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Kim DH, Kim SW, Han JS, Kim GJ, Basurrah MA, Hwang SH. Hypoglossal Nerve Stimulation Effects on Obstructive Sleep Apnea Over Time: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 170:736-746. [PMID: 38123511 DOI: 10.1002/ohn.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES This study aimed to determine the efficacy of hypoglossal nerve stimulation (HGS) in the treatment of obstructive sleep apnea. DATA SOURCES PubMed, Cochrane database, Embase, Web of Science, SCOPUS, and Google Scholar. REVIEW METHODS Five databases were reviewed to identify relevant studies that measured polysomnography parameters such as the apnea-hypopnea index (AHI) and oxygen desaturation index, as well as quality of life and functional outcomes of sleep questionnaire scores, before and after HGS. RESULTS In total, 44 studies involving 8670 patients met the inclusion criteria. At 12 months after treatment, approximately 47%, 72%, and 82% of patients achieved AHI values of <5, < 10, and <15, respectively. The reported clinical success rates according to Sher criteria were 80% within 12 months and 73% between 12 and 36 months. While the favorable effects exhibited a gradual reduction up to 12 months postimplantation, they generally maintained a consistent level between the 12th and 36th months, as assessed by AHI < 5, <15, and success rate according to Sher criteria. CONCLUSION HGS can enhance quality of life scores and polysomnography outcomes in obstructive sleep apnea patients. Although the positive effects gradually decreased until 12 months after implantation, they generally remained consistent between 12 and 36 months.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae Sang Han
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Geun-Jeon Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | | | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Abu K, Khraiche ML, Amatoury J. Obstructive sleep apnea diagnosis and beyond using portable monitors. Sleep Med 2024; 113:260-274. [PMID: 38070375 DOI: 10.1016/j.sleep.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/03/2023] [Accepted: 11/21/2023] [Indexed: 01/07/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic sleep and breathing disorder with significant health complications, including cardiovascular disease and neurocognitive impairments. To ensure timely treatment, there is a need for a portable, accurate and rapid method of diagnosing OSA. This review examines the use of various physiological signals used in the detection of respiratory events and evaluates their effectiveness in portable monitors (PM) relative to gold standard polysomnography. The primary objective is to explore the relationship between these physiological parameters and OSA, their application in calculating the apnea hypopnea index (AHI), the standard metric for OSA diagnosis, and the derivation of non-AHI metrics that offer additional diagnostic value. It is found that increasing the number of parameters in PMs does not necessarily improve OSA detection. Several factors can cause performance variations among different PMs, even if they extract similar signals. The review also highlights the potential of PMs to be used beyond OSA diagnosis. These devices possess parameters that can be utilized to obtain endotypic and other non-AHI metrics, enabling improved characterization of the disorder and personalized treatment strategies. Advancements in PM technology, coupled with thorough evaluation and validation of these devices, have the potential to revolutionize OSA diagnosis, personalized treatment, and ultimately improve health outcomes for patients with OSA. By identifying the key factors influencing performance and exploring the application of PMs beyond OSA diagnosis, this review aims to contribute to the ongoing development and utilization of portable, efficient, and effective diagnostic tools for OSA.
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Affiliation(s)
- Kareem Abu
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon; Neural Engineering and Nanobiosensors Group, American University of Beirut, Beirut, Lebanon; Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon
| | - Massoud L Khraiche
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon; Neural Engineering and Nanobiosensors Group, American University of Beirut, Beirut, Lebanon
| | - Jason Amatoury
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon; Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon.
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Corr F, Kilinç F, Oros J, Qasem LE, Al-Hilou A, Jussen D, Czabanka M, Quick-Weller J. Increased Body Mass Index Correlates with Less Favorable Postoperative Outcomes After Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: A Retrospective Cohort Study. World Neurosurg 2023; 180:e210-e218. [PMID: 37714455 DOI: 10.1016/j.wneu.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE Obstructive sleep apnea is associated with high morbidity. Hypoglossal nerve stimulation (HNS) has become a novel (neuro-) surgical treatment strategy for obstructive sleep apnea, demonstrating good success rates. Beyond predefined inclusion and exclusion criteria, no precise data are available, enabling individual preoperative risk assessment. To improve preoperative risk stratification, this study analyzed individual patient factors that affect outcomes of HNS. METHODS Fourteen patients treated with unilateral HNS were analyzed retrospectively. Assessed risk factors included: hypertension, diabetes mellitus, depression, smoking, alcohol consumption, body mass index (BMI), and disease duration. Treatment success was defined as a reduction in the postoperative apnea-hypopnea index (AHI) to ≤20 events/hour, with a relative reduction of at least 50% compared to baseline. RESULTS A significant reduction in the postoperative apnea-hypopnea index was observed in all patients (P < 0.0001). BMI correlated significantly with postoperative AHI scores (95% confidence interval, 0.1519-0.8974; P = 0.018). Significant treatment success was observed in 50% of patients. Compared with the "Excellent Responder group," the "Responder group" demonstrated a significantly higher BMI (95% confidence interval, 1.174-6.226; P = 0.0078). Diabetes, hypertension, disease duration, smoking, depression, and alcohol consumption were not significantly associated with AHI reduction. CONCLUSIONS Our findings suggest that BMI may be an independent risk factor for the response to HNS, with patients who had less benefit from therapy having significantly higher BMI than "Excellent Responders." Therefore, carefully selecting patients is crucial in obtaining optimal outcomes with HNS therapy, especially those with a high BMI.
