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Chieffe D, Baldassari CM, Friedman N, Smith D, Heubi C, Hartnick C. Pediatric Down Syndrome Upper Airway Stimulation: Patient Selection and Post-Implantation Optimization. Otolaryngol Head Neck Surg 2024; 170:1158-1166. [PMID: 38169046 DOI: 10.1002/ohn.633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/30/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE The Food and Drug Administration recently approved upper airway stimulation (UAS) for children with Down Syndrome and persistent obstructive sleep apnea who meet certain inclusion and exclusion criteria. Although there is a robust experience with this therapy in the adult population, established protocols used in adults are not directly transferrable to a complex pediatric population. This review aims to combine the protocols from several institutions for patient selection and postimplantation optimization, including a protocol for Drug-Induced Sleep Endoscopy in children with Down Syndrome, preactivation threshold measurements, device titration, and follow-up sleep studies. STUDY DESIGN Expert panel development of best Practice algorithm. SETTING Multi-institutional investigator review. METHODS An expert panel was assembled of pediatric otolaryngologists with extensive experience in hypoglossal nerve stimulation in children with Down Syndrome. Thirty statements were created during an initial drafting session. A modified Delphi method was used assess consensus among the panel. RESULTS After 2 rounds of Delphi surveys, 29 statements met criteria for consensus. One statement did not meet consensus. The statements were grouped into several categories to facilitate presentation. CONCLUSIONS A standardized approach to UAS for children with Down Syndrome must take into account the unique challenges inherent to treating a complex pediatric population with a high rate of sensory processing disorders. This expert panel has met consensus on several statements that will guide clinicians as this novel therapy is adopted.
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Affiliation(s)
- Doug Chieffe
- Massachusetts Eye and Ear Infirmary, Boston, USA
| | - Cristina M Baldassari
- Eastern Virginia Medical School/Children's Hospital of The King's Daughters, Norfolk, USA
| | - Norman Friedman
- Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, USA
| | - David Smith
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital, Cincinnati, USA
| | - Christine Heubi
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital, Cincinnati, USA
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Dhanda Patil R, Suurna MV, Steffen A, Soose R, Coxe J, Chan T, Ishman SL. Relationship of Nocturnal Insomnia Symptoms and Outcomes After Hypoglossal Nerve Stimulation. OTO Open 2024; 8:e134. [PMID: 38646184 PMCID: PMC11032643 DOI: 10.1002/oto2.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/24/2024] [Indexed: 04/23/2024] Open
Abstract
Objective In patients undergoing hypoglossal nerve stimulation (HGNS), we examined the Insomnia Severity Index (ISI) to understand how baseline sleep onset insomnia (SOI), sleep maintenance insomnia (SMI), and early morning awakening (EMA) affected postsurgical outcomes. Study Design Observational. Setting Multicenter registry. Methods We included patients from the Adherence and Outcomes of Upper Airway Stimulation for Obstructive Sleep Apnea International Registry (ADHERE) with a baseline ISI from 2020 to 2023. Regression analysis examined the association of ISI question scores for SOI, SMI, and EMA and outcomes: Apnea-Hypopnea Index (AHI) reduction, device usage, changes in the Epworth Sleepiness Scale (ESS) and overall ISI score, final visit (FV) completion, and satisfaction. Results No relationship was noted between insomnia subtypes and AHI reduction or FV completion. In the subgroup of patients with baseline moderate/severe insomnia, patients with major impairment for SOI used their device 64 min/day longer than those with minimal impairment. Among all patients, those with baseline major impairment for SOI had a 2.3 points greater improvement in ISI from baseline to FV compared to patients with minimal impairment, while patients with baseline major impairment for SMI had a 2.0 and 3.5 points greater improvement in the ESS and ISI than those with minimal impairment. Patients with EMA and moderate/severe baseline insomnia had decreased odds of being satisfied after surgery. Conclusion In ADHERE, nocturnal symptoms of insomnia did not limit HGNS efficacy or therapy use. Conversely, those with worse insomnia subtype impairments at baseline had improved outcomes related to adherence, sleepiness, and insomnia at the FV.
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Affiliation(s)
- Reena Dhanda Patil
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CincinnatiCincinnatiOhioUSA
- Surgical ServicesCincinnati Veterans Affairs Medical CenterCincinnatiOhioUSA
| | - Maria V. Suurna
- Department of Otolaryngology–Head and Neck SurgeryUniversity of MiamiMiamiFloridaUSA
| | - Armin Steffen
- Department of OtorhinolaryngologyUniversity of LubeckLubeckGermany
| | - Ryan Soose
- Department of OtolaryngologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - James Coxe
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CincinnatiCincinnatiOhioUSA
| | - Teresa Chan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas‐Southwestern Medical CenterDallasTexasUSA
| | - Stacey L. Ishman
- Division of Otolaryngology–Head and Neck SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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Banerjee D, Lee CH, Im K. Case report of hypoglossal nerve stimulation therapy failure due to significant underlying central sleep apnea. J Clin Sleep Med 2024. [PMID: 38450516 DOI: 10.5664/jcsm.11094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Hypoglossal nerve stimulation (HNS) is indicated for obstructive sleep apnea (OSA) but is ineffective in treating central sleep apnea (CSA). We describe two patients implanted with HNS after being diagnosed with OSA at outside sleep labs and failing a trial of continuous positive airway pressure (CPAP) therapy. Despite successful HNS implantation, the patients continued to have persistent symptoms with residual apnea-hypopnea indices above 25 events/h. Although OSA was the presenting diagnosis, we discovered a significant CSA component in the original diagnostic sleep data upon careful review. One patient was confirmed to have a CSA-predominant sleep disorder and improved with adaptive servo ventilation therapy. The other was diagnosed with central sleep apnea and severe periodic limb movement disorder, and improved with medication. Based on these sleep apnea cases, we propose guidelines emphasizing the importance of reviewing basic clinical information upon treatment failure and initiating multi-disciplinary collaboration early in the treatment course.
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Affiliation(s)
- Dhruba Banerjee
- University of California Irvine, School of Medicine, Sleep Disorders Center
| | - Chang-Hoon Lee
- University of California Irvine, School of Medicine, Sleep Disorders Center
- Seoul National University, College of Medicine, Seoul, Korea
| | - Kyoungbin Im
- University of California Irvine, School of Medicine, Sleep Disorders Center
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Fischer R, Vielsmeier V, Kuehnel TS, Bohr C, Hintschich CA, Spoerl S, Rohrmeier C. Effect of hypoglossal nerve stimulation on snoring: an evaluation using objective acoustic parameters. J Clin Sleep Med 2024; 20:363-370. [PMID: 38426848 PMCID: PMC11019209 DOI: 10.5664/jcsm.10868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 03/02/2024]
Abstract
STUDY OBJECTIVES Hypoglossal nerve stimulation is an established therapy for sleep apnea syndrome. Whether or not this therapy on snoring and nighttime noise exposure is effective and how strong this effect may be has not been objectively investigated thus far and was the aim of this study. METHODS In 15 participants (14 males; age: 30-72 years; mean: 51.7 years), polysomnography and acoustic measurements were performed before and after hypoglossal nerve stimulation. RESULTS The therapy led to a significant improvement in sleep apnea (apnea-hypopnea index from 35.8 events/h to 11.2 events/h, P < .001). Acoustic parameters showed a highly significant reduction in the average sound pressure level (42.9 db[A] to 36.4 db[A], P < .001), averaged sound energy, A-weighted (LAeq; 33.1 db[A] to 28.7 db[A], P < .001), snoring index (1,068 to 506, P < .001), percentage snoring time (29.7-14.1%, P < .001), and psychoacoustic snore score, the latter being a measure of annoyance due to snoring (47.9 to 24.5, P < .001). CONCLUSIONS This study was able to show for the first time by means of objective acoustic and psychoacoustic parameters that hypoglossal nerve stimulation can not only cause a significant improvement in sleep apnea but also has a positive effect on snoring and thus noise annoyance experienced by the bed partner. CLINICAL TRIAL REGISTRATION Registry: German Clinical Trials Register; Name: Effect of Hypoglossal Nerve Stimulation on Snoring: An Evaluation Using Objective Acoustic Parameters; URL: https://drks.de/search/de/trial/DRKS00032354; Identifier: DRKS00032354. CITATION Fischer R, Vielsmeier V, Kuehnel TS, et al. Effect of hypoglossal nerve stimulation on snoring: an evaluation using objective acoustic parameters. J Clin Sleep Med. 2024;20(3):363-370.
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Affiliation(s)
- René Fischer
- Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany
| | - Veronika Vielsmeier
- Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany
| | - Thomas S. Kuehnel
- Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany
| | | | - Steffen Spoerl
- Department of Oral and Maxillofacial Surgery, University of Regensburg, Regensburg, Germany
| | - Christian Rohrmeier
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
- ENT Medicinal Office, Straubing, Germany
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Ali NS, Fitzpatrick Iv TH, Islam AS, Nord RS. Mitigating Infection Risk in Upper Airway Stimulation. Ann Otol Rhinol Laryngol 2024; 133:277-283. [PMID: 37927122 DOI: 10.1177/00034894231209540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
OBJECTIVE This study aims to define the incidence of infection with upper airway stimulation (UAS) devices requiring explantation in a single academic center and identify factors that may influence the risk of infection. METHODS A database of patients who underwent UAS at a single tertiary referral academic center from 2017 to 2021 was retrospectively reviewed to identify patients who developed surgical site infections, with and without subsequent explantation. Additional data for cases complicated by infection was extracted from the electronic medical record (EMR) and included: demographic information, medical history, complications and management, and overall outcomes. In March 2021, 2 modifications to infection control protocols were implemented: double skin preparation with Betadine and chlorhexidine, and MRSA decolonization. Statistical analysis was performed to compare infectious risk before and after these protocol changes. RESULTS In the study period, 215 patients underwent UAS in the specified time period and 3 cases (1.4%) of postoperative infections were identified, all of which required explantation. The infection rate did not significantly change after modifications to the surgical prep protocol (P = .52). CONCLUSIONS While no significant difference in infection risk was noted after modifying infection control protocols, additional longer-term study is warranted to elucidate effective infection reduction strategies.
