Drug-induced sleep endoscopy (DISE) changes the surgical plan in roughly half of children with conventional (surgery-naïve, non-syndromic) obstructive sleep apnea–hypopnea syndrome (OSAHS), yet all supporting evidence is non-randomized. The open problem is to establish, by adequately powered randomized controlled trials with objective polysomnographic outcomes, whether DISE-directed individualized treatment improves results over standard adenotonsillectomy guided by awake examination alone; two secondary questions, unresolved by the existing non-randomized evidence, are whether that effect is modified by the known risk factors for persistent OSAHS (obesity, small tonsil size, severe baseline apnea–hypopnea index) and whether the sedation agent (propofol vs. dexmedetomidine) systematically alters the obstruction patterns DISE observes. No completed randomized comparison of DISE-directed treatment with standard awake-examination-guided adenotonsillectomy in this population has been reported; the single directly on-point randomized trial (NCT06093802) had not yet begun recruitment.

Background

Obstructive sleep apnea–hypopnea syndrome (OSAHS, also called pediatric obstructive sleep apnea, OSA) is a disorder of repeated upper-airway collapse during sleep, affecting roughly 1–4% of children and diagnosed by polysomnography (PSG, an overnight multichannel sleep study); severity is quantified by the apnea–hypopnea index (AHI), the number of apneas and hypopneas per hour of sleep. First-line treatment is adenotonsillectomy (ATA, surgical removal of adenoids and tonsils), the most common pediatric airway operation, planned on the basis of awake clinical examination plus history. A substantial minority of children — about a quarter to a third — have persistent OSA after ATA, with obesity, small tonsil size, and severe baseline AHI recognized as independent risk factors for persistence. Drug-induced sleep endoscopy (DISE) is an alternative planning tool: while the child breathes under controlled sedation (typically propofol or dexmedetomidine), a flexible endoscope visualizes the dynamic sites and degrees of airway collapse, usually reported with site-based scores such as the velum–oropharynx–tongue base–epiglottis (VOTE) classification. Because collapse patterns frequently differ from what awake inspection suggests, DISE could individualize surgery — or, critics note, could add anesthetic risk, cost, and observer-dependent findings without improving outcomes. The key systematic review and meta-analysis is Wang, Chen, Li, Pan, and Teng (Sleep and Breathing 28(2):935–944; published online 2023, print issue 2024): pooling four non-randomized case series totaling 761 children with conventional OSAHS (no prior airway surgery, no craniofacial or syndromic comorbidity), it found obstruction at the adenoid in 93%, at the tonsils in 76%, and multilevel obstruction in 60% of children during DISE, and DISE changed the conventional surgical approach in 45% (95% CI 29–60). Postoperative symptoms and PSG parameters improved after DISE-guided surgery, but the authors stress that the evidence base consists exclusively of low-quality, non-randomized case series, that pooled estimates were too heterogeneous for BMI- or tonsil-size subgroup analysis because the primary studies lacked granular data, and that the sedation agent is a potential confound of the observed obstruction patterns, since propofol and dexmedetomidine affect airway tone and respiratory drive differently. Existing practice guidance, such as the expert consensus on persistent pediatric OSA after ATA (Ishman et al. 2023), positions DISE mainly for persistent disease; its role in the far larger surgery-naïve conventional OSAHS population is exactly what remains unsettled.

Problem Statement

Establish, with high-quality randomized controlled evidence, the role of DISE in the management of conventional pediatric OSAHS (children with no previous upper-airway surgery and no craniofacial abnormalities or syndromes): (1) determine whether a DISE-directed, individualized treatment plan improves objective outcomes — postoperative polysomnographic measures such as AHI and disease-severity classification, together with clinical outcomes — compared with standard adenotonsillectomy guided by awake examination alone. Two related questions are open secondary objectives rather than prerequisites for a definitive answer: (2) whether this effect is modified by the recognized risk factors for persistent OSAHS — obesity, small tonsil size, and severe baseline AHI; (3) whether the sedation agent (propofol vs. dexmedetomidine) systematically alters the obstruction patterns observed during DISE in children. No completed randomized comparison yet exists in this population, and the supporting evidence is exclusively non-randomized. Resolving (1) would determine whether DISE should be incorporated into routine surgical planning for conventional pediatric OSAHS or reserved for selected populations.

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