2025
-
Julianna G. Rodin, MD , Tice Harkins, BS, Erica Kent, BS, Chau Phung, BS, Rafa Khan, BS, Everett Seay, RPSGT, Brendan T. Keenan, MS, and Raj C. Dedhia, MD, MSCR
Surgical treatment of non obstructive sleep apnea (OSA) pathology poses the risk of inappropriate surgical indications. Herein, we sought to determine the prevalence of non-OSA respiratory disorders, specifically central sleep apnea (CSA), in new referrals to a Sleep Surgery Clinic.
2024
-
Eric R. Thuler, Manan H. Parekh, Jules G. Rodin, Everett G. Seay, Andrew Wiemken, Brendan T. Keenan, Richard J. Schwab, Alan R. Schwartz, Raj C. Dedhia
Positive airway pressure (PAP) titration during drug-induced sleep endoscopy (DISE) provides objective measures of upper airway collapsibility. While skeletal measurements relate to collapsibility measures on DISE, the influence of soft tissue dimensions on upper airway collapsibility is not known. We analyzed the relationship of measures of upper airway soft tissue volumes, specifically soft palate, pharyngeal lateral walls, and tongue, with metrics of collapsibility.
Full Text Link
-
Akshay Tangutur, Yi Cai, Everett G. Seay, Erica R. Thaler, Brendan T. Keenan, Raj C. Dedhia
Objective
To determine the effect of upper airway surgery on cardiovascular function in patients with obstructive sleep apnea (OSA).
Study Design
A prospective, self-controlled study from 2018 to 2023.
-
Julianna G. Rodin, Manan H. Parekh, Yi Cai, Brendan T. Keenan, Eric R. Thuler, Everett Seay, Joshua H. Atkins, Alan R. Schwartz, Raj C. Dedhia
With the recent addition of airflow and respiratory effort channels, our group has observed central and mixed apnea events during drug-induced sleep endoscopy (DISE). We measured the frequency and timing of sentinel central and/or mixed events (SCents), as well as assessed for differences in velum, oropharynx, tongue, and epiglottis (VOTE) classification compared to obstructive events.
-
Manan H Parekh, Eric Thuler, Vasiliki Triantafillou, Everett Seay, Chandra Sehgal, Susan Schultz, Brendan T Keenan, Alan R Schwartz, Raj C Dedhia
Purpose
To examine factors accounting for differences in hyoid motion during obstructive breathing events amongst obstructive sleep apnea (OSA) patients.
Methods
This was a prospective cohort study from June 2022 to October 2022. Patients with OSA undergoing evaluation for PAP alternative therapies with drug-induced sleep endoscopy with positive airway pressure titration (DISE-PAP). All patients underwent DISE-PAP and concurrent hyoid-focused ultrasound. DISE-PAP enabled measurement of airway physiology (flow, respiratory effort) and airway collapsibility (pharyngeal opening pressure, PhOP). Hyoid-ultrasound enabled hyoid bone movement during obstructive breathing. Respiratory effort was measured using a retro-epiglottic pressure-sensitive catheter. Hyoid position was measured using a standardized, awake, CT protocol. Regression analyses adjusted for age, race, sex, and BMI were performed to associate indices of respiratory effort and CT data with hyoid motion.
Results
On average, the 26 patients in this cohort were older (63.9 ± 10.5 years), male (69%), overweight (29.6 ± 3.99 kg/m2), and with moderate-to-severe OSA (26.8 ± 10.4 events/hour). Greater respiratory effort was associated with increased hyoid motion (β [95% CI] = 0.034 [0.016,0.052], standardized β = 0.261,p = 0.0003). Higher hyoid position was associated with greater hyoid displacement (β [95% CI] = -0.20 [-0.38, -0.01], Standardized β = -0.57, p = 0.036).
-
A 47-year-old male patient diagnosed with severe obstructive sleep apnea (OSA) sought alternatives to positive airway pressure, prompting evaluation with drug-induced sleep endoscopy (DISE). He underwent a specialized DISE with nasal airflow and pharyngeal pressure monitoring. During obstructive apneas, airflow and pressure signals demonstrated dynamic, multilevel upper airway collapse, with shifting sites of airflow obstruction as respiratory effort increased. This case report illustrates how quantitative airflow and pressure measurements can complement the standard DISE exam and aid in surgical decision-making.
