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Kaffenberger TM, Plawecki A, Kaki P, Boon M, Huntley C. Troubleshooting Upper Airway Stimulation Therapy Using Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg 2024. [PMID: 38643409 DOI: 10.1002/ohn.785] [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: 10/06/2023] [Revised: 01/17/2024] [Accepted: 02/17/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE This study assesses the utility of drug-induced sleep endoscopy (DISE) in guiding further treatment for patients with obstructive sleep apnea (OSA) who have difficulty tolerating upper airway stimulation (UAS) or have inadequate response to therapy. STUDY DESIGN We conducted a retrospective analysis of UAS patients at our institution who underwent DISE, post-UAS, and evaluated the efficacy of different electrode configurations and maneuvers. SETTING A tertiary care hospital. METHODS Out of 379 patients who received UAS therapy, 34 patients who underwent DISE post-UAS (DISE-UAS) were included. Palatal coupling (PC) was assessed with UAS stimulation alone, jaw thrust alone, and both simultaneously during DISE. RESULTS Among 34 patients, 5 had suboptimal adherence to UAS therapy, 19 had suboptimal therapy efficacy with residual OSA burden, and 10 had both. During DISE-UAS, PC was observed in 7 patients (21%) with UAS stimulation alone, 9 patients (26%) with jaw thrust alone, and 8 patients (24%) with both maneuvers combined. Notably, 10 patients (29%) did not exhibit PC with any maneuver. Based on DISE-UAS findings, 13 patients were recommended oral appliance therapy (OAT), and 8 patients underwent further surgical interventions. CONCLUSION DISE-UAS is a valuable adjunct in troubleshooting UAS therapy for patients intolerant to CPAP or with suboptimal therapy efficacy. This study provides an algorithm for targeted multimodality therapy based on DISE findings, facilitating personalized management approaches.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Andrea Plawecki
- Henry Ford Department of Otolaryngology, Detroit, Michigan, USA
| | - Praneet Kaki
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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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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Arambula AM, Bon-Nieves A, Alapati R, Wei J, Wagoner S, Lawrence A, Renslo B, Rouse D, Larsen C. Right Versus Left Cuff Position for Upper Airway Stimulation. Otolaryngol Head Neck Surg 2024; 170:1183-1189. [PMID: 38308558 DOI: 10.1002/ohn.668] [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: 09/21/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Upper airway stimulation (UAS) is a treatment option for obstructive sleep apnea in which electrical stimulation is applied to the hypoglossal nerve. Nerve branches that control tongue protrusion are located inferiorly. Due to positioning, left-sided implants are typically placed with an inferiorly oriented electrode cuff (L-down) as opposed to superiorly on the right (R-up). In this study, we assess the impact of left- versus right-sided UAS on patient outcomes. STUDY DESIGN Retrospective cohort study. SETTING Tertiary Academic Medical Center. METHODS Patients who underwent UAS implantation between 2016 and 2021 with an L-down or R-up oriented cuff as confirmed by X-ray were included. Data were collected retrospectively. Most recent sleep study variables were used for analysis. RESULTS A total of 190 patients met the inclusion criteria. The average age was 61.0 ± 11.0 years, with 55 (28.9%) females. L-down orientation was present in 21 (11.1%) patients vs 169 (88.9%) R-up. Indications for L-down included hunting/shooting (n = 15), prior radiation/surgery (n = 4), central port (n = 1), and brachial plexus injury (n = 1). Adherence was higher among L-down patients (47.1 vs 41.0 hours use/week, P = .037) in univariate analysis, with a similar time to adherence data collection (4.4 vs 4.2 months, P = .612), though this finding was not maintained in the multivariate regression analysis. Decrease in apnea-hypopnea index (21.3 vs 22.8, P = .734), treatment success (76.5% vs 84.0%, P = .665), functional threshold (1.5 vs 1.6, P = .550), therapeutic amplitude (2.3 vs 2.4, P = .882), and decrease in Epworth Sleepiness Scale (4.9 vs 2.6, P = .060) were not significantly different between cohorts. CONCLUSION This study is the first to examine the orientation of the UAS electrode cuff concerning the electrodes' natural position and the potential effect on postoperative outcomes. Our study found no significantly different treatment outcomes between the L-down versus R-up cohort, with the exception of device adherence, which was significantly higher in the L-down group on univariate analysis though not on multivariate analysis. Future studies with larger patient cohorts are needed to further investigate this potential relationship between treatment outcomes and electrode cuff orientation.
