Original Research
Otolaryngology–
Expert Consensus Statement: Pediatric
Drug-Induced Sleep Endoscopy
Cristina M. Baldassari, MD1, Derek J. Lam, MD, MPH2,
Stacey L. Ishman, MD, MPH3, Boris Chernobilsky, MD4,
Norman R. Friedman, MD5, Terri Giordano, DNP6,
Claire Lawlor, MD7, Ron B. Mitchell, MD8,
Heather Nardone, MD9, James Ruda, MD10, Habib Zalzal, MD11,
Adrienne Deneal, MHS12, Nui Dhepyasuwan, MEd12,
and Richard M. Rosenfeld, MD, MPH, MBA13
Abstract
Objective. To develop an expert consensus statement on
pediatric drug-induced sleep endoscopy (DISE) that clarifies
controversies and offers opportunities for quality improve-
ment. Pediatric DISE was defined as flexible endoscopy to
examine the upper airway of a child with obstructive sleep
apnea who is sedated and asleep.
Methods. Development group members with expertise in
pediatric DISE followed established guidelines for developing
consensus statements. A search strategist systematically
reviewed the literature, and the best available evidence was
used to compose consensus statements regarding DISE in
children 0 to 18 years old. Topics with significant practice
variation and those that would improve the quality of
patient care were prioritized.
Results. The development group identified 59 candidate con-
sensus statements, based on 50 initial proposed topics, that
focused on addressing the following high-yield topics: (1)
indications and utility, (2) protocol, (3) optimal sedation, (4)
grading and interpretation, (5) complications and safety, and
(6) outcomes for DISE-directed surgery. After 2 iterations
of the Delphi survey and removal of duplicative statements,
26 statements met the criteria for consensus; 11 statements
were designated as no consensus. Several areas, such as the
role of DISE at the time of adenotonsillectomy, were identi-
fied as needing further research.
Conclusion. Expert consensus was achieved for 26 statements
pertaining to indications, protocol, and outcomes for pedia-
tric DISE. Clinicians can use these statements to improve
quality of care, inform policy and protocols, and identify
areas of uncertainty. Future research, ideally randomized
controlled trials, is warranted to address additional contro-
versies related to pediatric DISE.
Keywords
drug-induced sleep endoscopy, drug-induced sedation endo-
scopy, bronchoscopy, nasopharyngoscopy, obstructive sleep
Head and Neck Surgery
1–14
Ó American Academy of
Otolaryngology–Head and Neck
Surgery Foundation 2021
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599820985000
http://otojournal.org
apnea, flexible fiberoptic endoscopy, upper airway endo-
scopy, expert consensus
Received September 2, 2020; accepted November 27, 2020.
O
bstructive sleep apnea (OSA) affects approximately
1.2% to 5.7% of children1 and is characterized by
repetitive cessations or reductions in airflow during
sleep with oxygen desaturation or arousals. Sequelae of
untreated pediatric OSA may include neurocognitive deficits,
behavioral problems, hyperactivity, poor school performance,
and decreased quality of life (QOL). Adenotonsillectomy
(AT) is most commonly the first-line surgical treatment,2 but
up to 30% of children will have persistent OSA after AT,
especially if obese, syndromic, or with other comorbid condi-
tions.3 To help guide decision making regarding the treatment
1
Eastern Virginia Medical School / Children’s Hospital of The King’s
Daughters, Norfolk, Virginia, USA
2
Oregon Health and Science University, Portland, Oregon, USA
3
Cincinnati Children’s Hospital Medical Center / University of Cincinnati
College of Medicine, Cincinnati, Ohio, USA
4
NYU Langone Health, New York, New York, USA
5
Children’s Hospital Colorado / University of Colorado Anschutz Medical
Campus, Aurora, Colorado, USA
6
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
7
Children’s National Medical Center / George Washington University
School of Medicine and Health Sciences, Washington, DC, USA
8
UT Southwestern Medical Center, Dallas, Texas, USA
9
Nemours / Alfred I. duPont Hospital for Children, New Castle County,
Delaware, USA
10
Nationwide Children’s Hospital, Columbus, Ohio, USA
11
West Virginia University, Morgantown, West Virginia, USA
12
American Academy of Otolaryngology–Head and Neck Surgery
Foundation, Alexandria, Virginia, USA
13
SUNY Downstate Health Sciences University, New York, New York, USA
Corresponding Author:
Cristina M. Baldassari, MD, Department of Otolaryngology–Head and Neck
Surgery, Eastern Virginia Medical School, 600 Gresham Drive, Suite 1100,
Norfolk, VA 23507, USA.
Emails: cristina.baldassari@chkd.org, Baldassc@gmail.com
2 Otolaryngology–Head and Neck Surgery
of OSA in children, drug-induced sleep endoscopy (DISE)
has become increasingly popular as a method to evaluate the
dynamic obstruction in the upper airway that occurs during
sleep.
DISE is flexible fiberoptic endoscopy that is performed
during sedated sleep that facilitates passage of the endoscope
transnasally into the pharynx without awakening the patient.
First described by Croft and Pringle in 1991,4 DISE has been
widely adopted and is frequently utilized to evaluate adults
with OSA who are being considered for surgical therapy.
The VOTE classification (velum, oropharynx, tongue base,
epiglottis) is the most widely used scale to report DISE find-
ings in adults.5 Many studies have been published describing
patterns of obstruction observed during DISE and associa-
tions with baseline OSA severity.6-9 In addition, there is a
growing body of literature describing the impact of DISE on
treatment decision making in adult OSA10-13 and the utility
of DISE in predicting surgical outcomes.14-17
The widespread utilization of DISE by sleep surgeons and
the significant advances that have been made in DISE-related
research have led to increased convergence in the practice of
adult DISE. In contrast, the interest in DISE as part of the
treatment paradigm for pediatric OSA has occurred far more
recently, principally in the past 5 years. DISE has been uti-
lized to identify sites of obstruction in children prior to or
concurrent with AT (‘‘surgically naı̈ve’’) and also in those
who have persistent post-AT OSA. However, evidence
demonstrating its utility and effectiveness is sparse; most liter-
ature in this field consists of small case series.
Although DISE has been shown to affect decision making
in surgically naı̈ve children, leading to a change in surgical
procedure in some cases,18 it remains unclear whether the
outcomes of DISE-directed interventions are superior to out-
comes of more conventional approaches. Multiple studies
have demonstrated substantial practice variation with respect
to DISE in children.19-21 Areas of controversy include the
appropriate indications, optimal sedation regimen, endo-
scopy protocol, and interpretation of DISE findings.
Given the knowledge gap that exists regarding the role of
DISE in the management of pediatric OSA, the American
Academy of Otolaryngology–Head and Neck Surgery (AAO-
HNSF) Guidelines Task Force (GTF) selected this topic for
expert consensus statement (ECS) development. The objective
of this ECS is to identify areas of consensus from a develop-
ment group of experts in the field regarding the appropriate
indications, perioperative protocols, and interpretation of
DISE in children. Our primary aim was to develop statements
that would address areas of controversy, with the goal of
reducing practice variation and improving the quality of care
for pediatric patients with OSA.
Methods
This ECS was developed according to an a priori protocol22
(previously used by AAO-HNSF to successfully develop
multiple other consensus statements) with the following
steps: (1) define the subject of the ECS as use of endoscopy
to examine the airway of children with OSA while in drug-
induced sleep, (2) recruit the expert development group, (3)
vet potential conflicts of interest among proposed develop-
ment group members, (4) perform a systematic literature
review, (5) determine the scope and population of interest
for the ECS, (6) develop topic questions and consensus for
statements for each topic question, (7) develop and imple-
ment modified Delphi Method surveys, (8) revise the ECSs
in an iterative fashion based on survey results, and (9) aggre-
gate the data for analysis and presentation. The pertinent
details of these steps are briefly described.
Determination of DISE as the Topic of an ECS and
Development Group Recruitment and Vetting
DISE was proposed for an ECS by the AAO-HNSF Sleep
Disorders Committee. After deliberation, the AAO-HNSF
GTF approved and prioritized the suggestion; development
group leadership was selected, and administrative support
was allocated. Development group membership was strategi-
cally developed to ensure appropriate representation of all
relevant stakeholder groups and organizations within otolar-
yngology. The stakeholders were contacted regarding the
consensus statement project and the requirements and
desired qualifications for development group membership;
each group then nominated its own representative content
expert to participate.
The ECS development group included representatives
from the American Society of Pediatric Otolaryngology, the
Society of Otorhinolaryngology and Head-Neck Nurses, the
International Surgical Sleep Society, and the Society of Ear
Nose and Throat Advancement in Children, as well as appro-
priate committees within the AAO-HNSF including the
Board of Governors, the Sleep Disorders Committee, the
Pediatric Otolaryngology Committee, and the Section for
Residents and Fellows-in-Training. The methodologist and
representatives from the Society of Otorhinolaryngology and
Head-Neck Nurses and Section for Residents and Fellows-
in-Training were nonvoting members of the development
group.
All development group members are in active clinical
practice, are content experts in DISE, and agreed in advance
of appointment to participate in all verbal discussions (per-
formed via teleconference) and votes. Once the development
group was assembled, complete disclosure of potential con-
flicts of interest were reported and vetted, including recusal
of panelists receiving support from Inspire Medical Systems,
Inc during potential discussions regarding hypoglossal nerve
stimulation. Conflicts of interest were consistent with the
Council of Medical Specialty Societies’ Code for Interactions
With Companies,23 which requires that the chair and a major-
ity of the participants do not have a direct conflict with the
deliberations. The development group chair and assistant
chair led the development of the consensus statements and the
Delphi process with input from a senior consultant/methodol-
ogist from AAO-HNSF leadership and GTF and with admin-
istrative support from an AAO-HNSF staff liaison.
Baldassari et al 3