-
Tice Harkins, Akshay Tangutur, Brendan T. Keenan, Everett G. Seay, Eric Thuler, Raj C. Dedhia, Alan R. Schwartz
IMPORTANCE
Drug-induced sleep endoscopy (DISE) is used to guide therapeutic management of obstructive sleep apnea (OSA), depending on the levels and patterns of pharyngeal collapse. However, the collapsibility of specific pharyngeal sites remains unknown.
OBJECTIVE
To assess collapse sites in patients with OSA undergoing DISE and whether number and location are associated with differences in airway collapsibility; and to quantify differences in collapsibility between primary and secondary sites in multilevel collapse.
-
Tice R. Harkins, BS1; Everett Seay, BS, RPSGT; Alan R. Schwartz, MD; Eric Thuler, MD, PhD; Raj C. Dedhia, MD, MSCR
A 71-year-old male with severe obstructive sleep apnea and nasal septal deviation presented to a positive airway pressure (PAP) alternatives clinic due to persistent obstructive events on both continuous PAP and bilevel PAP therapy delivered via oronasal mask. He underwent drug-induced sleep endoscopy with PAP titration to determine the mechanism of oronasal mask failure. A nasal mask was also applied and titrated for comparison. Drug-induced sleep endoscopy with PAP showed tongue base collapse which resolved at low pressure using a nasal mask. Application of an oronasal mask increased minimum therapeutic PAP level. Tightening the mask worsened tongue base collapse, which was not resolved by increasing the PAP level. Following nasal surgery, the patient was able to tolerate nasal continuous PAP at low therapeutic pressure, which resulted in both objective and subjective improvement is his obstructive sleep apnea. This case highlights the ability of drug-induced sleep endoscopy with PAP to determine the mechanistic cause of oronasal mask failure.
-
Tice R. Harkins, BS; Leonard J. M. Soh, MD; Everett G. Seay, BS, RPSGT; Eric Thuler, MD, PhD; Alan R. Schwartz, MD; Raj C. Dedhia, MD, MSCR
A 60-year-old female with moderate obstructive sleep apnea (apnea-hypopnea index = 26 events/h) was evaluated for positive airway pressure alternatives. She underwent drug-induced sleep endoscopy to provide a roadmap of her treatment options.1 Drug-induced sleep endoscopy showed complete anteroposterior collapse of the velum and tongue base, no lateral wall collapse, and a minimum therapeutic airway pressure requirement (ie, pharyngeal opening pressure) of 5 cmH2O, all of which indicated an increased likelihood of response to hypoglossal nerve stimulation (HGNS) therapy.2,3 An in-laboratory HGNS titration study showed objective improvement in her obstructive sleep apnea (residual apnea-hypopnea index = 1 events/h at 1.9 V); nevertheless, her bed partner still noticed nighttime snoring.
-
Tice R. Harkins, BS, Julianna G. Rodin, MD, Chau M. Phung, BS, Everett Seay, BS, RPSGT, Eric Thuler, MD, PhD, and Raj C. Dedhia, MD, MSCR
A 70-year-old obese male with moderate obstructive sleep apnea (OSA) sought alternative treatment after failing to tolerate positive airway pressure (PAP) therapy. He underwent drug-induced sleep endoscopy (DISE) with a nasal cannula and oral thermistor to differentiate nasal from oral breathing and a thoracoabdominal belt to track respiratory effort. DISE revealed a complete velum collapse in the anterior-posterior direction, consistent with his awake, supine computed tomography scan, yet the oral thermistor confirmed stable mouth breathing without respiratory distress. A mouth closure maneuver partially reopened the velum and appeared to enlarge the retroglossal airway. This case underscores the importance of evaluating a patient’s primary breathing route during DISE, as standard interpretations of airway collapse may be misleading without this information. Mouth breathing may bypass obstructions at the velum, affecting PAP efficacy and influencing treatment decisions. To address this gap in the VOTE (velum, oropharyngeal lateral walls, tongue base, and epiglottis) classification system, we propose “VM” to denote velum collapse in the context of mouth breathing. This addition could aid in tailoring OSA treatments, particularly for patients who predominantly breathe orally. Our findings advocate for a more patient-specific approach to DISE interpretations, emphasizing the physiological and anatomical aspects of airway collapse.