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Affiliation(s)
- Felix Corr
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany.
| | - Fatma Kilinç
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Jan Oros
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Lina-Elisabeth Qasem
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Ali Al-Hilou
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Daniel Jussen
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Johanna Quick-Weller
- Department of Neurosurgery, Johann Wolfgang Goethe University Hospital Frankfurt, Frankfurt, Germany
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Xia F, Li H, Li Y, Liu X, Xu Y, Fang C, Hou Q, Lin S, Zhang Z, Yang J, Sawan M. Minimally Invasive Hypoglossal Nerve Stimulator Enabled by ECG Sensor and WPT to Manage Obstructive Sleep Apnea. SENSORS (BASEL, SWITZERLAND) 2023; 23:8882. [PMID: 37960581 PMCID: PMC10648123 DOI: 10.3390/s23218882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023]
Abstract
A hypoglossal nerve stimulator (HGNS) is an invasive device that is used to treat obstructive sleep apnea (OSA) through electrical stimulation. The conventional implantable HGNS device consists of a stimuli generator, a breathing sensor, and electrodes connected to the hypoglossal nerve via leads. However, this implant is bulky and causes significant trauma. In this paper, we propose a minimally invasive HGNS based on an electrocardiogram (ECG) sensor and wireless power transfer (WPT), consisting of a wearable breathing monitor and an implantable stimulator. The breathing external monitor utilizes an ECG sensor to identify abnormal breathing patterns associated with OSA with 88.68% accuracy, achieved through the utilization of a convolutional neural network (CNN) algorithm. With a skin thickness of 5 mm and a receiving coil diameter of 9 mm, the power conversion efficiency was measured as 31.8%. The implantable device, on the other hand, is composed of a front-end CMOS power management module (PMM), a binary-phase-shift-keying (BPSK)-based data demodulator, and a bipolar biphasic current stimuli generator. The PMM, with a silicon area of 0.06 mm2 (excluding PADs), demonstrated a power conversion efficiency of 77.5% when operating at a receiving frequency of 2 MHz. Furthermore, it offers three-voltage options (1.2 V, 1.8 V, and 3.1 V). Within the data receiver component, a low-power BPSK demodulator was ingeniously incorporated, consuming only 42 μW when supplied with a voltage of 0.7 V. The performance was achieved through the implementation of the self-biased phase-locked-loop (PLL) technique. The stimuli generator delivers biphasic constant currents, providing a 5 bit programmable range spanning from 0 to 2.4 mA. The functionality of the proposed ECG- and WPT-based HGNS was validated, representing a highly promising solution for the effective management of OSA, all while minimizing the trauma and space requirements.
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Affiliation(s)
- Fen Xia
- Zhejiang University, Hangzhou 310024, China;
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Hanrui Li
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
- SAMA Labs, Computer, Electrical and Mathematical Science and Engineering (CEMSE) Division, Department of Electrical and Computer Engineering, King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Saudi Arabia
| | - Yixi Li
- State Key Laboratory of Superlattices, Microstructures Institute of Semiconductors, Chinese Academy of Sciences, Beijing 100045, China;
| | - Xing Liu
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Yankun Xu
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Chaoming Fang
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Qiming Hou
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Siyu Lin
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Zhao Zhang
- SAMA Labs, Computer, Electrical and Mathematical Science and Engineering (CEMSE) Division, Department of Electrical and Computer Engineering, King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Saudi Arabia
| | - Jie Yang
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
| | - Mohamad Sawan
- CenBRAIN Laboratory, School of Engineering, Westlake University, Hangzhou 310024, China; (H.L.)