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Affiliation(s)
- Naushin S Ali
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Thomas H Fitzpatrick Iv
- Department of Otolaryngology - Head and Neck Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Albina S Islam
- Department of Otolaryngology - Head and Neck Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Ryan S Nord
- Department of Otolaryngology - Head and Neck Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Chang M, Moore V, Eng K, Ryden A, Zeidler M. Hypoglossal nerve stimulation over-titration. J Clin Sleep Med 2024. [PMID: 38415706 DOI: 10.5664/jcsm.11066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
This case report reviews worsening obstructive sleep apnea (OSA) events in a patient over-titrated with a hypoglossal nerve stimulator (HNS). A healthy 57-year-old man underwent HNS implantation for moderate OSA. During an in- laboratory HNS titration the patient had improvement of his OSA at 2.1V. However further increase of voltage resulted in worsening of obstructive events. The pathophysiology behind this finding is unknown but may result from unfavorable changes in the upper anatomy due to higher energy delivered to the hypoglossal nerve and surrounding structures. This high energy may also lead to genioglossus muscle fatigue. This finding highlights the importance of hypoglossal nerve stimulation titration with a dedicated sleep study.
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Affiliation(s)
- Melisa Chang
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
| | - Virginia Moore
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
| | - Kevin Eng
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
| | - Armand Ryden
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
| | - Michelle Zeidler
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
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Kedarisetty S, Sharma A, Commesso EA, Woodson BT, Huyett P, Kent DT, D’Agostino MA, Green KK, Kezirian EJ. Palate shape is associated with Unilateral Hypoglossal Nerve Stimulation Outcomes. Laryngoscope 2024; 134:981-986. [PMID: 37672634 PMCID: PMC10840867 DOI: 10.1002/lary.31018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 07/06/2023] [Accepted: 07/26/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE The aim was to determine the potential association between palate shape and unilateral hypoglossal nerve stimulation (HNS) outcomes. METHODS Preoperative drug-induced sleep endoscopy (DISE) videos were reviewed and scored by 3 blinded reviewers to determine airway narrowing at the hard-soft palate junction (HP), soft palate genu, and inferior velum, as described by Woodson (2014). Scoring was as follows: 1-open airway, 2-narrow, 3-severe narrowing. Overall palate shape (oblique, intermediate, or vertical) was determined based on prior criteria. Successful surgical treatment was defined by the HNS titration polysomnogram as a reduction of ≥50% in the apnea-hypopnea index (AHI) to <15 events/h. RESULTS Of 332 adults, the majority was male (77%) with an average BMI of 29.2 ± 3.6 kg/m2 . Overall success rate was 73%. Success rate was lower in patients with vertical palate shape compared with the other shapes (56% vs. 75%, p = 0.029). HP score 3 compared with scores 2 and 1 was associated with lower success rates (60% vs. 76%, p = 0.028), but genu and velum scores were not associated with outcomes. Patients with both HP score 3 and complete oropharyngeal lateral wall-related obstruction had notably worse outcomes (22% vs. 74%, p = 0.026). HP score 3 (OR 0.45, 95%CI 0.22-0.92) and vertical palate shape (OR 0.33, 95%CI 0.15-0.78) were independently associated with lower odds of surgical response after adjustment for DISE findings, age, gender, and BMI. CONCLUSION Vertical palate shape and narrowing at the hard-soft palate junction are independently associated with lower HNS surgical success rates. LEVEL OF EVIDENCE 3 Laryngoscope, 134:981-986, 2024.
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Affiliation(s)
- Suraj Kedarisetty
- Department of Head and Neck Surgery, Kaiser Permanente, Vallejo, California
| | - Abhay Sharma
- Department of Otolaryngology Head and neck Surgery, University of South Florida, Tampa, Florida
| | - Emily A Commesso
- Department of Head and Neck Surgery & Communication Sciences, Duke University, School of Medicine, Durham, North Carolina
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A D’Agostino
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric J Kezirian
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California
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Dzierzewski JM, Soto P, Vahidi N, Nord R. Clinical Characteristics of Older Adults Seeking Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea. Ear Nose Throat J 2024; 103:NP118-NP123. [PMID: 34464165 PMCID: PMC9195674 DOI: 10.1177/01455613211042126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is a common sleep disorder with numerous clinical correlates. Although effective treatments abound, patient acceptance and adherence is low. Hypoglossal nerve stimulation (HNS) is a surgical treatment alternative for the treatment of OSA; however, the demographic and clinical characteristics of individuals seeking HNS are not well categorized. This study sought to determine the clinical characteristics of older adults seeking HNS for the treatment of OSA. METHODS Self-report questionnaires were administered to all patients older than 50 years seeking a HNS consultation at a large university medical center. Questionnaires included validated National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH PROMIS) measures of physical functioning, sleep-related impairment, cognitive abilities, depression, anxiety, and anger along with the Information extracted from electronic medical records included age, sex, race, and apnea-hypopnea index (AHI). RESULTS Patients included 113 adults (mean age 63.30 years, 57% male, 79% white) with severe OSA (AHI = 33.91, standard deviation = 20.63). Overall, 88% of patients reported elevated insomnia symptoms, 30% reported mild difficulty with physical functioning, and 36% indicated that they had experienced moderate-severe daytime impairments attributed to poor sleep. Additionally, we found 28% of sampled individuals reported moderate-severe depressive symptomology, over 19% reported moderate-severe anxiety, and over 17% reported moderate to severe anger issues. Approximately, 38% of the sample reported moderate to severe cognitive difficulties. CONCLUSIONS The aim of the study was to better understand the clinical characteristics of older patients with OSA seeking HNS treatment. Utilizing NIH PROMIS questionnaires, we identified unique clinical and psychosocial correlates in this sample, which included higher rates of insomnia symptoms, physical dysfunction, cognitive deficits, and depressive symptoms than the general population. Future studies will be needed to investigate these relationships more thoroughly and throughout the course of the treatment.
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Affiliation(s)
| | - Pablo Soto
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Nima Vahidi
- Department of Otolaryngology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Ryan Nord
- Department of Otolaryngology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Zheng YJ, Cai Y, Ifeagwu KC, Chang JL. Snoring Patterns During Hypoglossal Nerve Stimulation Therapy Up-Titration. Laryngoscope 2024; 134:987-992. [PMID: 37334840 DOI: 10.1002/lary.30815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023]
Abstract
Longitudinal snoring changes can be captured using a mobile phone application. During hypoglossal nerve stimulator (HNS) therapy up-titration, increasing stimulation voltage was associated with reduced snoring frequency and intensity in this case series of six patients. Laryngoscope, 134:987-992, 2024.
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Affiliation(s)
- Yixuan James Zheng
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Yi Cai
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Kene-Chukwu Ifeagwu
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
- Surgical Services, San Francisco Veterans Affairs Health Care System, San Francisco, California, U.S.A
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Dhanda Patil R, Ishman SL, Chang JL, Thaler E, Suurna MV. Impact of Insomnia on Hypoglossal Nerve Stimulation Outcomes in the ADHERE Registry. Laryngoscope 2024; 134:471-479. [PMID: 37560883 DOI: 10.1002/lary.30933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/19/2023] [Accepted: 07/23/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE We aimed to determine the preoperative prevalence of insomnia in the Adherence and Outcomes of Upper Airway Stimulation for OSA International Registry (ADHERE) and to examine serial sleep-related data longitudinally, in particular the Insomnia Severity Index (ISI), to compare outcomes between patients with no/subthreshold insomnia (ISI < 15) and moderate/severe insomnia (ISI ≥ 15) at baseline. METHODS We analyzed observational data from ADHERE between March 2020 and September 2022. Baseline demographic and mental health (MH) data, apnea hypopnea index (AHI), ISI, and ESS (Epworth Sleepiness Scale) were recorded. At post-titration (PT) and final visits, AHI, ISI, ESS and nightly usage were compared between baseline ISI < 15 and ISI ≥ 15 subgroups. RESULTS A baseline ISI was obtained in 928 patients (62% with ISI ≥ 15). Of the 578 and 141 patients reaching the 12- and 24-month time periods to complete PT and final visits, 292 (50.5%) and 91 (64.5%) completed the ISI, respectively. Baseline MH conditions were higher with ISI ≥ 15 than ISI < 15 (p < 0.001). AHI reduction and adherence did not differ between patients with baseline ISI ≥ 15 and ISI < 15. Patients with ISI ≥ 15 experienced greater improvement in ESS than ISI < 15 at post-titration and final visits (p = 0.014, 0.025). All patients had improved nocturnal, daytime, and overall ISI scores at follow-up visits (p < 0.001), especially for those with baseline ISI ≥ 15 compared with ISI < 15 (p < 0.05). CONCLUSION HGNS therapy efficacy and adherence were similar between ISI severity subgroups at follow-up visits. Insomnia and sleepiness scores improved in all patients with HGNS therapy and to a greater degree in patients with baseline moderate/severe insomnia. LEVEL OF EVIDENCE 4 Laryngoscope, 134:471-479, 2024.