2023
-
Eric Thuler, MD, PhD, Everett G. Seay, RPSGT, John Woo, MD, Jane Lee, MD, Niusha Jafari, MS, Brendan T. Keenan MS, Raj C. Dedhia, MD, MSCR, Alan R. Schwartz, MD
Objective
To examine the relationship between craniofacial skeletal anatomy and objective measures of pharyngeal collapse obtained during drug-induced sleep endoscopy. We hypothesized that transverse maxillary deficiency and an increased pharyngeal length will be associated with higher levels of pharyngeal collapsibility.
-
Manan H. Parekh, BA ; Eric Thuler, MD, PhD; Vasiliki Triantafillou, MD ; Everett Seay, BS, RPSGT; Chandra Sehgal, PhD; Susan Schultz, BA, RDMS; Brendan T. Keenan, MS; Alan R. Schwartz, MD; Raj C. Dedhia, MD, MSCR
Introduction
The significance of hyoid dynamics in OSA pathophysiology remains unclear. Drug-induced sleep endoscopy (DISE) is often used for evaluating patients intolerant to positive airway pressure (PAP) therapy. We performed DISE with concurrent hyoid-focused ultrasonography to quantify hyoid dynamics during obstructive and non-obstructive breathing.
Methods
A cross-sectional analysis from a prospective cohort of patients undergoing DISE with PAP titration (DISE-PAP) and hyoid-focused ultrasound was conducted. Hyoid ultrasound was performed during obstructive breathing, and nonobstructive breathing after PAP administration. Motion was quantified by generating displacement curves based on echotracking hyoid movement. The image analysis protocol for quantifying hyoid displacement was performed independently by two researchers, and reliability of measures was assessed. Univariate and multivariate regressions were performed for various clinical data and hyoid displacement during obstructive breathing.
-
Manan Parekh, Vasiliki Triantafillou, Brendan T Keenan, Everett G Seay, Eric Thuler, Alan R Schwartz, Raj C Dedhia
Introduction
Increased pharyngeal collapsibility leads to obstructive sleep apnea (OSA). Positive airway pressure titration during drug-induced sleep endoscopy (DISE-PAP) provides objective collapsibility metrics, the pharyngeal opening pressure (PhOP), and active pharyngeal critical pressure (PcritA ). We examined the interrelationships between risk factors of OSA, airway collapsibility measures, and clinical manifestations of the disease.
Methods
This is a cross-sectional analysis of consecutive OSA patients undergoing DISE-PAP. Nasal PAP was increased stepwise until inspiratory flow limitation was abolished, signifying PhOP. PcritA was derived from the resulting titration pressure-flow relationships. Clinical data including demographics, anthropometrics, sleep studies, and patient-symptom questionnaires were obtained from the electronic medical record. Multivariate regression was used to evaluate the relationship between risk factors, airway collapsibility, and clinical data.
-
Sebastian M Jara, Eric R Thuler, Michael J Hutz, Jason L Yu, Crystal S Cheong, Normand Boucher, Marianna Evans, Raj C Dedhia
Objective
Surgically assisted rapid palatal expansion (SARPE) addresses transverse maxillary deficiency, a known contributor to nasal obstruction. The purpose of this study was to assess the feasibility, preliminary outcomes, and safety of posterior palatal expansion via subnasal endoscopy (2PENN), a modified SARPE procedure, aimed at achieving anterior and posterior maxillary expansion.
-
Michael J Hutz, Eric Thuler, Crystal Cheong, Chau Phung, Marianna Evans, John Woo, Brendan T Keenan, Raj C Dedhia
Objectives
Recent evidence suggests that environmental factors impact craniofacial development. Specifically, the height and width of the maxilla may impact the degree of septal deviation. We sought to determine the relationship between transverse maxillary deficiency and severity of septal deviation.