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Kent D, Huyett P, Yu P, Roy A, Mehra R, Rundo JV, Stahl S, Manchanda S. Comparison of clinical pathways for hypoglossal nerve stimulation management: in-laboratory titration polysomnography vs home-based efficacy sleep testing. J Clin Sleep Med 2023; 19:1905-1912. [PMID: 37421320 PMCID: PMC10620657 DOI: 10.5664/jcsm.10712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 07/10/2023]
Abstract
STUDY OBJECTIVES We conducted this study to evaluate whether laboratory or home-based hypoglossal nerve stimulation (HNS) management would have equivalent objective and subjective obstructive sleep apnea outcomes 6 months after activation. METHODS Patients undergoing standard-of-care HNS implantation were randomly assigned in a prospective, multicenter clinical trial to either a 3-month postactivation in-laboratory titration polysomnography (tPSG) or an efficacy home sleep study (eHST) with tPSG by exception for eHST nonresponders at 5 months. Both groups underwent an eHST 6 months postactivation. RESULTS Sixty patients were randomly assigned. Patients experienced equivalent decreases in the apnea-hypopnea index (mean difference: -0.01 events/h [-8.75, 8.74]) across both groups with HNS; the selection of tPSG or eHST did not associate with therapy response rates (tPSG vs eHST: 63.2% vs 59.1%). The Epworth Sleepiness Scale (median of differences: 1 [-1, 3]) and device usage (median of differences: 0.0 hours [-1.3, 1.3]) outcomes were similar but did not meet a priori statistical equivalence criteria. CONCLUSIONS This prospective, multicenter, randomized clinical trial demonstrated that patients undergoing HNS implantation experienced statistically equivalent improvements in objective obstructive sleep apnea outcomes and similar improvements in daytime sleepiness regardless of whether they underwent tPSG. HNS titration with tPSG may not be required for all postoperative patients. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Inspire Home Study: Utilization of Home Monitoring During Therapy Optimization in Patients With an Inspire Upper Airway Stimulation System (Comparison of Home Sleep Testing vs. In-lab Polysomnography Testing) (HOME); URL: https://clinicaltrials.gov/ct2/show/NCT04416542; Identifier: NCT04416542. CITATION Kent D, Huyett P, Yu P, et al. Comparison of clinical pathways for hypoglossal nerve stimulation management: in-laboratory titration polysomnography vs home-based efficacy sleep testing. J Clin Sleep Med. 2023;19(11):1905-1912.
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Affiliation(s)
- David Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts
| | - Phoebe Yu
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear, Boston, Massachusetts
| | - Asim Roy
- Ohio Sleep Medicine Institute, Columbus, Ohio
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute; Respiratory Institute; Cardiovascular and Metabolic Sciences, Lerner Research Institute; Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jessica Vensel Rundo
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stephanie Stahl
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, and Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shalini Manchanda
- Department of Otolaryngology-Head and Neck Surgery, and Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Braun M, Stoerzel M, Wollny M, Schoebel C, Ulrich Sommer J, Heiser C. Patient-reported outcomes with hypoglossal nerve stimulation for treatment of obstructive sleep apnea: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2023; 280:4627-4639. [PMID: 37354340 PMCID: PMC10477259 DOI: 10.1007/s00405-023-08062-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/09/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Hypoglossal nerve stimulation (HNS) has recently been introduced as an alternative treatment for patients with OSA. A large number of studies have demonstrated substantial changes in OSA with this therapy by reducing respiratory events and improving symptoms such as daytime sleepiness and quality of life. The objective of this review was to conduct a systematic review and meta-analysis to evaluate patient-reported outcomes and experience with HNS therapy. METHODS A systematic literature search of MEDLINE, Cochrane, and Web of Science was performed to identify randomized controlled and observational studies reporting subjective outcomes with different HNS systems in patients with OSA. Abstracts of 406 articles were screened and a subset of 55 articles were reviewed for eligibility. Risk of bias was assessed using the ROBINS-I tool. Meta-analysis using RevMan was performed when > 2 studies were identified that reported data on a specific outcome. RESULTS Thirty-four publications reporting data on 3785 patients with a mean follow-up of 11.8 ± 12.2 months were identified and included in the meta-analysis. The analysis revealed a pooled effect of 4.59 points improvement in daytime sleepiness as measured by the ESS questionnaire (Z = 42.82, p < .001), 2.84 points improvement in daytime functioning as measured by the FOSQ score (Z = 28.38, p < .001), and 1.77 points improvement in sleep quality as measured by the PSQI questionnaire (Z = 2.53, p = .010). Patient-reported experience was consistently positive and revealed additional relevant aspects from this perspective. CONCLUSION HNS therapy significantly improves quality of life in patients with OSA and reliably produces clinically meaningful effects on daytime sleepiness, daytime functioning, and sleep quality. Treatment regularly meets or exceeds the minimum clinically important differences defined for the respective instruments. Additional research is needed to further investigate effects on quality of life beyond improvements in daytime sleepiness and daytime functioning.
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Affiliation(s)
- Marcel Braun
- Department of Pneumology, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Duisburg, Germany.
