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Suurna MV, Klasner M. Neurostimulation for Obstructive Sleep Apnea. Otolaryngol Clin North Am 2024; 57:457-465. [PMID: 38521724 DOI: 10.1016/j.otc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
Neurostimulation of hypoglossal nerve has emerged as an effective treatment option of obstructive sleep apnea (OSA). Since FDA approval in 2014, therapy has been widely used in select patients with moderate-to-severe OSA who do not benefit from positive airway pressure. Ongoing research and technological developments continue to advance the therapy to deliver personalized and efficient treatment to patients with OSA.
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Affiliation(s)
- Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, University of Miami Health System, 1120 Northwest 14th Street, 5th Floor, Miami, FL 33136, USA.
| | - Mia Klasner
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, University of Miami Health System, 1120 Northwest 14th Street, 5th Floor, Miami, FL 33136, USA
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Schwab RJ, Lin TC, Wiemken A, Dedhia RC, Wehrli FW, Keenan BT. State-Dependent Biomechanical Behavior of Oropharyngeal Structures in Apneic and Control Subjects: A Proof-of-Concept Study. Ann Am Thorac Soc 2024; 21:949-960. [PMID: 38507612 PMCID: PMC11160136 DOI: 10.1513/annalsats.202309-847oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 03/20/2024] [Indexed: 03/22/2024] Open
Abstract
Rationale: Apneic individuals have reduced airway caliber during sleep. The biomechanical changes in upper airway anatomy contributing to this airway narrowing are largely unknown. Objectives: We sought to investigate the state-dependent (wake vs. sleep) biomechanical behavior of the upper airway soft-tissue and craniofacial structures. Methods: Upper airway magnetic resonance imaging was performed in 15 sleep-deprived control subjects (apnea-hypopnea index, <5; 0.3 ± 0.5 events per hour) and 12 sleep-deprived apneic subjects (apnea-hypopnea index, ⩾5; 35.2 ± 18.1 events per hour) during wake and sleep and analyzed for airway measures and soft-tissue/mandibular movement. Results: In the retropalatal region, control subjects showed sleep-dependent reductions (P ⩽ 0.037) in average cross-sectional airway area (CSA), minimum CSA, and anteroposterior and lateral dimensions. Apneic subjects showed sleep-dependent reductions (P ⩽ 0.002) in average CSA, minimum CSA, and anteroposterior and lateral dimensions. In the retroglossal region, control subjects had no sleep-dependent airway reductions. However, apneic subjects had sleep-dependent reductions in minimal CSA (P = 0.001) and lateral dimensions (P = 0.014). Control subjects only showed sleep-dependent posterior movement of the anterior-inferior tongue octant (P = 0.039), whereas apneic subjects showed posterior movement of the soft palate (P = 0.006) and all tongue octants (P ⩽ 0.012). Sleep-dependent medial movement of the lateral walls was seen at the retropalatal minimum level (P = 0.013) in control subjects and at the retropalatal and retroglossal minimum levels (P ⩽ 0.017) in apneic subjects. There was posterior movement of the mandible in apneic subjects (P ⩽ 0.017). Conclusions: During sleep, control and apneic subjects showed reductions in retropalatal airway caliber, but only the apneic subjects showed retroglossal airway narrowing. Reductions in anteroposterior and lateral airway dimensions were primarily due to posterior soft palate, tongue and mandibular movement and to medial lateral wall movement. These data provide important initial insights into obstructive sleep apnea pathogenesis.
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Affiliation(s)
| | - Theodore C. Lin
- Division of Sleep Medicine, Department of Medicine
- Department of Otorhinolaryngology – Head and Neck Surgery, Temple University, Philadelphia, Pennsylvania
| | | | - Raj C. Dedhia
- Division of Sleep Medicine, Department of Medicine
- Department of Otorhinolaryngology – Head and Neck Surgery, and
| | - Felix W. Wehrli
- Laboratory for Structural, Physiologic, and Functional Imaging, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Serghani MM, Heiser C, Schwartz AR, Amatoury J. Exploring hypoglossal nerve stimulation therapy for obstructive sleep apnea: A comprehensive review of clinical and physiological upper airway outcomes. Sleep Med Rev 2024; 76:101947. [PMID: 38788518 DOI: 10.1016/j.smrv.2024.101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/17/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of upper airway collapse during sleep, which can lead to serious health issues like cardiovascular disease and neurocognitive impairments. While positive airway pressure serves as the standard treatment, intolerance in some individuals necessitates exploration of alternative therapies. Hypoglossal nerve stimulation (HGNS) promises to mitigate OSA morbidity by stimulating the tongue muscles to maintain airway patency. However, its effectiveness varies, prompting research for optimization. This review summarizes the effects of HGNS on upper airway obstruction from human and animal studies. It examines physiological responses including critical closing pressure, maximal airflow, nasal and upper airway resistance, compliance, stiffness, and geometry. Interactions among these parameters and discrepant findings in animal and human studies are explored. Additionally, the review summarizes the impact of HGNS on established OSA metrics, such as the apnea-hypopnea index, oxygen desaturation index, and sleep arousals. Various therapeutic modalities, including selective unilateral or bilateral HGNS, targeted unilateral HGNS, and whole unilateral or bilateral HGNS, are discussed. This review consolidates our understanding of HGNS mechanisms, fostering exploration of under-investigated outcomes and approaches to drive advancements in HGNS therapy.
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Affiliation(s)
- Marie-Michèle Serghani
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon
| | - Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department ENT-HNS, Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Alan R Schwartz
- Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jason Amatoury
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon.
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Kant E, Hardeman JA, Copper MP. The effect of velar collapse patterns on unilateral upper airway stimulation therapy. Sleep Breath 2024; 28:877-885. [PMID: 37817007 DOI: 10.1007/s11325-023-02911-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/21/2023] [Accepted: 09/01/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE Hypoglossal nerve stimulation is a promising alternative therapy for patients with obstructive sleep apnea with continuous positive airway pressure intolerance or failure. Previous studies concluded that a velar complete concentric collapse might prohibit a good therapeutic outcome. However, certain patients have an upper velar anteroposterior collapse and a lower velar complete concentric collapse. The effect of this velar collapse pattern is unknown, preventing evidence-based decision-making for these patients. This study aimed to compare the results of upper airway stimulation therapy in these patients to patients with a pure anteroposterior velar collapse. METHODS A retrospective single-center cohort study was performed. Patients were included who were implanted with an upper airway stimulation device and had a 1-year follow-up. RESULTS Of 66 patients, 10 had an upper velar anteroposterior collapse and lower velar complete concentric collapse. Fifty-six patients had a complete or partial velar anteroposterior collapse. At follow-up, all respiratory outcomes were similarly changed between the two groups. The mean apnea and hypopnea index reduced equally (26.9 events/hour vs. 23.9 events/hour, 95% CI (-5.0, 11.0), p = 0.46). A similar decrease in the oxygen desaturation index of ≥ 4% was observed (12.0/hour versus 11.5/hour, 95% CI (-8.7, 9.7) p = 0.92) CONCLUSION: Patients with an upper velar anteroposterior collapse and a lower velar complete concentric collapse are suitable candidates for upper airway stimulation therapy. In these patients, the lower velum may represent a transition zone between the anteroposterior collapse of the upper velum and the lateral collapse of the oropharynx, instead of being a real concentric collapse.
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Affiliation(s)
- E Kant
- Department of Otorhinolaryngology Head and Neck Surgery, Saint Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J A Hardeman
- Department of Pulmonology, Saint Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - M P Copper
- Department of Otorhinolaryngology Head and Neck Surgery, Saint Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands.
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Kedarisetty S, Sharma A, Commesso EA, Woodson BT, Huyett P, Kent DT, D’Agostino MA, Green KK, Kezirian EJ. Palate shape is associated with Unilateral Hypoglossal Nerve Stimulation Outcomes. Laryngoscope 2024; 134:981-986. [PMID: 37672634 PMCID: PMC10840867 DOI: 10.1002/lary.31018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 07/06/2023] [Accepted: 07/26/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE The aim was to determine the potential association between palate shape and unilateral hypoglossal nerve stimulation (HNS) outcomes. METHODS Preoperative drug-induced sleep endoscopy (DISE) videos were reviewed and scored by 3 blinded reviewers to determine airway narrowing at the hard-soft palate junction (HP), soft palate genu, and inferior velum, as described by Woodson (2014). Scoring was as follows: 1-open airway, 2-narrow, 3-severe narrowing. Overall palate shape (oblique, intermediate, or vertical) was determined based on prior criteria. Successful surgical treatment was defined by the HNS titration polysomnogram as a reduction of ≥50% in the apnea-hypopnea index (AHI) to <15 events/h. RESULTS Of 332 adults, the majority was male (77%) with an average BMI of 29.2 ± 3.6 kg/m2 . Overall success rate was 73%. Success rate was lower in patients with vertical palate shape compared with the other shapes (56% vs. 75%, p = 0.029). HP score 3 compared with scores 2 and 1 was associated with lower success rates (60% vs. 76%, p = 0.028), but genu and velum scores were not associated with outcomes. Patients with both HP score 3 and complete oropharyngeal lateral wall-related obstruction had notably worse outcomes (22% vs. 74%, p = 0.026). HP score 3 (OR 0.45, 95%CI 0.22-0.92) and vertical palate shape (OR 0.33, 95%CI 0.15-0.78) were independently associated with lower odds of surgical response after adjustment for DISE findings, age, gender, and BMI. CONCLUSION Vertical palate shape and narrowing at the hard-soft palate junction are independently associated with lower HNS surgical success rates. LEVEL OF EVIDENCE 3 Laryngoscope, 134:981-986, 2024.
