Multiple Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea: Obstruction Patterns and Outcomes

Objectives: Residual obstructive sleep apnea (OSA) following adenotonsillectomy (AT) is common in children with obesity. Drug-induced sleep endoscopy (DISE) identifies upper airway obstruction and guides surgery. A gap remains in evaluating multiple DISE-directed treatments. This study evaluates multiple DISE-directed procedure outcomes, obstruction patterns, and BMI in pediatric patients. Methods: This single-institution retrospective cohort study included pediatric patients who underwent DISE-directed interventions from 2009 to 2020. Variables included patient characteristics, DISE timing, obstruction patterns, obstructive apnea-hypopnea index (OAHI), and OSA-18 quality-of-life (QOL). Chi-square tests compared patient demographics and comorbidities between single and multiple DISE groups. Unpaired t -tests compared age, OAHI, and OSA-18 scores between single and multiple DISE groups as well as multiple-DISE outcomes for high versus normal BMI groups. Results: Of 122 children who underwent DISE, 27 (22%) had multiple DISE-directed procedures. Average age at first DISE for single and multiple DISE patients was 7.25 (SD = 3.93) and 4.99 (SD = 3.63) years, respectively ( P < .01). Common obstructions at second DISE involved the epiglottis (N = 20, 74%), adenoid (N = 18, 67%), and inferior turbinates (N = 15, 56%). Multilevel obstruction was identified in 96% (N = 26) of second and 80% (N = 4) of third DISEs. Children with high BMI (versus normal BMI) exhibited shorter intervals between DISEs. Patients who underwent single DISE exhibited significant OAHI improvement (mean 8.48 vs 3.91, P < .05), but this was not significant for multiple DISEs. The OSA-18 score improved significantly in patients with single DISE (mean summed score 61.3 vs 44.6, P < .05). Conclusions: Pediatric OSA involves persistent, multilevel obstruction, especially in younger patients with elevated BMI undergoing multiple DISE-directed procedures. These findings support anatomy-guided, patient-specific surgical planning for high-risk groups. While a single DISE-directed intervention can significantly improve OAHI and QOL, repeated procedures may yield diminishing returns, underscoring the need to consider their timing and utility. Early multidisciplinary evaluation and long-term follow-up are essential for managing persistent OSA.