Drug Induced Sleep Endoscopy (DISE). A comparative study between NOHL and VOTE classifications
Abstract Introduction and objective: There is no standardized method to express DISE results. Several classifications have been proposed, but none are globally accepted. The objective of this study is to analyze the most used classifications: NOHL and VOTE to assess which of them provides more advantages. Method: A prospective cohort study of 100 patients who underwent DISE was carried out. Three otolaryngologists blindly evaluated the DISE videos and coded the results according to the NOHL and VOTE scales and at what level surgery was indicated. Results: According to the main researcher, in 64% of patients, surgery of only one level was indicated, being the palate the predominant level, followed by a 26% where multilevel surgery was indicated, and in 10% no surgery was indicated. The global agreement to express the DISE results according to the NOHL, VOTE scales regarding the degree of obstruction is moderate / regular at the level of the epiglottis (k = 0.467) and low in the rest of the structures (k = 0.097). Discussion: Although the degree of interobserver agreement is similar in both scales, for VOTE it is slightly higher. Conclusions: DISE is a safe, reproducible and easy to perform test. We recommend the use of the VOTE scale because it has been demonstrated to have a higher degree of interobserver agreement, it is not only the most widely used scale, but also recommended in consensus documents.
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Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-53. doi: 10.1016/S0140-6736(05)71141-7.
Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173-8. doi: 10.1513/pats.200708-119MG.
Mediano O, González Mangado N, Montserrat JM, Alonso-Álvarez ML, Almendros I, Alonso-Fernández A, et al. International Consensus Document on Obstructive Sleep Apnea. Arch Bronconeumol (Engl Ed). 2021;2896(21):00115-0. Spanish. doi: 10.1016/j.arbres.2021.03.017.
Santos-Gorjón P, Sánchez-jara Sánchez JL, Martín-Hernández G, Morales-Martín AC, Intraprendente-Martini JF, Chaves-Araújo R, et al. Endoscopia del sueño mediante sedación inducida por fármacos o somnoscopia. Revista ORL. 2020; 1;11(4).
Rabelo FA, Küpper DS, Sander HH, Fernandes RM, Valera FC. Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls. Laryngoscope. 2013;123(9):2300-5. doi: 10.1002/lary.23664.
Dijemeni E, D'Amone G, Gbati I. Drug-induced sedation endoscopy (DISE) classification systems: a systematic review and meta-analysis. Sleep Breath. 2017;21:983-994. doi: 10.1007/s11325-017-1521-6.
Croft CB, Pringle M. Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1991;16:504-9. doi: 10.1111/j.1365-2273.1991.tb01050.x.
Kezirian EJ, Hohenhorst W, de Vries N. Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol. 2011;268:1233-1236. doi: 10.1007/s00405-011-1633-8.
Vicini C, De Vito A, Benazzo M, Frassineti S, Campanini A, Frasconi P, et al. The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients. Eur Arch Otorhinolaryngol. 2012;269:1297-300. doi: 10.1007/s00405-012-1965-z.
Amos JM, Durr ML, Nardone HC, Baldassari CM, Duggins A, Ishman SL. Systematic Review of Drug-Induced Sleep Endoscopy Scoring Systems. Otolaryngol Head Neck Surg. 2018;158:240-248. doi: 10.1177/0194599817737966.
De Vito A, Carrasco Llatas M, Ravesloot MJ, Kotecha B, De Vries N, Hamans E, et al. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol. 2018 Dec;43:1541-1552. doi: 10.1111/coa.13213.
von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.
da Cunha Viana A Jr, Mendes DL, de Andrade Lemes LN, Thuler LC, Neves DD, de Araújo-Melo MH. Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications. Eur Arch Otorhinolaryngol. 2017;274:627-635. doi: 10.1007/s00405-016-4081-7.
Gillespie MB, Reddy RP, White DR, Discolo CM, Overdyk FJ, Nguyen SA. A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Laryngoscope. 2013;123:277-82. doi: 10.1002/lary.23506.
Veer V, Zhang H, Mandavia R, Mehta N. Introducing a new classification for drug-induced sleep endoscopy (DISE): the PTLTbE system. Sleep Breath. 2020;24:1685-1693. doi: 10.1007/s11325-020-02035-y.
Carrasco-Llatas M, Zerpa-Zerpa V, Dalmau-Galofre J. Reliability of drug-induced sedation endoscopy: interobserver agreement. Sleep Breath. 2017;21:173-179. doi: 10.1007/s11325-016-1426-9.