Literature Review and Determination of the Scope was divided into 2 Delphi rounds. All answers were deidenti-
of the Consensus Statement fied and remained confidential to development group mem-
bers; however, names were collected by staff to ensure proper
Two systematic literature reviews were performed by an
follow-up, if needed.
information specialist, using keywords identified by the
According to the outcomes of the top ranked topic list
development group, to identify current evidence regarding
choices and resulting discussion, the development group
pediatric DISE. The literature searches were conducted from
chair and assistant chair developed the first Delphi survey,
October to December 2019 and included all relevant publica-
which consisted of 59 statements. Prior to dissemination to
tions in English from PubMed, Embase, Cumulative Index
the development group, the Delphi surveys were reviewed
to Nursing and Allied Health Literature, Cochrane Database
by the methodologist for content and clarity. Questions in
of Systematic Reviews, Web of Science, Agency for
the survey were answered with a 9-point Likert scale, where
Healthcare Research and Quality, ECRI National Guideline
1 = strongly disagree, 3 = disagree, 5 = neutral, 7 = agree,
Clearinghouse, Canadian Medical Association Infobase, UK
and 9 = strongly agree. The surveys were distributed, and
National Institute for Health and Care Excellence, TRIP
responses were aggregated, distributed back to the develop-
Database, UK National Library of Guidelines, Scottish
ment group, discussed via teleconference, and revised, if
Intercollegiate Guidelines Network, New Zealand Guidelines
warranted. The purpose of the teleconference was to provide
Group, Australian National Health and Medical Research
an opportunity to clarify any ambiguity, propose revisions,
Council, Guidelines International Network, and BIOSIS. The
or drop any statements recommended by the development
following terms were used in the search:
group.
Criteria for consensus were established a priori as
(drug-induced sleep endoscopy OR drug-induced sedation
follows22:
endoscopy) OR ((DISE OR bronchoscopy OR nasal endo-
scopy OR nasendoscopy OR nasopharyngoscopy OR flexible
Consensus: statements achieving a mean score of 7.00
fiberoptic endoscopy OR endoscopy) AND (snoring OR
or higher and having no more than 1 outlier,
sleep OR sleep apnea OR sleep apnea, obstructive OR sleep-
defined as any rating 2 or more Likert points from
disordered breathing OR airway)) AND (infant OR infants
the mean in either direction.
OR child OR children OR adolescent OR adolescents OR
Near consensus: statements achieving a mean score of
juvenile OR juveniles OR pediatric OR pediatrics OR youth)
6.50 or higher and having no more than 2 outliers.
No consensus: statements that did not meet the criteria
The target audience of the ECS was defined as otolaryn-
of consensus or near consensus.
gologists or other endoscopists performing DISE for children
with OSA. The target population was defined as patients
Two iterations of the Delphi survey were performed. All
aged 0 to 18 years. Once the target population and scope of
group members completed all survey items. The develop-
practice were determined, the development group used the
ment group extensively discussed (via teleconference) the
results of the literature reviews, combined with their expert
results of each item after the first Delphi survey. Most items
opinion and stakeholder needs, to propose topics and ques-
that reached consensus were accepted; however, 10 consen-
tions for which knowledge gaps, uncertainty, or opportuni-
sus statements were revised for improved clarity. Items that
ties for quality improvement existed. The main focus was
did not meet consensus were discussed to determine if word-
DISE-related areas with significant practice variation that
ing or specific language was pivotal in the item not reaching
would most benefit from consensus from expert clinicians.
consensus. The second iteration of the survey was used to
These topics were used as the basis for formulating the ini-
reassess items for which there was consensus or near consen-
tial statements, which were then evaluated through the
sus or for items for which there were suggestions for signifi-
Delphi Survey Method.
cant alterations in wording that could have affected survey
results. All items reaching consensus were accepted except
Delphi Survey Method Process and Administration for 4 statements removed due to redundancy. The factors
A modified Delphi Survey Method was utilized to assess leading to the remaining items not reaching consensus were
consensus for the proposed statements,22 with multiple anon- not attributed to wording or other modifiable factors but
ymous surveys completed to minimize bias within the devel- rather a true lack of consensus.
opment group and facilitate consensus.24 Web-based software The final version of the ECSs was grouped into several
(www.surveymonkey.com) was used to administer confiden- specific areas: indications and utility for pediatric DISE, pro-
tial surveys to development group members. A potential topic tocol for DISE, optimal sedation for DISE, grading/interpre-
list of 50 questions was put together by the development tation of DISE, outcomes of DISE-directed surgery, and
group during the first call, and each development group complications and safety. The final manuscript was drafted
member was invited to provide 1 draft statement for each of with participation and final review from each development
his or her top 5 ranked topic list choices. The survey period group member.
4 Otolaryngology–Head and Neck Surgery