- Faculty of Sleep and Telemedicine, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239, Essen, Germany.
| | - Manuel Stoerzel
- German Cancer Research Center (DKFZ), Heidelberg, BW, Germany
| | | | - Christoph Schoebel
- Department of Pneumology, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Duisburg, Germany
- Faculty of Sleep and Telemedicine, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239, Essen, Germany
| | - J Ulrich Sommer
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- ENT-Center Mangfall-Inn, Bad Aibling, Germany
| | - Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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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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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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Pordzik J, Seifen C, Ludwig K, Hackenberg B, Huppertz T, Bahr-Hamm K, Matthias C, Gouveris H. Drug-Induced Sleep Endoscopy Findings and Hypoglossal Nerve Stimulation Therapy Outcomes. J Pers Med 2023; 13:jpm13030532. [PMID: 36983714 PMCID: PMC10059915 DOI: 10.3390/jpm13030532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Hypoglossal-nerve stimulation (HGNS) is an established second-line therapy for patients with obstructive sleep apnea (OSA). Existing studies investigating the effect of preoperative drug-induced sleep endoscopic (DISE) findings on HGNS outcomes have mainly focused on the apnea/hypopnea index (AHI) among polysomnography (PSG) parameters, and have less frequently tested other PSG parameters such as the apnea index (AI), hypopnea index (HI), oxygen desaturation index (ODI), snoring index, and arousal index, or patient-reported excessive daytime sleepiness. The aim of this study was to investigate the correlation between DISE findings and the above-mentioned metrics after HGNS therapy. We only included patients with DISE findings providing detailed information about the degree of the anteroposterior velar (APV), oropharyngeal lateral wall (OPLW), or tongue-base (BT) obstruction based on the velum, oropharynx, base of tongue, and epiglottis (VOTE) classification. The data of 25 patients (9 female (36%)) were retrospectively evaluated. The mean age at the date of implantation was 54.52 ± 9.61 years, and the mean BMI was 29.99 ± 3.97 kg/m2. Spearman’s rho correlation coefficients were calculated. Significant correlations were found between the degree of APV obstruction and postoperative HI (r = −0.5, p < 0.05), and between the degree of OPLW obstruction and postoperative snoring index (r = 0.42, p < 0.05). BT obstruction was strongly correlated with postoperative metrics such as AHI (r = −0.57, p < 0.01), AI (r = −0.5, p < 0.05), ODI (r = −0.57, p < 0.01), ∆ AHI (r = 0.58, p < 0.01), ∆ AI (r = 0.54, p < 0.01) and ∆ ODI (r = 0.54, p < 0.01). No significant correlation was found between DISE findings and postoperative Epworth Sleepiness Scale values. These findings suggest that preoperative DISE findings, especially the degree of BT obstruction, are important for predicting an HGNS therapy outcome.
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Pordzik J, Ludwig K, Seifen C, Huppertz T, Bahr-Hamm K, Matthias C, Gouveris H. Insomnia in Patients Undergoing Hypoglossal Nerve Stimulation Therapy for Obstructive Sleep Apnea. BIOLOGY 2023; 12:biology12010098. [PMID: 36671790 PMCID: PMC9856015 DOI: 10.3390/biology12010098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/30/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
Hypoglossal nerve stimulation (HGNS) is a treatment for obstructive sleep apnea (OSA) patients with intolerance of positive airway pressure therapy. Comorbid insomnia is quite prevalent in OSA patients. We investigated the impact of insomnia and excessive daytime sleepiness (EDS) on polysomnography metrics after HGNS treatment. Data of 27 consecutive patients (9 female; mean age 55.52 ± 8.6 years) were retrospectively evaluated. Insomnia was assessed using the ISI (insomnia severity index) and EDS using the Epworth sleepiness scale (ESS). The median ISI was reduced significantly 3 months after HGNS activation (preoperative: 19; postoperative: 14; p < 0.01). Significant correlations emerged between preoperative ISI and postoperative AHI (apnea/hypopnea index; Spearman’s rho = 0.4, p < 0.05), ∆ AHI (r = −0.51, p < 0.01) and ∆ ODI (oxygen desaturation index; r = −0.48, p < 0.05). ISI correlated strongly with EES both preoperatively (r = 0.46; p < 0.02) and postoperatively (r = 0.79; p < 0.001). Therefore, HGNS therapy is associated with a significant reduction of insomnia-related symptoms, in addition to the improvement in respiratory metrics in OSA. Nonetheless, the preoperative severity of patient-reported insomnia symptoms was inversely correlated with the respiratory PSG-outcomes after HGNS. Insomnia should be considered in studies of EDS in OSA patients, especially those treated with HGNS.
