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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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2
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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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3
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Gruenberg E, Cooper J, Zamora T, Stepnowsky C, Vahabzadeh-Hagh AM, Malhotra A, Nokes B. Beyond CPAP: modifying upper airway output for the treatment of OSA. Front Neurol 2023; 14:1202271. [PMID: 37545734 PMCID: PMC10403235 DOI: 10.3389/fneur.2023.1202271] [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: 04/07/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
Obstructive Sleep Apnea (OSA) is exceedingly common but often under-treated. Continuous positive airway pressure (CPAP) has long been considered the gold standard of OSA therapy. Limitations to CPAP therapy include adherence and availability. The 2021 global CPAP shortage highlighted the need to tailor patient treatments beyond CPAP alone. Common CPAP alternative approaches include positional therapy, mandibular advancement devices, and upper airway surgery. Upper airway training consists of a variety of therapies, including exercise regimens, external neuromuscular electrical stimulation, and woodwind instruments. More invasive approaches include hypoglossal nerve stimulation devices. This review will focus on the approaches for modifying upper airway muscle behavior as a therapeutic modality in OSA.
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Affiliation(s)
- Eli Gruenberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Jessica Cooper
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Tania Zamora
- Health Services Research and Development, Veteran's Affairs (VA) San Diego Healthcare System, San Diego, CA, United States
| | - Carl Stepnowsky
- Health Services Research and Development, Veteran's Affairs (VA) San Diego Healthcare System, San Diego, CA, United States
| | - Andrew M. Vahabzadeh-Hagh
- Department of Otolaryngology—Head and Neck Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Brandon Nokes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
- Sleep Section at the Veteran's Affairs (VA) San Diego Healthcare System, San Diego, CA, United States
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4
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Computed tomography scanning of implanted hypoglossal nerve stimulators and approach to device malfunction: case series. J Laryngol Otol 2023; 137:231-236. [PMID: 34895370 DOI: 10.1017/s0022215121003996] [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: 11/06/2022]
Abstract
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.
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5
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Pham LV, Jun J, Polotsky VY. Obstructive sleep apnea. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:105-136. [PMID: 36031300 DOI: 10.1016/b978-0-323-91532-8.00017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.
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Affiliation(s)
- Luu V Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Jonathan Jun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
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Pépin JL, Eastwood P, Eckert DJ. Novel avenues to approach non-CPAP therapy and implement comprehensive OSA care. Eur Respir J 2021; 59:13993003.01788-2021. [PMID: 34824053 DOI: 10.1183/13993003.01788-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/16/2021] [Indexed: 11/05/2022]
Abstract
Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, "one size fits all", trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.
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Affiliation(s)
- Jean-Louis Pépin
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France .,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Peter Eastwood
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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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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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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d'Angelo E, Pecchiari M, Bellemare F, Cevenini G, Barbini P. Heliox administration in anesthetized rabbits with spontaneous inspiratory flow limitation. J Appl Physiol (1985) 2021; 130:1496-1509. [PMID: 33411637 DOI: 10.1152/japplphysiol.00830.2020] [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: 11/22/2022] Open
Abstract
We investigated the effects of heliox administration (80% helium in O2) on tidal inspiratory flow limitation (tIFL) occurring in supine anesthetized spontaneously breathing rabbits, regarded as an animal model of obstructive apnea-hypopnea syndrome. 22 rabbits were instrumented to record oro-nasal mask flow, airway opening, tracheal and esophageal pressures, and diaphragm and genioglossus electromyographic activities while breathing either room air or heliox, and, in 12 rabbits, also during the application of continuous positive airway pressure (CPAP; 6 cmH2O). For the group, heliox increased peak inspiratory flow, ventilation (18 ± 11%), peak inspiratory tracheal and dynamic transpulmonary pressures, but in no animal eliminated tIFL, as instead CPAP did in all. Muscle activities were unaffected by heliox. In the presence of IFL the increase in flow with heliox (ΔV̇ifl) varied markedly among rabbits (2 to 49%), allowing the distinction between responders and non-responders. None of the baseline variables discriminated responders and non-responders. However, fitting the Rohrer equation (R = K1 + K2V̇) to the tracheal pressure-flow relationship over the first 0.1 s of inspiration while breathing air allowed such discrimination on the basis of larger K2 in responders (0.005 ± 0.002 versus 0.002 ± 0.001 cmH2O·s2·ml-2; P < 0.001), suggesting a corresponding difference in the relative contribution of laminar and turbulent flow. The differences in ΔV̇ifl between responders and non-responders were simulated by modeling the collapsible segment of the upper airways as a non-linear resistor and varying its pressure-volume curve, length, and diameter, thus showing the importance of mechanical and geometrical factors in determining the response to heliox in the presence of tIFL.NEW & NOTEWORTHY In an obstructive sleep apnea rabbit model, heliox never abolishes tidal inspiratory flow limitation (IFL), but increases inspiratory flow and tidal volume, substantially in some and nearly nil in other animals. Positive response to heliox cannot be predicted on the basis of breathing pattern characteristics or upper airway resistance that preceded IFL onset, but is related to the mechanical and geometrical features of upper airway collapsible segment, as indicated by model simulation.
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Affiliation(s)
- Edgardo d'Angelo
- Department of Physiopathology and Transplantations, Università di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Physiopathology and Transplantations, Università di Milano, Milan, Italy
| | - François Bellemare
- Department of Physiopathology and Transplantations, Università di Milano, Milan, Italy
| | - Gabriele Cevenini
- Department of Medical Biotechnologies, Università di Siena, Siena, Italy
| | - Paolo Barbini
- Department of Information Engineering and Mathematics, Università di Siena, Siena, Italy
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10
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Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review. SENSORS 2021; 21:s21051784. [PMID: 33806496 PMCID: PMC7961570 DOI: 10.3390/s21051784] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.
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Doyle BM, Singer ML, Fleury-Curado T, Rana S, Benevides ES, Byrne BJ, Polotsky VY, Fuller DD. Gene delivery to the hypoglossal motor system: preclinical studies and translational potential. Gene Ther 2021; 28:402-412. [PMID: 33574581 PMCID: PMC8355248 DOI: 10.1038/s41434-021-00225-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/16/2020] [Accepted: 01/15/2021] [Indexed: 12/15/2022]
Abstract
Dysfunction and/or reduced activity in the tongue muscles contributes to conditions such as dysphagia, dysarthria, and sleep disordered breathing. Current treatments are often inadequate, and the tongue is a readily accessible target for therapeutic gene delivery. In this regard, gene therapy specifically targeting the tongue motor system offers two general strategies for treating lingual disorders. First, correcting tongue myofiber and/or hypoglossal (XII) motoneuron pathology in genetic neuromuscular disorders may be readily achieved by intralingual delivery of viral vectors. The retrograde movement of viral vectors such as adeno-associated virus (AAV) enables targeted distribution to XII motoneurons via intralingual viral delivery. Second, conditions with impaired or reduced tongue muscle activation can potentially be treated using viral-driven chemo- or optogenetic approaches to activate or inhibit XII motoneurons and/or tongue myofibers. Further considerations that are highly relevant to lingual gene therapy include (1) the diversity of the motoneurons which control the tongue, (2) the patterns of XII nerve branching, and (3) the complexity of tongue muscle anatomy and biomechanics. Preclinical studies show considerable promise for lingual directed gene therapy in neuromuscular disease, but the potential of such approaches is largely untapped.
