Inclusion of the first cervical nerve does not influence outcomes in upper airway stimulation for treatment of obstructive sleep apnea

Up versus down: Does cuff spine orientation affect early adherence to upper airway stimulation?

PURPOSE

Upper airway stimulation (UAS) is a treatment option for moderate-to-severe OSA, in which electrical stimulation is applied to the hypoglossal nerve via an electrode cuff. In this study, we assess the effect of electrode cuff positioning on UAS outcomes, in particular device adherence.

METHODS

Patients at a single academic institution who met the Food and Drug Administration criteria for UAS between 2016 and 2021 were included. The electrode position was documented as superior (cuff spine up) or inferior (cuff spine down) to the hypoglossal nerve based on postoperative lateral neck X-ray. Patients underwent titration polysomnography 2-6 months following surgery. The most recent postoperative variables from sleep studies following titration polysomnogram were used for statistical analysis. Adherence data was downloaded from the UAS device.

RESULTS

327 patients met inclusion criteria. The average age of patients was 60.9 ± 11.1 years, with 105 (32.1%) females. Cuff spine up position was present in 169 (51.7%) patients as compared to 158 (48.3%) with cuff spine down. UAS adherence was significantly higher among cuff spine down patients (45.4 vs. 41.0 h device use/week, p = 0.015). Cuff position was not significantly associated with therapeutic amplitude, change in apnea hypopnea index, or change in symptoms as measured by the Epworth Sleepiness Scale. On multivariable linear regression analysis, cuff spine down position (β = 3.7, CI [1.3, 7.4], p = 0.038) and increased age (β = 0.22, CI [0.07, 0.38], p = 0.005) were associated with increased adherence.

CONCLUSIONS

UAS cuff spine down position is associated with increased device adherence. Further investigation into cuff positioning is warranted.

Patient-reported outcomes with hypoglossal nerve stimulation for treatment of obstructive sleep apnea: a systematic review and meta-analysis

INTRODUCTION

Hypoglossal nerve stimulation (HNS) has recently been introduced as an alternative treatment for patients with OSA. A large number of studies have demonstrated substantial changes in OSA with this therapy by reducing respiratory events and improving symptoms such as daytime sleepiness and quality of life. The objective of this review was to conduct a systematic review and meta-analysis to evaluate patient-reported outcomes and experience with HNS therapy.

METHODS

A systematic literature search of MEDLINE, Cochrane, and Web of Science was performed to identify randomized controlled and observational studies reporting subjective outcomes with different HNS systems in patients with OSA. Abstracts of 406 articles were screened and a subset of 55 articles were reviewed for eligibility. Risk of bias was assessed using the ROBINS-I tool. Meta-analysis using RevMan was performed when > 2 studies were identified that reported data on a specific outcome.

RESULTS

Thirty-four publications reporting data on 3785 patients with a mean follow-up of 11.8 ± 12.2 months were identified and included in the meta-analysis. The analysis revealed a pooled effect of 4.59 points improvement in daytime sleepiness as measured by the ESS questionnaire (Z = 42.82, p < .001), 2.84 points improvement in daytime functioning as measured by the FOSQ score (Z = 28.38, p < .001), and 1.77 points improvement in sleep quality as measured by the PSQI questionnaire (Z = 2.53, p = .010). Patient-reported experience was consistently positive and revealed additional relevant aspects from this perspective.

CONCLUSION

HNS therapy significantly improves quality of life in patients with OSA and reliably produces clinically meaningful effects on daytime sleepiness, daytime functioning, and sleep quality. Treatment regularly meets or exceeds the minimum clinically important differences defined for the respective instruments. Additional research is needed to further investigate effects on quality of life beyond improvements in daytime sleepiness and daytime functioning.

Hypoglossal Nerve Stimulation Therapy for the Treatment of Obstructive Sleep Apnea

Hypoglossal nerve stimulation (HGNS) therapy was approved in 2014 for the treatment of obstructive sleep apnea in patients who are intolerant to continuous positive airway pressure (CPAP) therapy, which is reported in up to 40-60% of patients. This therapy works via direct neurostimulation of the hypoglossal nerve in synchrony with respiration, to open the airway via tongue stiffening and protrusion. Studies have demonstrated significant reductions in both respiratory parameters such as disordered breathing indices, as well as subjective sleep complaints, such as daytime sleepiness, with the use of this therapy. This has increased the repertoire of treatment options for sleep providers to recommend to those patients that are intolerant to CPAP therapy.

Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea

There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.