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Renslo B, Hobelmann K, Sagalow ES, Ananth A, Boon M, Huntley C. Palatal Coupling Maneuvers Do Not Predict Hypoglossal Nerve Stimulator Treatment Efficacy. Laryngoscope 2023; 133:431-436. [PMID: 36129159 DOI: 10.1002/lary.30397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/01/2022] [Accepted: 09/01/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE(S) Maneuvers during drug-induced sleep endoscopy (DISE), for patients with obstructive sleep apnea (OSA), have been used as predictors for success with oral appliances. Hypoglossal nerve stimulation (HGNS) promotes opening at the velum through palatoglossus coupling. In this study, we evaluate maneuvers during DISE as predictors for HGNS treatment efficacy. METHODS We evaluated patients undergoing HGNS between November, 2014 and February, 2021. We assessed maneuvers including jaw thrust and chin lift during preoperative DISE. The impact of tongue base and palatal opening during these maneuvers were rated from 1 to 4 (1: no improvement, 2: mild improvement, 3: moderate improvement, 4: significant improvement). Patients were grouped by a score of 1-2 (weak response) or 3-4 (strong response). Apnea hypopnea index (AHI) change was calculated from the difference between preoperative and postoperative sleep study. RESULTS One hundred and seventy one patients were included. With jaw thrust, there was no significant difference in AHI change between patients with weak or strong response at the palate (n = 68 vs. 94, 9.5 vs. 13.6, p = 0.21) or tongue base (n = 24 vs. 138, 16.6 vs. 11.3, p = 0.24). On chin lift, there was no significant difference at the palate (n = 82 vs. 18, 13.9 vs. 11.4, p = 0.63) or tongue base (n = 92 vs. 72, 10.8 vs. 14.6, p = 0.24). On multiple linear regression analysis, lower body mass index, higher preoperative AHI, and higher preoperative oxygen nadir were associated with a larger AHI change. CONCLUSION Palatal coupling maneuvers during DISE are not predictive of AHI change with HGNS. Findings using these maneuvers should not preclude HGNS candidacy. LEVEL OF EVIDENCE 3 Laryngoscope, 133:431-436, 2023.
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Affiliation(s)
- Bryan Renslo
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kealan Hobelmann
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emily S Sagalow
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashwin Ananth
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Viana A, Estevão D, Zhao C. The clinical application progress and potential of drug-induced sleep endoscopy in obstructive sleep apnea. Ann Med 2022; 54:2909-2920. [PMID: 36269026 PMCID: PMC9590429 DOI: 10.1080/07853890.2022.2134586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: Obstructive sleep apnoea (OSA) is characterized by nocturnal repetitive upper airway (UA) collapse. For sleep physicians, the recognition of UA collapse characteristics is critical for understanding OSA mechanisms and developing individualized treatment plans. Drug-induced sleep endoscopy (DISE) is an exam during simulated sleep that allows the dynamic assessment of the UA of individuals with OSA. The initial recognition of DISE was to locate the sites of UA obstruction and direct the surgical selection of OSA since it was introduced in the 1990s. After approximately 30 years of studies, based on advances in endoscopic operative techniques and innovative treatments of OSA, DISE had been performed to explore mechanisms and comprehensive treatments related to UA collapse. Methods: This article reviewed contemporary DISE advances, including indications and contraindications, technique of induced sleep, endoscopic operation, UA characteristics classification.Results and Conclusions: Precise selection based on the association between collapse patterns and treatment modalities, such as continuous positive airway pressure, oral appliance, positional therapy, robotic surgery and neurostimulator implanting, is the future research prospect based on DISE.Key messagesDISE provides sleep physicians with valuable information about the upper airway collapse characteristics and dynamic changes during sleep.The studies based on DISE findings improve the selectivity and efficiency of treatment modalities, including classical therapies such as continuous positive airway pressure, oral appliance, positional therapy, and innovative therapies such as neurostimulator implanting and robotic surgery, promote the advancement of OSA precision medicine.