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Affiliation(s)
- Suraj Kedarisetty
- Department of Head and Neck Surgery, Kaiser Permanente, Vallejo, California
| | - Abhay Sharma
- Department of Otolaryngology Head and neck Surgery, University of South Florida, Tampa, Florida
| | - Emily A Commesso
- Department of Head and Neck Surgery & Communication Sciences, Duke University, School of Medicine, Durham, North Carolina
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A D’Agostino
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric J Kezirian
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California
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6
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Nord RS, Fitzpatrick T, Pingree G, Islam A, Chafin A. Should lateral wall collapse be a contraindication for hypoglossal nerve stimulation? Am J Otolaryngol 2024; 45:104053. [PMID: 37769502 DOI: 10.1016/j.amjoto.2023.104053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/12/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The purpose of this study is to examine how lateral wall collapse affects treatment outcomes for hypoglossal nerve stimulation (HNS) patients. METHODS Patients (n = 111) queried from a single surgeon's database of HNS cases were divided into groups based on their degree of oropharyngeal lateral wall collapse noted on drug-induced sleep endoscopy (DISE): Complete, Partial, None. For each group, apnea hypopnea index (AHI) reduction, Epworth Sleepiness Scale (ESS) score, stimulation voltage, average nightly usage, need for alternate device configuration/awake sleep endoscopy, and rate of surgical success were collected. Patients with Complete collapse were compared to those with Partial/None via Student's t-tests and Pearson's Chi-square test. RESULTS Of the 111 eligible patients, 45 had complete, 30 partial, and 36 had no lateral oropharyngeal wall collapse. There were no statistically significant differences found between the Complete and Partial/None groups in terms of age, BMI, sex, AHI (pre and post-op), ESS (pre and post-op), voltage, alternate device configuration, or nightly adherence. Notably, a significantly greater number of the Partial/None group had surgical success (84.84 % vs 66.67 %, p = 0.024). CONCLUSIONS Patients with Partial/None oropharyngeal collapse were significantly more likely than patients with Complete lateral wall collapse to see surgical success. There are many factors to weigh when assessing a patient's surgical candidacy, it is clear that complete lateral wall collapse at the level of the oropharynx is a negative predictor for success in HNS.
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Affiliation(s)
- Ryan S Nord
- Virginia Commonwealth University Health System, United States of America.
| | - Thomas Fitzpatrick
- Virginia Commonwealth University Health System, United States of America
| | - Graham Pingree
- Virginia Commonwealth University School of Medicine, United States of America
| | - Albina Islam
- Virginia Commonwealth University Health System, United States of America
| | - Andrew Chafin
- Virginia Commonwealth University School of Medicine, United States of America
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Gao TZ, Ma J, Hall D, Pan X, Rings VK, Zia A, Harris MK, Chio EG. Hypoglossal Nerve Stimulation Therapy Outcomes in Apnea- Versus Hypopnea-Predominant Patients. Otolaryngol Head Neck Surg 2023; 169:1674-1682. [PMID: 37538037 DOI: 10.1002/ohn.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/15/2023] [Accepted: 07/14/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES The influence of apnea- and hypopnea-predominance on hypoglossal nerve stimulation therapy outcomes (HGNS) is still poorly defined. We assessed the significance of apnea- and hypopnea-predominance in HGNS outcomes. STUDY DESIGN Case series with chart review. SETTING Single-institution tertiary care center. METHODS A total of 216 subjects were included, all of which had undergone drug-induced sleep endoscopy (DISE) and HGNS implantation. Demographic and polysomnographic data were collected. The 4% apnea-hypopnea criteria were used to calculate apnea-hypopnea index (AHI). Central apneas were omitted. Univariate logistic and linear regression were used to study the association between these data and apnea-predominance and hypopnea-predominance. Kruskal-Wallis rank sum test was used to compare medians between groups for DISE collapse patterns. RESULTS Sixty-three patients were apnea-predominant, and 153 patients were hypopnea-predominant. These 2 groups were similar demographically (p > .20). There was no significant difference in HGNS outcomes between the groups assessed using Sher20 criteria at the 1-year mark using all-night, single-setting polysomnography or home sleep studies. Apnea index (AI)/AHI and reduction in AHI from preoperative to titration were significantly associated (p = .046). The median preoperative hypopnea index was significantly lower (p = .033) in subjects with no oropharyngeal collapse than patients with partial or complete oropharyngeal collapse. There were no significant relationships between AI/AHI and the different degrees of collapse at the velopharynx, oropharynx, tongue base, or epiglottis. CONCLUSIONS In line with CPAP, tonsillectomy, and mandibular advancement therapy studies, we found there was largely no significant difference in DISE anatomy or in HGNS treatment outcomes between apnea- and hypopnea-predominant individuals.
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Affiliation(s)
- Thomas Z Gao
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jianing Ma
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Daniel Hall
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Xueliang Pan
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Vijay K Rings
- Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - Ali Zia
- College of Medicine and Life Sciences, Toledo University, Toledo, Ohio, USA
| | - Micah K Harris
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Eugene G Chio
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Fleury Curado T, Pham L, Otvos T, Klopfer T, Freire C, Amorim MR, Nishimura Y, Sennes LU, Psoter KJ, Abdelwahab M, Huang A, Dedhia R, Liu S, Capasso R, Oliven A, Polotsky V, Eisele D, Schwartz A. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med 2023; 19:947-955. [PMID: 36727502 PMCID: PMC10152343 DOI: 10.5664/jcsm.10474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES The major goal of the study was to determine whether changes in tongue morphology under selective hypoglossal nerve therapy for obstructive sleep apnea were associated with alterations in airway patency during sleep when specific portions of the hypoglossal nerve were stimulated. METHODS This case series was conducted at the Johns Hopkins Sleep Disorders Center at Johns Hopkins Bayview Medical Center. Twelve patients with apnea implanted with a multichannel targeted hypoglossal nerve-stimulating system underwent midsagittal ultrasound tongue imaging during wakefulness. Changes in tongue shape were characterized by measuring the vertical height and polar dimensions between tongue surface and genioglossi origin in the mandible. Changes in patency were characterized by comparing airflow responses between stimulated and adjacent unstimulated breaths during non-rapid eye movement sleep. RESULTS Two distinct morphologic responses were observed. Anterior tongue base and hyoid-bone movement (5.4 [0.4] to 4.1 [1.0] cm (median and [interquartile range]) with concomitant increases in tongue height (5.0 [0.9] to 5.6 [0.7] cm) were associated with decreases in airflow during stimulation. In contrast, comparable anterior hyoid movement (tongue protrusion from 5.8 [0.5] to 4.5 [0.9] cm) without significant increases in height (5.2 [1.6] to 4.6 [0.8] cm) were associated with marked increases in airflow during sleep. CONCLUSIONS Tongue protrusion with preservation of tongue shape predicted increases in patency, whereas anterior movement with concomitant increases in height were associated with decreased pharyngeal patency. These findings suggest that pharyngeal patency can be best stabilized by stimulating lingual muscles that maintain tongue shape while protruding the tongue, thereby preventing it from prolapsing posteriorly during sleep. CITATION Fleury Curado T, Pham L, Otvos T, et al. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med. 2023;19(5):947-955.
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Affiliation(s)
- Thomaz Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luu Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamas Otvos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy Klopfer
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Freire
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Mateus R. Amorim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yoichi Nishimura
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luiz Ubirajara Sennes
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kevin J. Psoter
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamed Abdelwahab
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Allen Huang
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Raj Dedhia
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- B’nai Zion Hospital, Technion School of Medicine, Haifa, Israel
| | - Stanley Liu
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Robson Capasso
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Arie Oliven
- Department of Otorhinolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vsevolod Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David Eisele
- Department of Otorhinolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alan Schwartz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Saltagi MZ, Powell K, Saltagi AK, Stahl S, Manchanda S, Parker NP. Novel Outcome Analysis Tool for Hypoglossal Nerve Stimulator Sensor Lead Function and Comparison by Incision Type (2 Versus 3). Laryngoscope 2023; 133:423-430. [PMID: 36054604 PMCID: PMC10087886 DOI: 10.1002/lary.30365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE No reported outcome measures have been established to evaluate sensor lead function in the hypoglossal nerve stimulator (HNS). This study describes the development of novel functional outcome measures for intraoperative sensor electrode function and compares 2-incision and 3-incision outcomes for HNS. METHODS A retrospective cohort study of 100 consecutive patients who underwent HNS between June 2019 and September 2021. Demographic information, intraoperative findings, and immediate postoperative outcomes were recorded. Structured parameters were developed to compare intraoperative waveforms with six outcome measures utilized: waveform syncing, waveform amplitude, sensory current leakage, shark-fin morphology, cardiac artifact, and overall impression. Two sleep surgeons and two sleep medicine specialists compared all waveforms in a blinded fashion and assigned scores on the Likert Scale. RESULTS The cohort included 50 three-incision and 50 two-incision patients. Age, gender, average body mass index, comorbidity profiles, and sleep endoscopy findings did not significantly differ between the two groups. No major complications occurred. The interclass-correlation-coefficient was greater than 0.7 for all comparisons (good to very good interrater reliability). There was no difference in waveform amplitude, cardiac artifact, sensory current leakage, or shark-fin morphology between the two groups. Waveform syncing and overall impression were statistically better in the 2-incision cohort. CONCLUSIONS This study is the first to define a structured method of HNS sensor electrode outcome measurement and showed consistent measures by surgeons and sleep medicine specialists. This article supports the transition to the 2-incision technique among surgeons for placement of the sensor lead. Consideration should be given to utilizing this novel tool in the clinical/research setting and validating these measures moving forward. LEVEL OF EVIDENCE 3 Laryngoscope, 133:423-430, 2023.
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Affiliation(s)
- Mohamad Z Saltagi
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Kayla Powell
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Abdul K Saltagi
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Stephanie Stahl
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.,Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Shalini Manchanda
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.,Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Noah P Parker
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.,Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
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11
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Steffen A, Moritz FJ, König IR, Suurna MV, Brüggemann N. Electric field aspects in hypoglossal nerve stimulation for obstructive sleep apnea: A bilateral electrophysiological evaluation of unilateral electrode configuration changes. J Sleep Res 2023; 32:e13592. [PMID: 35596592 DOI: 10.1111/jsr.13592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/13/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023]
Abstract
Hypoglossal nerve stimulation is an established treatment option for obstructive sleep apnea in selected patients. A unilateral hypoglossal nerve stimulation system was approved a decade ago, yet the physiological effect of unilateral hypoglossal stimulation on bilateral tongue motion remains unclear. This study examined how electrode configuration, stimulation cuff position, or body mass index influenced the contralateral genioglossus electromyography (EMG) signal. Twenty-nine patients underwent three EMG recordings in a polysomnographic setting after being implanted with a unilateral hypoglossal nerve stimulator for at least 6 months. The ratio of EMG signals between the ipsi- and contralateral sides was evaluated. No difference in EMG signals was demonstrated based on electrode configurations, stimulation-cuff position, body-mass-index, or sleep apnea severity, even in patients with right tongue protrusion only. Our findings may be explained by a significant level of cross-innervation and by a smaller and less variable circumferential electric field than expected based on prior biophysical models. A patient's individual anatomy needs to be considered during therapy titration in order to achieve an optimal response.