Table 1. Indications and Utility for Pediatric DISE: Statements That Reached Consensus.
No. Statements that reached consensus Mean Outliers

4 Polysomnography is recommended prior to DISE to confirm presence and severity of OSA. 8.88 0
1b DISE is indicated for children with OSA who have small tonsils. 7.50 1
14b DISE is useful in children with persistent OSA to provide information about planning 7.75 1
additional sleep surgery.
6 Children should undergo DISE before being considered for additional pharyngeal surgery 8.13 1
for persistent OSA.
7 DISE should be performed in children with persistent OSA prior to performing additional 7.63 1
surgery for OSA.
10 There is limited utility for DISE in children with an apnea-hypopnea index \2. 7.75 1
13 The role of DISE at the time of adenotonsillectomy is limited in children with OSA and 8.25 0
adenotonsillar hypertrophy who are not at risk for persistent OSA.
20b Healthy children with OSA and small tonsils who have partial or complete obstruction at 8.50 0
the tonsils observed during DISE would benefit from a palatine tonsillectomy.
18 DISE performed concurrently with adenotonsillectomy in children at high risk of persistent 7.25 1
OSA identifies sites of additional obstruction beyond the tonsils and adenoids.
Abbreviations: DISE, drug-induced sleep endoscopy; OSA, obstructive sleep apnea.

Table 2. Protocol for Pediatric DISE: Statements That Reached Consensus.

No. Statements that reached consensus Mean Outliers

24b Photo and video documentation of pediatric DISE are useful to facilitate education, 8.38 0
collaboration, and research.
22 Jaw thrust and lateral positioning maneuvers may be utilized during pediatric DISE to augment 9.00 0
the exam.
23 Evaluation of the airway below the glottis should be carried out at the time of DISE in children 8.38 1
with signs or symptoms suggesting tracheal or bronchial pathology.
32 Information obtained from DISE is most useful when no supplemental oxygen is being given. 8.13 1
37 Topical nasal decongestion should not be used during DISE as it alters nasal anatomy and 7.38 1
airflow dynamics that may mask the true obstructive breathing pattern.

Abbreviation: DISE, drug-induced sleep endoscopy.

Results Indications and Utility for Pediatric DISE

The literature search yielded 123 articles, with 62 remaining
after the titles and abstracts were screened for relevance.
Additional exclusions at this stage included commentaries,
letters to the editor, editorials, studies in animals, and
research limited to adults. The remaining 62 articles were
reviewed independently by the chair and assistant chair and
classified per the Oxford Centre for Evidence-Based Medicine’s
2011 levels of evidence.25 Based on the evidence levels,
there were 11 level 1 articles, 1 level 2 article, 4 level 3 arti-
cles, 45 level 4 articles, and 1 level 5 article. Thus, most rel-
evant articles were small case series.
A total of 59 consensus statements were developed for
assessment. After 2 iterations of the Delphi survey and
removal of duplicative and similar statements, 26 statements
met the standardized definition for consensus (Tables 1-6),
and 11 did not (Table 7). The expert statements were orga-
nized into the specific subject areas.
A total of 9 statements reached consensus regarding the indi-
cations and utility of pediatric DISE (Table 1). There were
5 statements that did not reach consensus (Table 7). The
development group emphasized the importance of obtaining
a polysomnogram (PSG) prior to performing DISE in chil-
dren and that DISE has limited utility in children with an
apnea-hypopnea index (AHI) \2.
There was extensive discussion regarding appropriate
indications for DISE. Consensus was reached that DISE was
indicated in the following scenarios: (1) children with OSA
and small tonsils, (2) children with persistent OSA following
AT, and (3) at the time of AT for children at high risk of per-
sistent OSA. The development group identified the following
factors as being associated with a high risk of persistent
OSA following AT: (1) severe baseline disease, defined as
an obstructive AHI .10 events/hour; (2) obesity; (3) craniofacial
syndromes, including Down syndrome; and (4) neuromuscular
Baldassari et al 5

Table 3. Optimal Sedation for Pediatric DISE: Statements That Reached Consensus.
No. Statements that reached consensus Mean Outliers

26 Either propofol or dexmedetomidine is an optimal form of sedation for use in pediatric DISE. 7.75 0
27 The level of sedation during pediatric DISE should be titrated to audible snoring, an obstructive 8.25 0
breathing pattern, or both while allowing for flexible endoscopy without patient reactivity or
awakening.
30 Inhalational agents may be used for induction and to gain intravenous access during DISE but 8.50 0
should be discontinued for the diagnostic portion of the study.
31 The surgeon and anesthetist should agree on the sedation protocol prior to DISE. 9.00 0
Abbreviation: DISE, drug-induced sleep endoscopy.

