Use and Cost of a Hypoglossal Nerve Stimulator Device for Obstructive Sleep Apnea Between 2015 and 2018

Hypoglossal Nerve Stimulator Explantation Technique and Outcomes: A Retrospective Case Series

INTRODUCTION

Upper airway stimulation via the hypoglossal nerve stimulator (HGNS) implant is a surgical method for treating obstructive sleep apnea. However, patients may need the implant removed for a variety of reasons. The purpose of this case series is to assess surgical experiences with HGNS explantation at our institution. We report on surgical approach, overall operative times, operative and postoperative complications, and discuss relevant patient-specific surgical findings when removing the HGNS.

METHODS

We performed a retrospective case series of all patients that underwent HGNS implantation at a single tertiary medical center between January 9, 2021, and January 9, 2022. Subjects included adult patients who presented to the sleep surgery clinic of the senior author for surgical management of previously implanted HGNS. Patient clinical history was reviewed to determine the timing of the patient's implant, reasons for explant, and postoperative recovery course. Operative reports were reviewed to determine overall duration of surgery and any associated difficulties or deviations from the general approach.

RESULTS

Between January 9, 2021, and January 9, 2022, 5 patients had an explantation of their HGNS implant. Explantation occurred between 8 and 63 months of their original implant surgery. The average operative time from incisional start time to close was 162 min for all cases with a range of 96-345 min. No significant complications were reported including pneumothorax and nerve palsy.

CONCLUSION

This reported case series outlines the general steps for Inspire HGNS explantation as well as details the experiences in a case series of 5 subjects explanted over the year at a single institution. The results from the cases suggest that the explantation of the device can be performed efficiently and safely.

Transoral awake state neuromuscular electrical stimulation therapy for mild obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) is a common disorder with major neurocognitive and cardiovascular sequelae. The treatment of symptomatic patients with mild OSA remains controversial given that adherence to positive airway pressure (PAP) has historically been suboptimal. With this notion in mind, we assessed a daily transoral neuromuscular electrical stimulation (NMES) device for individuals with mild OSA.

Methods

The sample represents a subset of participants with a baseline AHI 5–14.9 events/hour, drawn from a parent study which also included participants with primary snoring. Outcome measures for the current study included changes in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and snoring levels before and after use of the NMES. 

Results

Among 65 participants (68% men) with median age of 49 years (range 24 to 79) and median BMI of 27.7 kg/m2 (range 20 to 34), the NMES device was used daily for 6 weeks. We observed a significant improvement in the AHI from 10.2 to 6.8 events/hour among all participants and from 10.4 to 5.0 events/h among responders. Statistically significant improvements in the ESS, PSQI, objectively measured snoring, and bed partner-reported snoring were observed. Adherence among all participants was 85%.

Discussion

This NMES device has the benefit of being a treatment modality of daytime therapy which confers a high level of tolerability and patient acceptance. It alleviates the need for an in situ device during sleep and leads to improvements in OSA severity, snoring, and subjective sleep metrics, potentially crucial in mild OSA. Further studies are needed to define which individuals may benefit most from the device across the wider spectrum of OSA severity and assess long-term therapeutic outcomes.

Trial registration

ClinicalTrials.gov Identifier: NCT03829956.

Daytime Neuromuscular Electrical Therapy of Tongue Muscles in Improving Snoring in Individuals with Primary Snoring and Mild Obstructive Sleep Apnea

Study Objectives: Evaluating daytime neuromuscular electrical training (NMES) of tongue muscles in individuals with Primary Snoring and Mild Obstructive Sleep Apnea (OSA). Methods: A multicenter prospective study was undertaken in patients with primary snoring and mild sleep apnea where daytime NMES (eXciteOSA^® Signifier Medical Technologies Ltd., London W6 0LG, UK) was used for 20 min once daily for 6 weeks. Change in percentage time spent snoring was analyzed using a two-night sleep study before and after therapy. Participants and their bed partners completed sleep quality questionnaires: Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI), and the bed partners reported on the nighttime snoring using a Visual Analogue Scale (VAS). Results: Of 125 patients recruited, 115 patients completed the trial. Ninety percent of the study population had some reduction in objective snoring with the mean reduction in the study population of 41% (p < 0.001). Bed partner-reported snoring reduced significantly by 39% (p < 0.001). ESS and total PSQI scores reduced significantly (p < 0.001) as well as bed partner PSQI (p = 0.017). No serious adverse events were reported. Conclusions: Daytime NMES (eXciteOSA^®) is demonstrated to be effective at reducing objective and subjective snoring. It is associated with effective improvement in patient and bed partner sleep quality and patient daytime somnolence. Both objective and subjective measures demonstrated a consistent improvement. Daytime NMES was well tolerated and had minimal transient side effects.

Association Between Conflict of Interest and Published Position on Hypoglossal Nerve Stimulation for Sleep Apnea

OBJECTIVE

To determine if there is an association between authors' financial conflict of interest and published position on clinical use of hypoglossal nerve stimulation for obstructive sleep apnea.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

International roster of authors and articles analyzed.

METHODS

A Google Scholar search was performed for editorials and reviews citing the 2014 New England Journal of Medicine article on hypoglossal nerve stimulation for obstructive sleep apnea. Included articles were coded as favorable or neutral. Conflict of interest was recorded as declared by the authors in these articles and as independently searched in the Open Payments registry.

RESULTS

Sixteen articles from 45 independent authors were analyzed. Nine articles by authors were coded as favorable. Among authors of articles with favorable views, 16 (59%) had a financial conflict of interest with the manufacturer of the hypoglossal nerve stimulator device, as opposed to only 1 of 21 (5%) authors of neutral/unfavorable articles. When we included only authors to whom payments could be identified or excluded on Open Payments, 16 of 20 (80%; 95% CI, 62%-98%) authors of favorable articles had a financial conflict, while 1 of 10 (10%; 95% CI, 0%-29.6%) of neutral/unfavorable articles did (P = .004).

CONCLUSION

Our study demonstrates an association between published position on hypoglossal nerve stimulator use and financial conflict with the device manufacturer. Several undeclared conflicts were also found, suggesting a role for independent search for conflicts during the review process.