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Affiliation(s)
- Brendan M Doyle
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Rehabilitation Science PhD Program, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Michele L Singer
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Rehabilitation Science PhD Program, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Thomaz Fleury-Curado
- Department of Pediatrics and Powell Gene Therapy Center, University of Florida, Gainesville, FL, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sabhya Rana
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Ethan S Benevides
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Rehabilitation Science PhD Program, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Barry J Byrne
- Department of Pediatrics and Powell Gene Therapy Center, University of Florida, Gainesville, FL, USA
| | - Vsevolod Y Polotsky
- Department of Pediatrics and Powell Gene Therapy Center, University of Florida, Gainesville, FL, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA. .,McKnight Brain Institute, University of Florida, Gainesville, FL, USA. .,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.
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12
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Olson MD, Junna MR. Hypoglossal Nerve Stimulation Therapy for the Treatment of Obstructive Sleep Apnea. Neurotherapeutics 2021; 18:91-99. [PMID: 33559036 PMCID: PMC8116425 DOI: 10.1007/s13311-021-01012-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 11/30/2022] Open
Abstract
Hypoglossal nerve stimulation (HGNS) therapy was approved in 2014 for the treatment of obstructive sleep apnea in patients who are intolerant to continuous positive airway pressure (CPAP) therapy, which is reported in up to 40-60% of patients. This therapy works via direct neurostimulation of the hypoglossal nerve in synchrony with respiration, to open the airway via tongue stiffening and protrusion. Studies have demonstrated significant reductions in both respiratory parameters such as disordered breathing indices, as well as subjective sleep complaints, such as daytime sleepiness, with the use of this therapy. This has increased the repertoire of treatment options for sleep providers to recommend to those patients that are intolerant to CPAP therapy.
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Affiliation(s)
- Michael D Olson
- Department of Otolaryngology, Head and Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Mithri R Junna
- Center for Sleep Medicine, Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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13
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Recognizing and refuting the myth of tongue swallowing during a seizure. Seizure 2020; 83:32-37. [DOI: 10.1016/j.seizure.2020.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 11/23/2022] Open
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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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Arens P, Penzel T, Fietze I, Blau A, Weller B, Olze H, Dommerich S. Safety and effectiveness in explantation and re-implantation of hypoglossal nerve stimulation devices. Eur Arch Otorhinolaryngol 2020; 278:477-483. [PMID: 32592011 DOI: 10.1007/s00405-020-06170-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/23/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Since 2001, hypoglossal nerve stimulators have been implanted in patients with obstructive sleep apnea around the world, initially in trial situations but more recently also in regular care settings. Medium term data indicate effectiveness and tolerability of treatment. However, when assessing the safety of the procedure, the safe feasibility of explantation or reimplantation must also be considered. PATIENTS AND METHODS Nine patients with an implanted respiratory-driven hypoglossal nerve stimulator. We have evaluated the feasibility and safety of explantation or re-implantation with another stimulation system. RESULTS In 2012, nine patients were implanted with a respiratory-driven hypoglossal nerve stimulator as part of the Apnex Medical Pivotal Study. The study was ended in 2013. For a variety of reasons, the system was explanted from all nine patients by the year 2019. Three of these patients were re-implanted with a different system with respiratory sensing during the same session (mean incision to closure time for explantation 88.2 ± 35.01 min., mean incision to closure time for re-implantation 221.75 ± 52.73 min.). Due to extensive scar tissue formation, all procedures were technically challenging. Complication rate was significantly higher when re-implantation was performed or attempted in the same surgical session (0 of 5 patients with explantation versus 3 of 4 patients with attempted re-implantation; p = 0.018). There was no significant difference between the AHI values before and after implantation in patients with re-implantation. CONCLUSION Explantation and re-implantation are technically challenging though possible procedures. The single-staged equilateral reimplantation of another hypoglossal nerve stimulation system can, but need not, be successful.
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Affiliation(s)
- Philipp Arens
- Department of Otorhinolaryngology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Thomas Penzel
- Department of Cardiology and Pulmonology, Center of Sleep Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Ingo Fietze
- Department of Cardiology and Pulmonology, Center of Sleep Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Alexander Blau
- Department of Cardiology and Pulmonology, Center of Sleep Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Bodo Weller
- Department of Cardiology and Pulmonology, Center of Sleep Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Heidi Olze
- Department of Otorhinolaryngology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Steffen Dommerich
- Department of Otorhinolaryngology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
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Adair D, Truong D, Esmaeilpour Z, Gebodh N, Borges H, Ho L, Bremner JD, Badran BW, Napadow V, Clark VP, Bikson M. Electrical stimulation of cranial nerves in cognition and disease. Brain Stimul 2020; 13:717-750. [PMID: 32289703 PMCID: PMC7196013 DOI: 10.1016/j.brs.2020.02.019] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 02/06/2023] Open
Abstract
The cranial nerves are the pathways through which environmental information (sensation) is directly communicated to the brain, leading to perception, and giving rise to higher cognition. Because cranial nerves determine and modulate brain function, invasive and non-invasive cranial nerve electrical stimulation methods have applications in the clinical, behavioral, and cognitive domains. Among other neuromodulation approaches such as peripheral, transcranial and deep brain stimulation, cranial nerve stimulation is unique in allowing axon pathway-specific engagement of brain circuits, including thalamo-cortical networks. In this review we amalgamate relevant knowledge of 1) cranial nerve anatomy and biophysics; 2) evidence of the modulatory effects of cranial nerves on cognition; 3) clinical and behavioral outcomes of cranial nerve stimulation; and 4) biomarkers of nerve target engagement including physiology, electroencephalography, neuroimaging, and behavioral metrics. Existing non-invasive stimulation methods cannot feasibly activate the axons of only individual cranial nerves. Even with invasive stimulation methods, selective targeting of one nerve fiber type requires nuance since each nerve is composed of functionally distinct axon-types that differentially branch and can anastomose onto other nerves. None-the-less, precisely controlling stimulation parameters can aid in affecting distinct sets of axons, thus supporting specific actions on cognition and behavior. To this end, a rubric for reproducible dose-response stimulation parameters is defined here. Given that afferent cranial nerve axons project directly to the brain, targeting structures (e.g. thalamus, cortex) that are critical nodes in higher order brain networks, potent effects on cognition are plausible. We propose an intervention design framework based on driving cranial nerve pathways in targeted brain circuits, which are in turn linked to specific higher cognitive processes. State-of-the-art current flow models that are used to explain and design cranial-nerve-activating stimulation technology require multi-scale detail that includes: gross anatomy; skull foramina and superficial tissue layers; and precise nerve morphology. Detailed simulations also predict that some non-invasive electrical or magnetic stimulation approaches that do not intend to modulate cranial nerves per se, such as transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS), may also modulate activity of specific cranial nerves. Much prior cranial nerve stimulation work was conceptually limited to the production of sensory perception, with individual titration of intensity based on the level of perception and tolerability. However, disregarding sensory emulation allows consideration of temporal stimulation patterns (axon recruitment) that modulate the tone of cortical networks independent of sensory cortices, without necessarily titrating perception. For example, leveraging the role of the thalamus as a gatekeeper for information to the cerebral cortex, preventing or enhancing the passage of specific information depending on the behavioral state. We show that properly parameterized computational models at multiple scales are needed to rationally optimize neuromodulation that target sets of cranial nerves, determining which and how specific brain circuitries are modulated, which can in turn influence cognition in a designed manner.
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Affiliation(s)
- Devin Adair
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Dennis Truong
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Zeinab Esmaeilpour
- Department of Biomedical Engineering, City College of New York, New York, NY, USA.
| | - Nigel Gebodh
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Helen Borges
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Libby Ho
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - J Douglas Bremner
- Department of Psychiatry & Behavioral Sciences and Radiology, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Bashar W Badran
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Vitaly Napadow
- Martinos Center for Biomedical Imaging, Department of Radiology, MGH, Harvard medical school, Boston, MA, USA
| | - Vincent P Clark
- Psychology Clinical Neuroscience Center, Dept. Psychology, MSC03-2220, University of New Mexico, Albuquerque, NM, 87131, USA; Department of Psychology, University of New Mexico, Albuquerque, NM, 87131, USA; The Mind Research Network of the Lovelace Biomedical Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA
| | - Marom Bikson
- Department of Biomedical Engineering, City College of New York, New York, NY, USA.