Table 4. Grading/Interpretation of Pediatric DISE: Statements That Reached Consensus.

No. Statements that reached consensus Mean Outliers

39 During pediatric DISE, the following parameters should be observed and documented for each 8.75 0
anatomic level: (a) site, (b) pattern or shape, and (c) severity of obstruction.
40 During pediatric DISE, the following anatomic sites should be assessed and documented: nasal 8.86 0
airway (including nasal cavities, nasopharynx), palate/velum, pharyngeal airway (including lateral
oropharyngeal wall and tongue base), and supraglottic larynx.
48b Cine MRI can be a useful adjuvant to DISE in children to determine the thickness of lingual tonsils 7.50 1
and assess the contribution of the tongue base to palatal obstruction observed during DISE.
Abbreviations: DISE, drug-induced sleep endoscopy; MRI, magnetic resonance imaging.

Table 5. Complications and Safety of Pediatric DISE: Statements That Reached Consensus.
No. Statements that reached consensus Mean Outliers

25 DISE can be performed safely outside the operating room if anesthesia support is available. 7.88 1
52b Children with OSA undergoing DISE may be discharged the same day. 8.38 0
50 The preoperative polysomnogram will guide the severity of hypoxemia and oxygen desaturations 7.88 1
that should be tolerated during DISE.
Abbreviations: DISE, drug-induced sleep endoscopy; OSA, obstructive sleep apnea.

Table 6. Outcomes of DISE-Directed Surgery in Children: Statements That Reached Consensus.

No. Statements that reached consensus Mean Outliers

44 Children undergoing DISE-directed surgery for OSA experience improvement in symptomatology 8.00 0
and quality of life.
45 Children undergoing DISE-directed surgery for OSA experience improvement in apnea-hypopnea 7.63 0
index and oxygen saturation nadir.

Abbreviations: DISE, drug-induced sleep endoscopy; OSA, obstructive sleep apnea.

disorders. The group was not able to identify how ‘‘small’’ ton-
sils should be defined.
There was lengthy discussion regarding the controversial
topic of the appropriateness of performing DISE at the time of
AT in children with OSA. Ultimately, the development group
agreed that DISE performed at the time of AT for children at
risk for persistent OSA can identify sites of additional obstruc-
tion beyond the tonsils and adenoids. However, whether DISE
can change surgical decision making at the time of AT in chil-
dren at risk for persistent OSA achieved only near consensus.
There was consensus that the role of DISE at the time of
AT is limited in children with OSA and adenotonsillar
6 Otolaryngology–Head and Neck Surgery

Table 7. Statements That Were Classified as No Consensus.

No. Statement Mean Outliers

Indications and utility for pediatric DISE

47b DISE is indicated at the time of adenotonsillectomy in surgically naı̈ve children who are at risk for 5.63 5
persistent OSA.
11b Performance of DISE at the time of adenotonsillectomy in children at high risk of persistent 6.50 4
disease may guide future OSA management.
3 DISE is indicated at the time of adenotonsillectomy for children with OSA who have a high risk of 6.00 4
persistent sleep apnea, such as those with trisomy 21 or obesity.
9 Children with mild OSA and symptoms can be assessed with DISE. 5.75 3
17 Children at high risk of persistent OSA who are undergoing a planned adenotonsillectomy benefit 6.00 3
from DISE if the surgeon and family are prepared to proceed with adjuvant surgery at the time of
the adenotonsillectomy.
Protocol for DISE
33 Supplemental oxygen should be used during DISE if intraprocedure levels of oxygen saturation fall 6.63 5
below the nadir seen on PSG.
34 DISE results can be altered by supplemental oxygen. 7.13 3
36 Topical nasal decongestants should be avoided during assessment of the nasal airway but can be 5.13 5
used to facilitate advancement of the endoscope for the rest of the DISE evaluation after the
nasal examination is complete.
12 Children with persistent OSA should attempt positive airway pressure therapy prior to DISE. 5.50 3
Optimal sedation for DISE
38 Ketamine should be avoided when DISE is performed in children because it increases muscle tone, 5.38 5
which can stiffen the airway and mask a child’s true obstructive breathing pattern.
Outcomes of DISE-directed surgery
19 For children at high risk of persistent OSA, DISE findings at the time of adenotonsillectomy may 7.13 3
direct surgery to address additional sites of obstruction at the time of adenotonsillectomy

Abbreviations: DISE, drug-induced sleep endoscopy; OSA, obstructive sleep apnea; PSG, polysomnogram.

