Drug-induced sleep endoscopy (DISE) is now routinely performed in children with persistent obstructive sleep apnea (OSA) following adenotonsillectomy. DISE uses a flexible fiberoptic scope to examine airway collapse while the patient is sedated and spontaneously breathing. DISE, which allows for dynamic evaluation of sites of obstruction, is superior to static measures such as Muller maneuver and radiographs. The use of lateral neck radiograph (LNR) in children with persistent OSA, promoted in the June 2023 article by Senthilvel et al,1 is outdated. A recent Expert Consensus Statement from the American Academy of Otolaryngology Head and Neck surgery identifies the utility of DISE in improving treatment outcomes for children with persistent OSA.2
We respectfully disagree with the suggestion that LNR is an adequate screening method to identify adenoid regrowth in a population of children with persistent OSA. Data are mixed regarding the ability of LNRs to accurately evaluate adenoid size even prior to surgery3–5 and there are no data to suggest that LNRs provide an accurate assessment of adenoid size after surgery. When interpreting radiographs, the adenoid-to-nasopharynx ratio, defined as the ratio of adenoid thickness to nasopharyngeal aperture, is the most commonly used measurement.6 The estimation of adenoid size based on visual inspection alone, the method used by Senthivel et al, has proven to be inaccurate when compared with nasal endoscopy.3 Similarly in our institutional experience, adenoid size on LNR in children with a history of prior adenoidectomy has not correlated well with adenoid size from direct visualization at the time of revision adenoidectomy.
While adenoid and tonsil regrowth following adenotonsillectomy is one reason that children develop persistent OSA, there are numerous other sites of obstruction, including lingual tonsil hypertrophy, nasal turbinate hypertrophy, and sleep-dependent laryngomalacia, that are not detectable on radiographs. Furthermore, LNRs expose children to unnecessary radiation. Given the advances in pediatric DISE, referral to a pediatric otolaryngologist is the most appropriate course of action for children with persistent OSA. The decision to make a referral should not be influenced by radiographic findings.
DISCLOSURE STATEMENT
Both authors have seen and approved this manuscript. This manuscript does not report on a clinical trial or off-label or investigational work of any kind. The authors report no conflicts of interest.
Citation: Servos Li MM, Baldassari C. The case for drug-induced sleep endoscopy. J Clin Sleep Med. 2023;19(12):2137.
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