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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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18
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Yu JL, Thaler ER. Hypoglossal Nerve (Cranial Nerve XII) Stimulation. Otolaryngol Clin North Am 2020; 53:157-169. [DOI: 10.1016/j.otc.2019.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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19
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Measurement and State-Dependent Modulation of Hypoglossal Motor Excitability and Responsivity In-Vivo. Sci Rep 2020; 10:550. [PMID: 31953471 PMCID: PMC6969049 DOI: 10.1038/s41598-019-57328-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/19/2019] [Indexed: 12/17/2022] Open
Abstract
Motoneurons are the final output pathway for the brain’s influence on behavior. Here we identify properties of hypoglossal motor output to the tongue musculature. Tongue motor control is critical to the pathogenesis of obstructive sleep apnea, a common and serious sleep-related breathing disorder. Studies were performed on mice expressing a light sensitive cation channel exclusively on cholinergic neurons (ChAT-ChR2(H134R)-EYFP). Discrete photostimulations under isoflurane-induced anesthesia from an optical probe positioned above the medullary surface and hypoglossal motor nucleus elicited discrete increases in tongue motor output, with the magnitude of responses dependent on stimulation power (P < 0.001, n = 7) and frequency (P = 0.002, n = 8, with responses to 10 Hz stimulation greater than for 15–25 Hz, P < 0.022). Stimulations during REM sleep elicited significantly reduced responses at powers 3–20 mW compared to non-rapid eye movement (non-REM) sleep and wakefulness (each P < 0.05, n = 7). Response thresholds were also greater in REM sleep (10 mW) compared to non-REM and waking (3 to 5 mW, P < 0.05), and the slopes of the regressions between input photostimulation powers and output motor responses were specifically reduced in REM sleep (P < 0.001). This study identifies that variations in photostimulation input produce tunable changes in hypoglossal motor output in-vivo and identifies REM sleep specific suppression of net motor excitability and responsivity.
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20
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Oliven A, Dotan Y, Golibroda T, Somri M, Oliven R, Schwartz AR. Electrical stimulation of the whole hypoglossal nerve in patients with obstructive sleep apnea. Sleep Breath 2020; 24:1473-1480. [PMID: 31907824 DOI: 10.1007/s11325-019-02011-1] [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] [Received: 11/03/2019] [Revised: 12/13/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Electrical stimulation of the whole hypoglossal nerve (HGp-ES) has been demonstrated to enlarge the pharynx and improve pharyngeal stability and patency to airflow in all animals studied, but not in humans. The present study was undertaken to better understand the effect of HGp-ES on the human pharynx. METHODS Eight patients with obstructive sleep apnea who had implanted stimulators with electrodes positioned proximally on the main truck of the hypoglossus were studied under propofol sedation. Pharyngoscopy and air flow measurements at multiple levels of continuous positive airway pressure (CPAP) were performed before and during Hgp-ES. RESULTS HGp-ES that activates both tongue protrusors and retractors narrowed the pharyngeal lumen at the site of collapse (velopharynx in all subjects) from 1.38 ± 0.79 to 0.75 ± 0.44 cm2, p < 0.05 (measured at mid-range of CPAP levels) and lowered airflow (from 8.88 ± 2.08 to 6.69 ± 3.51 l/min, p < 0.05). Changes in critical pressure (Pcrit) and velopharyngeal compliance were not significant, but oropharyngeal compliance decreased (from 0.43 ± 0.18 to 0.32 ± 0.13 cm2/cmH2O, p < 0.05). No correlation was found between the pattern of change in luminal shape (determined as the ratio of a-p vs. lateral diameter when lowering CPAP) or changes in cross-sectional area and airflow during Hgp-ES. CONCLUSIONS Our findings indicate that human retractors dominate when stimulated together with the protrusors during HGp-ES. While co-activation of retractors may be beneficial, it should be limited. We speculate that exercises that augment protrusor force may improve the response to hypoglossal stimulation. The exclusion of patients with concentric pharyngeal obstruction should be re-evaluated.
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Affiliation(s)
- A Oliven
- Department of Medicine, Bnai-Zion Medical Centre, 47 Golomb Str, 31048, Haifa, Israel. .,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel.
| | - Y Dotan
- St. Luke's Pulmonary & Critical Care Associates, Bethlehem, PA, USA
| | | | - M Somri
- Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel.,Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel
| | - R Oliven
- Department of Medicine, Bnai-Zion Medical Centre, 47 Golomb Str, 31048, Haifa, Israel
| | - A R Schwartz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Universidad Peruana Cayetano Heredia, Lima, Peru.,Pulmonary and Critical Care Associates of Baltimore, Baltimore, USA
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21
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Garrec P, Legris S, Soyer Y, Vi-Fane B, Jordan L. [Orthodontic management of obstructive sleep-disordered respiratory disorders]. Orthod Fr 2019; 90:321-335. [PMID: 34643519 DOI: 10.1051/orthodfr/2019029] [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: 06/13/2023]
Abstract
Through his/her knowledge of cranio-facial growth, the orthodontist plays a leading role within the multidisciplinary team that tracks and treats sleep-disordered breathing (SDB) in children. Correction of craniofacial risk factors (maxillary deficiency and retrognathia) is commonly used by practitioners alongside orthodontic treatment such as OMA and RME in the optimal conditions afforded by childhood growth. Myofunctional therapies are performed to restore correct stomatognathic function and play a central role in the management of SDB in children. The orthodontist is therefore a key player in the medical treatment chain of these children.
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Affiliation(s)
- Pascal Garrec
- Université Paris Diderot-UFR Odontologie, 5 rue Garancière, 75006 Paris, France, Hôpital Pitié Salpêtrière, AP-HP, UF d'Orthodontie, 75013 Paris, France, AP-HP, Centre de référence des malformations rares de la face et de la cavité buccale O Rares-Hôpital Rothschild, 75012 Paris, France, Société Française de Médecine Dentaire du Sommeil, 13-15 rue de Nancy, 75010 Paris, France
| | - Sylvie Legris
- AP-HP, Centre de référence des malformations rares de la face et de la cavité buccale O Rares-Hôpital Rothschild, 75012 Paris, France, Société Française de Médecine Dentaire du Sommeil, 13-15 rue de Nancy, 75010 Paris, France
| | - Yves Soyer
- Hôpital Pitié Salpêtrière, AP-HP, UF d'Orthodontie, 75013 Paris, France, Société Française de Médecine Dentaire du Sommeil, 13-15 rue de Nancy, 75010 Paris, France
| | - Brigitte Vi-Fane
- Université Paris Diderot-UFR Odontologie, 5 rue Garancière, 75006 Paris, France, Hôpital Pitié Salpêtrière, AP-HP, UF d'Orthodontie, 75013 Paris, France, AP-HP, Centre de référence des malformations rares de la face et de la cavité buccale O Rares-Hôpital Rothschild, 75012 Paris, France, Société Française de Médecine Dentaire du Sommeil, 13-15 rue de Nancy, 75010 Paris, France
| | - Laurence Jordan
- Université Paris Diderot-UFR Odontologie, 5 rue Garancière, 75006 Paris, France, AP-HP, Centre de référence des malformations rares de la face et de la cavité buccale O Rares-Hôpital Rothschild, 75012 Paris, France, PSL Research University, Institut de Recherche de Chimie Paris, UMR 8247-Chimie ParisTech, 75005 Paris, France, Société Française de Médecine Dentaire du Sommeil, 13-15 rue de Nancy, 75010 Paris, France
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22
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Aaron KA, Mudry AC. History of Cranial Nerve-Implanted Stimulators in Otolaryngology. Otolaryngol Clin North Am 2019; 53:1-19. [PMID: 31699407 DOI: 10.1016/j.otc.2019.09.012] [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: 11/19/2022]
Abstract
This article aims to clearly understand the historical development of cranial nerve-implanted stimulators in otolaryngology. The authors also discuss cranial nerve history; initial theory of the functional concept of animal spirit; electrical nerve impulse theory; first electrical otolaryngology cranial nerve stimulation devices; and the development of implanted stimulators.