hypertrophy who are not at risk for persistent OSA. In chil-
dren with persistent OSA following AT, DISE is useful in
assessing candidacy for additional sleep surgery. The devel-
opment group considered children to have persistent OSA if
they have severe persistent OSA (obstructive AHI .10
events/hour) or mild to moderate OSA (obstructive AHI
between 2 and 10 events/hour) with associated daytime and/
or nighttime OSA symptomatology. The development group
recommended that children undergo DISE prior to perform-
ing additional surgery for persistent OSA, including pharyn-
geal surgery. Pharyngeal surgery refers to procedures that
address lateral oropharyngeal wall collapse and tongue base
obstruction, such as expansion pharyngoplasty and midline
glossectomy, respectively.
Protocol for DISE
Nine statements were created pertaining to the protocol for
performing pediatric DISE, of which 5 reached consensuses
(Table 2). The importance of photo and video documentation
during DISE was highlighted. In addition, there was consen-
sus on the utility of positioning and maneuvers such as jaw
thrust during pediatric DISE to augment the examination.
Evaluation of the subglottis and lower airway during DISE
was deemed unnecessary unless patients have symptoms to
suggest tracheal or bronchial pathology. The development
group agreed that nasal decongestants and supplemental
oxygen should be avoided during pediatric DISE.
Optimal Sedation for DISE
A total of 4 statements met consensus regarding the optimal
sedation for DISE (Table 3), while 1 did not reach consensus.
These statements address the use of inhalational anesthesia,
the choice of intravenous sedative agent, the level of sedation,
and communication with the anesthetist during pediatric
DISE.
The development group felt that there was an opportunity
for quality improvement regarding sedation for pediatric
DISE as there is a significant amount of practice variation in
this area. Propofol and dexmedetomidine were identified as the
optimal sedation agents for use in pediatric DISE. Inhalational
agent use should be minimized during DISE; if used during
induction, these agents should be discontinued prior to the diag-
nostic portion of the procedure. The development group could
not reach consensus regarding the use of ketamine during
DISE, due to concern that it increases muscle tone and masks a
child’s true pattern of upper airway obstruction.
The ideal level of sedation for pediatric DISE is reached
when the child has audible snoring and/or an obstructive
Baldassari et al
breathing pattern as well as a lack of responsiveness to the
introduction of the flexible endoscope.
Grading/Interpretation of DISE
All 3 proposed statements regarding grading and interpreta-
tion of pediatric DISE met consensus (Table 4). The impor-
tance of a systematic approach to the DISE examination was
emphasized, including the evaluation of the location, pattern,
and severity of obstruction. The anatomic sites that should
be documented during pediatric DISE are the nasal cavity
and nasopharynx, the velum, the pharynx (including lateral
walls and tongue base), and the supraglottic larynx. Cine
magnetic resonance imaging (MRI) can be a useful adjuvant
to DISE in children in that it can provide additional informa-
tion regarding lingual tonsil thickness and tongue base con-
tribution to palatal obstruction.
Complications and Safety
All 3 statements related to complications and safety reached
consensus (Table 5). While DISE is typically performed in
the operating room, the procedure may be safely performed
outside this setting, provided there is support from anesthesia
clinicians. Children, even those with severe disease and
comorbid medical conditions, can typically be discharged
the same day that DISE is performed. Pre-DISE PSG pro-
vides valuable information regarding a child’s oxygenation
that can be used to guide the degree of desaturation allowed
during the procedure.
Outcomes of DISE-Directed Surgery
Both statements reached consensus regarding outcomes of
DISE-directed surgery (Table 6). These statements high-
lighted the improvements that occur in PSG measures, such
as AHI and oxygen saturation nadir, as well as QOL and
symptomatology following DISE-directed surgery.
Discussion
Indications and Utility for Pediatric DISE
In agreement with the survey of pediatric DISE practices
published in 2017,20 there was a strong consensus among
group members to obtain a PSG prior to DISE. The rationale
for this recommendation is that multiple studies have
demonstrated that clinical assessment is a poor predictor of
the presence of OSA and its severity.1,26-29 In the Childhood
Adenotonsillectomy Trial, otolaryngologists accurately pre-
dicted the presence of OSA only 50% of the time in healthy
children between the ages of 5 and 9 years.30
There are several advantages to confirming the diagnosis
and severity of OSA by PSG prior to performing pediatric
DISE. Because a child who has infrequent obstructive
respiratory events during PSG is unlikely to exhibit a repeti-
tive obstructive breathing pattern during DISE, DISE was
not felt to be appropriate for children with an AHI \2
events/hour. In addition, these children may be managed
with watchful waiting or anti-inflammatory medications.
Other useful information that can be obtained from PSG that
7
may affect the execution of pediatric DISE includes identifi-
cation of a positional component of OSA, as well as the
degree of hypoxemia.
Since the development of DISE in adults in the 1990s, the
indications and utility of DISE have evolved for children
with OSA.21 The most common reason to perform pediatric
DISE has been to direct additional surgical intervention in
children with persistent OSA following AT. Indeed, children
with persistent OSA benefit from DISE to identify sites of
obstruction that may be addressed surgically.19,21,31,32
Common sites of obstruction noted upon DISE in children
with persistent disease include the tongue base, adenoids
(secondary to regrowth), inferior turbinates, velum, and lat-
eral oropharynx.19,32-34 In a review21 of the pediatric DISE
literature, 100% of 162 children undergoing DISE for the
indication of persistent OSA had at least 1 site of obstruction
identified.
The development group reached consensus that DISE-
directed surgery for children with persistent OSA can improve
PSG parameters such as AHI and symptomatology more than
surgery performed without this information. Indeed, there are
some emerging data that DISE may be superior to in-office
clinical examination in identifying sites of obstruction in chil-
dren with persistent OSA. In a series of 22 children35 with
persistent OSA, DISE resulted in a change of the surgical
plan in 73% of patients, with the most common modifications
being performance of turbinate reduction and pharyngoplasty.
There is significant controversy regarding when DISE
should be performed in children concurrently with AT (‘‘sur-
gically naı̈ve’’) to assess other sites of upper airway obstruc-
tion. The development group agreed that DISE can be
appropriately used in surgically naı̈ve children to evaluate
children with OSA and small tonsils. However, the develop-
ment group was unable to agree on the definition of small
tonsils, due to some members defining small tonsils as size 1
(based on Brodsky 1-4 scoring)36 while others included size
1 and 2. The literature supports the idea that DISE is useful
in children with OSA and small tonsils to identify potential
sites of obstruction beyond the naso- and oropharynx.37 One
recent study38 found that 60% of children with size 1 tonsils
(n = 65) undergoing DISE did not have lateral pharyngeal
wall collapse. Similarly, a review by Galluzzi39 found that
30% of surgically naı̈ve children undergoing DISE had no
