Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea: Clinical Applications, Classification Systems, and Anesthetic Considerations.

Background/Objectives: Drug-induced sleep endoscopy (DISE) enables dynamic, real-time visualization of the level, severity, and configuration of upper airway collapse during pharmacologically induced sleep, providing anatomical information that polysomnography cannot. It is increasingly used to guide individualized surgical planning in obstructive sleep apnea (OSA), particularly in children with persistent OSA after adenotonsillectomy or at elevated risk of surgical failure. However, the absence of a universally accepted pediatric-specific classification system and standardized protocol continues to limit comparability across studies and the development of evidence-based treatment algorithms. This review evaluates the role of DISE in pediatric OSA, focusing on airway assessment, classification systems, anesthesia protocols, and its impact on surgical decision-making. Methods: A PubMed literature review (2013-2025) identified 42 pediatric-specific studies, including cohort studies, systematic reviews, and meta-analyses. Data were extracted regarding indications, classification scales, anesthetic techniques, safety, and surgical outcomes. Results: DISE provides dynamic visualization of multilevel obstructions often missed during awake examinations. While adult-derived systems such as VOTE are used, pediatric-specific tools (e.g., Chan-Parikh, NAVOTEL, PedDISE-8, IPSES) offer more age-appropriate assessments. Anesthetic choice is a key factor; dexmedetomidine, alone or with ketamine, best approximates non-rapid eye movement (NREM) sleep while maintaining airway tone and stability. DISE findings altered surgical plans in 30-60% of patients, facilitating targeted procedures such as supraglottoplasty, lingual tonsillectomy, and epiglottopexy. Conclusions: DISE is a valuable diagnostic and decision-support tool for complex pediatric OSA. Clinical utility depends on standardized assessment and anesthesia. Further multicenter studies are required to validate classification systems and determine long-term impacts on quality of life.