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Affiliation(s)
- Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | | | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, USA
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12
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Wang H, Wu H, Ji C, Wang M, Xiong H, Huang X, Fan T, Gao S, Huang Y. Mechanical mechanism to induce inspiratory flow limitation in obstructive sleep apnea patients revealed from in-vitro studies. J Biomech 2023; 146:111409. [PMID: 36521227 DOI: 10.1016/j.jbiomech.2022.111409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Inspiratory flow limitation means that when the flowrate reaches a certain value, it no longer increases, or even decreases, which is called negative effort dependence flow limitation, even if the inspiration effort is increased. This occurs often in obstructive sleep apnea patients, but its mechanism remains unclear. To reveal the mechanism of inspiratory flow limitation, we constructed a unique partially collapsible in-vitro upper airway model of obstructive sleep apnea patients to observe the change of airway resistance with inspiratory driving pressure. The important findings demonstrate that with the increase of inspiratory effort, the driving pressure increases faster than the airway resistance in the early stages, and then the reverse occurs as the airway becomes narrower. The airway collapse caused by the transmural pressure can lead to a rapid increase in downstream resistance with the increase of inspiratory effort, which is the key reason causing the flow reduction and the formation of typical negative effort dependence flow limitation. The mechanical mechanism revealed in this study will lead to fully new insights into the study and treatment of obstructive sleep apnea.
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Affiliation(s)
- Hui Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Haijun Wu
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Changjin Ji
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Mengmeng Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Huahui Xiong
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Xiaoqing Huang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Tingting Fan
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Simiao Gao
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Yaqi Huang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China.
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13
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Weiner JS, Munhall CC, Kent DT. Supine Pharyngeal Width Is Associated With Complete Concentric Palatal Collapse During Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulator Outcomes. EAR, NOSE & THROAT JOURNAL 2022:1455613221148313. [PMID: 36583238 DOI: 10.1177/01455613221148313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Hypoglossal nerve stimulation (HNS) implantation in the US requires preoperative drug-induced sleep endoscopy (DISE) screening for complete concentric palatal collapse (CCC) to establish treatment candidacy. We hypothesized that supine pharyngeal width (SPW) in awake patients is associated with CCC and HNS therapy outcomes. METHODS Adults with moderate to severe obstructive sleep apnea underwent awake measurement of SPW followed by DISE screening for CCC. Eligible patients electing for HNS implantation underwent postoperative polysomnography per standard of care. RESULTS SPW was measured in 73 patients. For SPW >20 mm, the positive likelihood ratio for absence of CCC was 6.67 with pre- and post-test odds of 6.3 and 42.0, respectively. Postoperative PSG data were available from 31 of 44 (70.5%) patients subsequently implanted with HNS. Patients with SPW >20 mm had a greater rate of HNS response than those with SPW ≤20 (62 vs 30%; P < .05). Only SPW and BMI were significantly associated with CCC and HNS response in regression models. CONCLUSION In a retrospective cohort study, SPW was significantly associated with CCC and postoperative apnea-hypopnea index following HNS implantation. SPW may be a viable screening tool for HNS candidacy.
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Affiliation(s)
| | | | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Maresch KJ. Perioperative and Perianesthesia Considerations for Hypoglossal Nerve Stimulator Implantation in Obstructive Sleep Apnea Patients. J Perianesth Nurs 2022; 37:760-765.e1. [PMID: 35618616 DOI: 10.1016/j.jopan.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/06/2022] [Accepted: 02/11/2022] [Indexed: 10/18/2022]
Abstract
Hypoglossal nerve stimulation (Inspire Medical Systems, Maple Grove, Minnesota) is an innovative treatment option for eligible patients with moderate to severe obstructive sleep apnea (OSA). Since U.S. Food and Drug Administration approval in 2014, over 18,000 patients have been implanted. The device includes an implanted pacemaker-sized pulse generator, one sensing lead, and one stimulation lead. During sleep, inspirations and expirations are detected by the sensing lead. At end expiration, the stimulation lead triggers the hypoglossal nerve to contract and stiffen the tongue thus preventing airway obstruction and improving OSA. Perioperative and perianesthesia nurses have an important role in caring for these patients during all aspects of the surgical insertion process: evaluation for eligibility, device implantation, and future visits to the perioperative area for related and unrelated procedures. This article reviews anatomic and physiologic factors contributing to airway collapse in OSA, function of the hypoglossal nerve stimulation device, the evaluation, implantation, and activation process, and considerations for patient care in the perioperative and perianesthesia periods. Precautions needed for other therapies, including Magnetic Resonance Imaging, diathermy, and radiation are also discussed.
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Affiliation(s)
- Karen J Maresch
- Staff CRNA, University of Pittsburgh Medical Center, Pittsburgh, PA.
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15
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Maxillomandibular Advancement and Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: A Systematic Review. J Clin Med 2022; 11:jcm11226782. [PMID: 36431259 PMCID: PMC9697253 DOI: 10.3390/jcm11226782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
Abstract
This systematic review aimed to comparatively evaluate the efficacy and safety of maxillomandibular advancement (MMA) and upper airway stimulation (UAS) in obstructive sleep apnea (OSA) treatment. A MEDLINE and Embase database search of articles on MMA and/or UAS for OSA was conducted. Twenty-one MMA studies and nine UAS studies were included. All the MMA studies demonstrated a reduction in apnea hypopnea index (AHI) postoperatively, and success rates ranged from 41.1% to 100%. Ten MMA studies reported pre- and postoperative Epworth sleepiness scale (ESS), and all but one study demonstrated a reduction in ESS. In the UAS studies, all but one demonstrated a reduction in AHI, and success rates ranged from 26.7% to 77.8%. In the eight UAS studies reporting pre- and postoperative ESS, an ESS reduction was demonstrated. No studies reported any deaths related to MMA or UAS. The most common postoperative complications after MMA and UAS were facial paresthesia in the mandibular area and discomfort due to electrical stimulation, respectively. This systematic review suggests that both MMA and UAS are effective and generally safe therapies for OSA. However, due to the limitations of the included studies, there is no evidence yet to directly compare these two procedures in OSA treatment.
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16
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Nord R, Fitzpatrick T, DeShazo JP, Reiter ER. Comparison of readmission and complication rates between traditional sleep surgery and hypoglossal nerve stimulation. Laryngoscope Investig Otolaryngol 2022; 7:1659-1666. [PMID: 36258877 PMCID: PMC9575102 DOI: 10.1002/lio2.883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
Objective This study aims to compare readmission and complication rates between hypoglossal nerve stimulation (HNS) and traditional sleep surgery (TSS) in the 90‐day postoperative period using a federated electronic health record (EHR) database. Methods We queried TriNetX, a global federated health research network providing access to EHR data from approximately 70 million patients in 49 large health care organizations to identify individuals who underwent either HNS or TSS for obstructive sleep apnea (OSA) from April 2014 to March 2021. Propensity scores based on demographics and obesity were used to balance groups. We compared the frequency of readmission/representation and surgical‐related complication rates between cohorts. Results After propensity score matching of HNS versus palatal surgery (n = 1014 in each cohort) and HNS versus multilevel surgery (n = 374 in each cohort), we found palatal and multilevel surgery had a significantly higher risk of readmission versus HNS. (12% vs. 4%, p < .0001). Palatal surgery complication rate was also higher than HNS (21% vs. 2%, p < .0001). Multi‐level surgery results were similarly higher (22% vs. 3%, p < .001). The most common diagnoses at ER readmission for TSS were procedural complications and pain, while common diagnoses for HNS readmission were general complaints such as malaise and headache. Conclusions Hypoglossal nerve stimulation has lower risk of readmission and postoperative complications than traditional sleep surgery as demonstrated in a large research network database analysis. Level of Evidence: 3. This study aims to compare readmission and complication rates between hypoglossal nerve stimulation, a novel implantable neurostimulation system to treat selected CPAP‐intolerant obstructive sleep apnea by stimulating the distal branches of the hypoglossal nerve, against traditional sleep surgery methods in the 90‐day postoperative period using a federated electronic health record database. We found that hypoglossal nerve stimulation has a significantly lower risk of readmission and postoperative complications than traditional sleep surgery.
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Affiliation(s)
- Ryan Nord
- Department of Otolaryngology—Head and Neck Surgery Virginia Commonwealth University Richmond Virginia USA
| | - Thomas Fitzpatrick
- Department of Otolaryngology—Head and Neck Surgery Virginia Commonwealth University Richmond Virginia USA
| | - Jonathan P. DeShazo
- Department of Health Administration Virginia Commonwealth University Richmond Virginia USA
| | - Evan R. Reiter
- Department of Otolaryngology—Head and Neck Surgery Virginia Commonwealth University Richmond Virginia USA
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Jomha M, Dabboussi T, Parker NP, Manchanda S, Chernyak Y, Stahl SM. Prevalence of Insomnia and Restless Legs Syndrome in Patients with Upper Airway Stimulation Therapy and Effects on Treatment Outcomes. Sleep Med 2022; 98:121-126. [DOI: 10.1016/j.sleep.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
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18
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Bosschieter PF, de Vries N, Mehra R, Manchanda S, Padhya TA, Vanderveken OM, Ravesloot M. Similar effect of hypoglossal nerve stimulation for obstructive sleep apnea in 5 disease severity categories. J Clin Sleep Med 2022; 18:1657-1665. [PMID: 35236551 PMCID: PMC9163616 DOI: 10.5664/jcsm.9956] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Data on adherence and outcome of upper airway stimulation (UAS) for patients with obstructive sleep apnea (OSA) are collected in an international registry (ADHERE). Previous publications report significant improvement in self-reported and objective OSA outcomes, durable effectiveness, and high adherence. Debate remains whether the effectiveness of UAS is influenced by preoperative OSA severity; therefore, we aimed to evaluate this using data from the ADHERE Registry. METHODS ADHERE is a postmarket, ongoing, international multicenter registry. Adult patients were included if they had undergone UAS implantation and had at least 1 follow-up visit recorded in the database on June 8, 2021. We divided the patients into 5 subgroups, based on OSA severity at baseline (AHI in events/h): subgroup 1 (0-15), 2 (15-30), 3 (≥ 30-50), 4 (> 50-65), and 5 (> 65). We compared results regarding objective and self-reported treatment outcomes. RESULTS A total of 1,963 patients were included. Twelve months after implantation, there was a significant (P < .0001) improvement in objective sleep parameters in all subgroups with an AHI above 15 events/h. Patients in subgroup 1 had the lowest AHI at the final visit and the AHI reduction in patients in subgroup 5 was the largest (P < .0001). No significant difference was found between the subgroups in overall treatment success (66.6%) and improvement in self-reported outcomes. CONCLUSIONS Our results suggest that UAS is an effective treatment for patients with an AHI ≥ 15 events/h, independent of preoperative OSA severity. Self-reported outcomes and treatment success did not differ significantly between the 5 subgroups. These results clearly support that the indication of UAS could be broadened for patients with an AHI above 65 events/h, which, to date, is not common practice. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Adherence and Outcome of Upper Airway Stimulation (UAS) for OSA International Registry (ADHERE Registry); Identifier: NCT02907398; URL: https://www.clinicaltrials.gov/ct2/show/NCT02907398. CITATION Bosschieter PFN, de Vries N, Mehra R, et al. Similar effect of hypoglossal nerve stimulation for obstructive sleep apnea in 5 disease severity categories. J Clin Sleep Med. 2022;18(6):1657-1665.
