The Laryngoscope

© 2019 The American Laryngological,

Rhinological and Otological Society, Inc.

Positional Awake Endoscopy Versus DISE in Assessment of OSA:

A Comparative Study

Sherif M. Askar, MD ; Amal S. Quriba, MD; Elham M. Hassan, MD; Ali M. Awad, MD

Objective: To compare awake endoscopy with Müller’s maneuver (MM) during both sitting and supine positions, with
drug-induced sleep endoscopy (DISE) as regard determination of different levels, patterns, and degrees of collapse of the upper
airway in adult patients with obstructive sleep apnea (OSA).
Methods: The study included adult patients with OSA symptoms, who had apnea hypopnea index (AHI) > 15. Patients
were examined by MM in a sitting position, then during supine position; DISE then followed. Site, pattern, and degree of
obstruction were assessed by experienced examiners according to the nose oropharynx hypopharynx and larynx classification.
Results: Eighty-one adult subjects were included. The most common pattern of collapse at the retro-palatal level was the
concentric pattern, while the predominant pattern at the hypopharyngeal level was the lateral wall collapse. The analysis of
the pattern of collapse of the study group revealed that the individual pattern did not change (for the same patient at the same
level) in the majority of patients whatever the maneuver or the position.
Conclusion: This study demonstrates the feasibility of positional awake endoscopy for providing valuable surgical infor-
mation as regard level, pattern, and degree of severity in OSA. The data of positional awake endoscopy were comparable to
those gained from DISE with less morbidity and costs. The idea and results of this work provide a useful foundation for future
research in this area. Multicenter studies are encouraged to obtain more reliable conclusions and more clear standards aiming
at a better surgical planning.
Key Words: Awake endoscopy, Müller’s maneuver, DISE, obstructive sleep apnea.
Level of Evidence: 4
Laryngoscope, 00:1–6, 2019

INTRODUCTION Drug-induced sleep endoscopy (DISE) and awake

Obstructive sleep apnea (OSA) is associated with signifi-
cant morbidity and negative health, social, and financial
impacts. It affects quality of life of patients with subsequent
harmful consequences and high risks of mortality.1–4 Poly-
somnography (PSG) is considered the cornerstone in diagnos-
ing OSA. It can be used to distinguish snoring from OSA and
to determine the severity of OSA. Unfortunately, from a sur-
gical point of view, PSG cannot provide a topographical evalu-
ation of the upper airway (UA); while accurate detection of
the level and the pattern of airway collapse have the utmost
importance for the surgical plan of the individual OSA
patient.5–19 The topographical assessment of the UA had
relied on radiological examinations (CT, lateral cephalome-
try, and magnetic resonance imaging). However, these proce-
dures have inherent limitations (eg, patient wakefulness,
costs, time consumption, and different departments’ involve-
ment). Also, they are considered static (non-dynamic) evalua-
tions. Although many tools are available no adequate one had
gained universal agreement among reports so far.5–9,20–32
From the Phoniatric Unit (A.S.Q., E.M.H.), and the Department of
Otorhinolaryngology–Head and Neck Surgery (S.M.A., A.M.A.), Faculty of
Medicine, Zagazig University, Zagazig, Egypt.
Editor’s Note: This Manuscript was accepted for publication on
October 17, 2019.
The authors have no funding or conflicts of interest to declare.
Send correspondence to Sherif M. Askar, MD, (2) Othman Bin Affan
st, Zagazig city, Sharkia Governorate, Egypt. E-mail: askr_sh@yahoo.com;
askr_sh2000@yahoo.com
DOI: 10.1002/lary.28391
endoscopy with Müller’s maneuver (MM) could define
sites and patterns of airway collapse in OSA patients and
could provide a three-dimensional anatomical topography
of the involved area; thus, both maneuvers help sleep sur-
geons in making proper surgical plans and decisions.
DISE and MM might be considered the most reliable
radiation-free tools in the diagnostic protocol of patients;
however, both are not free of disadvantages. The costs,
availability, and lack of experienced personnel are still
problems especially in developing countries.6–9 MM may
have many advantages over DISE as it is an outpatient
procedure, is performed without drug induction, and has
less patient/hospital burden. However, with respect to all
the mentioned advantages, concerns regarding the accu-
racy of MM in assessment of the grade and the pattern of
collapsibility might show up.20–32
The main differences (regarding the dynamic anatomy
of the UA) between sleep and wakefulness are the effects of
both gravity and muscle tone.5,10 Thus, we hypothesized
that if MM was done in the supine position (MM-P), the
gravity factor could be minimized, then the tone of muscles
would be the leading parameter to be assessed. So, MM-P
could provide useful surgical data comparable to DISE.
This study was planned to compare MM (during both
sitting and supine positions), with DISE regarding the
determination of different levels, patterns, and degrees of
collapse of the upper airway in adult patients with OSA.
This may help selection of most appropriate diagnostic

