační i neoperační) u pacientů s obstrukční spánkovou apnoí. Cesk Slov Neurol N 2017; 80 (4): 428–433. Doi: 10.14735/amcsnn2017428.

17. Fernández-Julián E, García-Pérez MÁ, García-Callejo J et al. Surgical planning after sleep versus awake techniques in patients with obstructive sleep apnea. Laryngoscope 2014; 124 (8): 1970–1974. Doi: 10.1002/lary.24577.

18. Belgu AU, Erdogan B, San T et al. The relationship between AHI, Epworth scores and sleep endoscopy in patients with OSAS. Eur Arch Otorhinolaryngol 2015; 272 : 241–245.

19. Kalhous J, Kordík J. Léky navozená spánková endoskopie –⁠ odpovídá lokální nález v horních cestách dýchacích závažnosti syndromu spánkové apnoe? Cesk Slov Neurol N 2021; 84/117 (2): 179–182. Doi: 10.48095/cccsnn2021179.

20. Askar SM, Quriba AS, Hassan EM et al. Positional awake endoscopy versus DISE in assessment of OSA: a comparative study. Laryngoscope 2020; 130 (9): 2269–2274. Doi: 10.1002/lary.28391.

21. Eichler C, Sommer JU, Stuck BA et al. Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea? Sleep Breath 2013; 17 (1): 63–68. Doi: 10.1007/s11325-012-0647-9.

22. Gillespie MB, Reddy RP, White DR et al. A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Laryngoscope 2013; 123 (1): 277–282. Doi: 10.1002/lary.23659.

23. Yegïn Y, Çelik M, Kaya KH et al. Comparison of drug-induced sleep endoscopy and Müller‘s maneuver in diagnosing obstructive sleep apnea using the VOTE classification system. Braz J Otorhinolaryngol 2017; 83 (4): 445–450. Doi: 10.1016/j.bjorl.2016.05.009.

24. Di Bari M, Colombo G, Giombi F et al. The effect of drug-induced sleep endoscopy on surgical outcomes for obstructive sleep apnea: a systematic review. Sleep Breath 2024; 28 (2): 859–867. Doi: 10.1007/s11325-023-02931-z.

25. Klozar J, Plzák J, Ondrová M et al. Doporučený postup u dospělých pacientů s poruchami dýchání ve spánku. 2016 [online]. Česká společnost pro výzkum spánku a spánkovou medicínu. Dostupné z: https: //www.sleep-society.cz/doc/doporucene-postupy/Guidelines-2016-def-13.9..pdf.

26. Vicini C, Dallan I, Canzi P et al. Transoral robotic tongue base resection in obstructive sleep apnoea-hypopnoea syndrome: a preliminary report. ORL J Otorhinolaryngol Relat Spec 2010; 72 (1): 22–27. Doi: 10.1159/000284352.