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Affiliation(s)
- Reena Dhanda Patil
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Surgical Services, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Stacey L Ishman
- Department of Community and Population Health, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jolie L Chang
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
- Surgical Services, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA
| | - Erica Thaler
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Dirks CAH, Bachmann CG. Case report: An OSAS patient with comorbid RLS/PLMS - a closer look at the causes of PAP intolerance. Front Neurol 2023; 14:1257736. [PMID: 37885481 PMCID: PMC10598657 DOI: 10.3389/fneur.2023.1257736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/11/2023] [Indexed: 10/28/2023] Open
Abstract
Since 2017, hypoglossal nerve stimulation has been included in the S3-guidelines on restorative sleep/sleep disorders as an alternative treatment for patients with obstructive sleep related breathing disorders who cannot tolerate conventional PAP-therapy. Under certain conditions, some of these patients have the option to have a tongue pacemaker implanted during a surgical procedure to regain a restful night's sleep. However, in some cases it does not solve the problem. In this case report, we present a patient who continued to have restless sleep despite implantation of a hypoglossus nerve stimulator. We provide a closer look at the underlying causes of PAP intolerance and emphasize the importance of a combined pneumological and neurological approach to sleep medicine in sleep-specific therapy evaluation.
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13
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Grond SE, Urban MJ, Hutz MJ, LoSavio P. Successful Reimplantation of Extruded Lead after Hypoglossal Nerve Stimulation Surgery. Laryngoscope 2023; 133:2821-2822. [PMID: 37036098 DOI: 10.1002/lary.30681] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 04/11/2023]
Abstract
Infection and extrusion of hardware are known complications of hypoglossal nerve stimulation surgery. We present a unique case of an extruded hardware lead successfully managed with reimplantation without need for explantation and new device placement. The topic will be discussed in context of the body of literature related to extruded medical device management. Laryngoscope, 133:2821-2822, 2023.
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Affiliation(s)
- Sarah E Grond
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, 60612, USA
| | - Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, 60612, USA
| | - Michael J Hutz
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, 60612, USA
- Section of Sleep Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, 60612, USA
| | - Phillip LoSavio
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, 60612, USA
- Section of Sleep Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, 60612, USA
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14
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Magaña LC, Strollo PJ, Steffen A, Ravesloot M, van Maanen P, Harrison C, Maurer JT, Soose RJ. Long-Term Generator Replacement Experience in Hypoglossal Nerve Stimulator Therapy Recipients With CPAP-Intolerant Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2023; 169:1064-1069. [PMID: 37003598 DOI: 10.1002/ohn.340] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/10/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE In the last decade, hypoglossal nerve stimulation (HNS) has emerged as a therapeutic alternative for patients with obstructive sleep apnea. The original clinical trial cohorts are entering the phase of expected battery depletion (8-12 years). This study aimed to examine the surgical experience with implantable pulse generator (IPG) replacements and the associated long-term therapy outcomes. STUDY DESIGN Retrospective analysis of patients from the original clinical trial databases (STAR, German post-market) who were followed in the ongoing ADHERE registry. SETTING International multicenter HNS registry. METHODS The ADHERE registry and clinical trial databases were cross-referenced to identify the serial numbers of IPGs that were replaced. Data collection included demographics, apnea-hypopnea index (AHI), therapy use, operative times, and adverse events. RESULTS Fourteen patients underwent IPG replacement 8.3 ± 1.1 years after their initial implantation. Body mass index was unchanged between the original implant and IPG replacement (29 ± 4 vs 28 ± 2 kg/m2 , p = .50). The mean IPG replacement operative time was shorter than the original implant (63 ± 50 vs 154 ± 58 minutes, p < .002); however, 2 patients required stimulation lead replacement which significantly increased operative time. For patients with available AHI and adherence data, the mean change in AHI from baseline to latest follow-up (8.7 ± 1.1 years after de novo implant) was -50.06%, and the mean therapy use was 7.2 hours/night. CONCLUSION IPG replacement surgery was associated with low complications and shorter operative time. For patients with available outcomes data, adherence and efficacy remained stable after 9 years of follow-up.
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Affiliation(s)
- Linda C Magaña
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick J Strollo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine and Veterans Administration Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
| | - Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Madeline Ravesloot
- Department of Otorhinolaryngology-Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
| | - Peter van Maanen
- Department of Otorhinolaryngology-Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
| | - Christine Harrison
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joachim T Maurer
- Department of Otorhinolaryngology, Head and Neck Surgery, Division of Sleep Medicine, University Hospital Mannheim, Mannheim, Germany
| | - Ryan J Soose
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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15
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Scheffler P, Eitan D, Drewek R, Gnagi S. Hypoglossal Nerve Stimulation as Treatment for Obstructive Apnea in a Patient with a Pharyngeal Flap. Laryngoscope 2023; 133:2428-2429. [PMID: 36912369 DOI: 10.1002/lary.30637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/19/2023] [Indexed: 03/14/2023]
Abstract
Hypoglossal nerve stimulation can be a successful form of treatment for obstructive sleep apnea in patients with a pharyngeal flap. Although the Inspire device is geared at relieving obstructive sleep apnea due to tongue base obstruction, it can still be highly efficacious in improving AHI and OSA symptoms in the presence of nasopharyngeal narrowing from the pharyngeal flap. Laryngoscope, 133:2428–2429, 2023
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Affiliation(s)
- Patrick Scheffler
- Division of Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Creighton University School of Medicine, Phoenix, Arizona, USA
- University of Arizona - Phoenix College of Medicine, Phoenix, Arizona, USA
| | - Dana Eitan
- Creighton University School of Medicine, Phoenix, Arizona, USA
| | - Rupali Drewek
- Division of Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona, USA
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16
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Morse E, Dodhia S, Suurna M. Upper Airway Stimulation in Female Patients: Safety and Efficacy of a Novel Lateral Approach. Otolaryngol Head Neck Surg 2023; 169:406-411. [PMID: 36939570 DOI: 10.1002/ohn.225] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 11/05/2022] [Accepted: 11/18/2022] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To describe a novel lateral approach for hypoglossal nerve stimulator (HNS) implantation in women and provide evidence for its safety and efficacy. STUDY DESIGN Retrospective case series. SETTING Single academic medical center. METHODS We identified patients implanted with HNS by a single surgeon from January 2017 to December 2021. Patient characteristics, postoperative complications, surgical duration, response to therapy, and need for revision surgery were recorded. RESULTS One hundred four patients were included, including 93 males and 11 females. The lateral approach for HNS implantation involves placing the chest incision for the implantable pulse generator and respiratory sensor lead vertically in the anterior axillary line instead of horizontally in the infraclavicular area. No changes are made to the stimulator lead placement. All female patients were implanted using a lateral approach and all male patients were implanted via the standard anterior approach. Half of the patients were implanted via a 2-incision technique. The median surgical time duration was equivalent in male and female patients (119 [interquartile range (IQR): 105-138] vs 126 [IQR: 115-141], respectively). Revision was required in 2 (18%) females versus 6 (6%) males (p = .17). There were equivalent rates of therapy response as well as postoperative complications. CONCLUSION A more cosmetic lateral approach is feasible for HNS in female patients and has a similar rate of adverse events and therapy responsiveness. Additional considerations in female patients include the ability to tolerate mammography as well as HNS implantation in the setting of existing breast implants.
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Affiliation(s)
- Elliot Morse
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Sonam Dodhia
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Maria Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, USA
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17
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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: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Benedict PA, Kravietz A, Yang J, Achlatis E, Doyle C, Johnson AM, Dion GR, Amin MR. Longitudinal Effects of Base of Tongue Concurrent Chemoradiation Therapy in a Pre-Clinical Model. Laryngoscope 2023; 133:1455-1461. [PMID: 36134872 PMCID: PMC10030382 DOI: 10.1002/lary.30393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES Base of tongue (BOT) dysfunction is common following oropharyngeal concurrent chemoradiation therapy (CCRT). We present a clinically relevant animal model quantifying the effects of CCRT on tongue strength and elasticity over time. METHODS Fifty-three male and 53 female Sprague-Dawley rats were randomized to control or experimental groups. Experimental animals received cisplatin, 5-fluorouracil, and 5 fractions of 7 Gy directed to the BOT. Controls received no intervention. At 2 weeks, 5 months, or 10 months after CCRT, animals underwent non-survival surgery to measure twitch and tetanic tongue strength, which were analyzed using multivariate linear mixed effects models. Tongue displacement, a surrogate for tongue elasticity, was also determined via stress-strain testing and analyzed via a multivariate linear mixed effects model. RESULTS Reporting the combined results of both sexes, the estimated experimental group mean peak twitch forces became more divergent over time compared to controls, being 8.3% lower than controls at 2 weeks post-CCRT, 15.7% lower at 5 months, and 31.6% lower at 10 months. Estimated experimental group mean peak tetanic forces followed a similar course and were 2.9% lower than controls at 2 weeks post CCRT, 20.7% lower at 5 months, and 27.0% lower at 10 months. Stress-strain testing did not find CCRT to have a significant effect on tongue displacement across experimental timepoints. CONCLUSIONS This study demonstrates an increasing difference in tongue strength over time between controls and animals exposed to CCRT. Tongue elasticity was not significantly affected by CCRT, suggesting that changes in strength may not be caused by fibrosis. LEVEL OF EVIDENCE NA Laryngoscope, 133:1455-1461, 2023.
