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Original Investigation |

A New Scoring System for Upper Airway Pediatric Sleep Endoscopy

Dylan K. Chan, MD, PhD1; Bryan J. Liming, MD3; David L. Horn, MD2; Sanjay R. Parikh, MD2
[+] Author Affiliations
1Division of Pediatric Otolaryngology, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco
2Division of Pediatric Otolaryngology, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle
3Division of Otolaryngology, Department of Otolaryngology–Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
JAMA Otolaryngol Head Neck Surg. 2014;140(7):595-602. doi:10.1001/jamaoto.2014.612.
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Published online

Importance  Sleep-associated upper-airway obstruction in children is a significant cause of morbidity. Development of a simple, standardized, quantitative technique to assess anatomic causes of sleep-related breathing disorder is important for surgical planning, clinical communication, and research.

Objective  To design, implement, and evaluate a scoring system to quantify airway obstruction in pediatric drug-induced sleep endoscopy.

Design, Setting, and Participants  This study was a retrospective case series conducted at a tertiary pediatric hospital. The patients were children with sleep-related breathing disorder who underwent polysomnography and drug-induced sleep endoscopy.

Interventions  Flexible fiber-optic laryngoscopy was performed. Endoscopic examinations were recorded on video and assessed by 4 independent raters based on a scoring template.

Main Outcomes and Measures  Five locations in the upper aerodigestive tract (adenoid, velum, lateral pharyngeal wall, tongue base, and supraglottis) were evaluated on a 4-point scale for minimum and maximum obstruction. Internal reliability was assessed by calculating interrater and intrarater intraclass correlation coefficients (ICCs). For external validation, aggregate and site-specific scores were correlated with preoperative polysomnographic indices.

Results  Videos recorded of sleep endoscopies from 23 children (mean age, 2.2 years) were reviewed and rated. Children had an average apnea-hypopnea index of 24.8. Seventy percent of interrater and intrarater ICC values (7 of 10 for each set) were above 0.6, demonstrating substantial agreement. Higher total obstructive scores were associated with lower oxygen saturation nadir (P = .04). The scoring system was also used to quantitatively identify children with multilevel airway obstruction, who were found to have significantly worse polysomnographic indices compared with children with single-level obstruction (P = .02).

Conclusions and Relevance  The proposed scoring system, which is designed to be easy to use and allow for subjectivity in evaluating obstruction at multiple levels, nonetheless achieves good internal reliability and external validity. Implementing this system will allow for standardization of reporting for sleep endoscopy outcomes, as well as aid the practicing clinician in the interpretation of sleep endoscopy findings to inform site-directed surgical intervention in cases of complicated obstructive sleep apnea.

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Figures

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Figure 1.
Scoring Form and Guidelines

The form (A) and guidelines (B) used for post hoc scoring of drug-induced sleep endoscopy are presented. Some data fields in the scoring form, including turbinate and tonsil size, and use of adjunct airway, were not included in our analysis. LPW indicates lateral pharyngeal wall.

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Figure 2.
Patient Profile

Individual patient obstructive, polysomnographic, and demographic profiles are shown. Mean obstructive score at each of the 5 evaluated sites (adenoid, velum, lateral pharyngeal wall [LPW], tongue base, and supraglottis) is graphically represented as either less than 2.0 (white box) or 2.0 or more (black box). Multilevel obstruction group (1, 2, or 3) was defined as follows: Group 1: No or 1 site with obstructive score greater than 2; group 2: 2 or more sites with obstructive score greater than 2 but confined to upper (adenoid, velum, LPW) or lower (tongue base, supraglottis) airway complex; group 3: 2 or more sites with obstructive score greater than 2, encompassing both upper and lower airway complexes. Total indicates total obstructive score (sum of obstructive scores at each of the 5 sites) from sleep endoscopy. AHI indicates apnea-hypopnea index from preoperative polysomnography. Oxygen nadir is low oxygen saturation from preoperative polysomnography. Age in years, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), prior sleep surgery (N, none; A, adenoidectomy; or TA: adenotonsillectomy), and medical comorbidities (neuromuscular, syndromic, pulmonary, or chromosomal) are shown.

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Figure 3.
Representative Images

Each of the 4 ordinal scores at each of the 5 upper-airway sites are shown.

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Figure 4.
Internal Reliability

Interrater (A) and intrarater (B) reliability assessed with the intraclass correlation coefficient (ICC) are shown for the 5 sites of upper airway obstruction scored for videos of drug-induced sleep endoscopy. Ratings for minimum (light blue) and maximum (white) obstruction at each site are shown. 1.0 indicates perfect correlation; 0, no correlation. Error bars indicate 95% CIs for each measurement. LPW indicates lateral pharyngeal wall.

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Figure 5.
Multilevel Obstruction

Multilevel obstruction was determined based solely on objective site-specific obstructive scores. Apnea-hypopnea index (AHI) and low oxygen saturation values for patients in the 3 multilevel obstruction groups were compared. Multilevel obstruction group (1, 2, or 3) was defined as follows: group 1, no or 1 site with obstructive score greater than 2; group 2, 2 or more sites with obstructive score greater than 2 but confined to upper (adenoid, velum, lateral pharyngeal wall [LPW]) or lower (tongue base, supraglottis) airway complex; group 3, 2 or more sites with obstructive score greater than 2, encompassing both upper and lower airway complexes.aP = .02.

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