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Affiliation(s)
- Pien F.N. Bosschieter
- Department of Otorhinolaryngology—Head and Neck surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Nico de Vries
- Department of Otorhinolaryngology—Head and Neck surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Department of Oral Kinesiology, Academisch Centrum Tandheelkunde Amsterdam MOVE Research Institute Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- Department of Otorhinolaryngology—Head and Neck Surgery Antwerp University Hospital (UZA), Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reena Mehra
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Shalini Manchanda
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tapan A. Padhya
- Department of Otolaryngology—Head and Neck Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Olivier M. Vanderveken
- Department of Otorhinolaryngology—Head and Neck Surgery Antwerp University Hospital (UZA), Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - M.J.L. Ravesloot
- Department of Otorhinolaryngology—Head and Neck surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - on behalf of the ADHERE Registry Investigators
- Department of Otorhinolaryngology—Head and Neck surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Department of Oral Kinesiology, Academisch Centrum Tandheelkunde Amsterdam MOVE Research Institute Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- Department of Otorhinolaryngology—Head and Neck Surgery Antwerp University Hospital (UZA), Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Otolaryngology—Head and Neck Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida
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19
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Arens P, Hänsel T, Wang Y. Hypoglossal Nerve Stimulation Therapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1384:351-372. [PMID: 36217095 DOI: 10.1007/978-3-031-06413-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hypoglossal nerve stimulation (HNS) has been shown to be a safe alternative in the treatment of moderate-to-severe obstructive sleep apnea (OSA). A recent meta-analysis of 12 studies by Costantino et al. indicated the surgical success rates at 55-75%, a reduction of the apnea hypopnea index (AHI) of 18 events/h, and a reduction of the Epworth Sleepiness Scale (ESS) of 2.9-5.3. After animal studies in the 1970s, the first trial on humans to decrease upper airway resistance by transcutaneous electrical stimulation of the genioglossus was reported in 1989. A separate stimulation of protruding and retracting muscles was realized in 1995 by fine-wire electrodes that were placed into the tongue transoral. Over the next years, several companies developed implantable devices for hypoglossal stimulation in OSA. Initially, devices were developed that used unilateral stimulation of the hypoglossal nerve. In 2014, a device for unilateral respiratory frequency-controlled hypoglossal stimulation finally received FDA approval after a successful phase III trial. In recent years, a device for bilateral breath rate-independent stimulation of the hypoglossal nerve has been added to these approaches as a new development. Accordingly, hypoglossal nerve stimulation, on the one hand, is now an established tool for patients with OSA when standard treatments are not satisfactory. Beyond that, hypoglossal stimulation is undergoing a continuous and impressive development like hardly any other field of surgical therapy for OSA.
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Affiliation(s)
- Philipp Arens
- Department of Otorhinolaryngology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Toni Hänsel
- Department of Otorhinolaryngology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yan Wang
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Interdisciplinary Sleep Medicine Center, Berlin, Germany
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20
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Upper airway muscles: influence on obstructive sleep apnoea pathophysiology and pharmacological and technical treatment options. Curr Opin Pulm Med 2021; 27:505-513. [PMID: 34431788 DOI: 10.1097/mcp.0000000000000818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Obstructive sleep apnoea (OSA) is highly prevalent with numerous deleterious effects on neurocognitive and cardiovascular health. It is characterized by collapse of the upper airway during sleep, due to the decrease in both basal and compensatory UA muscle activities. However, the leading treatment, continuous positive airway pressure, is often poorly tolerated. This review presents latest works focusing on novel interventions targeting upper airway muscles to alleviate OSA severity. RECENT FINDINGS In the last years, researchers have focused on the development of alternative treatment strategies targeting UA muscle activation, including pharmacological and nonpharmacological interventions. SUMMARY Among the nonpharmacological treatments, hypoglossal nerve stimulation aims to increase upper airway muscle phasic activity during sleep through electrical stimulation, while myofunctional therapy improves the activity and coordination of upper airway dilator muscles.Regarding OSA pharmacotherapy, recent findings strongly suggest that selective norepinephrine reuptake inhibitors such as atomoxetine and reboxetine, when administered with antimuscarinics such as oxybutynin, can alleviate OSA in most patients increasing pharyngeal dilator muscles activity during sleep. New combinations of norepinephrine reuptake inhibitors and antimuscarinics have further been explored with variable success and animal models showed that leptin, thyrothropin releasing hormone analogues and gene therapy hold potential for the future of OSA pharmacotherapy.
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Ilegbusi OJ, Kuruppumullage DNS, Schiefer M, Strohl KP. A computational model of upper airway respiratory function with muscular coupling. Comput Methods Biomech Biomed Engin 2021; 25:675-687. [PMID: 34494928 DOI: 10.1080/10255842.2021.1973445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A two dimensional finite element model of upper airway respiratory function was developed emphasizing the effects of dilator muscular activation on the human retro-lingual airway. The model utilized an upright mid-sagittal computed tomography of the human head and neck to reconstruct relevant structures of the tongue, mandible, and the hyoid-related soft tissues, along with the retro-lingual airway. The reconstructed geometry was divided into fluid and solid domains and discretized into finite element (FE) meshes used for the computational model. Three cases were investigated: standing position; supine position; and supine position coupled with dilator muscle activation. Computations were performed for the inspiration stage of the breathing cycle, utilizing a fluid-structure interaction (FSI) method to couple structural deformation with airflow dynamics. The spatio-temporal deformation of the structures surrounding the airway wall were predicted to be in general agreement with known changes from upright to supine posture on luminal opening, as well as the distribution of airflow. The model effectively captured the effects of muscular stimulation on the upper airway anatomical changes, the flow characteristics relevant to airway reduction in the supine position and airway enlargement with muscle activation. The smallest airway opening in the retro-lingual section is predicted to occur at the epiglottic region in all the three cases considered, an unexpected vulnerable location of airway obstruction. The model also predicted that hyoid displacement would be associated with recovery from airway collapse. This information may be useful for building more complex models relevant to mechanisms and clinical interventions for obstructive sleep apnea.
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22
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Optimization of Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea With Ultrasound Assessment of Tongue Movement. Am J Ther 2021; 29:e205-e211. [PMID: 34264881 DOI: 10.1097/mjt.0000000000001424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypoglossal nerve stimulation (HGNS) is an Food and Drug Administration-approved therapy for obstructive sleep apnea. Initial programming of HGNS is based on the observation of anterior tongue movement, which may not reflect opening at the retroglossal airway. We developed an ultrasonographic technique to assess the base of tongue movement with HGNS to be used to optimize the initial voltage settings. STUDY QUESTION This study aimed to investigate the use of ultrasound to assess tongue movement with HGNS and related this measure to the apnea hypopnea index (AHI) on subsequent home sleep apnea testing or in-laboratory polysomnography with therapy. STUDY DESIGN Seventeen subjects (n = 17) implanted with HGNS were enrolled at least 1 month postimplantation. Ultrasonographic measures were then used to optimize HGNS voltage to produce observable base of tongue protrusion without producing discomfort. Responders were defined as a reduction in AHI > 50% and an AHI of <20 events/h. RESULTS There were 17 subjects, 11 men and 6 women, with age = 64.6 ± 9.8 years, body mass index = 27.9 ± 2.7 kg/m2, and pretreatment AHI = 36.5 ± 14.4/h, T-90% = 10.7 ± 14.8%. The mean hyoid bone excursion (HBE) in responders = 1.0 ± 0.13 cm versus 0.82 ± 0.12 cm in nonresponders (P = 0.017). HBE was correlated with AHI during HGNS treatment (coef. -0.54, P = 0.03). Best subsets regression analysis using treatment-based AHI as the dependent variable and age, body mass index, baseline AHI, HBE, and HGNS voltage as independent variables showed that HBE (coef. -44.6, P = 0.044) was the only independent predictor of response. Receiver operator curve analysis showed that HBE > 0.85 cm had a sensitivity of 83.3% and specificity of 80.0% with a positive likelihood ratio of 4.17 to predict responder status. CONCLUSION We demonstrated that ultrasound assessment of HBE during HGNS programming is a useful tool to optimize therapy.
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23
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Steffen A, Jeschke S, Soose RJ, Hasselbacher K, König IR. Impulse Configuration in Hypoglossal Nerve Stimulation in Obstructive Sleep Apnea: The Effect of Modifying Pulse Width and Frequency. Neuromodulation 2021; 25:1312-1316. [PMID: 34214238 DOI: 10.1111/ner.13490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/13/2021] [Accepted: 03/30/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Hypoglossal nerve stimulation is an effective treatment option for obstructive sleep apnea (OSA) in positive airway pressure therapy failure. Nonetheless, data regarding the functional effect of modifying stimulation parameters within each electrode configuration are limited. MATERIALS AND METHODS In a retrospective study of 76 patients with 12 months or more follow-up, functional tongue protrusion thresholds were compared for pulse width and frequency configurations of 90 μsec 33 Hz vs 120 μsec 40 Hz. The number of tolerated voltage amplitude steps between sensation, functional, and subdiscomfort thresholds were assessed for both settings as well as impedances. RESULTS The overall cohort showed improvement in OSA metrics: median apnea-hypopnea index from 30.0/hour to 18.6/hour and Epworth Sleepiness Scale from 13.5 to 7.6. For both bipolar and unipolar electrode configurations, the stimulation amplitude required for functional tongue protrusion was significantly reduced when the pulse width and frequency were converted from 90 μsec 33 Hz to 120 μsec 40 Hz (p < 0.001). Nevertheless, the number of voltage amplitude steps from sensation, functional, to subdiscomfort thresholds did not differ between the two settings. The ratio of automatically derived impedances between bipolar and unipolar electrode configurations was relevantly correlated with the ratio of functional thresholds at these parameters. CONCLUSION Changing the stimulation parameters may lower the voltage requirements while maintaining the same effect on tongue protrusion. Changing these stimulation parameters does not affect the range of tolerated impulse steps between functional and subdiscomfort thresholds. Future technical appliances could help estimate functional thresholds at different electrode configurations for each patient by automatically measuring impedances.