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Affiliation(s)
- Alexandra M Arambula
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University/University Hospitals, Cleveland, Ohio, USA
| | - Antonio Bon-Nieves
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Rahul Alapati
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah Wagoner
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amelia Lawrence
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bryan Renslo
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Rouse
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher Larsen
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, 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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Islam AS, Pingree G, Chafin A, Fitzpatrick TH, Nord RS. Respiratory Sensing Lead Malfunction in Upper Airway Stimulation: A Single Institution Report. Laryngoscope 2024; 134:1479-1484. [PMID: 37732709 DOI: 10.1002/lary.31056] [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: 05/01/2023] [Revised: 07/25/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Upper airway stimulation (UAS) is an effective treatment for patients with obstructive sleep apnea. The device consists of a stimulating electrode, an internal pulse generator, and a respiratory sensing lead. The purpose of this study is to characterize the incidence of sensing lead malfunction necessitating revision surgery in a high-volume center in conjunction with a review of the FDA Manufacturer and User Facility Device Experience (MAUDE) database reports on adverse events associated with the sensing lead component. METHODS Patients age ≥18 implanted with the device were reviewed between July 2017 and June 2022. Those determined to have sensing lead malfunction were analyzed. The FDA MAUDE database was reviewed for reports associated with "Inspire Model 4323 Respiratory" and "Inspire Model 4340 Respiratory" between January 2014 and September 2022. RESULTS One hundred ninety patients underwent UAS at our institution during the study period and four (2.1%) patients were found to have sensing lead malfunction. Analysis of the MAUDE database revealed 122 reports of adverse events associated with the sensing lead component, with 72% (88/122) of these requiring revision surgery. The most frequently reported adverse event was sensing lead tip separation from lead body, noted in 46% of these reports (56/122). CONCLUSION The functionality of the sensing lead component is vital to the integrity of the UAS device and is measurable through waveform analysis. To provide optimal care after device implantation, it is essential to have a comprehensive understanding of the scenarios in which this component fails, the incidence of such events, and appropriate management. LEVEL OF EVIDENCE 4 Laryngoscope, 134:1479-1484, 2024.
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Affiliation(s)
- Albina S Islam
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Graham Pingree
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Andrew Chafin
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Thomas H Fitzpatrick
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ryan S Nord
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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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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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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Tschopp S, Janjic V, Borner U, Tschopp K. Treatment of Residual Palatal Collapse in Hypoglossal Nerve Stimulation Using a Palatal Device. Laryngoscope 2024. [PMID: 38265126 DOI: 10.1002/lary.31309] [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: 08/23/2023] [Revised: 11/29/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
Hypoglossal nerve stimulation (HNS) has increasingly become an alternative therapy for obstructive sleep apnea patients with CPAP intolerance. Stimulation of the hypoglossal nerve during sleep enhances airway patency and alleviates collapse. Suboptimal responses to HNS often stem from insufficient palatal coupling and residual velar collapse. Combining palatal devices, such as Velumount®, with HNS represents a simple and cost-effective strategy to treat residual palatal collapse. Patients desiring conservative treatment for residual palatal obstruction under HNS may consider this combined approach. Laryngoscope, 2024.
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Affiliation(s)
- Samuel Tschopp
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital Baselland, Liestal, Switzerland
| | - Vlado Janjic
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital Baselland, Liestal, Switzerland
| | - Urs Borner
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kurt Tschopp
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital Baselland, Liestal, Switzerland
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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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Kaffenberger TM, Chandna M, Kaki P, Corr AM, Plawecki A, Doghramji K, Boon M, Huntley C. Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med 2023; 19:1997-2004. [PMID: 37589148 PMCID: PMC10692932 DOI: 10.5664/jcsm.10752] [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: 03/16/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
STUDY OBJECTIVES Upper airway stimulation (UAS) is a hybrid surgical-medical device used to treat moderate-to-severe obstructive sleep apnea (OSA). Comorbid insomnia and OSA (COMISA) is present in ∼50% of these patients. Our aim was to study UAS outcomes and adherence in patients with COMISA. METHODS A retrospective review of 379 patients with OSA who underwent UAS implantation at a single institution between 2014 and 2021. Demographics, OSA severity metrics, and insomnia data were collected. Patients were categorized into OSA alone (OSAa) or COMISA. Objective adherence data were collected from device downloads during follow-up. Data were analyzed with using R Studio (R Foundation for Statistical Computing, Vienna, Austria) and Prism (Boston, MA, USA). RESULTS Of the 274 patients included, 148 had COMISA (54.0%) and 126 OSAa (46.0%). Average follow-up time was 2.5 years and OSAa had more males than COMISA (P < .001). Patients with COMISA had higher insomnia severity index scores than OSAa preoperatively (16 vs 8.7; P = .003). All groups showed significant decreases in objective and self-reported OSA outcomes postoperatively, but there was no difference between COMISA and OSAa. Patient with COMISA had decreased device usage (4.9 vs 5.8 h/night; P = .015) and paused therapy more often than patients with OSAa (1.4 vs 0.4 pauses/night; P < .001). Multivariate linear regression, when controlling for sex as a covariate, showed insomnia to be an independent predictor of lower UAS hours/night and more pauses/night (P < .01). CONCLUSIONS Patients with COMISA use UAS therapy for shorter durations and require more breaks from therapy when compared with those with OSAa. Future research is needed to explore the underlying mechanism and improve UAS treatment adherence in patients with COMISA. CITATION Kaffenberger TM, Chandna M, Kaki P, et al. Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):1997-2004.