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Affiliation(s)
- Ksenia A Aaron
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Albert C Mudry
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
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23
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Kent DT, Carden KA, Wang L, Lindsell CJ, Ishman SL. Evaluation of Hypoglossal Nerve Stimulation Treatment in Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2019; 145:1044-1052. [PMID: 31556927 DOI: 10.1001/jamaoto.2019.2723] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Hypoglossal nerve stimulation is a treatment option for patients with obstructive sleep apnea unable to tolerate continuous positive airway pressure. This study evaluates demographic factors that may be associated with greater improvements in postoperative outcomes of interest. Objective To examine the association of hypoglossal nerve stimulation with obstructive sleep apnea severity, daytime sleepiness, and sleep-related quality of life. Design, Setting, and Participants Patient-level data were pooled from 3 prospective cohorts and 1 retrospective observational cohort comprising 584 adults with moderate to severe obstructive sleep apnea unable to tolerate or benefit from continuous positive airway pressure. The data were gathered from the Stimulation Therapy for Apnea Reduction Trial; a postmarket approval study conducted in Germany; the multicenter, international Adherence and Outcome of Upper Airway Stimulation for OSA Registry; and a retrospective cohort study from 2 sites in the United States. Exposure Hypoglossal nerve stimulation. Main Outcomes and Measures Severity of obstructive sleep apnea was the primary outcome. The apnea-hypopnea index (AHI) (<5, normal; 5-15, mild; 15-30, moderate, and >30, severe) and Epworth Sleepiness Scale (range, 0-24; score >10 indicates pathologic sleepiness) outcomes were available at 2 to 6 months from 2 cohorts (n = 398), at 12 months from 1 cohort (n = 126), and at both times from 1 cohort (n = 60). Sleep-related quality of life and oxygen saturation nadir data were collected where available. Linear mixed-effects models were constructed to examine associations between clinical variables and reported postoperative outcomes at 6 and 12 months with study included as a random effect. Results Of the 584 patients included in the study, 472 were men (80.8%); mean (SD) age was 58.5 (11.0) years. Greater improvement in the postoperative AHI was associated with a higher preoperative AHI (-0.74 events/h; 95% CI, -0.82 to -0.67), older patient age (-0.10 events/h; 95% CI, -0.20 to -0.00), and lower body mass index (0.52; 95% CI, 0.22-0.83). After adjusting for these variables and considering all patients in the analysis, the AHI was statistically higher at 12 months than at 6 months (3.24 events/h; 95% CI, 1.67-4.82 events/h). Conclusions and Relevance Hypoglossal nerve stimulation demonstrated clinically significant improvements in obstructive sleep apnea severity, daytime sleepiness, and sleep-related quality of life in this pooled cohort of patient-level results. Age, body mass index, and preoperative AHI appeared to be associated with treatment outcomes, and these variables may explain some of the difference between 2- to 6-month and 12-month outcomes.
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Affiliation(s)
- David T Kent
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly A Carden
- Sleep Specialists, St Thomas Medical Partners, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Stacey L Ishman
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati, Cincinnati, Ohio
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24
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Seo J, Kim JW, Cho SW, Shim S, Choi JW, Kim SJ. Preliminary Study of Palatal Implant for Sleep Apnea Control. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:1498-1501. [PMID: 30440676 DOI: 10.1109/embc.2018.8512463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A fully-implantable device for treating obstructive sleep apnea (OSA) is conceptually suggested using soft palate stimulation. In this research, two in vivo studies were conducted to demonstrate electrical and physical feasibilities of the suggested device. First, electrical stimulation was delivered to the soft palate of a rabbit using a stimulator ASIC. The stimulation frequencies were swept from 20 Hz to 200 Hz to find out the appropriate parameter. Also, threshold level of the current pulse was evaluated to be 1.10 mA with an observance of a C-arm fluoroscopy. Second, a mock-up was fabricated with liquid crystal polymer (LCP), reflecting dimensions of the suggested device. The mock-up was inserted toward the soft palate of a rabbit by incising the hard palate in a lateral direction. After the mock-up was inserted, protrusion of the device was not detected and the subject stayed alive for at least a month at the time of this writing. Finally, several discussions on the palatal implant fabrication with LCP are presented.
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25
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Heiser C, Hofauer B. Hypoglossal Nerve Stimulation: An Update on the Latest Evidence. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00244-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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26
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Heiser C, Hofauer B. [Stimulation for sleep apnea : Targeting the hypoglossal nerve in the treatment of patients with OSA]. HNO 2019; 66:705-716. [PMID: 30054649 DOI: 10.1007/s00106-018-0534-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Standard treatment of obstructive sleep apnea (OSA) is nightly application of positive airway pressure therapy (CPAP). However, adherence to CPAP is limited due to side effects and complications, and patients are frequently untreated or undertreated. In this scenario, patients with OSA are at risk of developing comorbidities such as arterial hypertension, coronary artery disease, or diabetes, and are exposed to an increased risk of experiencing traffic or occupational accidents due to daytime sleepiness. Alternative treatments include mandibular advancement devices or positional devices to prevent patients sleeping on their back, as well as anatomy-altering surgical procedures. For several years now, an additional surgical treatment-hypoglossal nerve stimulation-has been available for selected OSA patients. Hypoglossal nerve stimulation is a dynamic surgical approach that uses electrical stimulation to activate key muscles of the upper airway to achieve airway patency.
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Affiliation(s)
- C Heiser
- Hals-Nasen-Ohrenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - B Hofauer
- Hals-Nasen-Ohrenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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27
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Fleury Curado TA, Pho H, Dergacheva O, Berger S, Lee R, Freire C, Asherov A, Sennes LU, Mendelowitz D, Schwartz AR, Polotsky VY. Silencing of Hypoglossal Motoneurons Leads to Sleep Disordered Breathing in Lean Mice. Front Neurol 2018; 9:962. [PMID: 30487776 PMCID: PMC6246694 DOI: 10.3389/fneur.2018.00962] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/25/2018] [Indexed: 12/15/2022] Open
Abstract
Obstructive Sleep Apnea (OSA) is a prevalent condition and a major cause of morbidity and mortality in Western Society. The loss of motor input to the tongue and specifically to the genioglossus muscle during sleep is associated with pharyngeal collapsibility and the development of OSA. We applied a novel chemogenetic method to develop a mouse model of sleep disordered breathing Our goal was to reversibly silence neuromotor input to the genioglossal muscle using an adeno-associated viral vector carrying inhibitory designer receptors exclusively activated by designer drugs AAV5-hM4Di-mCherry (DREADD), which was delivered bilaterally to the hypoglossal nucleus in fifteen C57BL/6J mice. In the in vivo experiment, 4 weeks after the viral administration mice were injected with a DREADD ligand clozapine-N-oxide (CNO, i.p., 1mg/kg) or saline followed by a sleep study; a week later treatments were alternated and a second sleep study was performed. Inspiratory flow limitation was recognized by the presence of a plateau in mid-respiratory flow; oxyhemoglobin desaturations were defined as desaturations >4% from baseline. In the in vitro electrophysiology experiment, four males and three females of 5 days of age were used. Sixteen-nineteen days after DREADD injection brain slices of medulla were prepared and individual hypoglossal motoneurons were recorded before and after CNO application. Positive mCherry staining was detected in the hypoglossal nucleus in all mice confirming successful targeting. In sleep studies, CNO markedly increased the frequency of flow limitation n NREM sleep (from 1.9 ± 1.3% after vehicle injection to 14.2 ± 3.4% after CNO, p < 0.05) and REM sleep (from 22.3% ± 4.1% to 30.9 ± 4.6%, respectively, p < 0.05) compared to saline treatment, but there was no significant oxyhemoglobin desaturation or sleep fragmentation. Electrophysiology recording in brain slices showed that CNO inhibited firing frequency of DREADD-containing hypoglossal motoneurons. We conclude that chemogenetic approach allows to silence hypoglossal motoneurons in mice, which leads to sleep disordered breathing manifested by inspiratory flow limitation during NREM and REM sleep without oxyhemoglobin desaturation or sleep fragmentation. Other co-morbid factors, such as compromised upper airway anatomy, may be needed to achieve recurrent pharyngeal obstruction observed in OSA.