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11
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Weiner JS, Munhall CC, Kent DT. Supine Pharyngeal Width Is Associated With Complete Concentric Palatal Collapse During Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulator Outcomes. EAR, NOSE & THROAT JOURNAL 2022:1455613221148313. [PMID: 36583238 DOI: 10.1177/01455613221148313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Hypoglossal nerve stimulation (HNS) implantation in the US requires preoperative drug-induced sleep endoscopy (DISE) screening for complete concentric palatal collapse (CCC) to establish treatment candidacy. We hypothesized that supine pharyngeal width (SPW) in awake patients is associated with CCC and HNS therapy outcomes. METHODS Adults with moderate to severe obstructive sleep apnea underwent awake measurement of SPW followed by DISE screening for CCC. Eligible patients electing for HNS implantation underwent postoperative polysomnography per standard of care. RESULTS SPW was measured in 73 patients. For SPW >20 mm, the positive likelihood ratio for absence of CCC was 6.67 with pre- and post-test odds of 6.3 and 42.0, respectively. Postoperative PSG data were available from 31 of 44 (70.5%) patients subsequently implanted with HNS. Patients with SPW >20 mm had a greater rate of HNS response than those with SPW ≤20 (62 vs 30%; P < .05). Only SPW and BMI were significantly associated with CCC and HNS response in regression models. CONCLUSION In a retrospective cohort study, SPW was significantly associated with CCC and postoperative apnea-hypopnea index following HNS implantation. SPW may be a viable screening tool for HNS candidacy.
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Affiliation(s)
| | | | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Pordzik J, Seifen C, Ludwig K, Huppertz T, Bahr K, Matthias C, Gouveris H. Short-Term Outcome of Unilateral Inspiration-Coupled Hypoglossal Nerve Stimulation in Patients with Obstructive Sleep Apnea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16443. [PMID: 36554323 PMCID: PMC9779234 DOI: 10.3390/ijerph192416443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/24/2022] [Accepted: 12/03/2022] [Indexed: 06/17/2023]
Abstract
Hypoglossal nerve stimulation (HGNS) is a therapeutic option for patients with obstructive sleep apnea (OSA) and intolerance of positive airway pressure (PAP) therapy. Most reported data are based on multicentre pivotal trials with selected baseline core clinical features. Our aim was to investigate polysomnography (PSG)-based outcomes of HGNS-therapy in a patient cohort with higher average AHI and BMI than previously reported. Data of 29 consecutive patients (nine female; mean age: 55.52 ± 8.6 years, mean BMI 30.13 ± 3.93 kg/m2) were retrospectively evaluated. Numerical values of PSG- based metrics were compared before and after intervention using Wilcoxon's rank-sum test. AHI (38.57/h ± 12.71, 24.43/h ± 13.3, p < 0.001), hypopnea index (24.05/h ± 9.4, 15.27/h ± 8.23, p < 0.001), apnea index (14.5/h ± 12.05, 9.17/h ± 10.86, p < 0.01), snoring index (262.68/h ± 170.35, 143.48/h ± 162.79, p < 0.001), cortical arousal index (20.8/h ± 10.34 vs. 14.9/h ± 8.36, p < 0.01) and cumulative duration of apnea and hypopnea during sleep (79.79 min ± 40.32 vs. 48.62 min ± 30.56, p < 0.001) were significantly lower after HGNS. HGNS provides an effective therapy option for selected patients not tolerating PAP-therapy with higher average AHI and BMI than usually reported. HGNS-therapy appears to suppress central nervous system arousal circuits while not eliciting peripheral autonomous sympathetic activation. Such metrics as the snoring index and the cumulative duration of respiratory events during sleep may be considered in future HGNS studies.
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Baptista P, Di Frisco IM, Urrestarazu E, Alcalde J, Alegre M, Sanchez I, O’Connor-Reina C, Plaza G. Quality of Life Impact of Hypoglossal Nerve Stimulation with Inspire ® Device in Patients with Obstructive Sleep Apnea Intolerant to Continuous Positive Airway Pressure Therapy. Life (Basel) 2022; 12:life12111737. [PMID: 36362892 PMCID: PMC9694893 DOI: 10.3390/life12111737] [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: 10/01/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with obstructive sleep apnea (OSA) that do not tolerate/accept continuous positive airway pressure (CPAP) are candidates for surgical alternatives. Hypoglossal nerve stimulation (HNS) through the implantation of the Inspire® device constitutes a minimally invasive operative option. The main objective of this study is to estimate, under real-world clinical practice conditions, the 3-month impact on the quality of life (IQoL) of the HNS in patients with moderate/severe OSA who do not tolerate or accept CPAP, compared to patients who did not receive HNS. As a baseline, the unadjusted EuroQol utility index was 0.764 (SD:0.190) in the intervention group (IGr) and 0.733 (SD:0.205) in the control group (CGr); three months later, the indexes were 0.935 (SD: 0.101) and 0.727 (SD:0.200), respectively. The positive impact on quality of life was estimated to be +0.177 (95% CI: 0.044−0.310; p = 0.010). All dimensions in the IGr improved compared to CGr, especially for usual activities (p < 0.001) and anxiety/depression (p > 0.001). At the end of the follow-up, there was no significant difference in the quality of life between the general Spanish population and the IGr (difference: 0.012; CI95%: −0.03 to −0.057; p = 0.0578) for the same age range; however, there was a difference concerning the CGr (difference: −0.196; CI95%: −0.257 to −0.135; p < 0.001). In conclusion, patients with moderate/severe OSA implanted with the Inspire® device showed a positive IQoL.