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Affiliation(s)
- Peter A. Benedict
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Adam Kravietz
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jackie Yang
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Efstratios Achlatis
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Carina Doyle
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Aaron M. Johnson
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Gregory R. Dion
- Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
- Dental and Craniofacial Trauma Research Department, U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Milan R. Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, NY, USA
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19
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Fleury Curado T, Pham L, Otvos T, Klopfer T, Freire C, Amorim MR, Nishimura Y, Sennes LU, Psoter KJ, Abdelwahab M, Huang A, Dedhia R, Liu S, Capasso R, Oliven A, Polotsky V, Eisele D, Schwartz A. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med 2023; 19:947-955. [PMID: 36727502 PMCID: PMC10152343 DOI: 10.5664/jcsm.10474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES The major goal of the study was to determine whether changes in tongue morphology under selective hypoglossal nerve therapy for obstructive sleep apnea were associated with alterations in airway patency during sleep when specific portions of the hypoglossal nerve were stimulated. METHODS This case series was conducted at the Johns Hopkins Sleep Disorders Center at Johns Hopkins Bayview Medical Center. Twelve patients with apnea implanted with a multichannel targeted hypoglossal nerve-stimulating system underwent midsagittal ultrasound tongue imaging during wakefulness. Changes in tongue shape were characterized by measuring the vertical height and polar dimensions between tongue surface and genioglossi origin in the mandible. Changes in patency were characterized by comparing airflow responses between stimulated and adjacent unstimulated breaths during non-rapid eye movement sleep. RESULTS Two distinct morphologic responses were observed. Anterior tongue base and hyoid-bone movement (5.4 [0.4] to 4.1 [1.0] cm (median and [interquartile range]) with concomitant increases in tongue height (5.0 [0.9] to 5.6 [0.7] cm) were associated with decreases in airflow during stimulation. In contrast, comparable anterior hyoid movement (tongue protrusion from 5.8 [0.5] to 4.5 [0.9] cm) without significant increases in height (5.2 [1.6] to 4.6 [0.8] cm) were associated with marked increases in airflow during sleep. CONCLUSIONS Tongue protrusion with preservation of tongue shape predicted increases in patency, whereas anterior movement with concomitant increases in height were associated with decreased pharyngeal patency. These findings suggest that pharyngeal patency can be best stabilized by stimulating lingual muscles that maintain tongue shape while protruding the tongue, thereby preventing it from prolapsing posteriorly during sleep. CITATION Fleury Curado T, Pham L, Otvos T, et al. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med. 2023;19(5):947-955.
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Affiliation(s)
- Thomaz Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luu Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamas Otvos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy Klopfer
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Freire
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Mateus R. Amorim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yoichi Nishimura
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luiz Ubirajara Sennes
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kevin J. Psoter
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamed Abdelwahab
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Allen Huang
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Raj Dedhia
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- B’nai Zion Hospital, Technion School of Medicine, Haifa, Israel
| | - Stanley Liu
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Robson Capasso
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Arie Oliven
- Department of Otorhinolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vsevolod Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David Eisele
- Department of Otorhinolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alan Schwartz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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20
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Estephan LE, Sussman S, Stewart M, Zhan T, Thaler A, Boon M, Hunt P, Huntley C. Total Intravenous Anesthesia Versus Inhaled Sevoflurane in Obstructive Sleep Apnea Surgery: A Randomized Controlled Trial. Laryngoscope 2023; 133:984-992. [PMID: 36239660 DOI: 10.1002/lary.30438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Specific guidelines regarding an optimal general anesthesia (GA) approach to obstructive sleep apnea (OSA) patients remain undefined. Literature comparing the efficacy of total intravenous anesthesia (TIVA) and inhalational anesthesia in this population is sparse. We hypothesize that OSA patients receiving TIVA will experience reduced recovery times and other improved post-surgical outcomes. STUDY DESIGN Randomized controlled trial. METHODS Adult OSA patients undergoing upper airway surgery (hypoglossal nerve stimulation [HNS], nasal, or palate surgery) from February 2020-December 2020 were included. A post-anesthesia care unit (PACU) nursing survey documented patients' alertness, pain, oxygen supplementation, and postoperative nausea and vomiting from PACU arrival to 2 hours. Perioperative timepoints from the electronic medical record (EMR) and a nurse-estimated Phase I recovery time were collected. RESULTS One hundred eleven patients were included (46 TIVA and 65 inhalational anesthesia). Per EMR-recorded timepoints, TIVA patients undergoing HNS and palate surgery experienced Phase I Time reductions of 12.5 min (p = 0.042) and 27.5 min (p = 0.016), respectively. Per the PACU survey, TIVA patients undergoing any surgery, HNS, or palate surgery experienced nurse-estimated Phase I Time reductions of 16.5 min (p = 0.004), 12.5 min (p = 0.031), and 38.5 min (p = 0.024), respectively. Overall, TIVA patients experienced higher alertness and pain ratings, and lower oxygen supplementation requirements from PACU arrival to 30 min (p < 0.05). CONCLUSION Patients with OSA receiving TIVA for GA maintenance during upper airway procedures experienced reduced recovery times and oxygen supplementation requirements, and a more rapid return to alertness. Future work toward developing optimized anesthetic guidelines for OSA patients is merited. LEVEL OF EVIDENCE 3 Laryngoscope, 133:984-992, 2023.
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Affiliation(s)
- Leonard E Estephan
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Sarah Sussman
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam Thaler
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Patrick Hunt
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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21
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Lorenz FJ, Goyal N. Iatrogenic Pneumothorax During Hypoglossal Nerve Stimulator Implantation: A Large Database Analysis. Otolaryngol Head Neck Surg 2023; 168:876-880. [PMID: 36066978 PMCID: PMC10474953 DOI: 10.1177/01945998221122696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE There have been case reports of adverse events of hypoglossal nerve stimulator (HNS) implantation not seen in previous clinical trials, including pneumothorax and pleural effusion. The purpose of this study was to determine the rates of these complications and potential risk factors. STUDY DESIGN Retrospective case-control study during 2014 to 2021. SETTING Twenty-five health care organizations across the United States. METHODS The TriNetX Research Network was queried by using disease codes to retrospectively identify patients with obstructive sleep apnea who underwent HNS implantation. Rates of pneumothorax, pleural effusion, other complications, and need for revision/replacement or explant were determined. RESULTS We identified 1813 patients from 25 health care organizations who underwent HNS implantation. The average age was 60 years, and there were 68% males and 32% females. Of the cohort, 2.4% (n = 44 from 7 implant centers) experienced a pneumothorax, and 0.6% (n = 11) were diagnosed with a pleural effusion on the day of surgery. Patients who experienced pneumothorax were more likely to have a history of chronic lower respiratory diseases when compared with those who did not (odds ratio, 2.2; 95% CI, 1.1-4.1; P = .02). CONCLUSION The incidence of intraoperative pneumothorax and pleural effusion during HNS implantation may be greater than initially thought. Patients with chronic lower respiratory diseases may be at increased risk. This should be communicated with patients during the informed consent process.
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Affiliation(s)
- F. Jeffrey Lorenz
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Neerav Goyal
- Department of Otolaryngology–Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
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22
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Miller SM, Miller MB. Treatment of obstructive sleep apnea with hypoglossal nerve stimulation in a patient with Ehlers-Danlos syndrome. J Clin Sleep Med 2023; 19:631-632. [PMID: 36458732 PMCID: PMC9978430 DOI: 10.5664/jcsm.10368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 12/04/2022]
Abstract
Ehlers-Danlos syndrome is a group of hereditary connective tissue disorders caused by defects in collagen synthesis and structure that manifests as tissue fragility, hypermobility, and vascular abnormalities. Patients with Ehlers-Danlos syndrome are at a high risk of developing obstructive sleep apnea due to increased tissue laxity in the upper airway, in addition to nasal-maxillary cartilaginous defects, scoliosis, or other abnormalities. Here we present the case of a patient with Ehlers-Danlos syndrome who underwent successful treatment of obstructive sleep apnea using hypoglossal nerve stimulation after continuous positive airway pressure therapy failure, demonstrating that this can be a useful treatment modality in this population. CITATION Miller SM, Miller MB. Treatment of obstructive sleep apnea with hypoglossal nerve stimulation in a patient with Ehlers-Danlos syndrome. J Clin Sleep Med. 2023;19(3):631-632.
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Affiliation(s)
- Stefanie M. Miller
- Department of Otolaryngology, University of South Florida, Tampa, Florida
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23
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Steffen A, Moritz FJ, König IR, Suurna MV, Brüggemann N. Electric field aspects in hypoglossal nerve stimulation for obstructive sleep apnea: A bilateral electrophysiological evaluation of unilateral electrode configuration changes. J Sleep Res 2023; 32:e13592. [PMID: 35596592 DOI: 10.1111/jsr.13592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/13/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023]
Abstract
Hypoglossal nerve stimulation is an established treatment option for obstructive sleep apnea in selected patients. A unilateral hypoglossal nerve stimulation system was approved a decade ago, yet the physiological effect of unilateral hypoglossal stimulation on bilateral tongue motion remains unclear. This study examined how electrode configuration, stimulation cuff position, or body mass index influenced the contralateral genioglossus electromyography (EMG) signal. Twenty-nine patients underwent three EMG recordings in a polysomnographic setting after being implanted with a unilateral hypoglossal nerve stimulator for at least 6 months. The ratio of EMG signals between the ipsi- and contralateral sides was evaluated. No difference in EMG signals was demonstrated based on electrode configurations, stimulation-cuff position, body-mass-index, or sleep apnea severity, even in patients with right tongue protrusion only. Our findings may be explained by a significant level of cross-innervation and by a smaller and less variable circumferential electric field than expected based on prior biophysical models. A patient's individual anatomy needs to be considered during therapy titration in order to achieve an optimal response.