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Affiliation(s)
- Thomas M. Kaffenberger
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Megha Chandna
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Praneet Kaki
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew M. Corr
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrea Plawecki
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karl Doghramji
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
| | - Maurits Boon
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin Huntley
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
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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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12
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Renslo B, Virgen CG, Sawaf T, Arambula A, Sykes KJ, Larsen C, Rouse DT. Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter? J Clin Sleep Med 2023; 19:1061-1071. [PMID: 36740926 PMCID: PMC10235707 DOI: 10.5664/jcsm.10496] [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: 09/11/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVES Upper airway stimulation is a surgical option for patients with obstructive sleep apnea who fail other forms of noninvasive treatment. Current guidelines recommend a baseline body mass index (BMI) below 32 kg/m2 for eligibility. In this study, we identify trends in BMI before and after upper airway stimulation to characterize the influence of BMI on treatment success. METHODS Patients underwent upper airway stimulation implantation between 2016 and 2021. Sleep study data were collected from preoperative and most recent postoperative sleep study. BMI data were collected and compared across the following time points: preoperative sleep study (BMI-1), initial surgeon consultation (BMI-2), surgery (BMI-3), titration polysomnogram (BMI-4), and second postoperative sleep study (BMI-5). Patients were categorized into groups (BMI ≥32 [BMI32], 25 ≤ BMI <32 [BMI25], BMI <25 [BMI18]) based BMI-1, and clinical outcomes were compared. RESULTS 253 patients were included. The BMI32 group showed a significant decrease in BMI between BMI-1 and BMI-3 (33.9 vs 32.2; P < .001) and a significant increase in BMI between BMI-3 and BMI-5 (32.2 vs 33.0; P = .047). Apnea-hypopnea index improvement and treatment success rate were not significantly different between groups. On univariate and multivariable logistic regression, a lower BMI-5 was significantly predictive of treatment success (odds ratio: 0.88; 95% confidence interval: 0.79-0.97; P = .016). BMI-5 was also significantly associated with improvement in apnea-hypopnea index (P = .002). Other BMI time points were not associated with measures of treatment success. CONCLUSIONS Reduced BMI after upper airway stimulation implantation, as opposed to baseline BMI, predicted treatment success. These findings may guide patient counseling, with implications for long-term adherence and therapy success. CITATION Renslo B, Virgen CG, Sawaf T, et al. Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter? J Clin Sleep Med. 2023;19(6):1061-1071.