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Affiliation(s)
- Peter Baptista
- Otorhinolaryngology Department, University Clinic of Navarra, 31007 Pamplona, Spain
- Correspondence: or
| | | | - Elena Urrestarazu
- Otorhinolaryngology Department, University Clinic of Navarra, 31007 Pamplona, Spain
| | - Juan Alcalde
- Otorhinolaryngology Department, University Clinic of Navarra, 31007 Pamplona, Spain
| | - Manuel Alegre
- Otorhinolaryngology Department, University Clinic of Navarra, 31007 Pamplona, Spain
| | - Isabel Sanchez
- Otorhinolaryngology Department, University Clinic of Navarra, 31007 Pamplona, Spain
| | | | - Guillermo Plaza
- Otorhinolaryngology Department, University Hospital of Fuenlabrada, University Rey Juan Carlos, 28042 Madrid, Spain
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14
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Boroosan A, Salapatas AM, Friedman M. Clinical Predictors of OSA Treatment Success Following Implantation of a Hypoglossal Nerve Stimulation Device. Otolaryngol Head Neck Surg 2022; 167:891-895. [PMID: 35439088 DOI: 10.1177/01945998221087594] [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: 11/16/2022]
Abstract
OBJECTIVE To identify prognostic indicators associated with successful hypoglossal nerve stimulation (HGNS) therapy to treat obstructive sleep apnea (OSA), focusing on patients' physiologic response to awake tongue protrusion. STUDY DESIGN Retrospective chart review. SETTING Tertiary care center. METHODS We included consecutive patients with moderate-severe OSA who underwent HGNS implantation from December 2017 to December 2019. Data abstracted include standard demographics, body mass index (BMI), pre- and postoperative apnea-hypopnea index (AHI), and Friedman tongue position (FTP). Additionally, change in hypopharyngeal cross-sectional area on awake tongue protrusion was abstracted. Patients protruded their tongues, and the physician visualized change. Positive change in hypopharyngeal cross-sectional area was documented as +1 and a negative change as -1. Chi-square tests for independence and logistic regression analysis were performed to determine indicators of successful surgery. RESULTS Thirty-nine patients were included in this study. Mean ± SD AHI decreased significantly from 43.1 ± 17.36 to 9.18 ± 8.18. Surgical success was achieved in 79.5% of patients. Variables analyzed included BMI >32, preoperative AHI, FTP, and change in hypopharyngeal cross-sectional area on awake tongue protrusion (positive, 65.8%; negative, 34.2%). Positive predictors of success were positive change in hypopharyngeal cross-sectional area (P = .0133), severe OSA (P = .0290), and FTP IIb (P < .0001). Negative predictors were BMI >32 (P = .041) and negative change in hypopharyngeal cross-sectional area (P = .02). CONCLUSION Positive change in hypopharyngeal cross-sectional area on awake tongue protrusion and severe baseline AHI were positive predictors of successful HGNS therapy. Negative change in hypopharyngeal cross-sectional area on awake tongue protrusion and BMI >32 were negative predictors.