-
Thomaz Fleury Curado, MD, PhD; Luu Pham, MD; Tamas Otvos, MD; Tracy Klopfer; Carla Freire, MD; Mateus R. Amorim, PhD; Yoichi Nishimura, MD; Luiz Ubirajara Sennes, MD, PhD; Kevin J. Psoter, MD; Mohamed Abdelwahab, MD, MS; Allen Huang, DDS, MD; Raj Dedhia, MD; Stanley Liu, MD; Robson Capasso, MD; Arie Oliven, PhD; Vsevolod Polotsky, MD, PhD; David Eisele, MD; Alan Schwartz, MD
Study Objectives
The major goal of the study was to determine whether changes in tongue morphology under selective hypoglossal nerve therapy for obstructive sleep apnea were associated with alterations in airway patency during sleep when specific portions of the hypoglossal nerve were stimulated
-
Raj C. Dedhia, MD, MSCR; Donald L. Bliwise, PhD; Arshed A. Quyyumi, MD; Erica R. Thaler, MD; Maurits S. Boon, MD; Colin T. Huntley, MD; Everett G. Seay, RPSGT; Akshay Tangutur, MS; Patrick J. Strollo, MD; Nil Gurel, PhD; Brendan T. Keenan, MS
IMPORTANCE
Sham-controlled trials are needed to characterize the effect of hypoglossal nerve stimulation (HGNS) therapy on cardiovascular end points in patients with moderate-severe obstructive sleep apnea (OSA).
OBJECTIVE
To determine the effect of therapeutic levels of HGNS, compared to sham levels, on blood pressure, sympathetic activity, and vascular function.
2022
-
Jason L Yu, Eric Thuler, Everett G Seay, Alan R Schwartz, Raj C Dedhia
Objective
To examine the accuracy and interrater reliability of a visually assessed vs airflow-based measure of pharyngeal collapsibility obtained in patients with obstructive sleep apnea undergoing drug-induced sleep endoscopy (DISE).
-
Jason L. Yu, MD; Akshay Tangutur, MS; Eric Thuler, MD, PhD, MBA; Marianna Evans, DMD; Raj C. Dedhia, MD, MSCR
Study Objectives
There is increasing recognition that environmental factors affect human craniofacial development and our risk for disease. A scoping review of the literature was performed looking at environmental influences on craniofacial development to better understand this relationship and investigate what further study is needed to determine how this relationship may impact obstructive sleep apnea.
-
Crystal S Cheong, Raj C Dedhia, Everett G Seay, Sebastian M Jara, Jorge I Mora, Erica R Thaler, Alan R Schwartz
This case report describes a patient originally diagnosed with obstructive sleep apnea (OSA) who was later found to have central sleep apnea (CSA) during drug-induced sleep endoscopy, which was subsequently confirmed on an in-laboratory sleep study. The revised diagnosis resulted in a change in recommended therapy from hypoglossal nerve stimulation to phrenic nerve stimulation. This case report is a reminder that the sleep surgeon must be cognizant of the possibility of CSA being misclassified as OSA especially as home sleep studies become increasingly routine, and discusses ways to more easily distinguish between CSA and OSA.
2021
-
Raj C. Dedhia, Everett G. Seay, Alan R. Schwartz
Alternatives to positive airway pressure therapy, including surgery, represent an important area of research. Specifically, predictors of response to surgical therapy remain underdeveloped. Drug-induced sleep endoscopy (DISE) holds promise as a diagnostic tool to identify patient-specific causes of airway collapse. Herein, we present a novel, standardized approach which combines anatomic and physiologic measurements during DISE. Our DISE platform measures airflow, airway compliance, airway collapsibility, and structural drivers of collapse. Taken together, these inputs provide a comprehensive framework to further inform the surgeon in providing personalized care of the patient with obstructive sleep apnea.
