Adverse Events in Hypoglossal Nerve Stimulator Implantation: 5-Year Analysis of the FDA MAUDE Database

Adverse events associated with device assisted hyoid and tongue base suspension for obstructive sleep apnea

PURPOSE

Hyoid and tongue base suspension may treat obstructive sleep apnea (OSA). This study summarizes device-related adverse events associated with the AIRvance and AIRLIFT systems used for hyoid and tongue base suspension.

MATERIALS AND METHODS

The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports describing adverse events associated with hyoid or tongue base suspension from January 2012 to December 2022.

RESULTS

77 adverse events were identified. When performed separately, adverse events were equally as common with hyoid suspension as with tongue base suspension. More complications occurred postoperatively (51 [66.2 %]) than intraoperatively (26 [33.8 %]). The most reported adverse events were infection (23 [29.9 %]), broken screw (15 [19.5 %]), pain or discomfort (10 [13.0 %]), suture rupture (8 [10.4 %]), and dislodged screw (7 [9.1 %]). 10 infections required drainage or debridement; 12 required device explantation.

CONCLUSIONS

The present study is the largest and most longitudinal review of adverse events associated with hyoid and tongue base suspension. Infection was the most common adverse event, and may require device explantation. While adverse events were most frequently attributed to device malfunction, broken screw, suture rupture, and broken needle were often attributed to operator error due to application of excessive force. Surgeon training to increase familiarity with hyoid and tongue base suspension may reduce adverse events caused by operator error. The MAUDE database is limited as a passive surveillance system. Standardized reporting may improve understanding of associated adverse events, enabling better informed comparisons between surgical treatment options for OSA.

Assessing the Reproducibility of Research Based on the Food and Drug Administration Manufacturer and User Facility Device Experience Data

OBJECTIVE

This article aims to assess the reproducibility of Manufacturer and User Facility Device Experience (MAUDE) data-driven studies by analyzing the data queries used in their research processes.

METHODS

Studies using MAUDE data were sourced from PubMed by searching for "MAUDE" or "Manufacturer and User Facility Device Experience" in titles or abstracts. We manually chose articles with executable queries. The reproducibility of each query was assessed by replicating it in the MAUDE Application Programming Interface. The reproducibility of a query is determined by a reproducibility coefficient that ranges from 0.95 to 1.05. This coefficient is calculated by comparing the number of medical device reports (MDRs) returned by the reproduced queries to the number of reported MDRs in the original studies. We also computed the reproducibility ratio, which is the fraction of reproducible queries in subgroups divided by the query complexity, the device category, and the presence of a data processing flow.

RESULTS

As of August 8, 2022, we identified 523 articles from which 336 contained queries, and 60 of these were executable. Among these, 14 queries were reproducible. Queries using a single field like product code, product class, or brand name showed higher reproducibility (50%, 33.3%, 31.3%) compared with other fields (8.3%, P = 0.037). Single-category device queries exhibited a higher reproducibility ratio than multicategory ones, but without statistical significance (27.1% versus 8.3%, P = 0.321). Studies including a data processing flow had a higher reproducibility ratio than those without, although this difference was not statistically significant (42.9% versus 17.4%, P = 0.107).

CONCLUSIONS

Our findings indicate that the reproducibility of queries in MAUDE data-driven studies is limited. Enhancing this requires the development of more effective MAUDE data query strategies and improved application programming interfaces.

Respiratory Sensing Lead Malfunction in Upper Airway Stimulation: A Single Institution Report

OBJECTIVES

Upper airway stimulation (UAS) is an effective treatment for patients with obstructive sleep apnea. The device consists of a stimulating electrode, an internal pulse generator, and a respiratory sensing lead. The purpose of this study is to characterize the incidence of sensing lead malfunction necessitating revision surgery in a high-volume center in conjunction with a review of the FDA Manufacturer and User Facility Device Experience (MAUDE) database reports on adverse events associated with the sensing lead component.