Vroegop AV, Vanderveken OM, Wouters K, Hamans E, Dieltjens M, Michels NR, et al. Observer variation in drug-induced sleep endoscopy: experienced versus nonexperienced ear, nose, and throat surgeons. Sleep. 2013;36:947-53. doi: 10.5665/sleep.2732.
Altinta? A, Yegin Y, Çelik M, Kaya KH, Koç AK, Kayhan FT. Interobserver Consistency of Drug-Induced Sleep Endoscopy in Diagnosing Obstructive Sleep Apnea Using a VOTE Classification System. J Craniofac Surg. 2018;29:e140-e143. doi: 10.1097/SCS.0000000000003876.
Bartier S, Blumen M, Chabolle F. Is image interpretation in drug-induced sleep endoscopy that reliable? Sleep Breath. 2020;24:677-685. doi: 10.1007/s11325-019-01958-5.
Rodriguez-Bruno K, Goldberg AN, McCulloch CE, Kezirian EJ. Test-retest reliability of drug-induced sleep endoscopy. Otolaryngol Head Neck Surg. 2009;140:646-51. doi: 10.1016/j.otohns.2009.01.012.
Kezirian EJ, White DP, Malhotra A, Ma W, McCulloch CE, Goldberg AN. Interrater reliability of drug-induced sleep endoscopy. Arch Otolaryngol Head Neck Surg. 2010;136:393-7. doi: 10.1001/archoto.2010.26.
Woodson BT. A method to describe the pharyngeal airway. Laryngoscope. 2015;125:1233-8. doi: 10.1002/lary.24972.
Kim JS, Heo SJ. Test-retest reliability of drug-induced sleep endoscopy using midazolam. J Clin Sleep Med. 2020;16:675-678. doi: 10.5664/jcsm.8314.
Green KK, Kent DT, D'Agostino MA, Hoff PT, Lin HS, Soose RJ, et al. Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study. Laryngoscope. 2019;129:761-770. doi: 10.1002/lary.27655.
Vroegop AV, Vanderveken OM, Boudewyns AN, Scholman J, Saldien V, Wouters K, et al. Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. Laryngoscope. 2014;124:797-802. doi: 10.1002/lary.24479.
Verse T, Hörmann K. The surgical treatment of sleep-related upper airway obstruction. Dtsch Arztebl Int. 2011;108:216-21. doi: 10.3238/arztebl.2010.0216.
MacKay S, Carney AS, Catcheside PG, Chai-Coetzer CL, Chia M, Cistulli PA, et al. Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial. JAMA. 2020;324:1168-1179. doi: 10.1001/jama.2020.14265.
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-53. doi: 10.1016/S0140-6736(05)71141-7.
Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173-8. doi: 10.1513/pats.200708-119MG.
Mediano O, González Mangado N, Montserrat JM, Alonso-Álvarez ML, Almendros I, Alonso-Fernández A, et al. International Consensus Document on Obstructive Sleep Apnea. Arch Bronconeumol (Engl Ed). 2021;2896(21):00115-0. Spanish. doi: 10.1016/j.arbres.2021.03.017.
Santos-Gorjón P, Sánchez-jara Sánchez JL, Martín-Hernández G, Morales-Martín AC, Intraprendente-Martini JF, Chaves-Araújo R, et al. Endoscopia del sueño mediante sedación inducida por fármacos o somnoscopia. Revista ORL. 2020; 1;11(4).
Rabelo FA, Küpper DS, Sander HH, Fernandes RM, Valera FC. Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls. Laryngoscope. 2013;123(9):2300-5. doi: 10.1002/lary.23664.
Dijemeni E, D'Amone G, Gbati I. Drug-induced sedation endoscopy (DISE) classification systems: a systematic review and meta-analysis. Sleep Breath. 2017;21:983-994. doi: 10.1007/s11325-017-1521-6.
Croft CB, Pringle M. Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1991;16:504-9. doi: 10.1111/j.1365-2273.1991.tb01050.x.
Kezirian EJ, Hohenhorst W, de Vries N. Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol. 2011;268:1233-1236. doi: 10.1007/s00405-011-1633-8.
Vicini C, De Vito A, Benazzo M, Frassineti S, Campanini A, Frasconi P, et al. The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients. Eur Arch Otorhinolaryngol. 2012;269:1297-300. doi: 10.1007/s00405-012-1965-z.