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1
methods for assessment of patients with OSA, for whom TABLE I.
the best maneuver is yet to come. Demographic Data of the Study Group (n = 81).
Variables Range Mean
SD

PATIENTS AND METHODS Age 19–58 y 31.4
7.2 y

Settings AHI 18–76 38.5
4.1

This prospective comparative study included adult BMI 29.8–34.6 31.7
1.9
OSA patients presented to the ORL-HN Surgery Depart- Sex N = 81 (%)
ment, Zagazig University Hospitals, from June 2014 to
April 2019. Male 49 60.4%
Female 32 39.6%

Ethical Considerations AHI = Apnea Hypopnea Index, BMI = body mass index, SD = standard
deviation.
This study was conducted according to the Declaration
of Helsinki on Biomedical Research Involving Human Sub- an induction bolus of 1 mg/kg propofol was injected
jects. Deceptive practices were avoided during the design of followed by 20-mg doses every 2 minutes until the start of
the research. A prior written informative consent was gained the snoring-apnea cycle. Then a lubricated FN was gently
from all included patients. Participants were not exposed to introduced into the nasal cavity.
any physical, psychological, or social harm. Patient privacy During MM-S, MM-P and DISE, the sites and degrees
and confidentiality were protected. The participants had the of obstructions were assessed using the NOHL classification.
right to withdraw from the study at any time. This scale evaluates the primary structures that contribute
to the collapse of the UA; namely: The nose (N), the ret-
ropalatal region (oropharynx [O]), the retro-lingual region
Inclusion and Exclusion Criteria
(hypopharynx [H]), and laryngeal (L). For the first three
The study included adult patients with OSA symptoms
levels the grading of collapse is: 1 = 0–25%, 2 = 25–50%,
who had apnea hypopnea index (AHI) > 15 (on PSG) and
3 = 50–75%, and 4 = 75–100%. As to the pattern of collapse,
body mass index (BMI) ≤ 35 kg/m2. All patients were CPAP
the retro-palatal and the hypopharyngeal can be: transver-
intolerant, thus were candidates for surgical intervention.
sal (lateral; L), anteroposterior (AP), or concentric (C). For
Exclusion criteria included patients with history of sur-
the larynx, the classification includes (p = positive) or the
gical intervention for snoring/OSA (eg, UPPP). Patients who
absence (n = negative) of obstructions.11–13
gave history of tonsillectomy, adenoidectomy, and nasal sur-
For all maneuvers (MM-S, MM-P, and DISE), data
geries were excluded. Patients who missed follow-up ses-
(as regard sites, patterns, and degrees of obstruction) were
sions were also excluded from the study.
assessed by three independent experienced examiners (with
at least two agreements). During all assessments, examiners
Methods were blinded with the patient’s identity. In one session,
After detailed history taking, and general and otorhi- observers gave their comments about a single maneuver (eg,
nolaryngology examinations, all patients had Epworth MM-S) for a group of patients, and then other maneuvers
Sleepiness Scale (ESS) analysis as a subjective measure of were examined in later separate sessions. This method could
daytime somnolence. Oral examination included detailed assure the blindness of the patients’ identity.
assessment of dentition, soft palate and uvula, and tonsil
size with specific estimation of tongue base size.9
Then, flexible naso-fibroscope (FN) (Xion, 3.2 mm Statistical Analysis
diameter; Xion Medical, Berlin, Germany) was used for Data analysis was performed using statistic package
assessment of UA. The computerized system included a SPSS version 20 (SPSS Inc., Chicago, IL). Numerical data
camera and a light source (Xion Medicals). The software
enabled video recording and saving of the recorded mate- TABLE II.
rial. FN was applied for both MM and DISE. Comparison Between the Pattern of Endoscopic Closure Among
During MM, patients were placed in a sitting position the Study Group During MM-S, MM-P, and DISE (n = 81).
(MM-S) while FN was passed through the nostril towards MM-S MM-P DISE X2 P
the nasopharynx. Müller’s maneuver was then performed
by maintaining maximal inspiration with an open glottis RP-L C 52 (64.6%) 51 (62.9 %) 52 (64.6%) 0.103 .998
against closed mouth and nose. All patients were taught AP 14 (17.2%) 15 (18.5%) 15 (18.5%)
how to perform the maneuver and were given the opportu- Lat 15 (18.5%) 15 (18.5%) 14 (17.2%)
nity to practice before nasal endoscopy. Then the same tech- HP-L C 2 (2.5%) 2 (2.5%) 2 (2.5%)
nique was repeated again in the supine position (MM-P). AP 1 (1.2%) 1 (1.2%) 2 (2.5%) 0.508 .973
DISE was performed for all patients at the operating Lat 78 (96.3%) 78 (96.3%) 77 (95%)
room just before induction of the general anesthesia
for sleep surgery. The anesthetist gave propofol, under MM-S = Müller’s maneuverer in sitting position, MM-P = Müller’s
maneuverer in supine position, DISE = drug-induced sleep endoscopy,
electrocardiography and pulse oximetry monitoring. RP-L = retropalatal level, HP-L = hypopharyngeal level, C = concentric,
A 20-ml syringe containing 2% propofol was used. At first, AP = anteroposterior, Lat = lateral. P < .05 considered significant.