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Affiliation(s)
- Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | | | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, USA
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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25
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Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med 2023; 19:403-408. [PMID: 36117433 PMCID: PMC9892739 DOI: 10.5664/jcsm.10296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
Treatment of moderate to severe obstructive sleep apnea poses clinical challenges in persons with intolerance or inadequate response to traditional treatment modalities, including positive airway pressure and mandibular advancement devices. Hypoglossal nerve stimulation is a new treatment option, but few management guidelines exist when it is intolerable or ineffective. Combining several treatment modalities has been an effective strategy for improving symptoms, tolerance, and efficacy. We describe a patient intolerant to positive airway pressure therapy who had continued sleepiness, morning headaches, and snoring with a mandibular advancement device. He underwent hypoglossal nerve stimulation implantation but was intolerant of the voltages required to adequately control his obstructive sleep apnea. Multimodal management with hypoglossal nerve stimulation, mandibular advancement device, and positional therapy was successfully implemented to improve sleepiness, nocturnal symptoms, and the apnea-hypopnea index. This case highlights the personalization and adaptability of combination therapy to suit patient needs while effectively controlling obstructive sleep apnea. CITATION Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med. 2023;19(2):403-408.
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Affiliation(s)
- Megan M. Lowery
- Pulmonary, Critical Care and Sleep, University of Florida, Gainesville, Florida
| | - Jessica Vensel Rundo
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Harneet K. Walia
- Sleep Medicine, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Vaishal Shah
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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26
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Wong ACL, Jones A, Stone A, MacKay SG. Combination CPAP and bilateral hypoglossal nerve stimulation for obstructive sleep apnea in Treacher Collins syndrome: first case report. J Clin Sleep Med 2023; 19:197-199. [PMID: 36038987 PMCID: PMC9806783 DOI: 10.5664/jcsm.10274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023]
Abstract
We report the first case of bilateral hypoglossal nerve stimulator implantation in a patient with Treacher Collins syndrome and very severe obstructive sleep apnea, who was initially intolerant of continuous positive airway pressure (CPAP) treatment. Novel bilateral hypoglossal nerve stimulation in combination with CPAP allowed near obliteration of snoring, improved sleep quality, and ability to maintain the CPAP mask in position in the setting of craniofacial changes associated with this condition. CITATION Wong ACL, Jones A, Stone A, MacKay SG. Combination CPAP and bilateral hypoglossal nerve stimulation for obstructive sleep apnea in Treacher Collins syndrome: first case report. J Clin Sleep Med. 2023;19(1):197-199.
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Affiliation(s)
- Andrew Chun Lok Wong
- Department of Otolaryngology, Head and Neck Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia
- Department of Otorhinolaryngology, New Territories West Cluster, Hospital Authority, Hong Kong
| | - Andrew Jones
- Illawarra Sleep Medicine Centre, Wollongong, New South Wales, Australia
| | - Andrew Stone
- Riverina Respiratory and Sleep Centre, Wagga Wagga, New South Wales, Australia
| | - Stuart Grayson MacKay
- Department of Otolaryngology, Head and Neck Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia
- University of Wollongong Graduate School of Medicine, Wollongong, New South Wales, Australia
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27
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Patel M, Yarlagadda H, Upadhyay S, Neupane R, Qureshi U, Raco JD, Jain R, Jain R. Disturbed Sleep is Not Good for the Heart: A Narrative Review. Curr Cardiol Rev 2023; 19:e301122211378. [PMID: 36453501 PMCID: PMC10280991 DOI: 10.2174/1573403x19666221130100141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 12/04/2022] Open
Abstract
Sleep-related breathing disorders, including obstructive sleep apnea (OSA) and central sleep apnea (CSA), have a major impact on cardiovascular function. It has shown an association with hypertension, coronary artery disease, cardiac arrhythmias, sudden cardiac death, and congestive heart failure (CHF). This review focuses on highlighting the relationship between sleep apnea and CHF. We discuss the underlying pathophysiology, which involves the mechanical, neurohormonal, and inflammatory mechanisms; in addition, the similarities and differentiating clinical features of OSA in patients with CHF and without CHF. We have also discussed several treatment strategies, including weight loss, continuous positive airway pressure (CPAP), supplemental oxygen therapy, theophylline, acetazolamide, mandibular advancement device, and hypoglossal nerve stimulation (HGNS). We conclude that since there are several overlapping clinical features in patients with OSA with Heart Failure (HF) and without HF, early detection and treatment are crucial to decrease the risk of HF, coronary artery disease, and stroke.
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Affiliation(s)
- Meet Patel
- Department of Internal Medicine, Tianjin Medical University, Tianjin, P.R. China
| | | | | | - Ritesh Neupane
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Umer Qureshi
- Penn State College of Medicine, Hershey, PA, USA
| | - Joseph D. Raco
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Rahul Jain
- Avalon University School of Medicine, Willemstad, Curaçao
| | - Rohit Jain
- Avalon University School of Medicine, Willemstad, Curaçao
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28
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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 J 2022:1455613221148313. [PMID: 36583238 DOI: 10.1177/01455613221148313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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29
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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. Int J Environ Res 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] [What about the content of this article? (0)] [Affiliation(s)] [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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30
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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31
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Khan M, Stone A, Soose RJ, Cohen SM, Howard J, Capasso R, Itayem D, Gillespie MB, Mehra R, Chio E, Strollo PJ, Menzl A, Kaplan A, Ni Q. Does race-ethnicity affect upper airway stimulation adherence and treatment outcome of obstructive sleep apnea? J Clin Sleep Med 2022; 18:2167-2172. [PMID: 35681251 PMCID: PMC9435342 DOI: 10.5664/jcsm.10068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Untreated obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness, decreased quality of life, and cardiovascular disease. Positive airway pressure is the first-line therapy for OSA; however, adherence is difficult. Upper airway stimulation is a Food and Drug Administration-approved treatment of OSA. The objective of this study was to evaluate for a difference in treatment efficacy and adherence of upper airway stimulation therapy for OSA between individuals who are White and non-White using data from the ADHERE registry. METHODS ADHERE registry is a multicenter prospective study of real-world experience of upper airway stimulation for treatment of OSA in the United States and Europe. Propensity score matching was used to create a balanced dataset between the White and non-White groups. t-Tests at a significance level of 5% were used to compare numeric values between groups. RESULTS There were 2,755 participants of the ADHERE registry: 27 were excluded due to not having a race identified, 125 participants identified as non-White, 2,603 identify as White, and 27 did not provide race information. Propensity score matching was used to select 110 participants, with 55 White and 55 non-White for the noninferiority analysis. We did not find a difference in adherence, treatment apnea-hypopnea index, changes in Epworth Sleepiness Scale score, or clinical global impression after intervention score between White and non-White individuals. CONCLUSIONS Our study found that there was no statistically significant difference in adherence or efficacy with upper airway stimulation therapy between White and non-White individuals. However, the percent of non-White people implanted is low, which suggests a need to expand access to this therapy for non-White populations with OSA who cannot tolerate positive airway pressure therapy. CITATION Khan M, Stone A, Soose RJ, et al. Does race-ethnicity affect upper airway stimulation adherence and treatment outcome of obstructive sleep apnea? J Clin Sleep Med. 2022;18(9):2167-2172.
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Affiliation(s)
- Meena Khan
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andre Stone
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ryan J Soose
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samuel M Cohen
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Javier Howard
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Robson Capasso
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Deeyar Itayem
- Department of Otolaryngology Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - M Boyd Gillespie
- Department of Otolaryngology Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Reena Mehra
- Sleep Disorders Center, Neurologic Institute, Respiratory Institute, Heart and Vascular Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene Chio
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Patrick J Strollo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine and Veterans Administration Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Anna Menzl
- Inspire Medical Systems, Golden Valley, Minnesota
| | - Adam Kaplan
- Inspire Medical Systems, Golden Valley, Minnesota
| | - Quan Ni
- Inspire Medical Systems, Golden Valley, Minnesota
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Hinder D, Schams SC, Knaus C, Tschopp K. Home sleep apnea testing with peripheral arterial tonometry to assess outcome in upper airway stimulation. J Clin Sleep Med 2022; 18:2197-2205. [PMID: 35689596 PMCID: PMC9435336 DOI: 10.5664/jcsm.10082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To determine whether home sleep apnea testing with peripheral arterial tonometry (HSAT-PAT) can be used in upper airway stimulation to evaluate therapy success. METHODS Data analysis from 50 consecutive patients receiving upper airway stimulation was performed. Baseline values were measured by polysomnography and HSAT-PAT. Follow-up was performed during and after titration (3-6 months) by polysomnography and HSAT-PAT and after 1 year by HSAT-PAT only. Primary outcome measures were reduction in the apnea-hypopnea index and oxygen desaturation index. In addition, an analysis of night-to-night variability for HSAT-PAT was performed. RESULTS All 50 patients completed their posttitration visit (3-6 months) and 41 patients completed the 1-year follow-up. In HSAT-PAT after 1 year, the mean apnea-hypopnea index (desaturation 3%) was reduced from 29.5 ± 17.1 events/h to 19.9 ± 13.1 events/h (P < .01) and the oxygen desaturation index (desaturation 4%) was reduced from 17.8 ± 12.6 events/h to 10.2 ± 8.3 events/h (P < .01). Therapy adherence after 1 year was high (6.6 ± 1.9 hours per night) and led to improvement in daytime sleepiness, meaning a reduction in the Epworth Sleepiness Scale score from 12.8 ± 5.4 to 5.9 ± 4.0 (P < .01). Analysis of night-to-night variability showed similar apnea-hypopnea index values between the 2 nights. CONCLUSIONS Upper airway stimulation was able to reduce the apnea-hypopnea index and oxygen desaturation index after 1 year, as assessed by full-night efficacy studies with HSAT-PAT. In addition, improvements in self-reported outcome parameters were observed. The importance of publishing the scoring criteria is highlighted and whether data are based on full-night efficacy studies or a selected period of time from a sleep study. This is a prerequisite for comparing data with other trials in the emerging field of upper airway stimulation. CITATION Hinder D, Schams SC, Knaus C, Tschopp K. Home sleep apnea testing with peripheral arterial tonometry to assess outcome in upper airway stimulation. J Clin Sleep Med. 2022;18(9):2197-2205.