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Affiliation(s)
- Bryan Renslo
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Celina G. Virgen
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Tuleen Sawaf
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Alexandra Arambula
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Kevin J. Sykes
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher Larsen
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - David T. Rouse
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
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13
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Saltagi MZ, Powell K, Saltagi AK, Stahl S, Manchanda S, Parker NP. Novel Outcome Analysis Tool for Hypoglossal Nerve Stimulator Sensor Lead Function and Comparison by Incision Type (2 Versus 3). Laryngoscope 2023; 133:423-430. [PMID: 36054604 PMCID: PMC10087886 DOI: 10.1002/lary.30365] [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: 03/29/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE No reported outcome measures have been established to evaluate sensor lead function in the hypoglossal nerve stimulator (HNS). This study describes the development of novel functional outcome measures for intraoperative sensor electrode function and compares 2-incision and 3-incision outcomes for HNS. METHODS A retrospective cohort study of 100 consecutive patients who underwent HNS between June 2019 and September 2021. Demographic information, intraoperative findings, and immediate postoperative outcomes were recorded. Structured parameters were developed to compare intraoperative waveforms with six outcome measures utilized: waveform syncing, waveform amplitude, sensory current leakage, shark-fin morphology, cardiac artifact, and overall impression. Two sleep surgeons and two sleep medicine specialists compared all waveforms in a blinded fashion and assigned scores on the Likert Scale. RESULTS The cohort included 50 three-incision and 50 two-incision patients. Age, gender, average body mass index, comorbidity profiles, and sleep endoscopy findings did not significantly differ between the two groups. No major complications occurred. The interclass-correlation-coefficient was greater than 0.7 for all comparisons (good to very good interrater reliability). There was no difference in waveform amplitude, cardiac artifact, sensory current leakage, or shark-fin morphology between the two groups. Waveform syncing and overall impression were statistically better in the 2-incision cohort. CONCLUSIONS This study is the first to define a structured method of HNS sensor electrode outcome measurement and showed consistent measures by surgeons and sleep medicine specialists. This article supports the transition to the 2-incision technique among surgeons for placement of the sensor lead. Consideration should be given to utilizing this novel tool in the clinical/research setting and validating these measures moving forward. LEVEL OF EVIDENCE 3 Laryngoscope, 133:423-430, 2023.
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Affiliation(s)
- Mohamad Z Saltagi
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Kayla Powell
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Abdul K Saltagi
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Stephanie Stahl
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.,Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Shalini Manchanda
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.,Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Noah P Parker
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.,Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
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14
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McKinlay AJ, Walters BK, Aden JK, Scalzitti NJ. Upper Airway Stimulation Therapy Effect on Blood Pressure. Otolaryngol Head Neck Surg 2023; 168:1551-1556. [PMID: 36939476 DOI: 10.1002/ohn.210] [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: 06/07/2022] [Revised: 11/04/2022] [Accepted: 11/10/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Upper airway stimulation (UAS) therapy has become increasingly utilized to treat obstructive sleep apnea, which is an independent risk factor for the development of hypertension. This study examines the impact of this therapy on blood pressure (BP). STUDY DESIGN Retrospective cross-sectional cohort study. SETTING Tertiary center, Military Health System. METHODS Patients who underwent UAS implantation at Brooke Army Medical Center between July 2015 and July 2020 were included if they used their device for at least 25 h/wk. Pre- and postoperative systolic BP, diastolic blood pressure (DBP), calculated mean arterial pressure (MAP), and the apnea-hypopnea index (AHI) were compared using paired t test or Wilcoxon's signed-rank test. RESULTS Thirty patients met the inclusion criteria. The median age was 60, and the median body mass index was 29.9 kg/m2 . The mean time between pre- and postoperative BP measurements was 11.6 months. AHI decreased from 35.1 to 16.5 events/h (p < .001). DBP decreased from 78.5 (73.8, 85.0) to 74.5 mm Hg (68.8, 81.3), with a mean difference of -3.7 mm Hg (p = .002). MAP decreased from 94.8 (89.6, 100.6) to 90.2 mm Hg (84.3, 100.0), with a mean difference of -3.7 mm Hg (p = .004). CONCLUSION UAS therapy was associated with a significant reduction in DBP, MAP, and AHI. These reductions in BP could potentially lead to favorable decreases in cardiovascular morbidity.
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Affiliation(s)
- Alex J McKinlay
- Department of Otolaryngology, Brooke Army Medical Center, San Antonio, Texas, USA.,Sleep Disorders Center, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas, USA
| | - Benjamin K Walters
- Department of Otolaryngology, Brooke Army Medical Center, San Antonio, Texas, USA
| | - James K Aden
- Graduate Medical Education, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Nicholas J Scalzitti
- Department of Otolaryngology, Brooke Army Medical Center, San Antonio, Texas, USA.,Sleep Disorders Center, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas, USA
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15
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Maresch KJ. Perioperative and Perianesthesia Considerations for Hypoglossal Nerve Stimulator Implantation in Obstructive Sleep Apnea Patients. J Perianesth Nurs 2022; 37:760-765.e1. [PMID: 35618616 DOI: 10.1016/j.jopan.2022.02.010] [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: 09/16/2021] [Revised: 02/06/2022] [Accepted: 02/11/2022] [Indexed: 10/18/2022]
Abstract
Hypoglossal nerve stimulation (Inspire Medical Systems, Maple Grove, Minnesota) is an innovative treatment option for eligible patients with moderate to severe obstructive sleep apnea (OSA). Since U.S. Food and Drug Administration approval in 2014, over 18,000 patients have been implanted. The device includes an implanted pacemaker-sized pulse generator, one sensing lead, and one stimulation lead. During sleep, inspirations and expirations are detected by the sensing lead. At end expiration, the stimulation lead triggers the hypoglossal nerve to contract and stiffen the tongue thus preventing airway obstruction and improving OSA. Perioperative and perianesthesia nurses have an important role in caring for these patients during all aspects of the surgical insertion process: evaluation for eligibility, device implantation, and future visits to the perioperative area for related and unrelated procedures. This article reviews anatomic and physiologic factors contributing to airway collapse in OSA, function of the hypoglossal nerve stimulation device, the evaluation, implantation, and activation process, and considerations for patient care in the perioperative and perianesthesia periods. Precautions needed for other therapies, including Magnetic Resonance Imaging, diathermy, and radiation are also discussed.