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Affiliation(s)
- Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Stephanie Jeschke
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Ryan J Soose
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
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Kent DT, Scott WC, Zealear D, Schwartz AR. Ansa cervicalis stimulation increases pharyngeal patency in patients with obstructive sleep apnea. J Appl Physiol (1985) 2021; 131:487-495. [PMID: 34197226 DOI: 10.1152/japplphysiol.00076.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypoglossal nerve stimulation (HNS) is an alternative treatment option for obstructive sleep apnea (OSA) that reduces pharyngeal collapsibility, but HNS nonresponders often demonstrate continued retropalatal and lateral pharyngeal wall collapse. Recent evidence suggests that caudal pharyngeal traction with sternothyroid muscle contraction via ansa cervicalis stimulation (ACS) can also stabilize the pharynx, but the underlying mechanisms have not been elucidated. Our objective was to evaluate the effect of ACS on pharyngeal patency during expiration when the airway is most hypotonic. Eight participants with OSA underwent sustained ultrasound-guided fine-wire stimulation of the medial branch of the right hypoglossal nerve with and without transient stimulation of the branch of the ansa cervicalis nerve plexus innervating the right sternothyroid muscle during drug-induced sleep endoscopy. Airway cross-sectional area and expiratory airflow (V̇e) were measured from endoscopy video with ImageJ and pneumotachometry, respectively. ACS significantly increased retropalatal cross-sectional area (CSARP) to 211% [159-263] of unstimulated CSARP (P < 0.05). Adding ACS to HNS increased CSARP from baseline by 341% [244-439] (P < 0.05), a 180% [133-227] increase over isolated HNS (P < 0.05). ACS increased V̇e from baseline by 177% [138-217] P < 0.05). Adding ACS to HNS increased V̇e by 254% [207-301], reflecting decreases in pharyngeal collapsibility. Combining ACS with HNS increased retropalatal cross-sectional area and increased expiratory airflow, suggesting decreases in pharyngeal collapsibility. Our findings suggest that ACS exerts caudal traction on the upper airway through sternothyroid muscle contraction and that it may augment HNS efficacy in patients with OSA.NEW & NOTEWORTHY Ansa cervicalis stimulation (ACS) is a recently proposed neurostimulation mechanism for generating caudal pharyngeal traction that may benefit patients with obstructive sleep apnea. Here, we document endoscopic findings with ACS during drug-induced sleep endoscopy and additionally detail the effects of ACS on expiratory airflow, when the pharynx is known to be most hypotonic.
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Affiliation(s)
- David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William C Scott
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Zealear
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan R Schwartz
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Universidad Peruana Cayetano Heredia School of Medicine, Lima, Peru
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25
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Van de Perck E, Op de Beeck S, Dieltjens M, Vroegop AV, Verbruggen AE, Willemen M, Verbraecken J, Van de Heyning PH, Braem MJ, Vanderveken OM. The relationship between specific nasopharyngoscopic features and treatment deterioration with mandibular advancement devices: a prospective study. J Clin Sleep Med 2021; 16:1189-1198. [PMID: 32267227 DOI: 10.5664/jcsm.8474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVES The variable efficacy of mandibular advancement device (MAD) treatment necessitates both accessible and accurate methods for patient selection. However, the role of awake nasopharyngoscopy for this purpose remains dubious. We introduced an assessment method based on anatomical upper airway features during tidal breathing for nasopharyngoscopy. The current study aimed to relate these features to MAD treatment outcome. METHODS One hundred patients diagnosed with obstructive sleep apnea were prospectively recruited for MAD treatment in a fixed 75% degree of maximal protrusion. Nasopharyngoscopic observations during Müller's maneuver and tidal breathing were recorded both with and without MAD. Treatment outcome, confirmed by 3-month follow-up polysomnography with MAD, was classified as (1) apnea-hypopnea index reduction ≥ 50%, (2) treatment apnea-hypopnea index < 5 events/h, and (3) ≥ 10% increase in apnea-hypopnea index compared with baseline (treatment deterioration). RESULTS A complete dataset was obtained in 65 patients. After adjusting for baseline apnea-hypopnea index, body mass index, and supine dependency, the position of the soft palate (odds ratio, 4.0; 95% confidence interval, 1.3-11.8; P = .013) and crowding of the oropharynx (odds ratio, 7.7; 95% confidence interval, 1.4-41.4; P = .017) were related to treatment deterioration. Addition of both features significantly (P = .031) improved the accuracy of baseline models based on clinical measurements alone. Moreover, with the MAD in situ, a posteriorly located soft palate (odds ratio, 9.8; 95% confidence interval, 1.7-56.3; P = .010) and a posteriorly located tongue base (odds ratio, 7.4; 95% confidence interval, 1.5-35.9; P = .013) were associated with treatment deterioration. CONCLUSIONS Awake nasopharyngoscopy might be a valuable office-based examination to exclude the risk of treatment deterioration and improve patient selection for MAD treatment. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnea (PROMAD); URL: https://clinicaltrials.gov/ct2/show/NCT01532050; Identifier: NCT01532050.
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Affiliation(s)
- Eli Van de Perck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Anneclaire V Vroegop
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Annelies E Verbruggen
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Paul H Van de Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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Wirth M, Bautz M, von Meyer F, Hofauer B, Strassen U, Heiser C. Obstruction level associated with outcome in hypoglossal nerve stimulation. Sleep Breath 2021; 26:419-427. [PMID: 34091793 PMCID: PMC8857010 DOI: 10.1007/s11325-021-02396-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 01/14/2023]
Abstract
Purpose Selective hypoglossal nerve stimulation (sHNS) constitutes an effective surgical alternative for patients with obstructive sleep apnea (OSA). sHNS results in tongue protrusion and consecutive alleviation of obstructions at the tongue base level (lower obstructions). Furthermore, obstructions at the soft palate level (upper obstructions) may be prevented through palatoglossal coupling as seen on sleep endoscopy. However, it has not been studied if the distribution of obstruction level during a whole night measurement is a relevant factor for the treatment outcome. Methods Obstruction levels were measured with a manometry system during a whole night of sleep in 26 patients with OSA (f = 1, m = 25; age 59.4 ± 11.3; BMI = 29.6 ± 3.6) either before (n = 9) or after sHNS implantation (n = 12). Five patients received a measurement before and after implantation. Obstructions were categorized into velar (soft palate and above), infravelar (below soft palate), and multilevel obstructions. An association between obstruction level and treatment outcome was calculated. Results The mean distribution of preoperative obstruction level could be divided into the following: 38% velar, 46% multilevel, and 16% infravelar obstructions. Patients with a good treatment response (defined as AHI < 15/h and AHI reduction of 50%) had fewer preoperative velar obstructions compared to non-responder (17% vs. 54%, p-value = 0.006). In patients measured after sHNS implantation, a significantly higher rate of multilevel obstructions per hour was measured in non-responders (p-value = 0.012). Conclusions Selective hypoglossal nerve stimulation was more effective in patients with fewer obstructions at the soft palate level. Manometry may be a complementary diagnostic procedure for the selection of patients for HNS.
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Affiliation(s)
- Markus Wirth
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Maximilian Bautz
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Franziska von Meyer
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Benedikt Hofauer
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Ulrich Strassen
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Clemens Heiser
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
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Abstract
Undiagnosed and untreated obstructive sleep apnea (OSA) is associated with health comorbidities and negatively affects quality of life. Alternative treatments should be considered in patients who are unable to tolerate or benefit from positive airway pressure treatment. When properly indicated, positional devices, oral appliances, airway surgery, and hypoglossal nerve stimulation have been shown to be effective in treating OSA. Hypoglossal nerve stimulation is a successful second-line treatment with low associated morbidity and complication rate.
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Seay EG, Keenan BT, Schwartz AR, Dedhia RC. Evaluation of Therapeutic Positive Airway Pressure as a Hypoglossal Nerve Stimulation Predictor in Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2021; 146:691-698. [PMID: 32496539 DOI: 10.1001/jamaoto.2020.1018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Recent retrospective hypoglossal nerve stimulation (HGNS) outcomes data suggest that patients with low therapeutic positive airway pressure (PAP) levels achieve greater success than patients with high therapeutic PAP levels. Objective To examine the use of therapeutic nasal PAP levels at the soft palate in predicting the outcomes of HGNS for patients with obstructive sleep apnea. Design, Setting, and Participants This prospective cohort study used drug-induced sleep endoscopy (DISE) to evaluate the predictive capacity of therapeutic PAP levels in HGNS outcomes. In an academic sleep surgery center, 27 consecutive patients with obstructive sleep apnea who underwent DISE before implantation of an HGNS device were evaluated. The study was conducted from May 1, 2018, to June 26, 2019. Exposures Positive airway pressure delivered through a nasal mask during DISE. Main Outcomes and Measures Improvement in apnea-hypopnea index as measured from full-night preoperative and postoperative efficacy studies. Results Twenty-seven patients met all inclusion criteria. The mean (SD) age was 62.0 (14.4) years, 14 participants were men (51.9%), and mean body mass index was 28.1 (4.0). Responders to HGNS therapy (n = 18) had significantly lower mean (SD) palatal opening pressure compared with nonresponders (n = 9) (5.0 [2.8] vs 9.2 [3.7] cm H2O, respectively; mean difference, -4.2; 95% CI, -6.8 to -1.6 cm H2O). After adjusting for age, sex, and body mass index, the mean palatal opening pressure value for the responders remained 3.5 cm H2O lower (95% CI, -6.7 to -0.4 cm H2O) than that of nonresponders. A palatal opening pressure cutoff level less than 8 cm H2O demonstrated a positive predictive value of 82.4%; sensitivity, 77.8%; and specificity, 66.7%. Conclusions and Relevance In this small prospective cohort study, therapeutic nasal PAP levels during DISE differed significantly between responder and nonresponders to HGNS. Because DISE represents a mandatory, relatively standardized diagnostic tool for HGNS candidacy, the use of therapeutic nasal PAP through DISE can be broadly implemented and studied across multiple centers to possibly improve patient selection for HGNS.