METHODS

Patients age ≥18 implanted with the device were reviewed between July 2017 and June 2022. Those determined to have sensing lead malfunction were analyzed. The FDA MAUDE database was reviewed for reports associated with "Inspire Model 4323 Respiratory" and "Inspire Model 4340 Respiratory" between January 2014 and September 2022.

RESULTS

One hundred ninety patients underwent UAS at our institution during the study period and four (2.1%) patients were found to have sensing lead malfunction. Analysis of the MAUDE database revealed 122 reports of adverse events associated with the sensing lead component, with 72% (88/122) of these requiring revision surgery. The most frequently reported adverse event was sensing lead tip separation from lead body, noted in 46% of these reports (56/122).

CONCLUSION

The functionality of the sensing lead component is vital to the integrity of the UAS device and is measurable through waveform analysis. To provide optimal care after device implantation, it is essential to have a comprehensive understanding of the scenarios in which this component fails, the incidence of such events, and appropriate management.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1479-1484, 2024.

Upper airway stimulation device failure: A 7-year single center experience

OBJECTIVE

To identify and report a single center experience with upper airway stimulator device-related failures.

STUDY DESIGN

Retrospective case series.

SETTING

Single tertiary academic center.

METHODS

Retrospective data on 352 patients who underwent UAS surgery with an Inspire device from 2016 to 2023 was collected, including demographics, comorbidities, and nature of device failure requiring revision surgery.

RESULTS

Out of the 348 patients included in our analysis, 16 (4.6 %) required revision due to device failure, with an average interval of 772 days (∼2 years) between initial implant and revision. Most failures were attributed to respiratory sensing lead damage (n = 11, 68.8 %), resulting in high system impedance and subsequent device malfunction. Lead fracture causes varied, including idiopathic occurrences and potential trauma. Lead migration was noted in one case (6.3 %), where the hypoglossal electrode detached from the nerve. Two patients (12.3 %) required implantable pulse generator (IPG) replacement, one after experiencing trauma and the other due to unclear source of malfunction. One patient (6.3 %) required complete system replacement following high lead impedance and absent tongue motion. The last patient required replacement of both the IPG and respiratory lead after experiencing high lead impedance (6.3 %).

CONCLUSION

Respiratory sensing lead fracture emerged as the leading cause of device failure in this cohort, underscoring the need to address this under-reported issue, potentially linked to the time lapse after device implantation.

Hypoglossal Nerve Stimulation Effects on Obstructive Sleep Apnea Over Time: A Systematic Review and Meta-analysis

OBJECTIVES

This study aimed to determine the efficacy of hypoglossal nerve stimulation (HGS) in the treatment of obstructive sleep apnea.

DATA SOURCES

PubMed, Cochrane database, Embase, Web of Science, SCOPUS, and Google Scholar.

REVIEW METHODS

Five databases were reviewed to identify relevant studies that measured polysomnography parameters such as the apnea-hypopnea index (AHI) and oxygen desaturation index, as well as quality of life and functional outcomes of sleep questionnaire scores, before and after HGS.

RESULTS

In total, 44 studies involving 8670 patients met the inclusion criteria. At 12 months after treatment, approximately 47%, 72%, and 82% of patients achieved AHI values of <5, < 10, and <15, respectively. The reported clinical success rates according to Sher criteria were 80% within 12 months and 73% between 12 and 36 months. While the favorable effects exhibited a gradual reduction up to 12 months postimplantation, they generally maintained a consistent level between the 12th and 36th months, as assessed by AHI < 5, <15, and success rate according to Sher criteria.

CONCLUSION

HGS can enhance quality of life scores and polysomnography outcomes in obstructive sleep apnea patients. Although the positive effects gradually decreased until 12 months after implantation, they generally remained consistent between 12 and 36 months.