Laryngoscope 00: 2019 Askar et al.: Awake Endoscopy vs. DISE in OSA
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Fig. 1. The mean grade of collapse at the retropalatal level. [Color
figure can be viewed in the online issue, which is available at www.
laryngoscope.com.]
Fig. 2. The mean grade of collapse at the hypopharyngeal level.
[Color figure can be viewed in the online issue, which is available at
www.laryngoscope.com.]
were presented with mean and standard deviation.
One-way ANOVA was used to compare more than two
variables, when significance was detected the post-hoc
Turkey HSD test was used to detect intervariable sig-
nificance. Ordinal data were presented as number and
percentage. The chi-squared test was used for their
analysis. P was considered significant when P value
was less than .5.
RESULTS
The current study was applied on 81 subjects with a
mean age of 31.4
7.2 years. All candidates had snoring,
other obstructive sleep apnea symptoms and AHI range
from 18 to 76 (on PSG). Table I presents the basic demo-
graphic data of the study group.
During endoscopic evaluations (MM-S, MM-P, and
DISE), the most common site of collapse was the retro-palatal
level (81 patients; 100%); all of them had surgical interven-
tion. Hypopharyngeal level collapse was detected in all
patients (81 patients; 100%), but 59 patients (72.84%) showed
high grades of collapse (grade 3–4) thus needed surgical inter-
vention. Seventy-two patients (88.89%) had a multilevel col-
lapse (at least two levels).
The most commonly noticed pattern of collapse at
the retro-palatal level was the concentric pattern, while
the predominant pattern at the hypopharyngeal level was
the lateral wall collapse. The analysis of the pattern of
collapse of the study group revealed that the individual
pattern did not change (for the same patient at the same
level) in the majority of patients whatever the maneuver
or the position; there were no significant differences
among the three endoscopic maneuvers at both retro-
palatal and hypopharyngeal levels (Table II).
As regard the grade of collapse, the retro-palatal
level had a mean grade of (3.589
0.594) for MM-S, and
(3.7
0.674) for MM-P. DISE showed a mean grade of
collapse (3.92
0.273) (Fig. 1). There was significant dif-
ference among the three results. Intervariable compari-
son revealed that the significance was awed to DISE
results that showed significant difference from both posi-
tions of MM, while there was non-significant difference
between MM-S and MM-P.
For the hypopharyngeal level the mean grade of collapse
was (3.4
0.81) for MM-S and (3.49
0.757) for MM-P.
DISE showed a mean grade of collapse (3.872
0.339)
(Fig. 2). There was a significant difference among the three
results. Intervariable comparison revealed that the signifi-
cance between MM-S and DISE results was higher
(P < .01) than the significance between MM-P and DISE
(P < .05) (Table III). In the study group, we had no cases of
epiglottic/laryngeal collapse causes (n).
It was observed that the change between the grades
of collapse did not exceed one grade between different
maneuvers of examination (MM-S, MM-P, and DISE) for
the same patient and at the same level.

TABLE III.
Comparison Between the Grade of Endoscopic Closure Among the Study Group During MM-S, MM-P, and DISE (n = 81).
(A) MM-S (B) MM-P (C) DISE
Mean
SD Mean
SD Mean
SD F P Turkey HSD Post-hoc

Gd RP-L 3.589
0.594 3.7
0.674 3.92
0.273 7.822 .005* A vs. B = 0.359
A vs. C = 0.042; P < .05*
B vs C = 0.028; P < .05*
HP-L 3.4
0.81 3.49
0.757 3.872
0.339 11.354 .002* A vs. B = 0.669
A vs. C = 0.00001; P < .01*
B vs. C = 0.014; P < .05*

MM-S = Müller’s maneuverer (sitting position), MM-P = Müller’s maneuverer (supine position), DISE = drug-induced sleep endoscopy, RP-L = retropalatal
level, HP-L = hypopharyngeal level, SD = standard deviation, F = one-way ANOVA test, P = probability (*Significant: P < .05).