Amos JM, Durr ML, Nardone HC, Baldassari CM, Duggins A, Ishman SL. Systematic Review of Drug-Induced Sleep Endoscopy Scoring Systems. Otolaryngol Head Neck Surg. 2018;158:240-248. doi: 10.1177/0194599817737966.
De Vito A, Carrasco Llatas M, Ravesloot MJ, Kotecha B, De Vries N, Hamans E, et al. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol. 2018 Dec;43:1541-1552. doi: 10.1111/coa.13213.
von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.
da Cunha Viana A Jr, Mendes DL, de Andrade Lemes LN, Thuler LC, Neves DD, de Araújo-Melo MH. Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications. Eur Arch Otorhinolaryngol. 2017;274:627-635. doi: 10.1007/s00405-016-4081-7.
Gillespie MB, Reddy RP, White DR, Discolo CM, Overdyk FJ, Nguyen SA. A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Laryngoscope. 2013;123:277-82. doi: 10.1002/lary.23506.
Veer V, Zhang H, Mandavia R, Mehta N. Introducing a new classification for drug-induced sleep endoscopy (DISE): the PTLTbE system. Sleep Breath. 2020;24:1685-1693. doi: 10.1007/s11325-020-02035-y.
Carrasco-Llatas M, Zerpa-Zerpa V, Dalmau-Galofre J. Reliability of drug-induced sedation endoscopy: interobserver agreement. Sleep Breath. 2017;21:173-179. doi: 10.1007/s11325-016-1426-9.
Vroegop AV, Vanderveken OM, Wouters K, Hamans E, Dieltjens M, Michels NR, et al. Observer variation in drug-induced sleep endoscopy: experienced versus nonexperienced ear, nose, and throat surgeons. Sleep. 2013;36:947-53. doi: 10.5665/sleep.2732.
Altinta? A, Yegin Y, Çelik M, Kaya KH, Koç AK, Kayhan FT. Interobserver Consistency of Drug-Induced Sleep Endoscopy in Diagnosing Obstructive Sleep Apnea Using a VOTE Classification System. J Craniofac Surg. 2018;29:e140-e143. doi: 10.1097/SCS.0000000000003876.
Bartier S, Blumen M, Chabolle F. Is image interpretation in drug-induced sleep endoscopy that reliable? Sleep Breath. 2020;24:677-685. doi: 10.1007/s11325-019-01958-5.
Rodriguez-Bruno K, Goldberg AN, McCulloch CE, Kezirian EJ. Test-retest reliability of drug-induced sleep endoscopy. Otolaryngol Head Neck Surg. 2009;140:646-51. doi: 10.1016/j.otohns.2009.01.012.
Kezirian EJ, White DP, Malhotra A, Ma W, McCulloch CE, Goldberg AN. Interrater reliability of drug-induced sleep endoscopy. Arch Otolaryngol Head Neck Surg. 2010;136:393-7. doi: 10.1001/archoto.2010.26.
Woodson BT. A method to describe the pharyngeal airway. Laryngoscope. 2015;125:1233-8. doi: 10.1002/lary.24972.
Kim JS, Heo SJ. Test-retest reliability of drug-induced sleep endoscopy using midazolam. J Clin Sleep Med. 2020;16:675-678. doi: 10.5664/jcsm.8314.
Green KK, Kent DT, D'Agostino MA, Hoff PT, Lin HS, Soose RJ, et al. Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study. Laryngoscope. 2019;129:761-770. doi: 10.1002/lary.27655.
Vroegop AV, Vanderveken OM, Boudewyns AN, Scholman J, Saldien V, Wouters K, et al. Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. Laryngoscope. 2014;124:797-802. doi: 10.1002/lary.24479.
Verse T, Hörmann K. The surgical treatment of sleep-related upper airway obstruction. Dtsch Arztebl Int. 2011;108:216-21. doi: 10.3238/arztebl.2010.0216.
MacKay S, Carney AS, Catcheside PG, Chai-Coetzer CL, Chia M, Cistulli PA, et al. Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial. JAMA. 2020;324:1168-1179. doi: 10.1001/jama.2020.14265.
Pérez-Martín, N., Bosco-Morales, G., Morato-Galán, M., Hernández-García, E., O´Connor-Reina, C., & Plaza-Mayor, G. (2022). Drug Induced Sleep Endoscopy (DISE). A comparative study between NOHL and VOTE classifications. Revista ORL, 13(1), e27166. https://doi.org/10.14201/orl.27166 (Original work published October 21, 2021)
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