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Affiliation(s)
- Everett G Seay
- Perelman School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Alan R Schwartz
- Perelman School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia.,Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Raj C Dedhia
- Perelman School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia.,Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
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Johnson MD, Dweiri YM, Cornelius J, Strohl KP, Steffen A, Suurna M, Soose RJ, Coleman M, Rondoni J, Durand DM, Ni Q. Model-based analysis of implanted hypoglossal nerve stimulation for the treatment of obstructive sleep apnea. Sleep 2021; 44:S11-S19. [PMID: 33647987 DOI: 10.1093/sleep/zsaa269] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/12/2020] [Indexed: 11/15/2022] Open
Abstract
STUDY OBJECTIVES Individuals with obstructive sleep apnea (OSA), characterized by frequent sleep disruptions from tongue muscle relaxation and airway blockage, are known to benefit from on-demand electrical stimulation of the hypoglossal nerve. Hypoglossal nerve stimulation (HNS) therapy, which activates the protrusor muscles of the tongue during inspiration, has been established in multiple clinical studies as safe and effective, but the mechanistic understanding for why some stimulation parameters work better than others has not been thoroughly investigated. METHODS In this study, we developed a detailed biophysical model that can predict the spatial recruitment of hypoglossal nerve fascicles and axons within these fascicles during stimulation through nerve cuff electrodes. Using this model, three HNS programming scenarios were investigated including grouped cathode (---), single cathode (o-o), and guarded cathode bipolar (+-+) electrode configurations. RESULTS Regardless of electrode configuration, nearly all hypoglossal nerve axons circumscribed by the nerve cuff were recruited for stimulation amplitudes <3 V. Within this range, monopolar configurations required lower stimulation amplitudes than the guarded bipolar configuration to elicit action potentials within hypoglossal nerve axons. Further, the spatial distribution of the activated axons was more uniform for monopolar versus guarded bipolar configurations. CONCLUSIONS The computational models predicted that monopolar HNS provided the lowest threshold and the least sensitivity to rotational angle of the nerve cuff around the hypoglossal nerve; however, this setting also increased the likelihood for current leakage outside the nerve cuff, which could potentially activate axons in unintended branches of the hypoglossal nerve. CLINICAL TRIAL REGISTRATION NCT01161420.
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Affiliation(s)
- Matthew D Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN
| | - Yazan M Dweiri
- Department of Biomedical Engineering, Jordan University of Science and Technology, Irbid, Jordan
| | - Jason Cornelius
- Minneapolis Clinic of Neurology and North Memorial Help Sleep Medicine, Maple Grove, MN
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care, and Sleep Medicine, Louis Stokes Veterans Affairs Medical Center and Case Medical Center, Case Western Reserve University, Cleveland, OH
| | - Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Maria Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY
| | - Ryan J Soose
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Dominique M Durand
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH
| | - Quan Ni
- Inspire Medical Systems, Inc., Minneapolis, MN
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30
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A Phenotypic Approach for Personalised Management of Obstructive Sleep Apnoea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00346-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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31
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Pawlak D, Bohorquez D, König IR, Steffen A, Thaler ER. Effect of Electrode Configuration and Impulse Strength on Airway Patency in Neurostimulation for Obstructive Sleep Apnea. Laryngoscope 2021; 131:2148-2153. [PMID: 33864394 DOI: 10.1002/lary.29530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hypoglossal nerve stimulation (HNS) has gained increasing interest for the treatment of patients with obstructive sleep apnea (OSA). Drug-induced sleep endoscopy (DISE) can both exclude improper airway collapse patterns and visualize airway changes under stimulation. Stimulation outcome effects depend on the impulse voltage and electric field resulting from the electrode configuration of the implanted device. The effects of various combinations of voltage and electric field on DISE airway patterns in contrast to awake endoscopy are unknown. STUDY DESIGN Cohort study. METHODS During therapy adjustment about 6 months after implantation, patients underwent a DISE and awake endoscopy with 100% and 125% of functional voltage in three typical electrode configurations (+ - +, o - o, - - -). All videos were analyzed by two separate persons for the opening of the airway at velum, tongue base, and epiglottis level. RESULTS Thirty patients showed typical demographic data. The opening effects were visible in all patients, but there were changes between different electrode configurations. Several demographic or therapeutic aspects such as obesity, OSA severity, or prior soft palate surgery were associated with changes arising from different electrode configurations, but none resulted in a consistently better airway opening. CONCLUSIONS In patients with poor results during the therapy adjustment, electric configuration changes can improve airway patency-an independent variable from increasing voltage. As these effects can only be seen in awake endoscopy or DISE, both endoscopies with live stimulation may be considered in cases with insufficient improvement in apnea-hypopnea index after initiation of HNS therapy. LEVEL OF EVIDENCE Prospective case series; level 4. Laryngoscope, 131:2148-2153, 2021.
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Affiliation(s)
- Dominik Pawlak
- Department of Otorhinolaryngology, University of Lubeck, Lubeck, Germany
| | - Dominique Bohorquez
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Inke R König
- Department of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Armin Steffen
- Department of Otorhinolaryngology, University of Lubeck, Lubeck, Germany
| | - Erica R Thaler
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-020-00264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mashaqi S, Patel SI, Combs D, Estep L, Helmick S, Machamer J, Parthasarathy S. The Hypoglossal Nerve Stimulation as a Novel Therapy for Treating Obstructive Sleep Apnea-A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041642. [PMID: 33572156 PMCID: PMC7914469 DOI: 10.3390/ijerph18041642] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnea (OSA) is a common sleep disorder that affects all age groups and is associated with many co-morbid diseases (especially cardiovascular diseases). Continuous positive airway pressure (CPAP) is the gold standard for treating OSA. However, adherence to PAP therapy has been a major challenge with an estimated adherence between 20% and 80%. Mandibular advancement devices (MAD) are a good alternative option if used in the appropriate patient. MAD are most effective in mild and moderate OSA but not severe OSA. Surgical options are invasive, not appropriate for severe OSA, and associated with pain and long healing time. Hypoglossal nerve stimulation (HGNS), or upper airway stimulation (UAS), is a novel therapy in treating moderate and severe degrees of OSA in patients who cannot tolerate CPAP therapy. We reviewed the MEDLINE (PubMed) database. The search process yielded 303 articles; 31 met the inclusion and exclusion criteria and were included. We concluded that hypoglossal nerve stimulation is a very effective and novel alternative therapy for moderate and severe OSA in patients who cannot tolerate CPAP therapy. Adherence to HGNS is superior to CPAP. However, more developments are needed to ensure the highest safety profile.
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Affiliation(s)
- Saif Mashaqi
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
- Correspondence: ; Tel.: +1-(304)-690-0586
| | - Salma Imran Patel
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Daniel Combs
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arizona, Tucson, AZ 85724, USA;
| | - Lauren Estep
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Sonia Helmick
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Joan Machamer
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Sairam Parthasarathy
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
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Flynn J, Boyd C, Yalamanchali S, Rouse D, Goodwin S, Penn J, Larsen C. The Effect of Lateral Pharyngeal Collapse Patterns on Therapy Response in Upper Airway Stimulation Surgery. Ann Otol Rhinol Laryngol 2021; 130:985-989. [PMID: 33455440 DOI: 10.1177/0003489420987979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. METHODS A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. RESULTS About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, P = .001), AHI (29.8 vs 5.4, P < .001) and minimum oxygen saturation (79% vs 83%, P < .001). No DISE findings significantly predicted AHI response after UAS. Specifically, multiple types of lateral pharyngeal collapse patterns did not adversely effect change in AHI or AHI response rate. CONCLUSION Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. LEVEL OF EVIDENCE VI.
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Affiliation(s)
- John Flynn
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Christopher Boyd
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Sreeya Yalamanchali
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - David Rouse
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Sara Goodwin
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Joseph Penn
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Christopher Larsen
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
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Huyett P, Kent DT, D'Agostino MA, Green KK, Soose RJ, Kaffenberger TM, Woodson BT, Huntley C, Boon MS, Heiser C, Birk A, Suurna MV, Lin HS, Waxman JA, Kezirian EJ. Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study. Laryngoscope 2021; 131:1676-1682. [PMID: 33443811 DOI: 10.1002/lary.29396] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/03/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN Cohort study. METHODS A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1676-1682, 2021.
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Affiliation(s)
- Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Mark A D'Agostino
- Southern New England Ear, Nose and Throat Group, Middlesex Hospital, Middlesex, Connecticut, U.S.A.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Ryan J Soose
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Thomas M Kaffenberger
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Maurits S Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Amelie Birk
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, U.S.A
| | - Ho-Sheng Lin
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Jonathan A Waxman
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Eric J Kezirian
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, California, Los Angeles, U.S.A
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MacKay SG, Lewis R, McEvoy D, Joosten S, Holt NR. Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association . Respirology 2020; 25:1292-1308. [PMID: 33190389 PMCID: PMC7839593 DOI: 10.1111/resp.13967] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 12/11/2022]
Abstract
Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.