2020
-
Phoebe K. Yu, MD, MPH ; Asitha D. L. Jayawardena, MD, MPH; Matthew Stenerson, BA; Margaret B. Pulsifer, PhD; Julie A. Grieco, PsyD; Leonard Abbeduto, PhD; Raj C. Dedhia, MD, MSCR ; Ryan J. Soose, MD; Allison Tobey, MD; Nikhila Raol, MD, MPH; Stacey L. Ishman, MD, MPH; Sally R. Shott, MD; Michael S. Cohen, MD; Brian G. Skotko, MD, MPP; Thomas B. Kinane, MD; Donald G. Keamy Jr MD, MPH; Christopher J. Hartnick, MD, MS
Objectives/Hypothesis
Patients with Down syndrome have a high incidence of obstructive sleep apnea (OSA) and limited treatment options. Hypoglossal stimulation has shown efficacy but has not yet been approved for pediatric populations. Our objective is to characterize the therapy response of adolescent patients with down syndrome and severe OSA who underwent hypoglossal stimulation.
-
Jason L Yu, Yifan Liu, Akshay Tangutur, Monique Arnold, Everett G Seay, Alan R Schwartz, Raj C Dedhia
Study Objectives
Lower therapeutic positive airway pressure (PAP) levels are associated with improved response to non-PAP therapies in the treatment of obstructive sleep apnea. The aim of this study was to evaluate the prevailing notion that patients with apnea-predominant obstructive sleep apnea require higher therapeutic PAP levels compared to patients with hypopnea-predominant obstructive sleep apnea.
-
Everett G. Seay, BS, RPSGT; Graeme Mulholland, MD; Raj C. Dedhia, MD, MSCR
This is a case report of an 41-year-old male with obesity (bodymass index 90 kg/m2), severe obstructive sleep apnea (OSA), and an apnea-hypopnea index of 90 events/h despite high bilevel positive airway pressure (BPAP). He presented to the PAP Alternatives Clinic and underwent tonsillectomy, expansion sphincter pharyngoplasty, and partial uvulectomy to improve positive airway pressure effectiveness. Postoperative BPAP retitration resolved the patient’s OSA. The patient is currently using BPAP therapy at home with improvement in both objective and self-reported OSA outcomes.
-
Everett G. Seay, BS, RPSGT; Brendan T. Keenan, MS; Alan R. Schwartz, MD; Raj C. Dedhia, MD, MSCR
IMPORTANCE
Recent retrospective hypoglossal nerve stimulation (HGNS) outcomes data suggest that patients with low therapeutic positive airway pressure (PAP) levels achieve greater success than patients with high therapeutic PAP levels.
OBJECTIVE
To examine the use of therapeutic nasal PAP levels at the soft palate in predicting the outcomes of HGNS for patients with obstructive sleep apnea.
-
Graeme B. Mulholland, MD ; Raj C. Dedhia, MD
Objectives/Hypothesis
Hypoglossal nerve stimulation (HGNS) effectively treats obstructive sleep apnea in select patients. Drug-induced sleep endoscopy (DISE) is required for HGNS candidacy. Data suggest that mandibular advancement (MA) devices and HGNS share similar target populations. We aimed to test the association between MA’s effect on the velum and lateral walls during DISE in relation to the improvement in the apnea-hypopnea index (AHI) with HGNS.
-
Clara H Lee, Everett G Seay, James W Reese, Xin Wu, Richard J Schwab, Brendan Keenan, Raj C Dedhia
Objective
To determine if clinically acquired cephalometric measurements, specifically soft palate size, can predict hypoglossal nerve stimulation outcomes.
-
Clara H. Lee, MD ; Graeme B. Mulholland, MD; Raj C. Dedhia, MD, MSCR
Objectives/Hypothesis
To examine the correlation between transoral and awake endoscopic examination and investigate their respective ability to predict outcomes of hypoglossal nerve stimulation (HGNS).
-
Raj C. Dedhia, MD, MSCR, and Gary F. Bouloux, DDS, MD, MDSc
The purpose of this study was to determine if submental intubation during maxillomandibular advancement (MMA) reduces the development of nasal obstruction in patients with obstructive sleep apnea (OSA).