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 Multilevel surgery was performed in 72 (88.89%)
patients. Single-level palatal surgery (suspension sutures
with tonsillectomy) was performed in nine (11.1%) patients.
Hyoid bone surgery (for cases of grade 3–4 hypopharyngeal
collapse) was performed in 59 patients (72.84%) while nasal
surgery was required in 21 (25.9%) patients.9,14–19
DISCUSSION
The recent trends in surgical management of patients
with OSA depend on accurate determination of sites of UA
collapse and obstruction. Various tools of examination exist
but no universally adequate one has been developed so
far.5,6,9,20–32
Drug-induced sleep endoscopy (DISE) is the use of FN
to examine the UA during a pharmacologically induced
sleep, while awake endoscopy with MM is done (as an outpa-
tient procedure) in the awake candidate. Both tests have no
radiation exposure. Both tests are employed to assess differ-
ent levels of collapse and to comment on patterns and
degrees of collapse of the upper airway in patients with
OSA. DISE and MM could influence surgical decisions and
outcomes by determining a suitable surgical plan based on
the precise determination of the three-dimensional anatomi-
cal topography of the level of obstruction. Moreover, DISE
and MM could reduce the rate of multilevel (and thus more
extensive) resection, and could improve success rates of sur-
gical intervention. Thus, MM and DISE are the most fre-
quently used maneuvers by sleep surgeon for assessment
and planning of OSA patients.22–32
DISE (first proposed by Croft and Pringle in 1991)
might be considered by many sleep surgeons the most
reliable tool in the topographical diagnostic protocol of
patients.10 Unfortunately, DISE has limitations. First, it
is a drug-induced sleep (ie, not a natural sleep). Although
different drugs (with different pharmaceutical character-
istics) are described, concerns about the safety, efficacy,
and methods of administration of these drugs were men-
tioned. Second, it needs special rooms, equipment, and
trained personnel. Third, as it is performed during inter-
mittent short sleep cycle, it does not permit examination
of multiple airway levels simultaneously during the same
cycle. Fourth, there are no clear standards for surgical
planning based on data of the degree/pattern of obstruc-
tion. Fifth, follow-up of patients by DISE is a well-known
obstacle for sleep surgeons, especially in successful sur-
geries. Sixth, discussions over the validity/reliability of
DISE have been mentioned. Obviously, DISE is costly
and not widely available especially in developing coun-
tries with limited health budgets.5,22–24,27–32 DISE could
be performed just before surgery (before induction of gen-
eral anesthesia) or few days before surgery: in the former
situation, concerns as regard patients’ consents exist,
while in the later situation, twice entrances/appointments
to the theatre are needed for the individual patient.
MM is a simple, low-cost, convenient, informative, and
non-invasive maneuver; however, it is not free of limitations.
Clearly, it evaluates the UA when the patient is awake while
the basic problem occurs during sleep. Also (as DISE) no def-
inite standards are available for determining a precise
Laryngoscope 00: 2019
4
surgical plan according to the site and the degree of
obstruction.5–8,13–17,20,21,30–32
Previous studies assumed that there were different
endoscopic results regarding the grade and may be the
pattern of closure between MM and DISE. However, a
suggestive trend towards DISE is noticed13–19,23–32 We
suggest that these results reflect: A) the subjective nature
of endoscopic tests, B) different examination environment
and facilities, and C) different instrumentation. Also, the
experience of the examiner and the degree of patient’s
cooperation could never be ignored.
Our assumption provides the idea that the available
different results between MM and DISE may be due to
the following main possibilities: the first one is the differ-
ent positional effect as MM is usually done in sitting
while DISE is done during supine position, while the sec-
ond one is due to lower muscle tone during DISE (as the
patient is sleeping). In our study, MM was performed in
two different positions: sitting (MM-S) and supine (MM-
P). Then, DISE was done just before induction of general
anesthesia for sleep surgery. The results of the three
endoscopic methods were collected, examined by blinded
experts, and then the obtained results were compared.
Our results show that the most frequent site of col-
lapse visualized during MM (MM-P and MM-S) and DISE
was the retro-palatal area; several studies reported the
same figures.6,8,14–18,23,24,29–32
As regard the grade of collapse, there was a signifi-
cant difference between the results of MM (both positions)
with DISE. Intervariable comparison revealed that the
significance was awed to DISE results that showed signif-
icant difference from both positions of MM, while there
was nonsignificant difference between MM-S and MM-P.
It was also found that the significance between the grade
of collapse in MM-S and DISE was higher than the signif-