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Affiliation(s)
- Stuart G MacKay
- University of Wollongong, Wollongong, NSW, Australia.,Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia.,Department of Otolaryngology Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW, Australia
| | - Richard Lewis
- Hollywood Medical Centre, Perth, WA, Australia.,Department of Otolaryngology Head and Neck Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Doug McEvoy
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Respiratory and Sleep Service, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Simon Joosten
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, VIC, Australia.,School of Clinical Sciences, Melbourne, VIC, Australia
| | - Nicolette R Holt
- The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Mu L, Chen J, Li J, Fowkes M, Benson B, Nyirenda T, Sobotka S, Christopherson M, Sanders I. Innervation of human soft palate muscles. Anat Rec (Hoboken) 2020; 304:1054-1070. [PMID: 33034133 DOI: 10.1002/ar.24531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/07/2020] [Accepted: 08/05/2020] [Indexed: 11/07/2022]
Abstract
Our objective was to determine the branching and distribution of the motor nerves supplying the human soft palate muscles. Six adult specimens of the soft palate in continuity with the pharynx, larynx, and tongue were processed with Sihler's stain, a technique that can render large specimens transparent while counterstaining their nerves. The cranial nerves were identified and dissection followed their branches as they divided into smaller divisions toward their terminations in individual muscles. The results showed that both the glossopharyngeal (IX) and vagus (X) nerves have three distinct branches, superior, middle, and inferior. Only the middle branches of each nerve contributed to the pharyngeal plexus to which the facial nerve also contributed. The pharyngeal plexus was divided into two parts, a superior innervating the palatal and neighboring muscles and an inferior innervating pharyngeal constrictors. The superior branches of the IX and X nerves contributed innervation to the palatoglossus, whereas their middle branches innervated the palatopharyngeus. The palatoglossus and palatopharyngeus muscles appeared to be composed of at least two neuromuscular compartments. The lesser palatine nerve not only supplied the palatal mucosa and palatine glandular tissue but also innervated the musculus uvulae, palatopharyngeus, and levator veli palatine. The latter muscle also received its innervation from the superior branch of X nerve. The findings would be useful for better understanding the neural control of the soft palate and for developing novel neuromodulation therapies to treat certain upper airway disorders such as obstructive sleep apnea.
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Affiliation(s)
- Liancai Mu
- From Upper Airway Research Laboratory, Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Jingming Chen
- From Upper Airway Research Laboratory, Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Jing Li
- From Upper Airway Research Laboratory, Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Mary Fowkes
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Benson
- Department Otolaryngology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Themba Nyirenda
- From Upper Airway Research Laboratory, Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Stanislaw Sobotka
- From Upper Airway Research Laboratory, Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA.,Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Ira Sanders
- Linguaflex, Inc, Pittsburgh, Pennsylvania, USA
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Ansa Cervicalis Stimulation: A New Direction in Neurostimulation for OSA. Chest 2020; 159:1212-1221. [PMID: 33065104 PMCID: PMC8097630 DOI: 10.1016/j.chest.2020.10.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hypoglossal nerve stimulation (HNS) is an alternative treatment option for patients with OSA unable to tolerate positive airway pressure but implant criteria limit treatment candidacy. Previous research indicates that caudal tracheal traction plays an important role in stabilizing upper airway patency. RESEARCH QUESTION Does contraction of the sternothyroid muscle with ansa cervicalis stimulation (ACS), which pulls the pharynx caudally via thyroid cartilage insertions, increase maximum inspiratory airflow (VImax)? STUDY DESIGN AND METHODS Hook-wire percutaneous electrodes were used to stimulate the medial branch of the right hypoglossal nerve and right branch of the ansa cervicalis innervating the sternothyroid muscle during propofol sedation. VImax was assessed during flow-limited inspiration with a pneumotachometer. RESULTS Eight participants with OSA were studied using ACS with and without HNS. Compared with baseline, the mean VImax increase with isolated ACS was 298%, or 473 mL/s (95% CI, 407-539). Isolated HNS increased mean VImax from baseline by 285%, or 260 mL/s (95% CI, 216-303). Adding ACS to HNS during flow-limited inspiration increased mean VImax by 151%, or 205 mL/s (95% CI, 174-236) over isolated HNS. Stimulation was significantly associated with increase in VImax in both experiments (P < .001). INTERPRETATION ACS independently increased VImax during propofol sedation and drove further increases in VImax when combined with HNS. The branch of the ansa cervicalis innervating the sternothyroid muscle is easily accessed. Confirmation of the ansa cervicalis as a viable neurostimulation target may enable caudal pharyngeal traction as a novel respiratory neurostimulation strategy for treating OSA.
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Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic Labelling Using Drug-Induced Sleep Endoscopy Improves Patient Selection for Mandibular Advancement Device Outcome: A Prospective Study. J Clin Sleep Med 2020; 15:1089-1099. [PMID: 31482830 DOI: 10.5664/jcsm.7796] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVES Mandibular advancement device (MAD) outcome varies between patients. We hypothesized that upper airway collapse sites, patterns, and degrees assessed during baseline drug-induced sleep endoscopy (DISE) affect MAD outcome. METHODS One hundred patients with obstructive sleep apnea (OSA) were included and underwent baseline type 1 polysomnography. MAD was fitted intraorally at fixed 75% maximal protrusion. A total of 72 patients completed 3-month follow-up polysomnography and baseline DISE. Response was defined as apnea-hypopnea index (AHI) reduction ≥ 50%, deterioration as AHI increases during MAD treatment compared to baseline. RESULTS Adjusting for baseline AHI and body mass index, patients with tongue base collapse showed 3.69 higher odds (1.27-10.73; P = .0128) for response. Complete concentric collapse at the level of the palate (5.32 [1.21-23.28]; P = .0234) and complete laterolateral oropharyngeal collapse (6.62 [1.14-38.34]; P = .0330) related to deterioration. Results for tongue base collapse and complete concentric collapse at the level of the palate were confirmed in the moderate to severe OSA subgroup. Applying these results to this selected subgroup increased response rate with 54% and decreased deterioration rate with 53%. These results were confirmed using other response and deterioration definitions. CONCLUSIONS Three baseline DISE phenotypes identified during drug-induced sleep were significantly related to MAD treatment outcome: one beneficial, tongue base collapse, and two adverse, complete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse. If confirmed in future prospective studies, these results could guide patient selection for MAD outcome. CLINICAL TRIAL REGISTRATION This prospective clinical trial (PROMAD) was registered on Clinicaltrials.gov with identifier: NCT01532050. CITATION Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic labelling using drug-induced sleep endoscopy improves patient selection for mandibular advancement device outcome: a prospective study. J Clin Sleep Med. 2019;15(8):1089-1099.
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Affiliation(s)
- Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Annelies E Verbruggen
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Anneclaire V Vroegop
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Clinical Trial Centre (CTC), CRC Antwerp, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Evert Hamans
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium; Department of Pulmonology, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Wilfried A De Backer
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Paul H Van de Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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Abstract
PURPOSE OF REVIEW The purpose of this article is to highlight recent advances in the burgeoning field of drug-induced sleep endoscopy (DISE). RECENT FINDINGS One of the first studies to investigate the correlation of DISE findings and natural sleep endoscopy found good agreement in clinically significant obstruction. Previous studies have shown good agreement of DISE findings with the use of different sedative agents implying that the choice of sedative may not be crucial. However, recent studies show variable patterns of collapse, especially at the tongue base, with the use of different sedative agents. A universally accepted classification scheme for drug-induced sleep endoscopy is lacking. A new DISE classification system, termed Palate, Tonsils, Lateral pharyngeal wall, Tongue base, Epiglottis, was introduced this year with the noted advantage of being able to better differentiate between clinically relevant tonsillar and lateral pharyngeal wall collapse. Despite recent advances in the field, there remains no general consensus that DISE findings predict surgical success but may aid in the identification of patients who will respond well to oral appliance therapy. SUMMARY Drug-induced sleep endoscopy is a structure-based evaluation of the upper airway that more closely resembles the natural sleep state compared with awake evaluation.
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Steffen A, König IR, Baptista PM, Abrams N, Jeschke S, Hasselbacher K. Home Sleep Testing to Direct Upper Airway Stimulation Therapy Optimization for Sleep Apnea. Laryngoscope 2020; 131:E1375-E1379. [PMID: 32865831 DOI: 10.1002/lary.29043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/26/2020] [Accepted: 07/31/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES/HYPOTHESIS Selective upper airway stimulation (sUAS) is a well-established treatment option for obstructive sleep apnea (OSA). This study aimed to determine if there are benefits in performing a home sleep test (HST) to evaluate postoperative sUAS effectiveness after patient acclimatization compared to the generally used polysomnography (PSG) titration, as measured by long-term follow-up outcomes. STUDY DESIGN Retrospective comparative cohort analysis. METHODS We conducted an analysis of consecutive patients at our center who had completed a 6-month follow-up (month 6 [M6]) and recorded data from M6, month 12 (M12), and month 24 (M24). After device activation, we performed an HST with the patient's stimulation settings, and measured the apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and device usage. These values were compared to patients who had undergone PSG-based device titration. RESULTS Baseline values of the initial 131 patients show high ESS and moderate OSA. At the 2-month time point of the HST, nearly half of the patients (46.2%) reached an AHI ≤15/hr, and approximately a fifth (19.2%) reached <5/hr. The PSG and HST groups differed in median ESS at M24, but no other differences were observed for ESS at M6 and M12. Both groups showed similar AHI, oxygen desaturation, and usage hours per week. CONCLUSIONS Adjusting therapy by using the HST technique after device activation and acclimatization has clinical and economic advantages. These advantages are contingent on several conditions being met when deviating from the standard device protocol, including precise communication with the referring sleep medicine physicians, especially their role in helping with long-term follow-up. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1375-E1379, 2021.
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Affiliation(s)
- Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Peter M Baptista
- Department of Otorhinolaryngology, Navarra University Hospital, Pamplona, Spain
| | - Nils Abrams
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Stephanie Jeschke
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
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Schiefer M, Gamble J, Baskin J, Strohl K. Hypoglossal nerve stimulation in a rabbit model of obstructive sleep apnea reduces apneas and improves oxygenation. J Appl Physiol (1985) 2020; 129:442-448. [PMID: 32702266 DOI: 10.1152/japplphysiol.00828.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Based on a prior anesthetized model, we developed an unanesthetized model to evaluate the effects of hypoglossal nerve stimulation (HNS) during sleep. We prepared three rabbits with injections of hyaluronic acid in the base of tongue to produce upper airway obstruction followed by HNS implant. Two rabbits were saline controls, and one, a passive control. Measures were sleep, airflow, effort, oxygen saturation, and heart rate. HNS with electrodes around the right hypoglossal nerve were adjusted to a level without behaviorally disturbing the animal. During HNS stimulation in the tongue-base injected rabbits, obstructive apneas and hypopneas of intermediate (3 to 7 cycles of respiratory effort) or longer (≥8 cycles) duration were largely eliminated while less clinically relevant shorter events (<3) were unaffected, and oxygen saturation was improved. Control animals exhibited no intermediate or long events. In this model HNS can relieve induced sleep apnea, without disturbing the animal: however, despite being non-canine and of substantial size, the model has its challenges.NEW & NOTEWORTHY This report describes a rabbit model for testing the impact of hypoglossal nerve stimulation (HNS) on obstructive apneas. Obstructive sleep apnea (OSA) is induced by injecting hyaluronic acid (as a filler) into the base of the tongue. HNS reduced the length and rate of obstructions and improved oxygenation during sleep. Our efforts with this model advanced understanding of the complexities of this OSA preclinical model for neurostimulation reversal of sleep-disordered breathing.