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Affiliation(s)
- Thomaz A Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Otolaryngology, University of Sao Paulo, São Paulo, Brazil
| | - Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Olga Dergacheva
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC, United States
| | - Slava Berger
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Rachel Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carla Freire
- Department of Otolaryngology, University of Sao Paulo, São Paulo, Brazil
| | - Aya Asherov
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Luis U Sennes
- Department of Otolaryngology, University of Sao Paulo, São Paulo, Brazil
| | - David Mendelowitz
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC, United States
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Kompelli AR, Ni JS, Nguyen SA, Lentsch EJ, Neskey DM, Meyer TA. The outcomes of hypoglossal nerve stimulation in the management of OSA: A systematic review and meta-analysis. World J Otorhinolaryngol Head Neck Surg 2018; 5:41-48. [PMID: 30775701 PMCID: PMC6364516 DOI: 10.1016/j.wjorl.2018.04.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/08/2018] [Accepted: 04/02/2018] [Indexed: 01/14/2023] Open
Abstract
Objectives Obstructive sleep apnea (OSA) is a prevalent disease with significant health impacts. While first line therapy is CPAP, long-term compliance is low and device misuse is common, highlighting the need for alternative therapies. Upper airway surgery is one alternative, but substantial side effects hamper efficacy. A new alternative is an implantable hypoglossal nerve stimulator (HNS). These devices utilize neuromodulation to dilate/reinforce the airway and reduce side effects associated with traditional surgery. Several recent trials investigated the efficacy of these devices. The purpose of this study was to perform meta-analysis of available HNS studies investigating treatment of OSA to analyze objective and subjective outcomes and side effects. Methods A comprehensive literature search of PubMed and Scopus was performed. Two independent reviewers examined clinical trials investigating HNS in treatment of sleep apnea in adults. Studies with objective and subjective endpoints in sleep were included for analysis. Adverse events from trials were also recorded. Results Across 16 studies, 381 patients were analyzed. At 6 months (p = 0.008), mean SAQLI improved by 3.1 (95%CI, 2.6-3.7). At 12 months (p < 0.0001), mean AHI was reduced by 21.1 (95%CI, 16.9-25.3), mean ODI was reduced by 15.0 (95%CI, 12.7-17.4), mean ESS was reduced by 5.0 (95%CI, 4.2-5.8), mean FOSQ improved by 3.1 (95%CI, 2.6-3.4). Pain (6.2%:0.7-16.6), tongue abrasion (11.0%:1.2-28.7), and internal (3.0%:0.3-8.4)/external device (5.8%:0.3-17.4) malfunction were common adverse events. Conclusions HNS is a safe and effective treatment for CPAP refractory OSA. Further study comparing HNS to other therapies is required.
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Affiliation(s)
- Anvesh R Kompelli
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan S Ni
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Shaun A Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Eric J Lentsch
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - David M Neskey
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ted A Meyer
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Fleury Curado T, Oliven A, Sennes LU, Polotsky VY, Eisele D, Schwartz AR. Neurostimulation Treatment of OSA. Chest 2018; 154:1435-1447. [PMID: 30222959 DOI: 10.1016/j.chest.2018.08.1070] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/02/2018] [Accepted: 08/30/2018] [Indexed: 01/04/2023] Open
Abstract
Over the past 30 years, hypoglossal nerve stimulation has moved through a development pathway to become a viable treatment modality for patients with OSA. Initial pilot studies in animals and humans laid the conceptual foundation for this approach, leading to the development of fully implantable stimulating systems for therapeutic purposes. These devices were then shown to be both safe and efficacious in feasibility studies. One such closed-loop stimulating device was found to be effective in treating a limited spectrum of apneic patients and is currently approved by the US Food and Drug Administration for this purpose. Another open-loop stimulating system is currently being rigorously tested in a pivotal trial. Collectively, clinical trials of hypoglossal nerve stimulating systems have yielded important insights that can help optimize therapeutic responses to hypoglossal nerve stimulation. These insights include specific patient selection criteria and methods for delivering stimulation to specific portions of the hypoglossal nerve and/or genioglossus muscle. New approaches for activating efferent and afferent motor pathways are currently in early-stage laboratory development and hold some long-term promise as a novel therapy.
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Affiliation(s)
- Thomaz Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Otorhinolaryngology, University of São Paulo Medical School, São Paulo, Brazil.
| | - Arie Oliven
- Department of Medicine, Bnai Zion Medical Center, Technion, Haifa, Israel
| | - Luiz U Sennes
- Department of Otorhinolaryngology, University of São Paulo Medical School, São Paulo, Brazil
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Eisele
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University, Baltimore, MD
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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Bowen AJ, Nowacki AS, Kominsky AH, Trask DK, Benninger MS, Bryson PC. Voice and swallowing outcomes following hypoglossal nerve stimulation for obstructive sleep apnea. Am J Otolaryngol 2018; 39:122-126. [PMID: 29277289 DOI: 10.1016/j.amjoto.2017.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 12/14/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypoglossal nerve stimulation is an effective treatment for a subset of patients with Obstructive Sleep Apnea (OSA). Although multiple clinical trials demonstrate its efficacy, no previous literature explores the potential impact the stimulator has on swallowing and voice. Our primary objective is to evaluate patient reported post-operative changes in voice or swallowing following hypoglossal nerve stimulator placement. STUDY DESIGN Prospective cohort study. SETTING Tertiary care hospital. SUBJECT AND METHODS Patients scheduled to receive a hypoglossal stimulator were enrolled. Participants completed baseline Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) questionnaires preoperatively and again at 1week, 3months, and 6months post-operatively following placement of a hypoglossal nerve stimulator. RESULTS 9 males and 5 females completed the study. The mean pre-operative VHI-10 and EAT-10 score was 3 and 0.8 respectively. Using linear mixed models, a clinically and statistically significant increase in the mean EAT-10 score was observed post-operatively at 1week (p=0.007), which was not observed at the time points the stimulator was active. A clinically and statistically significant decrease in VHI-10 score was observed following 2months of active stimulator use (p=0.02), which was not observed at any other time point. CONCLUSION The implantation and use of the hypoglossal nerve stimulator over 5months did not demonstrate any sustained, patient reported changes in voice handicap and swallowing function. While larger studies are warranted, our findings can be used to provide further informed consent for hypoglossal nerve stimulator implantation.