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Affiliation(s)
- Dominik Hinder
- Address correspondence to: Dominik Hinder, MD, Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland;
| | | | - Christoph Knaus
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Kurt Tschopp
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
STUDY OBJECTIVES To assess early adherence to therapy with hypoglossal nerve stimulation therapy. METHODS This is a prospective study of consecutive patients with moderate to severe obstructive sleep apnea who underwent implantation of hypoglossal nerve stimulation therapy within a single academic practice and attended a follow-up appointment after greater than 30 days of therapy use. Objective adherence data were extracted from an objective monitoring database and compared to patient characteristics. RESULTS The study population was 79 participants who were 29.1% female with a mean age of 58.7 ± 12.8 years old, body mass index of 28.9 ± 3.4 kg/m2, and baseline apnea-hypopnea index of 33.8 ± 17.6 events/h. In the first 7 days after device activation, average use was 7.8 h/night, with 91.9% of nights with greater than 4 hours of therapy use and an average of 0.2 pauses in therapy per night. These figures remained stable after 30 days of use: 7.7 h/night, 91.0% of nights longer than 4 hours, and 0.3 pauses per night. Objective evidence of difficulty with acclimatization was associated with age less than 60 years (odds ratio 2.8, 95% confidence interval 1.1-7.1, P = .03) and a history of prior upper airway surgery (3.9, 1.2-11.9, P = .015). Insomnia was present in 31 patients and was not associated with objective evidence of difficulty tolerating therapy. CONCLUSIONS Early adherence to hypoglossal nerve stimulation is excellent (92.4% >4 hours on >70% of nights), suggesting that the acclimatization period is straightforward in most. Younger age and a history of prior upper airway surgery appear to be associated with an increased risk of difficulty with acclimatization. CITATION Huyett P. Early objective adherence to hypoglossal nerve stimulation therapy. J Clin Sleep Med. 2022;18(2):631-636.
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Affiliation(s)
- Phillip Huyett
- Address correspondence to: Phillip Huyett, Division of Sleep Medicine and Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA; Tel: (617) 573-3793;
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Gao TZ, Pan X, Naik A, Khandalavala R, Ramsell S, Gibbs H, Chio E. Identifying Patient Characteristics That Predict Drug-Induced Sleep Endoscopy Anatomy. Otolaryngol Head Neck Surg 2022; 167:785-790. [PMID: 35077242 DOI: 10.1177/01945998211072834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine if age, sex, body mass index (BMI), neck circumference, or apnea-hypopnea index can predict whether a patient will demonstrate velopharyngeal complete circumferential (CC) collapse on drug-induced sleep endoscopy (DISE). STUDY DESIGN Single-center retrospective review at The Ohio State Wexner Medical Center of 289 patients between March 2014 and June 2020. SETTING Quaternary care hospital. METHODS Patient characteristic and DISE information was extracted from charts and summarized with mean and standard deviation for continuous variables and count and percentage for categorical. CC collapse and patient characteristic associations were explored: 2-sample t test for continuous and chi-square test for categorical. Classification and regression tree (CART) analysis with 3-fold cross-validation was employed to search for the best CC collapse predictors. RESULTS Male and female BMI and female neck circumference were correlated to velopharyngeal CC collapse, with BMI more strongly correlated. CART analysis for males showed that a BMI ≤34.8 kg/m2 is associated with an 89.4% chance of not demonstrating velopharyngeal CC collapse vs 48% for BMI >34.8 (area under the curve [AUC] = 0.705; AUC >0.7 is acceptable). For females, the CART analysis showed that a BMI ≤36.4 is associated with a 98.4% of not demonstrating velopharyngeal CC collapse vs 30.8% for BMI >36.4 (AUC = 0.73). For females, a neck circumference ≤38.05 cm is associated with a 100% chance of not demonstrating velopharyngeal CC collapse vs 18.4% for >38.05 cm (AUC = 0.72). CONCLUSION The BMI values for males and females and the female neck circumference values established by the CART model may accurately predict DISE anatomy and possible candidacy for hypoglossal nerve stimulation.
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Affiliation(s)
- Thomas Zhang Gao
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Xueliang Pan
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Akash Naik
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rohan Khandalavala
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stuart Ramsell
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Hannah Gibbs
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Eugene Chio
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Wang Y, Penzel T, Salanitro M, Arens P. Persistent Treatment-Emergent Central Sleep Apnea (TECSA) Following Hypoglossal Nerve Stimulation. Nat Sci Sleep 2022; 14:2227-2236. [PMID: 36578670 PMCID: PMC9791954 DOI: 10.2147/nss.s382710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Since 2001, hypoglossal nerve stimulators (HNS) have been used worldwide to treat patients with obstructive sleep apnea (OSA). Recently, a few studies reported treatment-emergent central sleep apnea (TECSA) with spontaneous resolution following HNS. However, the evidence of persistent development of TECSA during long-term care visits was lacking. As a result, this study first report two patients with persistent TECSA and describe their development phenotype during more than two years of follow-up visits to help explore the influencing factors and underlying mechanisms. PATIENTS AND METHODS This retrospective study included twenty-seven patients who underwent HNS implantation from 2016 to 2021. Their demographic data, pre- and postoperative sleep study characteristics, and device use settings were collected. The possible factors associated with post-operative elevated CSA (central apnea index ≥5) were evaluated. Moreover, the development phenotype of the TECSA was observed and followed up with a titration trial study. RESULTS Among overall 27 patients with OSA, 3 patients with an increased preoperative Epworth Sleepiness Score (ESS) got an elevated CSA (CAI ≥ 5). Two of these 3 patients developed a persistent TECSA with a significant negative correlation between obstructive apnea index (OAI) and central and mixed sleep apnea index (CMAI) (R = -0.745, P = 0.021). These development phenotypes might be associated with different stimulation amplitudes of the HNS device. Furthermore, the following titration trial study also suggested that different amplitudes would influence the development of TECSA following HNS. CONCLUSION OSA patients with severe daytime sleepiness are more likely to have elevated CSA following HNS. An inappropriate stimulation amplitude might influence the development course of TECSA in such patients.
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Affiliation(s)
- Yan Wang
- Interdisciplinary Sleep Medicine Center Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Thomas Penzel
- Interdisciplinary Sleep Medicine Center Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Matthew Salanitro
- Interdisciplinary Sleep Medicine Center Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Philipp Arens
- Department of Otorhinolaryngology, Campus Virchow Klinikum Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Wang D, Modik O, Sturm JJ, Metkus J, Oaks-Leaf R, Kaplan A, Ni Q, Suurna M. Neurophysiological profiles of responders and non-responders to hypoglossal nerve stimulation: a single institution study. J Clin Sleep Med 2021; 18:1327-1333. [PMID: 34964435 PMCID: PMC9059610 DOI: 10.5664/jcsm.9852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Hypoglossal nerve stimulation (HGNS) is an effective alternative treatment for obstructive sleep apnea (OSA) that acts by opening the airway via selective stimulation of nerve fibers that innervate tongue muscles that protrude (genioglossus) and stiffen the tongue (transverse and vertical) while avoiding nerve fibers that innervate tongue muscles that retract the tongue (styloglossus and hyoglossus). There remains a subset of post-operative patients who fail to adequately respond to HGNS, in some cases due to simultaneous mixed activation of muscles that protrude and retract the tongue. This study aims to characterize the relationship between neurophysiological data from individual tongue muscle activation during intraoperative electromyographic (EMG) recordings and post-operative AHI responses to HGNS.. METHODS A single institution review of 46 patients undergoing unilateral HGNS implantation for OSA. Patients were separated into responders and non-responders through comparison of pre and postoperative AHI. Neurophysiological data included EMG responses of the genioglossus, styloglossus/hyoglossus, intrinsic/vertical, and hyoglossus (neck) muscles to intraoperative stimulation using unipolar (--- and o-o) and bipolar (+-+) settings. RESULTS The overall treatment success rate was 61% as determined by a post-operative AHI <20 events/hr with a greater than 50% AHI reduction. We observed no statistically significant relationships between treatment response and individual muscle responses. However, we did note that increasing BMI was correlated with worse post-operative responses. CONCLUSIONS Although we noted a significant sub-group of clinical non-responders to HGNS post-operatively, these patients were not found to exhibit significant inclusion of tongue retractors intraoperatively on neurophysiological analysis. Further research is needed to delineate additional phenotypic factors that may contribute to HGNS treatment responses.
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Affiliation(s)
- Daiqi Wang
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY
| | - Oleg Modik
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY
| | - Joshua J Sturm
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY
| | - James Metkus
- Division of Otolaryngology-Head and Neck Surgery, Stony Brook Medicine, Stony Brook, NY
| | - Rachel Oaks-Leaf
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY
| | - Adam Kaplan
- Inspire Medical Systems, Inc., Minneapolis, MN
| | - Quan Ni
- Inspire Medical Systems, Inc., Minneapolis, MN
| | - Maria Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY
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Abstract
This is a case series of 5 patients who underwent implantation of the hypoglossal nerve stimulator for obstructive sleep apnea via a left-sided, two incision technique. This represents a significant modification of the original right-sided, three-incision technique. All five patients were successfully implanted with this technique variant with no adverse events or negative impact on device functionality, such as cardiac artifact.