evidence of obstruction caused by adenoids and/or tonsils.
Data are lacking for whether performing DISE-directed
surgery improves outcomes, such as supraglottoplasty for
sleep-dependent laryngomalacia in children who do not have
adenotonsillar obstruction. In contrast, if DISE does reveal
lateral pharyngeal wall obstruction in children with small
tonsils, the development group agreed that tonsillectomy
should be performed. This is supported by the study by Chen
and He,40 which noted significant improvement in the
respiratory disturbance index following DISE-directed ton-
sillectomy for children with grade 1 tonsils.
The development group agreed that the role of DISE at
the time of AT is limited in children with enlarged tonsils
and adenoids who are not at risk for persistent OSA. In such
8 Otolaryngology–Head and Neck Surgery
patients, DISE has repeatedly identified adenotonsillar
hypertrophy as the most common site of obstruction.41 AT is
also well known to result in significant improvements in
symptomatology and PSG parameters in the majority of oth-
erwise healthy children.2 Furthermore, in a report of 88 chil-
dren, DISE did not change the surgical plan in .95% of
surgically naı̈ve children with OSA.35
For children at high risk for persistent disease, the devel-
opment group agreed that DISE performed at the time of AT
can identify sites of additional obstruction beyond the tonsils
and adenoids. However, there is limited evidence regarding
the utility of performing DISE at the time of AT in these
children. Previous research has demonstrated that children
with severe disease often have multilevel obstruction on
DISE.42 Some group members asserted that surgically
addressing additional sites of obstruction identified during
DISE at the time of AT may improve treatment outcomes.
For example, Ulualp43 reported on a series of children with
severe OSA who underwent modified expansion pharyngo-
plasty at the time of AT after DISE demonstrated lateral oro-
pharyngeal wall collapse. Larger improvements in the AHI
were noted in children who had additional palatal surgery
performed when compared with patients who were treated
with AT alone (control).
Another rationale for performing DISE at the time of AT
in children at high risk for persistent disease was to guide
future OSA management. However, the development group
was able to reach only near consensus on this point. Group
members expressed concern that removal of the tonsils and
adenoids may change airflow dynamics and necessitate
repeat DISE prior to any additional surgical intervention in
children found to have persistent obstruction.
Protocol for DISE
In 2017, a multi-institutional survey of pediatric DISE
experts was published that demonstrated agreement among
participants in regard to preoperative evaluation and DISE
protocols but not in the sedation technique.20 Similarly, the
development group identified several technical aspects of
DISE that providers should be aware of when performing
this procedure. They agreed that topical nasal decongestion
should not be used during DISE, as it alters nasal anatomy
and airflow dynamics that may mask the true obstructive
breathing pattern. Because the nasal passages account for
.50% of upper airway resistance and the Starling resister
model predicts that improving airflow through the nasal pas-
sages can decrease the collapsing forces in the hypophar-
ynx,44 there was concern from the development group that
nasal medications may result in alterations in the true hypo-
pharyngeal obstructive breathing patterns.
Controversy remains regarding the use of nasal anes-
thetics during pediatric DISE, and no consensus was reached
on this topic. A 2019 publication suggested that topical
anesthesia has no effect on DISE; however, this pilot study
included adults with primary snoring as well as OSA.45 An
investigation that compared topical lidocaine with placebo
demonstrated a fourfold increase in OSA by anesthetizing
the nose.46
The development group also agreed that pre-DISE PSG is
recommended and that the information obtained during
DISE was most useful when supplemental oxygen was
avoided. Surgeon and anesthesia provider awareness of the
baseline asleep oxygen saturation data from a pre-DISE PSG
is useful as it may allow for permissive oxygen desaturation
during DISE provided the patient’s other cardiorespiratory
parameters, including heart rate, are stable. While anesthesia
providers typically use supplemental oxygen to maintain
oxygen saturation .90% during surgery, DISE is ideally
performed when no supplemental oxygen is administered.
There were concerns expressed that respiratory control
instability (high loop gain) can contribute to obstructive
breathing patterns and that administration of supplemental
oxygen will mask loop gain’s effect on the upper airway.47
However, definitive data are lacking regarding if or how
supplemental oxygen can alter patterns of obstruction during
DISE.
In terms of airway evaluation below the glottis during
DISE, the consensus among group members was that tra-
cheoscopy and bronchoscopy should not routinely be per-
formed as part of DISE evaluation unless there are
additional clinical findings to suggest lower airway pathol-
ogy. A recent review48 of 335 patients who underwent tra-
cheoscopy and bronchoscopy during DISE found that while
5% of children had sites of obstruction in the lower airway,
only 0.3% of these children required additional intervention
for these findings. One member of the development group
did express concern that not performing bronchoscopy could
miss cases of tracheomalacia and bronchomalacia that might
be contributing to obstruction.
Group members universally agreed that providers per-
forming pediatric DISE should consider evaluating the
impact of jaw thrust and lateral positioning maneuvers on
airway dynamics and obstruction. While positioning devices
and oral appliances are more commonly used to manage
OSA in adults, there is evidence that they can be acceptable
treatment options for children with persistent OSA.49,50
Photo or video documentation of pediatric DISE was rec-
ommended to enable education, collaboration, and research.
Adoption of a standardized approach for DISE documenta-
tion would facilitate prospective multi-institutional research
studies that can advance our knowledge of pediatric DISE
outcomes. Friedman and Parikh51 recently developed a DISE
documentation protocol that establishes fixed examination
points for brief video recording. Establishment of standard
examination points allows for a consistent and reproducible
optical view, while reference point standardization ensures
that the focal distance from the telescope to the structure
will be similar for each DISE procedure.
Optimal Sedation for DISE
An ideal anesthetic for pediatric DISE maintains spontaneous
ventilation, mimics normal asleep airway tone, is repeatable,
Baldassari et al
and does not exacerbate underlying medical conditions. The
development group agreed that either propofol or dexmedeto-
midine was the optimal form of sedation for DISE. Both
agents have been found to have similar effects on upper
airway morphology as evaluated by cine MRI.52 The benefits
of propofol include quick onset of action and fast redistribu-
tion and metabolism, resulting in rapid awakening when dis-
continued. Its cost is also low. The major drawback of
propofol is the potential for dose-dependent airway collapse.
In a systematic review, 4 of 12 studies showed a decrease in
the upper airway cross-sectional area with increasing doses of
propofol.52 Three additional studies demonstrated a decrease
in genioglossus electromyography activity with propofol-
based induction.53-55 Dexmedetomidine’s effect on airway
collapsibility is less than that of propofol, and several studies