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Luu BL, Muceli S, Saboisky JP, Farina D, Héroux ME, Bilston LE, Gandevia SC, Butler JE. Motor unit territories in human genioglossus estimated with multichannel intramuscular electrodes. J Appl Physiol (1985) 2018; 124:664-671. [DOI: 10.1152/japplphysiol.00889.2017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The discharge patterns of genioglossus motor units during breathing have been well-characterized in previous studies, but their localization and territories are not known. In this study, we used two newly developed intramuscular multichannel electrodes to estimate the territories of genioglossus motor units in the anterior and posterior regions of the muscle. Seven healthy men participated. Each electrode contained fifteen bipolar channels, separated by 1 mm, and was inserted percutaneously below the chin, perpendicular to the skin, to a depth of 36 mm. Single motor unit activity was recorded with subjects awake, supine, and breathing quietly through a nasal mask for 180 s. Motor unit territories were estimated from the spike-triggered averages of the electromyographic signal from each channel. A total of 30 motor units were identified: 22 expiratory tonic, 1 expiratory phasic, 2 tonic, 3 inspiratory tonic, and 2 inspiratory phasic. Motor units appeared to be clustered based on unit type, with peak activities for expiratory units predominantly located in the anterior and superficial fibers of genioglossus and inspiratory units in the posterior region. Of these motor unit types, expiratory tonic units had the largest estimated territory, a mean 11.3 mm (SD 1.9). Estimated territories of inspiratory motor units ranged from 3 to 6 mm. In accordance with the distribution of motor unit types, the estimated territory of genioglossus motor units varied along the sagittal plane, decreasing from anterior to posterior. Our findings suggest that genioglossus motor units have large territories relative to the cross-sectional size of the muscle. NEW & NOTEWORTHY In this study, we used a new multichannel intramuscular electrode to address a fundamental property of human genioglossus motor units. We describe the territory of genioglossus motor units in the anterior and posterior regions of the muscle and show a decrease in territory size from anterior to posterior and that expiratory-related motor units have larger estimated territories than inspiratory-related motor units.
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Affiliation(s)
- Billy L. Luu
- Neuroscience Research Australia, Randwick, and University of New South Wales, Sydney, Australia
| | - Silvia Muceli
- Neurorehabilitation Systems Research Group, Clinic for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Julian P. Saboisky
- Neuroscience Research Australia, Randwick, and University of New South Wales, Sydney, Australia
| | - Dario Farina
- Neurorehabilitation Systems Research Group, Clinic for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Martin E. Héroux
- Neuroscience Research Australia, Randwick, and University of New South Wales, Sydney, Australia
| | - Lynne E. Bilston
- Neuroscience Research Australia, Randwick, and University of New South Wales, Sydney, Australia
| | - Simon C. Gandevia
- Neuroscience Research Australia, Randwick, and University of New South Wales, Sydney, Australia
| | - Jane E. Butler
- Neuroscience Research Australia, Randwick, and University of New South Wales, Sydney, Australia
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Durand DM. A Neural Prosthesis for Obstructive Sleep Apnea. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Upper Airway Neurostimulation to Treat Obstructive Sleep Apnea. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Güneri P, İlhan B, Çal E, Epstein JB, Klasser GD. Obstructive sleep apnoea and the need for its introduction into dental curricula. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2017; 21:121-129. [PMID: 26895614 DOI: 10.1111/eje.12190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 06/05/2023]
Abstract
Obstructive sleep apnoea (OSA) is a major health problem which causes blood oxygen desaturation that may initiate a cascade of events via inflammatory cytokines and adrenocorticotrophic hormone that may have impact upon quality of life and lead to potential life-threatening events. Even though OSA affects an increasing number of individuals, the role of dental practitioners in recognition, screening and management has not developed accordingly. The goal of this article was to provide updated information to dental practitioners on pathophysiology, consequences and treatment options of OSA with a focused discussion on oral appliance (OA) therapy, as this topic is not routinely included in current dental curricula of many dental schools. Additionally, we present a template dental curriculum for predoctoral and/or postdoctoral students in education regarding sleep disordered breathing.
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Affiliation(s)
- P Güneri
- Department of Oral and Maxillofacial Radiology, Ege University School of Dentistry, Izmir, Turkey
| | - B İlhan
- Department of Oral and Maxillofacial Radiology, Ege University School of Dentistry, Izmir, Turkey
| | - E Çal
- Department of Prosthetic Dentistry, Ege University School of Dentistry, Izmir, Turkey
| | - J B Epstein
- Division of Otolaryngology and Head and Neck Surgery City of Hope National Medical Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - G D Klasser
- Department of Diagnostic Sciences, School of Dentistry, Louisiana State University, New Orleans, LA, USA
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Rousseau E, Melo-Silva CA, Gakwaya S, Sériès F. Effects of repetitive transcranial magnetic stimulation of upper airway muscles during sleep in obstructive sleep apnea patients. J Appl Physiol (1985) 2016; 121:1217-1225. [DOI: 10.1152/japplphysiol.00487.2015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 11/22/2022] Open
Abstract
We tested the hypothesis that stimulating the genioglossus by repetitive transcranial magnetic stimulation (rTMS) during the ascendant portion of the inspiratory flow of airflow-limited breaths would sustain the recruitment of upper airway dilator muscles over time and improve airway dynamics without arousing obstructive sleep apnea (OSA) patients. In a cross-sectional design, nine OSA patients underwent a rTMS trial during stable non-rapid eye movement (NREM) sleep. Submental muscle motor threshold (SUB) and motor-evoked potential were evaluated during wakefulness and sleep. During NREM sleep, maximal inspiratory flow, inspiratory volume, inspiratory time, shifts of electroencephalogram frequency, and pulse rate variability were assessed under three different stimulation paradigms completed at 1.2 sleep SUB stimulation output: 1) 5Hz-08 (stimulation frequency: 5 Hz; duration of train stimulation: 0.8 s); 2) 25Hz-02 (stimulation frequency: 25 Hz; duration of train stimulation: 0.2 s); and 3) 25Hz-04 (stimulation frequency: 25 Hz; duration of train stimulation: 0.4 s). SUB increased during NREM sleep (wakefulness: 23.8 ± 6.1%; NREM: 26.8 ± 5.2%; = 0.001). Two distinct airflow patterns were observed in response to rTMS: with and without initial airflow drops, without other airflow variables change regardless the stimulation paradigm applied. Finally, rTMS-induced cortical and/or autonomic arousal were observed in 36, 26, and 35% of all delivered rTMS trains during 5Hz-08, 25Hz-02, and 25Hz-04 stimulation paradigms, respectively. In conclusion, rTMS does not provide any airflow improvement of flow-limited breaths as seen with nonrepetitive TMS of upper airway dilator muscles. However, rTMS trains were free of arousals in the majority of cases.
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Affiliation(s)
- Eric Rousseau
- Unité de Recherche en Pneumologie, Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec City, Canada; and
| | - César Augusto Melo-Silva
- Unité de Recherche en Pneumologie, Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec City, Canada; and
- Laboratory of Respiratory Physiology, University of Brasília (UnB), Brasília, Federal District, Brazil
| | - Simon Gakwaya
- Unité de Recherche en Pneumologie, Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec City, Canada; and
| | - Frédéric Sériès
- Unité de Recherche en Pneumologie, Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec City, Canada; and
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Kezirian EJ. Acclimation settings with identical or similar sensation and functional thresholds. Laryngoscope 2016; 126 Suppl 7:S20-1. [PMID: 27480341 DOI: 10.1002/lary.26117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
Hypoglossal nerve stimulation with an activated implanted device does not awaken individuals from sleep once they have acclimated to the new sensation of the resulting tongue movement. This case report illustrates the importance of an acclimation period, allowing a patient to become accustomed to stimulation settings below the level at which there is gross tongue movement. Laryngoscope, 126:S20-S21, 2016.