icance between MM-P and DISE at the hypopharyngeal
level. This may reveal that MM-P may exceed the MM-S
to give results nearer to DISE. A recent research reported
a significant moderate agreement (at oropharyngeal level
only) for MM as compared to DISE.31
Noticeably, although the statistically significant differ-
ence in grade was present, it did not exceed one grade of
severity in almost all patients. This might support the
hypothesis that the decreased muscle tone during sleep
could be considered the major effective factor that causes
differences between awake and sleep endoscopy. Our results
agreed with recent researchers who reported that the pat-
tern of the obstruction was similar in DISE and MM, while
the difference between both was the degree of collapse.22,31
In our study, MM-P had nearer results to DISE.
Accordingly, although we cannot deny the superiority of
DISE on MM in assessment of OSA when talking about
the grade of severity, it was from the statistics point of
view and presented no more than one grade. But, does
these data affect the surgical decision? This is the ques-
tion. Our answer, according to the gained data, is no; this
narrow difference would not affect the surgical decision.
This answer was also supported by the other interesting
data that the analysis of the pattern of collapse revealed
that the pattern does not change (for the same patient at
the same level) whatever the maneuver or the position.
Askar et al.: Awake Endoscopy vs. DISE in OSA
 From a surgical point of interest, these data might add
a favor for MM (MM-S and MM-P) over DISE as the deci-
sion of surgical intervention and the selection of the
required surgical technique (at the individual site) usually
depend on the pattern more than the grade of collapse.30–32
An interesting paper compared DISE and MM-S in cases of
retropalatal obstruction. They reported that MM has many
advantages over DISE. They added that although DISE
findings could lead to a change in surgical plan, the overall
patients0 improvement showed no significant difference; our
results might agree with them.32
Fernandez-Julian et al. reported that DISE could
change surgical decision making compared to MM. They
added that MM is capable of detecting obstruction levels in
the upper airway and can be used to determine surgical sites
in cases when DISE cannot be used due to a patient’s condi-
tion or a clinic’s circumstances.9 To some extent, our results
might agree with them. However, Lovato et al. compared data
of DISE and MM-S and reported that MM-S showed a fair
pattern agreement with DISE only in the oropharynx; while
in the other sites no significant agreement was found.31
Interestingly, in more than 95% of included subjects,
it was noticed that the pattern of obstruction at the hypo-
pharynx (by MM-S, MM-P, and DISE) was transverse.
This might explain the efficacy of hyoid bone surgeries in
cases of OSA with hypopharyngeal collapse, as those pro-
cedures support the lateral wall preventing the trans-
verse collapse.14–19
In the current study, there were nonsignificant dif-
ferences either in grade or pattern of obstruction between
positional MM and DISE at the epiglottic/laryngeal
levels. Although the number of included patients is rela-
tively small we could report that epiglottic collapse is an
uncommon finding in adults with OSA.
In brief, MM-P is a simple, less costly, outpatient
maneuver that could provide good conclusions that are com-
parable to DISE regarding both pattern and grading of col-
lapse at all UA levels. The difference between both is narrow
and does not affect surgical decision. MM-P has many advan-
tages over DISE. It needs no special anesthetic precautions,
rooms, or equipment. Follow-up is much easier with MM-P
and the issue of patient’s consent would be more convenient.
The strength of this study lies in its prospective nature,
which allowed data to be accurately assessed without
depending on data registration or patients’ recollection.
Moreover, the results were reported in a blinded manner
provided data validation.
This study has limitations. The small number of
patients is a limitation; however, we feel it was reason-
able for a preliminary report. The effects of drugs (prop-
ofol) on muscle relaxation during DISE and the effect of
topical anesthetics (if needed) during MM are question-
able. The subjective nature of MM and DISE is another
issue. Authors encourage future wide employment of posi-
tional MM (MM-S and MM-P) in different sleep centers to
get more validated data.
CONCLUSION
This study demonstrates the feasibility of positional
awake endoscopy for providing valuable surgical information
Laryngoscope 00: 2019
as regard level, pattern and degree of severity in OSA. The
data of positional awake endoscopy were comparable to
those gained from DISE with less morbidity and costs. The
idea and results of this work provide a useful foundation for
future research in this area. Multicenter studies are encour-
aged to obtain more reliable conclusions and more clear
standards aiming at a better surgical planning.
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