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Diagnosing Tongue Base Obstruction in Pierre Robin Sequence Infants: Sleep vs Awake Endoscopy
Jake J Lee1,2, Matthew D Ford3, Allison B Tobey4
11 University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Insights
Awake endoscopy has low sensitivity for diagnosing base-of-tongue obstruction in infants with Pierre Robin sequence. Drug-induced sleep endoscopy is recommended for high-risk infants to avoid underdiagnosis of airway obstruction.
Area of Science:
- Pediatric Otolaryngology
- Sleep Medicine
- Airway Management
Background:
- Pierre Robin sequence (PRS) is a congenital condition characterized by micrognathia, glossoptosis, and cleft palate, often leading to upper airway obstruction.
- Base-of-tongue collapse is a significant contributor to airway obstruction in infants with PRS.
- Accurate diagnosis of the degree and location of airway obstruction is crucial for effective management.
Purpose of the Study:
- To compare the diagnostic reliability of awake endoscopy (AE) versus drug-induced sleep endoscopy (DISE) for identifying base-of-tongue obstruction in infants with PRS.
- To evaluate the sensitivity, specificity, and likelihood ratios of AE in detecting base-of-tongue collapse compared to DISE.
Main Methods:
- A retrospective study was conducted involving 141 infants with PRS, with 35 undergoing both AE and DISE.
- Clinicians performing the endoscopies were blinded to patient identity.
- Findings from AE and DISE were assessed by a pediatric otolaryngologist, focusing on the presence of moderate to severe base-of-tongue collapse.
Main Results:
- Awake endoscopy demonstrated a sensitivity of 50.0% and a specificity of 86.7% for detecting base-of-tongue obstruction when compared to DISE.
- A significant false negative rate of 50.0% was observed with AE.
- Drug-induced sleep endoscopy identified significantly more cases of base-of-tongue obstruction than AE (P = .039).
Conclusions:
- Bedside awake endoscopy exhibits low sensitivity in detecting base-of-tongue collapse in infants with Pierre Robin sequence.
- Due to its high false negative rate, AE may not be a reliable tool for ruling out base-of-tongue obstruction in this vulnerable population.
- Drug-induced sleep endoscopy is recommended for high-risk infants to prevent underdiagnosis of upper airway obstruction.
Objective:
To investigate whether awake endoscopy can diagnose base-of-tongue obstruction as reliably as sleep endoscopy in infants with Pierre Robin sequence (PRS).
Design:
The study was retrospective with the clinicians blinded to patient identity. Endoscopy findings were assessed and measured by the performing pediatric otolaryngologist.
Setting:
Tertiary care children's hospital.
Patients:
All infants with PRS managed between January 2005 and July 2015 were included. There were 141 patients, of which 35 underwent both awake endoscopy (AE) and drug-induced sleep endoscopy (DISE).
Interventions:
Bedside AE and DISE in the operating room.
Main Outcome Measures:
Presence of moderate or severe base-of-tongue collapse was assessed. Sensitivity, specificity, and positive likelihood ratio of AE findings as well as intertest differences between AE and DISE were calculated.
Results:
AE had 50.0% sensitivity (95% confidence interval [CI] 27.2%-72.8%) and 86.7% specificity (95% CI 59.5%-98.3%) for detecting base-of-tongue obstruction compared to DISE; false negative rate was 50.0% (n = 10). Positive likelihood ratio was 3.75 (CI 0.96-14.65). Compared to AE, DISE demonstrated significantly more cases of base-of-tongue obstruction ( P = .039).
Conclusions:
Bedside AE has low sensitivity for detecting base-of-tongue collapse in infants with PRS. Because of the substantial false negative rate, AE may not be a reliable diagnostic modality for ruling out base-of-tongue obstruction in this susceptible population. DISE may be indicated in high-risk patients to avoid underdiagnosing upper airway obstruction.
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