report that this drug has minimal effect on upper airway
cross-sectional area.52 Benefits of dexmedetomidine include
maintaining spontaneous ventilation, airway patency, and
airway tone, even at higher doses.56 However, its slow redis-
tribution and metabolism result in prolonged time to awaken-
ing. Another side effect is bradycardia and hypotension, and it
is more expensive than propofol. However, dexmedetomidine
has been shown to result in a physiologic state similar to
NREM sleep. Of note, neither dexmedetomidine nor propofol
replicates stage R (REM) sleep.
Another agent that has been utilized for DISE is keta-
mine. The development group was unable to reach consensus
regarding its use, as some noted its utility in counteracting
the dexmedetomidine side effects while others expressed
concerns that it increases upper airway tone and subse-
quently masks a child’s true obstructive breathing pattern.57
This is supported by a study by Eikermann and colleagues58
that demonstrated that ketamine results in a much greater
increase in genioglossus activity as compared with propofol.
Inhalational agents are often used for anesthetic induction
and to gain intravenous access during pediatric procedures,
including DISE. However, the development group agreed
that inhalational agents should be discontinued for the diag-
nostic portion of the study because they have been shown to
cause upper airway obstruction in a dose-dependent manner.
Several studies have also suggested exaggerated upper
airway collapse with inhalational agents.56 A study of sevo-
flurane demonstrated a dose-dependent effect on 2 of the
major upper airway dilator muscles, the genioglossus and
palatoglossus.59 Litman et al reported decreased pharyngeal
dilator muscle activity with halothane and sevoflurane, with
sevoflurane causing relatively more upper airway obstruc-
tion.60 Due to these concerns, the development group agreed
that efforts should be made to minimize inhalation agent
usage during pediatric DISE.
A key component to a successful DISE procedure is the
communication between anesthesia and otolaryngology pro-
viders while sharing the airway. Therefore, the development
group agreed that prior to commencing DISE, the surgeon
and anesthesia provider should discuss the following DISE
sedation-related elements: (1) the agent or agents to be used,
(2) the form in which they will be administered (bolus,
9
infusion), and (3) the depth of anesthesia desired. Many cen-
ters have developed a specific DISE anesthetic protocol,20
and some have dedicated DISE anesthesia teams in an effort
to facilitate safety and consistency.
Decisions regarding the appropriate agent and depth of
anesthesia are of major importance, as overdosing can result
in significant oxygen desaturations and premature termina-
tion of the procedure. Alternatively, insufficient sedation
may result in poor patient tolerance and unnecessarily pro-
long the DISE procedure. Therefore, there was consensus
that the optimal sedation level is one where the child is snor-
ing and/or showing an obstructive breathing pattern and is
not responding to the introduction of the flexible endoscope.
While some adult studies have investigated BIS (bispectral
index) to measure depth of anesthesia with upper airway
obstruction, there is no widely accepted BIS score for pedia-
tric DISE, and its use with dexmedetomidine is known to be
less accurate than it is when propofol is use.61 For these rea-
sons, the patient’s depth of anesthesia is assessed clinically
by lack of responsiveness to stimulation.
Grading/Interpretation of DISE
The VOTE classification system for adult DISE, described
by Kezirian et al in 2011,5 has been widely adopted by adult
sleep surgeons. This system documents the pattern and
severity of obstruction at 4 anatomic sites: the velum, oro-
pharynx, tongue base, and epiglottis. However, it has not
been widely utilized in pediatric DISE likely because it fails
to account for additional sites of obstruction noted among
children with OSA, such as the nasal cavity and the supra-
glottis. Thus, investigators including Boudewyns, Chan-
Parikh (C-P score), Lam (Sleep Endoscopy Rating Scale),
Bachar, and Fishman have developed pediatric DISE grading
scales.62-67 These grading scales allow for a standardized
means of reporting DISE findings with the goal of predicting
surgical outcomes.
The C-P score has shown good internal and external
validity,64 and a follow-up series demonstrated correlation
with AHI severity and lowest oxygen saturation on PSG.68
Unlike the C-P score, the Sleep Endoscopy Rating Scale
incorporates the nasal cavity, and it yields a single total
score for pediatric DISE, which has been shown to correlate
with OSA severity and response to AT.37,65 To date, how-
ever, a universal grading scale has yet to be adopted.
Whereas the development group did not identify a single
superior DISE scoring system, the group highlighted the
importance of consistently documenting the site, pattern, and
severity of obstruction. It also agreed that this information
should be assessed/documented for the following anatomic
sites by all providers performing DISE in children: nasal
airway (including nasal cavities, nasopharynx), palate/
velum, pharyngeal airway (including lateral oropharyngeal
wall and tongue base), and supraglottic larynx. Further
research and collaboration are needed to develop a pediatric
DISE grading system that can be widely adopted and utilized
to allow for standardized research data collection and ulti-
mately improved evaluation and treatment algorithms.69
10
Cine MRI, which uses fast gradient echo sequence with
axial and midline sagittal images, has also been utilized to
assess sites of obstruction in children with OSA while the
child is spontaneously breathing under sedation. Advantages
include its high-resolution, dynamic airway evaluation that
allows for visualization of multiple anatomic sites at once.
Despite this, it has not been widely adopted across many
pediatric institutions nationally.19 This is likely due to safety
concerns regarding loss of the airway while obtaining the
MRI in sedated children with significant OSA, as well as the
cost and burden of additional testing. However, there are cer-
tain elements of the airway evaluation, including the thick-
ness of the lingual tonsils and the contribution of the tongue
base to palatal obstruction, that may be more readily appar-
ent during cine MRI than DISE. In a small case series70 that
examined findings in children undergoing both diagnostic
modalities, DISE and cine MRI found the same sites of
obstruction in 10 of 15 patients. DISE identified an addi-
tional site of obstruction not noted on cine MRI in 3
patients.
Complications and Safety
Overall, DISE is safe and well tolerated in children with
OSA, even those with comorbid conditions, such as obesity,
hypotonia, and Down syndrome.42,71-73 Potential complica-
tions include intraoperative loss of airway from laryngospasm
or bronchospasm, oversedation, hypotension, bradycardia, and
respiratory depression.21 Thus, DISE should be performed in
a setting that allows for cardiopulmonary monitoring, intrave-
nous access, availability of emergency airway equipment, and
presence of a skilled team of anesthesia personnel. While it is
frequently performed in the operative environment, DISE has
also been safely and successfully performed outside this
setting.
Group members deemed it appropriate for DISE to be
performed in settings other than the operating room provided
that there is access to the elements noted earlier. For exam-
ple, providers have safely performed DISE in the radiology
department following cine MRI. In a review of 118 children
undergoing DISE in an MRI induction suite, there were no
unplanned admissions or major complications.72 Performing