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Affiliation(s)
- Matthew Schiefer
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio.,Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida
| | - Jenniffer Gamble
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | - Jonathan Baskin
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | - Kingman Strohl
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
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Yu MS, Ibrahim B, Riley RW, Liu SYC. Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 13:225-233. [PMID: 32683836 PMCID: PMC7435433 DOI: 10.21053/ceo.2020.00360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Myeong Sang Yu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Badr Ibrahim
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Robert Wayne Riley
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
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Jenks CM, Yu JL, Schmitt KA, Schwab RJ, Thaler ER. Prospective Determination of Airway Response to Upper Airway Stimulation: A New Opportunity for Advanced Device Titration. Laryngoscope 2020; 131:218-223. [PMID: 32557705 DOI: 10.1002/lary.28758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Response to upper airway stimulation (UAS) is associated with the degree of airway opening during stimulation. UAS programming may affect this opening. The objective of this study was to examine airway changes in response to five different electrode configurations programmable within the Inspire UAS system. STUDY DESIGN Prospective single-arm cohort study. METHODS Subjects who underwent UAS implantation were recruited for a prospective single-arm cohort study during UAS device activation. Functional thresholds were recorded for all settings. Awake nasopharyngoscopy was performed to examine the retropalatal (RP) and retroglossal (RG) regions at rest and during activation with all settings at their functional thresholds. Cross-sectional measurements were made by two blinded reviewers and reported as percent change in airway size. RESULTS Sixteen patients were included. The standard setting (+-+) resulted in the greatest change in RP area in 43.8% of patients. An alternative setting resulted in greatest change in 56.2% of patients (--- and o-o in 18.8% each, -o- in 12.5%, and -+- in 6.3% of patients). Average response to all five settings was utilized to classify degree of palatoglossal coupling. Most patients had some enlargement (20%-70% change in RP area, 43.8%) or no enlargement (<20% change, 43.8%), whereas a minority of patients (12.5%) had marked enlargement (>70% change). RP and RG expansion were not correlated. CONCLUSION Degree of RP expansion varied among patients and settings. Although the standard setting resulted in greatest RP change in a plurality of patients, over half had a greater response to an alternative setting. Future studies should address whether choice of setting based on RP expansion results in improved outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 131:218-223, 2021.
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Affiliation(s)
- Carolyn M Jenks
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason L Yu
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Division of Sleep Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Katherine A Schmitt
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Richard J Schwab
- Division of Sleep Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Erica R Thaler
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Heiser C, Vanderveken OM, Edenharter GM, Hofauer B. Cross motor innervation of the hypoglossal nerve-a pilot study of predictors for successful opening of the soft palate. Sleep Breath 2020; 25:425-431. [PMID: 32488573 PMCID: PMC7987639 DOI: 10.1007/s11325-020-02112-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Selective hypoglossal nerve stimulation has proven to be a successful treatment option in patients with obstructive sleep apnea. The aim of this pilot study was to investigate if there is a cross-innervation of the hypoglossal nerve in humans and if patients with this phenotype show a different response to hypoglossal nerve stimulation compared to those with ipsilateral-only innervation METHODS: Nineteen patients who previously received a selective hypoglossal nerve stimulation system (Inspire Medical Systems, Golden Valley, USA) were implanted with a nerve integrity system placing electrodes on both sides of the tongue. Tongue motions were recorded one and two months after surgery from transoral and transnasal views. Polysomnography (PSG) was also performed at two months. Electromyogram (EMG) signals and tongue motions after activation were compared with PSG findings. RESULTS Cross-innervation showed significant correlation with bilateral tongue movement and bilateral tongue base opening, which were associated with better PSG outcomes. CONCLUSION Cross motor innervation of the hypoglossal nerve occurs in approximately 50% of humans, which is associated with a positive effect on PSG outcomes. Bilateral stimulation of the hypoglossal nerve may be a solution for non-responding patients with pronounced collapse at the soft palate during drug-induced sleep endoscopy.
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Affiliation(s)
- Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.
| | - Olivier M Vanderveken
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Günther M Edenharter
- Klinikum rechts der Isar der Technischen Universität München, Klinik für Anästhesie, Munich, Germany
| | - Benedikt Hofauer
- Department of Otorhinolaryngology, Head and Neck Surgery University of Freiburg, Freiburg im Breisgau, Germany
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Shah RR, Thaler ER. Base of Tongue Surgery for Obstructive Sleep Apnea in the Era of Neurostimulation. Otolaryngol Clin North Am 2020; 53:431-443. [PMID: 32334869 DOI: 10.1016/j.otc.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Retroglossal collapse is commonly seen in patients with obstructive sleep apnea. The role of upper airway stimulation surgery for these patients continues to evolve. However, base of tongue reduction surgery continues to have usefulness for appropriately selected patients with obstructive sleep apnea. Specific tongue base approaches may vary in response to patient and surgeon preferences and be used in multilevel surgery where appropriate. Key factors include patient age, willingness to undergo device implantation, and preferences for outpatient versus inpatient procedure, single procedure versus multiple, and tolerance for various procedure-specific postoperative restrictions and potential complications.
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Affiliation(s)
- Ravi R Shah
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, 5th Floor Silverstein Building, Philadelphia, PA 19104, USA
| | - Erica R Thaler
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, 5th Floor Silverstein Building, Philadelphia, PA 19104, USA.
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Abstract
Hypoglossal nerve stimulation (HNS) therapy represents a novel approach and a paradigm shift in the evolution of obstructive sleep apnea (OSA) treatment as a hybrid surgically implanted, medically titratable device. Unlike traditional sleep apnea surgical procedures, HNS augments the neuromuscular activity of the pharynx, preserves upper airway structure and function, and has the potential to provide multilevel upper airway improvement with one procedure. The early success of HNS sets the stage for new technology development, further investigation into optimal patient selection and therapy titration, and application to other subsets of the OSA population.
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Seo J, Yun S, Shim S, Cho SW, Choi JW, Kim JW, Kim SJ. Palatal implant system can provide effective treatment for obstructive sleep apnea by recovering retropalatal patency. J Neural Eng 2020; 17:026017. [DOI: 10.1088/1741-2552/ab7d61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Upper airway stimulation for obstructive sleep apnea-Can radiological position monitoring predict tongue motion one year after implantation? HNO 2020; 68:11-16. [PMID: 31598770 DOI: 10.1007/s00106-019-0717-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tongue motion patterns (TMP) can influence the outcome of upper airway stimulation (UAS) in the treatment of obstructive sleep apnea (OSA). As a postoperative control, the cuff position of the stimulation lead is monitored via X‑ray imaging. A multidimensional X‑ray assessment system was established and the association between these positional assessments and TMP was investigated 1 year after implantation. MATERIAL AND METHODS The study on TMP and the X‑ray assessments were carried out at a German ear nose and throat clinic as an implantation center. The TMPs were assessed under bipolar electrode configuration and were categorized according to the currently available literature as right-sided protrusion (RP), left-sided protrusion (LP), bilateral protrusion (BP) and mixed activation (MA). The X‑ray assessment was carried out in five dimensions: the position relative to the mandible and hyoid, cuff steepness in the lateral view of the neck, the cuff position based on the single electrode, and the lead connection to the cuff in the anterior-posterior view. The analyses were performed by three raters with different medical backgrounds and knowledge regarding TMP. RESULTS In approximately 60% of patients, the apnea-hypopnea index was reduced to below 15/h 1 year after implantation. The most common TMPs were RP and BP (82.9%). The interrater variability of the X‑ray assessment was good except for one category. Furthermore, no relevant associations were found apart from the correlation between a favorable TMP and the cuff position with respect to the lateral position of the stimulation cable. CONCLUSION Despite good interrater variability and convenient usage of the suggested X‑ray assessment system, this approach did not enable the identification of any associations by which a TM and, therefore, a possible straightforward or complicated treatment pathway could be predicted. Attention should possibly be paid to a rotation of the cuff during implantation with a lateral position of the stimulation lead.
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Mulholland GB, Dedhia RC. Success of Hypoglossal Nerve Stimulation Using Mandibular Advancement During Sleep Endoscopy. Laryngoscope 2020; 130:2917-2921. [PMID: 32108345 DOI: 10.1002/lary.28589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/24/2020] [Accepted: 02/04/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hypoglossal nerve stimulation (HGNS) effectively treats obstructive sleep apnea in select patients. Drug-induced sleep endoscopy (DISE) is required for HGNS candidacy. Data suggest that mandibular advancement (MA) devices and HGNS share similar target populations. We aimed to test the association between MA's effect on the velum and lateral walls during DISE in relation to the improvement in the apnea-hypopnea index (AHI) with HGNS. STUDY DESIGN Prospective case series METHODS: All patients completed preoperative polysomnography or home sleep study, DISE with MA prior to HGNS implantation, and full-night efficacy sleep tests. Adult patients with body mass index (BMI) ≤ 35 and AHI ≥ 15 were included. Two independent reviewers scored DISE videos. RESULTS Forty-six patients were included from October 2015 to January 2019. Mean BMI (standard deviation) was 28.5 (3.7) kg/m2 . Patients with a reduced airway response to MA had greater AHI improvement than patients with a robust response (21.7, 95% confidence interval [CI]: 14.4 to 29.0 vs. 4.9, 95% CI: -8.9 to 18.6; P = .03). Patients with complete baseline collapse at the velum and lateral walls (n = 11) had less response compared to those with partial collapse (n = 35) (AHI reduction of 4.4 [95% CI: -8.6 to 17.4] vs. 22.3 [95% CI: 15.1 to 29.6; P = .02]). CONCLUSIONS Patients having significant airway improvement in the upper pharynx with MA during DISE appear less likely to succeed with HGNS. This phenomenon might be secondary to the worsened baseline obstruction of the upper pharynx in such patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2020.
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Affiliation(s)
- Graeme B Mulholland
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Raj C Dedhia
- Division of Sleep Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.,CPAP Alternatives Clinic, Penn Sleep Center, Penn Medicine, Philadelphia, Pennsylvania, U.S.A
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