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Affiliation(s)
- Karen J Maresch
- Staff CRNA, University of Pittsburgh Medical Center, Pittsburgh, PA.
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16
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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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17
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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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18
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Luyster FS, Ni Q, Lee K, Harrison C, Ramprasad VH, Soose RJ, Strollo PJ. Factors affecting obstructive sleep apnea patients' use of upper airway stimulation treatment. J Clin Sleep Med 2022; 18:2207-2215. [PMID: 35689597 PMCID: PMC9435328 DOI: 10.5664/jcsm.10086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/19/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Upper airway stimulation (UAS) is an alternative treatment for obstructive sleep apnea that must be activated nightly. Although the implanted device offsets the mask- or pressure-related side effects often associated with continuous positive airway pressure therapy, some UAS recipients do not use the therapy consistently. This study qualitatively explored factors associated with UAS usage in obstructive sleep apnea patients. METHODS Semistructured interviews were conducted with 24 obstructive sleep apnea patients who received UAS treatment. Twelve patients were categorized as high users with mean usage of ≥ 4 hours/night and 12 were categorized as low users with < 4 hours/night or nonuse. Interviews explored patients' experiences regarding barriers and facilitators to UAS use and their advice for new UAS recipients. Demographic and clinical data including the Insomnia Severity Index and Generalized Anxiety Disorder Scale were collected. RESULTS Compared to high users, low users had higher levels of insomnia (mean Insomnia Severity Index: 3.6 vs 15.2, respectively) and anxiety (mean Generalized Anxiety Disorder Scale: 3.4 vs 6.9). High users reported more positive experiences with UAS treatment, such as improvements in symptoms and convenience of treatment, as facilitators of use. Low users tended to focus on the negative aspects of treatment, particularly stimulation-related discomfort and associated sleep disturbance. CONCLUSIONS Insomnia with or without anxiety contributes to differing patient-reported experiences in high vs low user groups, with increased insomnia symptoms among low users. Improved understanding of the specific barrier and facilitators of UAS adherence may drive better long-term use and more personalized management strategies, including concomitant insomnia treatment. CLINICAL TRIALS REGISTRATION Registry: ClinicalTrials.gov; Name: Stimulation Therapy for Apnea: Reporting Thoughts (START); URL: https://clinicaltrials.gov/ct2/show/NCT04768543; Identifier: NCT04768543. CITATION Luyster FS, Ni Q, Lee K, et al. Factors affecting obstructive sleep apnea patients' use of upper airway stimulation treatment. J Clin Sleep Med. 2022;18(9):2207-2215.