Hypoglossal nerve stimulation for adults with obstructive sleep apnea

ABSTRACT

Obstructive sleep apnea (OSA) is a common chronic condition in which upper airway collapse interferes with breathing during sleep, reducing sleep quality. Untreated OSA can impair a patient's health and quality of life. The recommended first-line treatment for OSA in adults is positive airway pressure, but difficulty tolerating this device limits adherence to treatment for many patients. Treatment with an implanted hypoglossal nerve stimulation (HNS) device is a relatively new second-line option for these patients, and is gaining more widespread use. Clinicians who treat OSA or provide other healthcare services to patients with HNS implants should be familiar with these devices. This article reviews HNS technology and relevant OSA pathophysiology, along with device candidacy criteria, efficacy, risks, and considerations related to use of other medical technologies for patients with HNS implants.

Successful Reimplantation of Extruded Lead after Hypoglossal Nerve Stimulation Surgery

Infection and extrusion of hardware are known complications of hypoglossal nerve stimulation surgery. We present a unique case of an extruded hardware lead successfully managed with reimplantation without need for explantation and new device placement. The topic will be discussed in context of the body of literature related to extruded medical device management. Laryngoscope, 133:2821-2822, 2023.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Iatrogenic Pneumothorax During Hypoglossal Nerve Stimulator Implantation: A Large Database Analysis

OBJECTIVE

There have been case reports of adverse events of hypoglossal nerve stimulator (HNS) implantation not seen in previous clinical trials, including pneumothorax and pleural effusion. The purpose of this study was to determine the rates of these complications and potential risk factors.

STUDY DESIGN

Retrospective case-control study during 2014 to 2021.

SETTING

Twenty-five health care organizations across the United States.

METHODS

The TriNetX Research Network was queried by using disease codes to retrospectively identify patients with obstructive sleep apnea who underwent HNS implantation. Rates of pneumothorax, pleural effusion, other complications, and need for revision/replacement or explant were determined.

RESULTS

We identified 1813 patients from 25 health care organizations who underwent HNS implantation. The average age was 60 years, and there were 68% males and 32% females. Of the cohort, 2.4% (n = 44 from 7 implant centers) experienced a pneumothorax, and 0.6% (n = 11) were diagnosed with a pleural effusion on the day of surgery. Patients who experienced pneumothorax were more likely to have a history of chronic lower respiratory diseases when compared with those who did not (odds ratio, 2.2; 95% CI, 1.1-4.1; P = .02).

CONCLUSION

The incidence of intraoperative pneumothorax and pleural effusion during HNS implantation may be greater than initially thought. Patients with chronic lower respiratory diseases may be at increased risk. This should be communicated with patients during the informed consent process.

Hypoglossal nerve stimulator on extraoral radiography and cone beam computed tomography scan: Case report

BACKGROUND

The hypoglossal nerve stimulator (HNS) device has been employed in some patients with refractory or unsatisfactory outcomes to chronic obstructive sleep apnea management. The objective of this article is to increase recognition of the radiologic appearances of this device within the head and neck region, as seen on extraoral radiographic and cone beam computed tomography (CBCT) images.

CLINICAL PRESENTATION

A 55-year-old man, refractory to a multitude of apneic medical therapies, underwent a series of preorthognathic radiologic studies. Notably, an implanted HNS lead and ribbon electrodes appeared as hyperdense structures on the panoramic radiograph, lateral cephalogram, and CBCT scan.

CONCLUSION

This article provides various radiologic views of the primary components of an HNS. Clinicians should be able to recognize the presence of neurostimulator devices used for management of chronic sleep apnea within the radiologic field of view of examinations of the head and neck.

Computed tomography scanning of implanted hypoglossal nerve stimulators and approach to device malfunction: case series

OBJECTIVE

Serious device-related complications for hypoglossal nerve stimulators are rare, but surgeons should implement a prompt and systematic approach to quickly troubleshoot a non-functioning device.

METHOD

Records were queried at a single academic tertiary referral centre between January 2019 and June 2021.

RESULTS

The authors present four cases of non-functioning hypoglossal nerve stimulator devices: one case in which migration of the stimulation lead required a revision implantation, one in which the implantable pulse generator was found to be non-functional intra-operatively, one case of an intramuscular sensory lead tract causing pain and one case of implantable pulse generator failure that was probably triggered by implantable cardiac device discharge. In this study, computed tomography imaging was critical to the diagnosis for the first and third cases.