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Affiliation(s)
- Eric J Kezirian
- University of Southern California, Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, Los Angeles, California, U.S.A
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Heiser C, Hofauer B, Lozier L, Woodson BT, Stark T. Nerve monitoring-guided selective hypoglossal nerve stimulation in obstructive sleep apnea patients. Laryngoscope 2016; 126:2852-2858. [DOI: 10.1002/lary.26026] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/14/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Clemens Heiser
- Department of Otorhinolaryngology; Head and Neck Surgery, Technische Universität München; Munich Germany
| | - Benedikt Hofauer
- Department of Otorhinolaryngology; Head and Neck Surgery, Technische Universität München; Munich Germany
| | - Luke Lozier
- Inspire Medical Systems; Maple Grove Minnesota
| | - B. Tucker Woodson
- Department of Otolaryngology; Medical College of Wisconsin; Milwaukee Wisconsin U.S.A
| | - Thomas Stark
- Department of Otorhinolaryngology; Head and Neck Surgery, Technische Universität München; Munich Germany
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Friedman M, Jacobowitz O, Hwang MS, Bergler W, Fietze I, Rombaux P, Mwenge GB, Yalamanchali S, Campana J, Maurer JT. Targeted hypoglossal nerve stimulation for the treatment of obstructive sleep apnea: Six-month results. Laryngoscope 2016; 126:2618-2623. [DOI: 10.1002/lary.25909] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/23/2015] [Accepted: 01/11/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Michael Friedman
- Rush University Medical Center and Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
| | - Ofer Jacobowitz
- ENT and Allergy Associates; Orange Regional Medical Center; Middletown New York U.S.A
| | - Michelle S. Hwang
- Rush University Medical Center and Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
| | | | - Ingo Fietze
- Department of Cardiology; Center of Sleep Medicine, Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Philippe Rombaux
- Saint Luc University Clinics; Department of Oto-Rhino-Laryngology; Institute of Neurosciences; University of Louvain; Brussels Belgium
| | - Gimbada B. Mwenge
- Saint Luc University Clinics; Department of Oto-Rhino-Laryngology; Institute of Neurosciences; University of Louvain; Brussels Belgium
| | - Sreeya Yalamanchali
- Rush University Medical Center and Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
| | - John Campana
- Colorado Head and Neck Specialists; Denver Colorado U.S.A
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Pengo MF, Steier J. Emerging technology: electrical stimulation in obstructive sleep apnoea. J Thorac Dis 2015; 7:1286-97. [PMID: 26380757 DOI: 10.3978/j.issn.2072-1439.2014.04.04] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 12/28/2022]
Abstract
Electrical stimulation (ES) of the upper airway (UAW) dilator muscles for patients with obstructive sleep apnoea (OSA) has been used for several decades, but in recent years research in this field has experienced a renaissance; the results of several studies have triggered a steady rise in the interest in this topic. Prospective trials, although still lacking a sham-controlled and randomised approach, have revealed the potential of ES. Hypoglossal nerve stimulation (HNS) leads to a significant reduction in the apnoea-hypopnoea index and the oxygen desaturation index (ODI). There are similar results published from feasibility studies for transcutaneous ES. A limitation of HNS remains the invasive procedure, the costs involved and severe adverse events, while for the non-invasive approach complications are rare and limited. The limiting step for transcutaneous ES is to deliver a sufficient current without causing arousal from sleep. Despite the progress up to date, numerous variables including optimal stimulation settings, different devices and procedures remain to be further defined for the invasive and the non-invasive method. Further studies are required to identify which patients respond to this treatment. ES of the UAW dilator muscles in OSA has the potential to develop into a clinical alternative to continuous positive airway pressure (CPAP) therapy. It could benefit selected patients who fail standard therapy due to poor long-term compliance. It is likely that international societies will need to review and update their existing guidance on the use of ES in OSA.
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Affiliation(s)
- Martino F Pengo
- 1 Guy's and St. Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK ; 2 Department of Medicine (DIMED), University of Padua, Padua, Italy ; 3 King's College London School of Medicine, London, UK ; 4 King's Health Partners, London, UK
| | - Joerg Steier
- 1 Guy's and St. Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK ; 2 Department of Medicine (DIMED), University of Padua, Padua, Italy ; 3 King's College London School of Medicine, London, UK ; 4 King's Health Partners, London, UK
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Heiser C, Maurer JT, Steffen A. Functional outcome of tongue motions with selective hypoglossal nerve stimulation in patients with obstructive sleep apnea. Sleep Breath 2015; 20:553-60. [DOI: 10.1007/s11325-015-1237-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 07/11/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
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Murphey AW, Baker AB, Soose RJ, Padyha TA, Nguyen SA, Xiao CC, Gillespie MB. Upper airway stimulation for obstructive sleep apnea: The surgical learning curve. Laryngoscope 2015; 126:501-6. [DOI: 10.1002/lary.25537] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/08/2015] [Accepted: 07/02/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Alexander W. Murphey
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Andrew B. Baker
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Ryan J. Soose
- Division of Sleep Surgery; Department of Otolaryngology; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Tapan A. Padyha
- Department of Otolaryngology-Head and Neck Surgery; University of South Florida; Tampa Florida U.S.A
| | - Shaun A. Nguyen
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Christopher C. Xiao
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - M. Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
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Abstract
Obstructive sleep apnoea syndrome (OSAS) is a common clinical condition in which the throat narrows or collapses repeatedly during sleep, causing obstructive sleep apnoea events. The syndrome is particularly prevalent in middle-aged and older adults. The mechanism by which the upper airway collapses is not fully understood but is multifactorial and includes obesity, craniofacial changes, alteration in upper airway muscle function, pharyngeal neuropathy and fluid shift towards the neck. The direct consequences of the collapse are intermittent hypoxia and hypercapnia, recurrent arousals and increase in respiratory efforts, leading to secondary sympathetic activation, oxidative stress and systemic inflammation. Excessive daytime sleepiness is a burden for the majority of patients. OSAS is also associated with cardiovascular co-morbidities, including hypertension, arrhythmias, stroke, coronary heart disease, atherosclerosis and overall increased cardiovascular mortality, as well as metabolic dysfunction. Whether treating sleep apnoea can fully reverse its chronic consequences remains to be established in adequately designed studies. Continuous positive airway pressure (CPAP) is the primary treatment modality in patients with severe OSAS, whereas oral appliances are also widely used in mild to moderate forms. Finally, combining different treatment modalities such as CPAP and weight control is beneficial, but need to be evaluated in randomized controlled trials. For an illustrated summary of this Primer, visit: http://go.nature.com/Lwc6te.