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Affiliation(s)
- Avrahan Boroosan
- College of Medicine, University of Illinois, Chicago, Illinois, USA.,Chicago ENT, Chicago, Illinois, USA
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15
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Hypoglossal Nerve Stimulation for Treatment of Severe Refractory Obstructive Sleep Apnea in Children with Down Syndrome. CURRENT SLEEP MEDICINE REPORTS 2021. [DOI: 10.1007/s40675-021-00219-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Kent DT, Chio EG, Weiner JS, Heiser C, Suurna MV, Weidenbecher M. A Noninferiority Analysis of 3- vs 2-Incision Techniques for Hypoglossal Nerve Stimulator Implantation. Otolaryngol Head Neck Surg 2021; 167:197-202. [PMID: 34846979 DOI: 10.1177/01945998211062150] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The only hypoglossal nerve stimulation (HNS) device available for US clinical use is implanted through 3 incisions. A recently proposed 2-incision modification moved the respiratory sensing lead from the fifth to the second intercostal space to eliminate the third lower chest incision. This study compared perioperative data and therapeutic outcomes between the techniques. STUDY DESIGN Noninferiority cohort analysis of a retrospective and prospective registry study. SETTING Tertiary care and community surgical centers. METHODS Patients with obstructive sleep apnea underwent HNS implantation via a modified 2-incision technique (I2). A cohort previously implanted via the standard 3-incision technique (I3) were 1:1 propensity score matched for a noninferiority analysis of postoperative outcomes. RESULTS There were 404 I3 patients and 223 I2 patients across 6 participating centers. Operative time decreased from 128.7 minutes (95% CI, 124.5-132.9) in I3 patients to 86.6 minutes (95% CI, 83.7-97.6) in I2 patients (P < .001). Postoperative sleep study data were available for 76 I2 patients who were matched to I3 patients. The change in apnea-hypopnea index between the cohorts was statistically noninferior (a priori noninferiority margin: 7.5 events/h; mean difference, 1.51 [97.5% CI upper bound, 5.86]). There were no significant differences between the cohorts for baseline characteristics, perioperative adverse event rates, or change in Epworth Sleepiness Score (P > .05). CONCLUSION In a multicenter registry, a 2-incision implant technique for a commercially available HNS device had a statistically noninferior therapeutic efficacy profile when compared with the standard 3-incision approach. The 2-incision technique is safe and effective for HNS implantation.
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Affiliation(s)
- David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eugene G Chio
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Clemens Heiser
- Department of Otorhinolaryngology-Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Mark Weidenbecher
- Department of Otolaryngology-Head and Neck Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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17
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Abstract
Undiagnosed and untreated obstructive sleep apnea (OSA) is associated with health comorbidities and negatively affects quality of life. Alternative treatments should be considered in patients who are unable to tolerate or benefit from positive airway pressure treatment. When properly indicated, positional devices, oral appliances, airway surgery, and hypoglossal nerve stimulation have been shown to be effective in treating OSA. Hypoglossal nerve stimulation is a successful second-line treatment with low associated morbidity and complication rate.
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18
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Op de Beeck S, Wellman A, Dieltjens M, Strohl KP, Willemen M, Van de Heyning PH, Verbraecken JA, Vanderveken OM, Sands SA. Endotypic Mechanisms of Successful Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea. Am J Respir Crit Care Med 2021; 203:746-755. [PMID: 32970962 DOI: 10.1164/rccm.202006-2176oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Approximately one-third of patients with obstructive sleep apnea (OSA) treated with hypoglossal nerve stimulation (HGNS) therapy are incomplete responders, despite careful patient selection based on baseline characteristics and drug-induced sleep endoscopy.Objectives: Here we use polysomnographic endotyping to assess the pathophysiological mechanisms underlying favorable versus incomplete responses to HGNS therapy.Methods: Baseline polysomnography data of the STAR (Stimulation Therapy for Apnea Reduction) trial were included. Raw baseline polysomnographic data from 91/126 patients were available for analysis. Traits-loop gain, arousal threshold, collapsibility, and muscle compensation-were calculated from the baseline polysomnography data according to Sands and colleagues (AJRCCM 2018, SLEEP 2018). Logistic regression assessed apnea-hypopnea index (AHI)-adjusted associations between HGNS response (>50% reduction in AHI to <10/h at 1 yr) and OSA traits.Measurements and Main Results: Overall, HGNS treatment reduced AHI from 30.7 (24.9-39.9) to 8.5 (4.0-19.5) events/h (P < 0.0001; median [quartiles 1-3]); N = 53/91 were responders. In adjusted analysis, a favorable response to therapy was independently associated with higher arousal threshold (odds ratio [95% confidence interval]: 6.76 [2.44-23.3], P = 0.001), greater compensation (odds ratio: 4.22 [1.70-12.55] per SD, P = 0.004), and lower loop gain (in milder collapsibility, per significant interaction, P = 0.003). The higher arousal threshold was evident in responders before adjusted analysis. Predicted responders had an approximately fourfold lower treatment AHI versus predicted nonresponders (4.9 [2.7-8.5] vs. 20.7 [10.9-29.7], P < 0.0001; median [quartiles 1-3]); differences remained significant after cross-validation.Conclusions: Favorable responses to HGNS therapy are associated with the pathophysiological traits causing OSA, particularly a higher arousal threshold. Along with established criteria, individuals with favorable traits could potentially be prioritized for precision HGNS therapy.This analysis was a secondary analysis of the STAR trial registered with clinicaltrials.gov (NCT01161420).
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Affiliation(s)
- Sara Op de Beeck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery.,Multidisciplinary Sleep Disorders Centre, and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Marijke Dieltjens
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery
| | - Kingman P Strohl
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Paul H Van de Heyning
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery
| | - Johan A Verbraecken
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, and.,Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery.,Multidisciplinary Sleep Disorders Centre, and
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
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19
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Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome. Lung 2021; 199:87-101. [PMID: 33713177 DOI: 10.1007/s00408-021-00426-w] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/09/2021] [Indexed: 02/08/2023]
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.