CONCLUSION

Given the limited complication reporting available for hypoglossal nerve stimulators, these cases highlight management and unique imaging findings. The authors present an algorithm to work-up non-functioning hypoglossal nerve stimulator devices.

Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device

Treatment of moderate to severe obstructive sleep apnea poses clinical challenges in persons with intolerance or inadequate response to traditional treatment modalities, including positive airway pressure and mandibular advancement devices. Hypoglossal nerve stimulation is a new treatment option, but few management guidelines exist when it is intolerable or ineffective. Combining several treatment modalities has been an effective strategy for improving symptoms, tolerance, and efficacy. We describe a patient intolerant to positive airway pressure therapy who had continued sleepiness, morning headaches, and snoring with a mandibular advancement device. He underwent hypoglossal nerve stimulation implantation but was intolerant of the voltages required to adequately control his obstructive sleep apnea. Multimodal management with hypoglossal nerve stimulation, mandibular advancement device, and positional therapy was successfully implemented to improve sleepiness, nocturnal symptoms, and the apnea-hypopnea index. This case highlights the personalization and adaptability of combination therapy to suit patient needs while effectively controlling obstructive sleep apnea.

CITATION

Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med. 2023;19(2):403-408.

Hypoglossal nerve stimulation in adolescents with down syndrome and obstructive sleep apnea: A systematic review and meta-analysis

Objective

To evaluate the efficacy and adverse effects of hypoglossal nerve stimulation in adolescents with down syndrome and obstructive sleep apnea.

Methods

A systematic search was conducted using PubMed, Web of Science, Embase, and Scopus databases. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search strategy used a combination of Medical Subject Headings and free words with “OR” and “AND.” Articles were screened to extract data reporting apnea-hypopnea index, quality of life, voltage, follow-up duration, and complications. All included participants were adolescents with down syndrome and obstructive sleep apnea.

Results

A total of 92 articles were identified, of which 9 articles met the inclusion criteria. A total of 106 patients were included. All the studies showed that patients receiving hypoglossal nerve stimulation experienced a significant decrease in apnea-hypopnea index (at least 50%). The pooled AHI was significantly lower in patients following treatment (mean AHI reduction 17.43 events/h, 95% confidence interval 13.98–20.88 events/h, P < 0.001) after 2 case reports were excluded. The pooled OSA-18 were significantly decreased in 88 patients after treatment (mean OSA-18 reduction 1.67, 95% confidence interval 1.27–2.08, P < 0.001) after excluding 5 studies. Four investigations examined the necessity to optimize stimulation voltage for arousal during treatment. The most common complication was pain or discomfort in the tongue or mouth. Most studies had relatively short patient follow-up periods, with the most extended follow-up being 44–58 months.

Conclusion

Hypoglossal nerve stimulation significantly reduces apnea-hypopnea index and improves the quality of life; and thus, could be a potential alternative therapy for obstructive sleep apnea in adolescents with down syndrome. The adolescent's age, potential complications, adverse events, long-term efficacy, and comfort, needs to be considered while performing hypoglossal nerve stimulation.

Hypoglossal Nerve Stimulation Therapy

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.

Space invader: pleural penetration of a hypoglossal nerve stimulator sensor lead

The mainstay of treatment for obstructive sleep apnea (OSA) is positive airway pressure (PAP). PAP therapy may be difficult to tolerate for some patients which may compromise adherence, requiring alternative therapies. Hypoglossal nerve stimulation (HGNS) has become an option for those who meet implantation criteria. Implantation of the device is an ambulatory surgical procedure and is generally well-tolerated, though rare adverse events have been reported. We report an unusual complication of HGNS in a patient who had initial success with this therapy. After three years of treatment, the sensor lead penetrated into the pleural space. Components of the HGNS were explanted, and a new sensor lead and generator were reimplanted. The new device was activated, and therapy was successfully resumed. This case demonstrates that there is a potential for a delayed complication of sensor lead penetration into the pleural space which has only rarely been reported.