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Affiliation(s)
- Chen Lin
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael D Olson
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Phillip Huyett
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - Eugene G Chio
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Van Daele DJ, Cromwell JW, Hsia JK, Nord RS. Post-operative Complication Rate Comparison Between Airway Surgery and Upper Airway Stimulation Using NSQIP and ADHERE. OTO Open 2021; 5:2473974X211051313. [PMID: 34661042 PMCID: PMC8512284 DOI: 10.1177/2473974x211051313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Postoperative complication rates were compared between obstructive sleep apnea surgery (OSAS) and hypoglossal nerve upper airway stimulation (UAS). Study Design Cohort. Setting Multi-institutional international databases. Methods OSAS data were collected from the NSQIP database (2014; American College of Surgeons National Surgery Quality Improvement Program). UAS data were obtained from the ADHERE registry (Adherence and Outcome of Upper Airway Stimulation for OSA International Registry; 2016-December 2019). ADHERE comorbidities and complications were categorized to match NSQIP definitions. A chi-square test was used for proportion P values. Results There were 1623 UAS procedures in ADHERE and 310 in NSQIP. The UAS group was older than the OSAS group (mean ± SD, 60 ± 11 vs 42 ± 13 years) but similarly male (75% vs 77%) and overweight (body mass index, 29 ± 4 vs 29 ± 3 kg/m2). There was a higher proportion of hypertension, diabetes, and heart disease in the UAS cohort. Palatopharyngoplasty was the most common surgical procedure (71%), followed by tonsillectomy (25%). UAS operative time was longer (132 ± 47 vs 54 ± 33 minutes). Postoperative length of stay was not normally distributed, as 71% of UAS stays were <1 day as opposed to 40% of OSA stays (P < .0001). Thirty-day return to the operating room related to the procedure was 0.1% for UAS and 4.8% for OSAS (P < .0001). Surgical site infections were 0.13% for UAS and 0.9% for OSAS (P = .046). Conclusion The UAS cohort was older and more likely to have comorbid hypertension, diabetes, and heart disease. Despite baseline differences, the postoperative complication rate was lower with UAS than with OSAS.
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Affiliation(s)
| | | | | | - Ryan S Nord
- Virginia Commonwealth University, Richmond, Virginia, USA
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Coca KK, Heiser C, Huntley C, Boon M, de Vries N, Mamidala M, Gillespie MB. Hypoglossal Nerve Stimulation Usage by Therapy Nonresponders. Otolaryngol Head Neck Surg 2021; 166:786-790. [PMID: 34372740 DOI: 10.1177/01945998211036867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study is to examine differences in therapy usage and outcomes of therapy between responder (R) and nonresponder (NR) groups in an international, multicenter prospective registry of patients undergoing hypoglossal nerve stimulation for obstructive sleep apnea (OSA). STUDY DESIGN Database analysis (level III). SETTING International, multicenter registry. METHODS The studied registry prospectively collects data pre- and postimplantation, including sleep parameters, Epworth score, patient experience, and safety questions, over the course of 12 months. Patients are defined as a "responder" based on Sher criteria, which require a final apnea-hypopnea index (AHI) of ≤20 and a final AHI reduction of >50% at their 12-month follow-up. RESULTS Overall, there were 497 (69%) R and 220 (31%) NR. Most patients in both groups experienced improvement in quality of life following implantation (96% of R; 77% of NR) with reductions in oxygen desaturation index and Epworth score. At final follow-up, the R group demonstrated significantly better adherence to recommended therapy (>4 hours/night) (P = .001), average hours of nightly use (P = .001), final Epworth scores (P = .001), and degree of subjective improvement (P < .001). CONCLUSION Patients classified as NR to upper airway stimulation continue to use therapy with improvement in percent time of sleep with O2 <90%, reduction in daytime sleepiness, and improvement in quality of life. Therefore, ongoing usage of the device should be encouraged in NR patients who note improvement while integrating additional strategies to lower the long-term effects of OSA.
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Affiliation(s)
- Kimberly K Coca
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Clemens Heiser
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nico de Vries
- Department of Otorhinolaryngology-Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
| | - Madhu Mamidala
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Xiao K, Campbell D, Mastrolonardo E, Boon M, Huntley C. Evaluating YouTube Videos on Hypoglossal Nerve Stimulation as a Resource for Patients. Laryngoscope 2021; 131:E2827-E2832. [PMID: 34363396 DOI: 10.1002/lary.29809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study evaluated the quality and comprehensiveness of YouTube videos on hypoglossal nerve stimulation (HNS) for patients. This study also investigated the relationship between video content, video metrics, and popularity. STUDY DESIGN Cross-sectional study. METHODS We identified 150 videos using three search terms: "inspire sleep apnea," "hypoglossal nerve stimulation," and "upper airway stimulation." Videos that were unrelated to the use of HNS for obstructive sleep apnea in adults, operating room recordings, lectures for medical professionals, non-English, or non-audio were excluded. Video quality and comprehensiveness were assessed using modified DISCERN criterion (range: 5-25) and novel content criterion (range: 0-12), respectively. Secondary outcomes included video metrics (views, likes, dislikes, comments, and days since upload) and Video Power Index to measure popularity. Outcomes were stratified by video uploader source (medical institutions, medical companies, individual users, other). RESULTS Users searched YouTube for "inspire sleep apnea" 2.48 times more in 2020 than in 2018. We identified 67 videos for review, with the majority coming from medical institutions (70.2%). Overall, the average-modified DISCERN (13.65 ± 4.88) and novel content (3.87 ± 2.09) scores were low and did not differ between medical institutions or other uploader sources. Higher quality and more comprehensive video content did not correlate with popularity. CONCLUSION Overall quality and comprehensiveness of information of HNS YouTube videos was low. Given the high demand for information on HNS, there is opportunity for medical institutions to implement new strategies to improve both video content and visibility to patients. LEVEL OF EVIDENCE N/A Laryngoscope, 2021.
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Affiliation(s)
- Kevin Xiao
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Campbell
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eric Mastrolonardo
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Kent D, Stanley J, Aurora RN, Levine CG, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:2507-2531. [PMID: 34351849 DOI: 10.5664/jcsm.9594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.
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Affiliation(s)
- David Kent
- Vanderbilt University Medical Center, Nashville, TN
| | | | - R Nisha Aurora
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Daniel J Gottlieb
- VA Boston Healthcare System, Brigham and Women's Hospital, Boston, MA
| | | | - Carlos A Torre
- University of Miami, Miller School of Medicine, Miami FL
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Suurna MV, Jacobowitz O, Chang J, Koutsourelakis I, Smith D, Alkan U, D'Agostino M, Boon M, Heiser C, Hoff P, Huntley C, Kent D, Kominsky A, Lewis R, Maurer JT, Ravesloot M, Soose R, Steffen A, Weaver E, Williams AM, Woodson T, Yaremchuk K, Ishman SL. Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum. J Clin Sleep Med 2021; 17:2477-2487. [PMID: 34279214 DOI: 10.5664/jcsm.9542] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea (OSA). Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction (STAR) trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, OSA phenotypes, individual health status, psychological conditions and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This manuscript presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel.
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Affiliation(s)
- Maria V Suurna
- Division of Sleep Surgery, Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY
| | | | - Jolie Chang
- Division of Sleep Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA
| | | | - David Smith
- Divisions of Pediatric Otolaryngology, Pulmonary Medicine, and the Sleep Center; Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Otolaryngology - Head and Neck Surgery of University of Cincinnati College of Medicine, Cincinnati, OH
| | - Uri Alkan
- Department of Otorhinolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark D'Agostino
- Southern New England Ear, Nose, Throat and Facial Plastic Surgery Group and Middlesex Hospital, Middletown, CT
| | - Maurits Boon
- Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Paul Hoff
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI
| | - Colin Huntley
- Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital
| | - David Kent
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN
| | - Alan Kominsky
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH
| | - Richard Lewis
- Perth Head & Neck Surgery, Hollywood Medical Centre, Nedlands, Australia
| | - Joachim T Maurer
- Division of Sleep Medicine, Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Ryan Soose
- Division of Sleep Surgery, Department of Otolaryngology, Pittsburgh School of Medicine, UPMC Mercy, University of Pittsburgh, Pittsburgh, PA
| | - Armin Steffen
- Department of otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Edward Weaver
- Department of Otolaryngology-Head and Neck Surgery, University of Washington; Surgery Service, Seattle Veterans Affairs Medical Center; Harborview Medical Center, Seattle, WA
| | - Amy M Williams
- Department of Otolaryngology - Head & Neck Surgery of Henry Ford Health System, Detroit, MI
| | - Tucker Woodson
- Division of Sleep Medicine and Sleep Surgery, Department of Otolaryngology and Human Communication of Medical College of Wisconsin, Milwaukee, WI
| | - Kathleen Yaremchuk
- Department of Otolaryngology - Head & Neck Surgery of Henry Ford Health System, Detroit, MI
| | - Stacey L Ishman
- Divisions of Pediatric Otolaryngology, Pulmonary Medicine, and the Sleep Center; Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Otolaryngology - Head and Neck Surgery of University of Cincinnati College of Medicine, Cincinnati, OH
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Steffen A, Jeschke S, Soose RJ, Hasselbacher K, König IR. Impulse Configuration in Hypoglossal Nerve Stimulation in Obstructive Sleep Apnea: The Effect of Modifying Pulse Width and Frequency. Neuromodulation 2021; 25:1312-1316. [PMID: 34214238 DOI: 10.1111/ner.13490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/13/2021] [Accepted: 03/30/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Hypoglossal nerve stimulation is an effective treatment option for obstructive sleep apnea (OSA) in positive airway pressure therapy failure. Nonetheless, data regarding the functional effect of modifying stimulation parameters within each electrode configuration are limited. MATERIALS AND METHODS In a retrospective study of 76 patients with 12 months or more follow-up, functional tongue protrusion thresholds were compared for pulse width and frequency configurations of 90 μsec 33 Hz vs 120 μsec 40 Hz. The number of tolerated voltage amplitude steps between sensation, functional, and subdiscomfort thresholds were assessed for both settings as well as impedances. RESULTS The overall cohort showed improvement in OSA metrics: median apnea-hypopnea index from 30.0/hour to 18.6/hour and Epworth Sleepiness Scale from 13.5 to 7.6. For both bipolar and unipolar electrode configurations, the stimulation amplitude required for functional tongue protrusion was significantly reduced when the pulse width and frequency were converted from 90 μsec 33 Hz to 120 μsec 40 Hz (p < 0.001). Nevertheless, the number of voltage amplitude steps from sensation, functional, to subdiscomfort thresholds did not differ between the two settings. The ratio of automatically derived impedances between bipolar and unipolar electrode configurations was relevantly correlated with the ratio of functional thresholds at these parameters. CONCLUSION Changing the stimulation parameters may lower the voltage requirements while maintaining the same effect on tongue protrusion. Changing these stimulation parameters does not affect the range of tolerated impulse steps between functional and subdiscomfort thresholds. Future technical appliances could help estimate functional thresholds at different electrode configurations for each patient by automatically measuring impedances.