DISE outside the operating room may also result in cost
reductions.72
The development group noted that children with OSA
may be discharged the same day as the DISE procedure, but
it did not make specific recommendations regarding the
duration of time that they should be observed in the posta-
nesthesia care unit. Children can be discharged the same day
as DISE, provided that they meet appropriate discharge cri-
teria. Such criteria may vary slightly among institutions. A
common clinical scale used to determine discharge eligibil-
ity is the modified Aldrete scale that assesses patient charac-
teristics such as consciousness, respiration, and motor
activity.74
Otolaryngology–Head and Neck Surgery
Outcomes of DISE-Directed Surgery
Much of the data regarding DISE-directed surgical outcomes
are small, single-institution case series. Thus, definitive data
demonstrating that DISE-directed surgery is superior to stan-
dard surgical therapy for OSA are lacking. Despite this,
there was consensus that children undergoing DISE-directed
surgery experience improvement in the severity of their
OSA as assessed by PSG parameters.75-77 This is supported
by a systematic review of 120 pediatric patients that found
improvement in AHI and nadir oxygen saturation following
DISE-directed surgery.75 DISE-directed surgery has also
been shown to reduce the AHI in certain subgroups of pedia-
tric patients with OSA, including infants,18,78 children with
small tonsils,40,79,80 children with persistent OSA following
an AT,81 children with Down syndrome,34,82-84 and children
with hypotonia.85 Despite this, persistent OSA has been
reported following DISE-directed surgery.34,75,84,85 It
remains unclear whether the residual disease burden in these
children would have been more severe if DISE had not been
utilized to direct their treatment. To definitively understand
the role of DISE in pediatric OSA management, further
research is needed to compare outcomes between children
treated with and without DISE-directed surgery.
Pediatric OSA can have a profound negative impact on
children’s QOL, with parents often reporting significant day-
time and nighttime symptomatology such as hyperactivity
and frequent nighttime awakenings.86 Thus, validated instru-
ments that assess disease-specific QOL and symptoms are
now often utilized in conjunction with PSG when assessing
treatment outcomes. The development group reached con-
sensus that children undergoing DISE-directed surgery for
OSA experience improvement in symptomatology and QOL.
Evidence supporting this can be found in the study by Park
et al,85 which demonstrated a significant improvement in
OSA-18 QOL scores in children with hypotonia after DISE-
directed surgery. Subjectively, DISE-directed surgery has
also been found to improve patient-reported symptoms such
as snoring, pauses in breathing, gasping for air, mouth
breathing, daytime somnolence, sleepwalking, sleep talking,
teeth grinding, enuresis, and feeling tired.87 Future prospec-
tive studies on pediatric DISE-directed surgery should
include validated QOL and symptom scores when assessing
outcomes.
Strengths and Limitations
A major strength of this consensus statement is the metho-
dology of the consensus statement process. It is rigorous and
follows an explicit, a priori, tested protocol to focus on qual-
ity improvement, reduce bias, and ensure consistency regarding
judgments of consensus, near consensus, and no consensus.
In addition, the participants are content experts in the field
with extensive clinical and research experience with DISE.
The primary limitation of this research was the lack of high-
quality, prospective studies to inform the group members’
Baldassari et al
opinions. In most studies that were reviewed, there was concern
for bias because most were small cases series based on chart
review without control or comparison groups. Additionally, as
the methodology protocol for ECS development involves only
otolaryngology stakeholders, direct input from other disciplines
such as anesthesia is lacking.
The development group identified numerous topics that
merit further research, including whether DISE performed at
the time of AT in children at risk for persistent disease
improves outcomes. Additional research is needed to deter-
mine an optimal sedation protocol and ideal grading system
for pediatric DISE. Future studies should also clarify how
best to define small tonsils and assess outcomes in children
with small tonsils in which DISE identifies alternate sites of
obstruction. Nationwide adoption of a standardized protocol
and grading system would allow for significant advances to
be made in research on DISE-directed surgical outcomes.
Conclusions
A development group of otolaryngologists and a head and
neck nurse developed a consensus statement on pediatric
DISE based on available evidence and expert opinion utilizing
an established protocol. Numerous topics related to pediatric
DISE were identified in which there were significant varia-
tions in practice and controversy, including indications, proto-
cols, and grading systems. Statements were created to
improve the quality of care provided to pediatric patients
undergoing DISE. The group members highlighted the impor-
tance of obtaining a PSG prior to performing DISE. As DISE
leads to improvements in AHI and QOL, it should be per-
formed in children with persistent OSA prior to additional
sleep surgery. The utilization of inhaled anesthetics should be
avoided during the diagnostic portion of DISE. For providers
performing pediatric DISE, it is essential to document the site,
severity, and pattern of obstruction in a standardized fashion.
The development of standardized sedation protocols and grad-
ing systems will facilitate research and ultimately lead to
higher-quality data on the utility of DISE. Further research,
with a focus on prospective randomized trials or prospective
cluster analysis, is needed to better understand how DISE
improves surgical outcomes in children with OSA.
Endorsing Societies
Endorsed by Society of Otorhinolaryngology and Head-Neck Nurses
(SOHN), International Surgical Sleep Society (ISSS), American
Society of Pediatric Otolaryngology (ASPO), and Society of Ear
Nose and Throat Advancement in Children (SENTAC).
Acknowledgments
We gratefully acknowledge the support of Lara Handler, MLS, for
conducting the literature searches.
Author Contributions
Cristina M. Baldassari, writer, chair; Derek J. Lam, writer, assis-
tant chair; Stacey L. Ishman, writer, methodologist; Boris
Chernobilsky, writer, panel member; Norman R. Friedman,
11
writer, panel member; Terri Giordano, writer, panel member;
Claire Lawlor, writer, panel member; Ron B. Mitchell, writer,
panel member; Heather Nardone, writer, panel member; James
Ruda, writer, panel member; Habib Zalzal, writer, panel member;
Adrienne Deneal, writer, AAO-HNSF staff liaison; Nui
Dhepyasuwan, writer, AAO-HNSF staff liaison; Richard M.
Rosenfeld, writer, senior adviser .
Disclosures
Competing interests: Cristina M. Baldassari, CORE Grant
Funding, Inspire Grant Funding; Stacey L. Ishman, Inspire
Medical—consultant, National Institutes of Health grant support
(National Heart, Lung, and Blood Institute / National Institute of
Dental and Craniofacial Research); Boris Chernobilsky, Inspire
Medical Systems, Inc—stock; Adrienne Deneal, salaried
employee of American Academy of Otolaryngology–Head and
Neck Surgery Foundation; Nui Dhepyasuwan, salaried employee
of American Academy of Otolaryngology–Head and Neck
Surgery Foundation.
Sponsorships: American Academy of Otolaryngology–Head and
Neck Surgery Foundation provided staff support and reimbursed
development group members for travel expenses.
Funding source: None.
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