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20
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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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21
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Overview of Recent Advances in Surgical Treatments for OSA. CURRENT SLEEP MEDICINE REPORTS 2020. [DOI: 10.1007/s40675-020-00186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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22
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Nitric oxide controls excitatory/inhibitory balance in the hypoglossal nucleus during early postnatal development. Brain Struct Funct 2020; 225:2871-2884. [PMID: 33130922 PMCID: PMC7674331 DOI: 10.1007/s00429-020-02165-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/17/2020] [Indexed: 01/18/2023]
Abstract
Synaptic remodeling during early postnatal development lies behind neuronal networks refinement and nervous system maturation. In particular, the respiratory system is immature at birth and is subjected to significant postnatal development. In this context, the excitatory/inhibitory balance dramatically changes in the respiratory-related hypoglossal nucleus (HN) during the 3 perinatal weeks. Since, development abnormalities of hypoglossal motor neurons (HMNs) are associated with sudden infant death syndrome and obstructive sleep apnea, deciphering molecular partners behind synaptic remodeling in the HN is of basic and clinical relevance. Interestingly, a transient expression of the neuronal isoform of nitric oxide (NO) synthase (NOS) occurs in HMNs at neonatal stage that disappears before postnatal day 21 (P21). NO, in turn, is a determining factor for synaptic refinement in several physiopathological conditions. Here, intracerebroventricular chronic administration (P7–P21) of the broad spectrum NOS inhibitor l-NAME (N(ω)-nitro-l-arginine methyl ester) differentially affected excitatory and inhibitory rearrangement during this neonatal interval in the rat. Whilst l-NAME led to a reduction in the number of excitatory structures, inhibitory synaptic puncta were increased at P21 in comparison to administration of the inactive stereoisomer d-NAME. Finally, l-NAME decreased levels of the phosphorylated form of myosin light chain in the nucleus, which is known to regulate the actomyosin contraction apparatus. These outcomes indicate that physiologically synthesized NO modulates excitatory/inhibitory balance during early postnatal development by acting as an anti-synaptotrophic and/or synaptotoxic factor for inhibitory synapses, and as a synaptotrophin for excitatory ones. The mechanism of action could rely on the modulation of the actomyosin contraction apparatus.
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Cheong CS, Loke W, Thong MKT, Toh ST, Lee CH. The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 14:149-158. [PMID: 33092317 PMCID: PMC8111386 DOI: 10.21053/ceo.2020.01704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 11/22/2022] Open
Abstract
Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.
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Affiliation(s)
- Crystal Sj Cheong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Weiqiang Loke
- Faculty of Dentistry, National University of Singapore, Singapore
| | - Mark Kim Thye Thong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Song Tar Toh
- Department of Otolaryngology, Singapore General Hospital, SingHealth Duke-NUS Sleep Centre, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
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Patel J, Daniels K, Bogdan L, Huntley C, Boon M. Effect of Gender, Age, and Profound Disease on Upper Airway Stimulation Outcomes. Ann Otol Rhinol Laryngol 2020; 129:772-780. [PMID: 32172600 DOI: 10.1177/0003489420911656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate treatment outcomes of upper airway stimulation (UAS) in obstructive sleep apnea (OSA) patients based on patient age, gender, and preoperative disease severity. METHODS Retrospective chart review of patients undergoing UAS from 2014 to 2018 at a tertiary care center. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. Profound OSA was defined as AHI >65 and age ≥65 was considered advanced age. The primary outcome measured was initial treatment response, defined as a post-operative AHI <20 with a >50% reduction from baseline. RESULTS 145 patients underwent UAS at our institution including 98 males and 47 females with a mean age of 61.7 ± 11.5 years, mean BMI of 29.1 ± 3.9 kg/m2, and mean preoperative AHI of 34.1 ± 18.2 events/hour. After surgery, patients had a significantly lower mean AHI of 8.6 ± 15.0 events/hour (<0.001). Older patients had a lower initial treatment response rate (78%) when compared to their younger counterparts (94%) (P = 0.005). Male gender and profound disease status did not significantly impact treatment response rates; young age was the only variable found to predict early treatment response on multivariate analysis (P = 0.003). CONCLUSION Although the overall OSA population showed significant postoperative AHI reduction with UAS, patients age ≥65 years were less likely to have an initial response to treatment, when compared to their younger counterparts. A larger proportion of elderly patients and patients with profound OSA had residual moderate disease (AHI > 15) after UAS. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kelly Daniels
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren Bogdan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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