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Affiliation(s)
- Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Stephanie Jeschke
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Ryan J Soose
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Heiser C, Steffen A, Hofauer B, Mehra R, Strollo PJ, Vanderveken OM, Maurer JT. Effect of Upper Airway Stimulation in Patients with Obstructive Sleep Apnea (EFFECT): A Randomized Controlled Crossover Trial. J Clin Med 2021; 10:jcm10132880. [PMID: 34209581 PMCID: PMC8269272 DOI: 10.3390/jcm10132880] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Several single-arm prospective studies have demonstrated the safety and effectiveness of upper airway stimulation (UAS) for obstructive sleep apnea. There is limited evidence from randomized, controlled trials of the therapy benefit in terms of OSA burden and its symptoms. Methods: We conducted a multicenter, double-blinded, randomized, sham-controlled, crossover trial to examine the effect of therapeutic stimulation (Stim) versus sham stimulation (Sham) on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS). We also examined the Functional Outcomes of Sleep Questionnaire (FOSQ) on sleep architecture. We analyzed crossover outcome measures after two weeks using repeated measures models controlling for treatment order. Results: The study randomized 89 participants 1:1 to Stim (45) versus Sham (44). After one week, the AHI response rate was 76.7% with Stim and 29.5% with Sham, a difference of 47.2% (95% CI: 24.4 to 64.9, p < 0.001) between the two groups. Similarly, ESS was 7.5 ± 4.9 with Stim and 12.0 ± 4.3 with Sham, with a significant difference of 4.6 (95% CI: 3.1 to 6.1) between the two groups. The crossover phase showed no carryover effect. Among 86 participants who completed both phases, the treatment difference between Stim vs. Sham for AHI was −15.5 (95% CI −18.3 to −12.8), for ESS it was −3.3 (95% CI −4.4 to −2.2), and for FOSQ it was 2.1 (95% CI 1.4 to 2.8). UAS effectively treated both REM and NREM sleep disordered breathing. Conclusions: In comparison with sham stimulation, therapeutic UAS reduced OSA severity, sleepiness symptoms, and improved quality of life among participants with moderate-to-severe OSA.
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Affiliation(s)
- Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 München, Germany;
- Correspondence:
| | - Armin Steffen
- Department of Otorhinolaryngology/Head and Neck Surgery, University of Luebeck, 23562 Luebeck, Germany;
| | - Benedikt Hofauer
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 München, Germany;
| | - Reena Mehra
- Department of Sleep Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA;
| | - Patrick J. Strollo
- Department of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA;
| | - Olivier M. Vanderveken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, 2650 Edegem, Antwerp, Belgium;
| | - Joachim T. Maurer
- Department of ORL-HNS, Division of Sleep Medicine, University Medical Centre Mannheim, University Heidelberg, 68167 Mannheim, Germany;
- Department of Information Technology, University of Applied Sciences, 68163 Mannheim, Germany
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Yu JL, Younes M. Relation between arousability and outcome of upper airway stimulation in the Stimulation for Apnea Reduction (STAR) Trial. J Clin Sleep Med 2021; 17:797-801. [PMID: 33295277 DOI: 10.5664/jcsm.9050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
STUDY OBJECTIVES Upper airway stimulation (UAS) is an innovative surgical treatment for obstructive sleep apnea; however, the treatment failure rate is approximately 22%. Easy arousability may limit the tolerability of stimulation and, by extension, its effectiveness. The odds ratio product (ORP) is a continuous electroencephalographic metric of arousal propensity (range: 0 [deep sleep] to 2.5 [full wakefulness]), and its rate of decline after arousal (ORP-9) is a risk factor for susceptibility to arousal in the presence of frequent arousal stimuli. We hypothesized that individuals with deeper sleep (low average ORP and low ORP-9) are more likely to respond to UAS. METHODS ORP and ORP-9 were calculated from 126 baseline polysomnograms of participants in the STAR Trial. These values were compared between responders and nonresponders. Adjusted linear modeling was performed to determine the association between ORP-derived variables and treatment response. RESULTS No differences were found between responders and nonresponders in unadjusted comparisons of ORP-derived variables. On linear regression modeling, significant correlation was found between non-rapid eye movement ORP and reduction in apnea-hypopnea index (P = .004). CONCLUSIONS No significant difference in ORP was noted between responders and nonresponders to UAS therapy; however, contrary to our initial hypothesis, linear regression modeling trended toward a positive relationship between ORP and UAS response, suggesting that those who have lighter sleep are more likely to respond to therapy; however, these results are only exploratory, and future larger prospective studies are needed to confirm this relationship. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: STAR Trial; Identifier: NCT01161420.
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Affiliation(s)
- Jason L Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Magdy Younes
- Sleep Disorders Centre, Winnipeg, Manitoba, Canada
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Huyett P. Sleep Study Measures on Postoperative Night 1 Following Implantation of the Hypoglossal Nerve Stimulator. Otolaryngol Head Neck Surg 2021; 166:589-594. [PMID: 34182839 DOI: 10.1177/01945998211023479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the changes in measures of sleep apnea severity and hypoxemia on the first postoperative night following implantation of the hypoglossal nerve stimulator. STUDY DESIGN This was a single-arm prospective cohort study. SETTING A single academic sleep surgical practice. METHODS Subjects with moderate to severe obstructive sleep apnea underwent implantation of the hypoglossal nerve stimulator (HGNS) and were discharged to home the same day as surgery. A single-night WatchPAT study was performed on the night immediately following surgery (PON 1) and was compared to baseline sleep testing. RESULTS Twenty subjects who were an average of 58.6 ± 2.5 years old, were 25% female, and had a mean body mass index of 28.1 ± 0.9 kg/m2 completed the study. Mean O2 nadir at baseline was 79.6% ± 1.1% compared to 82.7% ± 0.9% (P = .013) on PON 1. One patient demonstrated a >10% worsening in O2 nadir. Only 2 additional patients demonstrated a worsening in O2 nadir on PON 1, each by only 1 percentage point. Neither mean time spent below SpO2 88% nor oxygen desaturation index (ODI) worsened postoperatively (mean time spent below oxygen saturation of 88%, 27.8 ± 7.85 vs 11.2 ± 5.2, P = .03; mean ODI, 29.6 ± 5.2/h vs 21.0 ± 5.4/h, P = .10). Mean obstructive apnea hypopnea index (AHI) was no worse (40.6 ± 4.7/h to 28.7 ± 4.2/h, P = .02), with only 2 patients experiencing an obstructive AHI >20% more severe than baseline. Only 1 patient demonstrated a clinically meaningful increase in central AHI on PON 1. CONCLUSIONS Overall, AHI and measures of nocturnal hypoxemia are stable, if not improved, on PON 1 following HGNS implantation. These findings support the safety of same-day discharge following implantation of the hypoglossal nerve stimulator.
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Affiliation(s)
- Phillip Huyett
- Division of Sleep Medicine and Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Epidemiological studies show a steady rise in the prevalence of obstructive sleep apnea (OSA). Untreated OSA is responsible for numerous chronic health conditions, motor vehicle, and workplace-related accidents leading to substantial economic burden both to the individual and society. Multiple causes for OSA and a wide range of consequences has made its diagnosis and treatment difficult. Obstructive sleep apnea may be caused by anatomical variation, increased collapsibility of the upper airway, low sleep arousal threshold, and exaggerated response to desaturation. Lifestyle changes, anatomical corrective surgeries, and oral appliances have been used but patient compliance is poor as it interferes in the daily routine. Neuromodulation is a promising functional modifying option that addresses the cause of obstructive sleep apnea at multiple levels.
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Affiliation(s)
- Vikas Naik
- Department of Neurosurgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Ninad Khandekar
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Milind Deogaonkar
- Department of Functional Neurosurgery, West Virginia University Health Sciences, WV, USA
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