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Affiliation(s)
- Alonço Viana
- Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcilio Dias Naval Hospital, Rio de Janeiro, Brazil
| | - Débora Estevão
- Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Glória D'Or Hospital - Rede D'Or São Luiz, Rio de Janeiro, Brazil
| | - Chen Zhao
- Department of Otorhinolaryngology, the First Hospital of China Medical University, Shenyang, China
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Rodríguez Hermosa JL, Calle M, Guerassimova I, Fernández B, Montero VJ, Álvarez-Sala JL. Noninvasive electrical stimulation of oropharyngeal muscles in obstructive sleep apnea. Expert Rev Respir Med 2021; 15:1447-1460. [PMID: 34038311 DOI: 10.1080/17476348.2021.1935244] [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: 01/11/2023]
Abstract
Introduction: Continuous positive airway pressure (CPAP) therapy remains the standard treatment for obstructive sleep apnea. However, its proven effect is useless if the patient does not tolerate the treatment. The electrical stimulation approach has been investigated for several decades now and it seems that the implantable devices for invasive electrical stimulation of hypoglossal nerve are viewed as effective with some of them already approved for human use.Areas covered: in this review, we intent to summarize the existing records of noninvasive stimulation in sleep apnea to make the scientific community aware of the details before deciding on its future. We believe that this is a battle still to fight and more could be done bearing in mind the safety of this method.Expertopinion: noninvasive electrical stimulation has been left behind based on few, small and inconsistent studies using different stimulation parameters. These studies are difficult to compare and to draw conclusions.Electrical stimulation is a field for research in the treatment of obstructive sleep apnea, with many aspects still to be discovered, and which may become a therapeutic alternative to the use of CPAP in certain patients.
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Affiliation(s)
- Juan Luis Rodríguez Hermosa
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Myriam Calle
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Ina Guerassimova
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | | | - Víctor Javier Montero
- Torytrans SL, Innovative and technological-based company, Almagro, Ciudad Real, Spain
| | - José Luis Álvarez-Sala
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
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Wirth M, Bautz M, von Meyer F, Hofauer B, Strassen U, Heiser C. Obstruction level associated with outcome in hypoglossal nerve stimulation. Sleep Breath 2021; 26:419-427. [PMID: 34091793 PMCID: PMC8857010 DOI: 10.1007/s11325-021-02396-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 01/14/2023]
Abstract
Purpose Selective hypoglossal nerve stimulation (sHNS) constitutes an effective surgical alternative for patients with obstructive sleep apnea (OSA). sHNS results in tongue protrusion and consecutive alleviation of obstructions at the tongue base level (lower obstructions). Furthermore, obstructions at the soft palate level (upper obstructions) may be prevented through palatoglossal coupling as seen on sleep endoscopy. However, it has not been studied if the distribution of obstruction level during a whole night measurement is a relevant factor for the treatment outcome. Methods Obstruction levels were measured with a manometry system during a whole night of sleep in 26 patients with OSA (f = 1, m = 25; age 59.4 ± 11.3; BMI = 29.6 ± 3.6) either before (n = 9) or after sHNS implantation (n = 12). Five patients received a measurement before and after implantation. Obstructions were categorized into velar (soft palate and above), infravelar (below soft palate), and multilevel obstructions. An association between obstruction level and treatment outcome was calculated. Results The mean distribution of preoperative obstruction level could be divided into the following: 38% velar, 46% multilevel, and 16% infravelar obstructions. Patients with a good treatment response (defined as AHI < 15/h and AHI reduction of 50%) had fewer preoperative velar obstructions compared to non-responder (17% vs. 54%, p-value = 0.006). In patients measured after sHNS implantation, a significantly higher rate of multilevel obstructions per hour was measured in non-responders (p-value = 0.012). Conclusions Selective hypoglossal nerve stimulation was more effective in patients with fewer obstructions at the soft palate level. Manometry may be a complementary diagnostic procedure for the selection of patients for HNS.