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Rousseau E, Gakwaya S, Melo-Silva CA, Sériès F. Mechanical effects of repetitive transcranial magnetic stimulation of upper airway muscles in awake obstructive sleep apnoea subjects. Exp Physiol 2015; 100:566-76. [DOI: 10.1113/ep085005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/09/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Eric Rousseau
- Unité de recherche en pneumologie; Centre de recherche; Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Québec; QC Canada
| | - Simon Gakwaya
- Unité de recherche en pneumologie; Centre de recherche; Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Québec; QC Canada
| | - César Augusto Melo-Silva
- Unité de recherche en pneumologie; Centre de recherche; Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Québec; QC Canada
- Laboratory of Respiratory Physiology; University of Brasília - UnB; Brasília - DF Brazil
| | - Frédéric Sériès
- Unité de recherche en pneumologie; Centre de recherche; Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Québec; QC Canada
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Mu L, Sanders I. Human tongue neuroanatomy: Nerve supply and motor endplates. Clin Anat 2015; 23:777-91. [PMID: 20607833 DOI: 10.1002/ca.21011] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 04/25/2010] [Accepted: 05/04/2010] [Indexed: 02/02/2023]
Abstract
The human tongue has a critical role in speech, swallowing, and respiration, however, its motor control is poorly understood. Fundamental gaps include detailed information on the course of the hypoglossal (XII) nerve within the tongue, the branches of the XII nerve within each tongue muscle, and the type and arrangement of motor endplates (MEP) within each muscle. In this study, five adult human tongues were processed with Sihler's stain, a whole-mount nerve staining technique, to map out the entire intra-lingual course of the XII nerve and its branches. An additional five specimens were microdissected into individual muscles and stained with acetylcholinesterase and silver staining to study their MEP morphology and banding patterns. Using these techniques the course of the entire XII nerve was mapped from the main nerve to the smallest intramuscular branches. It was found that the human tongue innervation is extremely dense and complex. Although the basic mammalian pattern of XII is conserved in humans, there are notable differences. In addition, many muscle fibers contained multiple en grappe MEP, suggesting that they are some variant of the highly specialized slow tonic muscle fiber type. The transverse muscle group that comprises the core of the tongue appears to have the most complex innervation and has the highest percentage of en grappe MEP. In summary, the innervation of the human tongue has specializations not reported in other mammalian tongues, including nonhuman primates. These specializations appear to allow for fine motor control of tongue shape.
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Affiliation(s)
- Liancai Mu
- Upper Airway Research Laboratory, Department of Research, Hackensack University Medical Center, Hackensack, New Jersey.
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Certal VF, Zaghi S, Riaz M, Vieira AS, Pinheiro CT, Kushida C, Capasso R, Camacho M. Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope 2014; 125:1254-64. [PMID: 25389029 DOI: 10.1002/lary.25032] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Poor adherence to continuous positive airway pressure treatment in obstructive sleep apnea (OSA) adversely affects the effectiveness of this therapy. This study aimed to systematically review the evidence regarding the efficacy and safety of hypoglossal nerve stimulation as an alternative therapy in the treatment of OSA. DATA SOURCES Scopus, PubMed, and Cochrane Library databases were searched (updated through September 5, 2014). METHODS Studies were included that evaluated the efficacy of hypoglossal nerve stimulation to treat OSA in adults with outcomes for apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and effect on daytime sleepiness (Epworth Sleepiness Scale [ESS]). Tests for heterogeneity and subgroup analysis were performed. RESULTS Six prospective studies with 200 patients were included in this review. At 12 months, the pooled fixed effects analysis demonstrated statistically significant reductions in AHI, ODI, and ESS mean difference of -17.51 (95% CI: -20.69 to -14.34); -13.73 (95% CI: -16.87 to -10.58), and -4.42 (95% CI: -5.39 to -3.44), respectively. Similar significant reductions were observed at 3 and 6 months. Overall, the AHI was reduced between 50% and 57%, and the ODI was reduced between 48% and 52%. Despite using different hypoglossal nerve stimulators in each subgroup analysis, no significant heterogeneity was found in any of the comparisons, suggesting equivalent efficacy regardless of the system in use. CONCLUSIONS This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. Further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes. LEVEL OF EVIDENCE NA
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Affiliation(s)
- Victor F Certal
- Department of Otorhinolaryngology , Hospital Lusíadas, Porto, Portugal; Center for Research in Health Technologies and Information Systems , University of Porto, Porto, Portugal
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Woodson BT, Gillespie MB, Soose RJ, Maurer JT, de Vries N, Steward DL, Baskin JZ, Padhya TA, Lin HS, Mickelson S, Badr SM, Strohl KP, Strollo PJ. Randomized controlled withdrawal study of upper airway stimulation on OSA: short- and long-term effect. Otolaryngol Head Neck Surg 2014; 151:880-7. [PMID: 25205641 DOI: 10.1177/0194599814544445] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the efficacy and durability of upper airway stimulation via the hypoglossal nerve on obstructive sleep apnea (OSA) severity including objective and subjective clinical outcome measures. STUDY DESIGN A randomized controlled therapy withdrawal study. SETTING Industry-supported multicenter academic and clinical setting. SUBJECTS A consecutive cohort of 46 responders at 12 months from a prospective phase III trial of 126 implanted participants. METHODS Participants were randomized to either therapy maintenance ("ON") group or therapy withdrawal ("OFF") group for a minimum of 1 week. Short-term withdrawal effect as well as durability at 18 months of primary (apnea hypopnea index and oxygen desaturation index) and secondary outcomes (arousal index, oxygen desaturation metrics, Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, snoring, and blood pressure) were assessed. RESULTS Both therapy withdrawal group and maintenance group demonstrated significant improvements in outcomes at 12 months compared to study baseline. In the randomized assessment, therapy withdrawal group returned to baseline, and therapy maintenance group demonstrated no change. At 18 months with therapy on in both groups, all objective respiratory and subjective outcome measures showed sustained improvement similar to those observed at 12 months. CONCLUSION Withdrawal of therapeutic upper airway stimulation results in worsening of both objective and subjective measures of sleep and breathing, which when resumed results in sustained effect at 18 months. Reduction of obstructive sleep apnea severity and improvement of quality of life were attributed directly to the effects of the electrical stimulation of the hypoglossal nerve.
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Affiliation(s)
| | - M Boyd Gillespie
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ryan J Soose
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | - David L Steward
- University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | | | - Tapan A Padhya
- University of South Florida College of Medicine, Tampa, Florida, USA
| | | | | | | | | | - Patrick J Strollo
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Meadows PM, Whitehead MC, Zaidi FN. Effects of targeted activation of tongue muscles on oropharyngeal patency in the rat. J Neurol Sci 2014; 346:178-93. [PMID: 25190291 DOI: 10.1016/j.jns.2014.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 06/24/2014] [Accepted: 08/16/2014] [Indexed: 02/01/2023]
Abstract
Laboratory rats were acutely implanted with an electrode array composed of eight independently controllable contacts applied to ventral and dorsal aspects of the left and right hypoglossal nerves (HGNs) and their branches. Bipolar intramuscular electromyographic (EMG) electrodes were implanted into the left and right genioglossus, hyoglossus and styloglossus muscles to identify which muscles were activated during stimulation via the contacts. Elicited movements, including changes in the position of the tongue and in the size and the shape of the airway, were documented video-graphically through a surgery microscope and an endoscope. Constant current electrical stimulation activated various combinations of electrode contacts and the stimulation patterns were correlated with corresponding oral movements, airway sizes, and EMG activities. Results demonstrate that graded responses and differential activation of the various tongue muscles are achievable by stimulation of specific contacts in the electrode array. These effects are interpreted to result from the targeted activation of regions of the nerve lying under and between the electrodes. Further testing established that the muscle responses elicited by unilateral electrical stimulation with the present approach can be smoothly graded, that the muscle responses resulted in opening of the airway and could be reliably maintained for long durations.
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Schwartz AR. Hypoglossal nerve stimulation--optimizing its therapeutic potential in obstructive sleep apnea. J Neurol Sci 2014; 346:1-3. [PMID: 25190292 DOI: 10.1016/j.jns.2014.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 08/16/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Alan R Schwartz
- Division of Pulmonary, Critical Care and Sleep Medicine, Johns Hopkins School of Medicine, USA; Johns Hopkins Sleep Disorders Center (Bayview Campus), USA; Center for Interdisciplinary Sleep Research and Education, USA; Johns Hopkins Sleep Medicine Fellowship Training Program, USA.
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