MAD SIMULATOR DURING DRUG INDUCED SLEEP ENDOSCOPY IN OSAS PATIENTS: OUR EXPERIENCE AND COMPARISON WITH ESMARCH MANOUVRE

Introduction Understanding the sites of upper airway collapse and its pattern is mandatory for non ventilatory treatment decision-making and its efficacy in OSAS patients. The results and clinical outcomes of OSAS patients treated with mandibular advancement device (MAD) can not be adequately predicted using awake parameters. Objective The aim of the study is to analyze the changes in pharyngeal airway size both performing DISE with George Gauge bite fork and without it, before the MAD application. Methods After an accurate orthodontic assessment and the bite fork registration, MAD simulator was inserted in 16 awake patients before performing DISE. A standard DISE was carried out in all patients using TCI propofol sedation. After registration of parameters with MAD during adequate sedation, the bite fork was removed and a basal DISE parameters were recorded. Finally we performed an Esmarch manuvre gently advancing by up to 5 mm the mandible in order to observe its impact on airway patency and snoring and to compare it with the MAD results. All DISE procedures were carried out by the same, experienced, ENT surgeons team. The endoscopic results, both with and without MAD, have been classified, according to Sher modified staging: site, degree of airway narrowing, and configuration of obstruction. Results Preliminary results showed that the pattern of obstruction and snoring can change in a different ways performing DISE with a MAD simulator or with Esmarch manoeuvre, with an increase of retrolingual space due to the anterior repositioning of the tongue base and a stabilization of the lateral walls of hypo-velopharynx. Conclusion Several studies have proved that DISE offers possibilities as a prognostic indicator for MAD therapy. Because the response of the airway to MAD is dynamic, DISE could be expected to be a better therapeutic predictor than a static, awake, and frequently upright cephalometric assessment. Performing DISE with George Gauge bite fork gives the advantage to investigate the effectiveness of a repeatable protrusion and vertical opening of the mandible. Furthermore it can be used to produce the real MAD, without changing the parameters of registration. Our results support this technique as a promising additional tool to optimize the oral appliance treatment effectiveness and the patient selection. Further studies are necessary to better understand the effect of MAD on the anatomy of upper airway.