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Affiliation(s)
- Markus Wirth
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Maximilian Bautz
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Franziska von Meyer
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Benedikt Hofauer
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Ulrich Strassen
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
| | - Clemens Heiser
- Department of Otolaryngology - Head and Neck Surgery, Technical University of Munich, Klinikum rechts der Isar, Hals-Nasen-Ohren-Klinik, Ismaninger Straße 22, 81675, Munich, Germany
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Bachour A, Bäck L, Pietarinen P. No changes in nocturnal respiration with hypoglossal neurostimulation therapy for obstructive sleep apnoea. THE CLINICAL RESPIRATORY JOURNAL 2021; 15:329-335. [PMID: 33184972 DOI: 10.1111/crj.13303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 10/13/2020] [Accepted: 11/08/2020] [Indexed: 06/11/2023]
Abstract
STUDY OBJECTIVES We initiated Hypoglossal Neurostimulation therapy (HGNS) at the Helsinki University Hospital in late 2014. Here, we report our experience. METHODS We included all 15 HGNS patients. All patients had previously failed both CPAP and oral appliance therapy for sleep apnoea. Overnight polysomnography parameters were analysed before and at 1.5 years with HGNS. RESULTS Mean ± SD patient age was 53 ± 6 years; 2 women and 13 men were included. Mean ± SD efficient CPAP level was 11.4 ± 3.4 cm H2 O. Implantation technically succeeded in all patients. There were no significant changes of AHI and ODI4 after HGNS [median (quartile) 29.2/h (19.8-38.7) versus 30.1/h (15.6-52.6) and 15.0/h (5.9-20) versus 12.5/h (6.9-30.2) respectively]. CONCLUSION We did not observe significant changes in AHI and ODI4 indices with HGNS therapy. Larger multicentre randomised controlled trials are necessary before wider international use of HGNS.
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Affiliation(s)
- Adel Bachour
- Sleep Unit, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Leif Bäck
- Head and Neck Center, ENT Department, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Petra Pietarinen
- Head and Neck Center, ENT Department, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Huyett P, Kent DT, D'Agostino MA, Green KK, Soose RJ, Kaffenberger TM, Woodson BT, Huntley C, Boon MS, Heiser C, Birk A, Suurna MV, Lin HS, Waxman JA, Kezirian EJ. Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study. Laryngoscope 2021; 131:1676-1682. [PMID: 33443811 DOI: 10.1002/lary.29396] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/03/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN Cohort study. METHODS A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1676-1682, 2021.
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Affiliation(s)
- Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Mark A D'Agostino
- Southern New England Ear, Nose and Throat Group, Middlesex Hospital, Middlesex, Connecticut, U.S.A.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Ryan J Soose
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Thomas M Kaffenberger
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Maurits S Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Amelie Birk
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, U.S.A
| | - Ho-Sheng Lin
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Jonathan A Waxman
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Eric J Kezirian
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, California, Los Angeles, U.S.A
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Huyett P, Stagnone R. Use of overnight pulse oximetry and a type 3 sleep study to titrate hypoglossal nerve stimulation therapy. J Clin Sleep Med 2021; 16:2109-2111. [PMID: 32804072 DOI: 10.5664/jcsm.8754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
NONE This is a case series of 3 patients with moderate-severe OSA who were PAP-intolerant and underwent implantation of the hypoglossal nerve stimulator. All patients recorded baseline overnight pulse oximetry without the hypoglossal nerve stimulator and at least 1 night at each hypoglossal nerve stimulator setting as they up-titrated the device at home. Because of the impact of the novel coronavirus on sleep laboratories, all patients proceeded directly to type 3 sleep studies performed at a single setting determined by a combination of self-reported improvement and pulse oximetry data.
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Affiliation(s)
- Phillip Huyett
- Division of Sleep Medicine and Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Richard Stagnone
- Division of Sleep Medicine and Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
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Dedhia RC, Huyett P. A prognostic star was born: drug-induced sleep endoscopy for hypoglossal nerve stimulation. J Clin Sleep Med 2020; 16:15-16. [PMID: 33054960 DOI: 10.5664/jcsm.8882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Raj C Dedhia
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Penn Sleep Center, Penn Medicine, Philadelphia, Pennsylvania
| | - Phillip Huyett
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
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