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Affiliation(s)
- Faith S. Luyster
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Quan Ni
- Inspire Medical Systems, Inc., Minneapolis, Minnesota
| | - Kent Lee
- Inspire Medical Systems, Inc., Minneapolis, Minnesota
| | - Christine Harrison
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vaibhav H. Ramprasad
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ryan J. Soose
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick J. Strollo
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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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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20
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Sagalow ES, Rodin J, Estephan L, Jackson J, Crippen M, Boon M, Huntley C. Two-Incision Approach for Hypoglossal Nerve Stimulator Placement: A Single Institution Assessment. Laryngoscope 2022; 132:1687-1691. [PMID: 35147978 DOI: 10.1002/lary.30050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 10/28/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE(S) Upper airway stimulator (UAS) placement is a treatment for obstructive sleep apnea (OSA) with few complications and low morbidity. UAS placement has traditionally been performed using a three-incision approach, however, it has been implanted using a two-incision approach. This approach could significantly decrease operation time without a difference in postoperative complications, demonstrating its safety and feasibility for UAS placement. The objective was to assess operative time and complication rate in the two-incision approach for UAS placement compared to the three-incision approach. STUDY DESIGN Retrospectively reviewed. METHODS Patients who underwent UAS placement using the two- or three-incision approach at a single academic institution from November 2014 to June 2021 were retrospectively reviewed. The two-incision approach did not include the incision at the mid-axillary line. Main outcome measures included operation time and complication rates. RESULTS Three-hundred forty-eight patients underwent UAS placement. The three-incision approach demonstrated an average operation time of 143.3 minutes whereas the two-incision approach averaged 129.4 minutes (P < .001). There was no significant difference in rate of postoperative complications between the two- and three-incision cohorts including pneumothorax (0% vs. 0.4%, P > .99), patient-reported discomfort (5.6% vs. 6.5%, P > .99), activity restriction (0% vs. 1.4%, P > .50), and incisional pain (0.0% vs. 1.0%, P > .99). No patients experienced incision site bleeding or infection. The two-incision approach was associated with decreased rate of revision surgery (0.0% vs. 5.4%, P = .048). CONCLUSION The UAS two-incision approach proved to have a significantly shorter operative time without an increase in complications as compared to the three-incision approach. This approach is a safe and feasible option. LEVEL OF EVIDENCE III Laryngoscope, 2022.
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Affiliation(s)
- Emily S Sagalow
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Julianna Rodin
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Leonard Estephan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Jarrett Jackson
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Meghan Crippen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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21
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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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22
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Suurna MV, Steffen A, Boon M, Chio E, Copper M, Patil RD, Green K, Hanson R, Heiser C, Huntley C, Kent D, Larsen C, Manchanda S, Maurer JT, Soose R, de Vries N, Walia HK, Thaler E. Impact of Body Mass Index and Discomfort on Upper Airway Stimulation: ADHERE Registry 2020 Update. Laryngoscope 2021; 131:2616-2624. [PMID: 34626128 DOI: 10.1002/lary.29755] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 06/06/2021] [Accepted: 07/06/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To provide the ADHERE registry Upper Airway Stimulation (UAS) outcomes update, including analyses grouped by body mass index (BMI) and therapy discomfort. STUDY DESIGN Prospective observational study. METHODS ADHERE captures UAS outcomes including apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), therapy usage, patient satisfaction, clinician assessment, and safety over a 1-year period. BMI ≤32 kg/m2 (BMI32 ) and 32 < BMI ≤35 kg/m2 (BMI35 ) group outcomes were examined. RESULTS One thousand eight hundred forty-nine patients enrolled in ADHERE, 1,019 reached final visit, 843 completed the visit. Significant changes in AHI (-20.9, P < .0001) and ESS (- 4.4, P < .0001) were demonstrated. Mean therapy usage was 5.6 ± 2.2 hr/day. Significant therapy use difference was present in patients with reported discomfort versus no discomfort (4.9 ± 2.5 vs. 5.7 ± 2.1 hr/day, P = .01). Patients with discomfort had higher final visit mean AHI versus without discomfort (18.9 ± 18.5 vs. 13.5 ± 13.7 events/hr, P = .01). Changes in AHI and ESS were not significantly different. Serious adverse events reported in 2.3% of patients. Device revision rate was 1.9%. Surgical success was less likely in BMI35 versus BMI32 patients (59.8% vs. 72.2%, P = .02). There was a significant therapy use difference: 5.8 ± 2.0 hr/day in BMI32 versus 5.2 ± 2.2 hr/day in BMI35 (P = .028). CONCLUSIONS Data from ADHERE demonstrate high efficacy rates for UAS. Although surgical response rate differs between BMI32 and BMI35 patient groups, the AHI and ESS reduction is similar. Discomfort affects therapy adherence and efficacy. Thus, proper therapy settings adjustment to ensure comfort is imperative to improve outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2616-2624, 2021.
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Affiliation(s)
- Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, U.S.A
| | - Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Maurits Boon
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital
| | - Eugene Chio
- Department of Otolaryngology - Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Marcel Copper
- Department of Otolaryngology-Head and Neck Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Reena Dhanda Patil
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.,Department of Surgical Services, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, U.S.A
| | - Katherine Green
- Department of Otolaryngology, University of Colorado, Denver, Colorado, U.S.A
| | - Ronald Hanson
- Otolaryngology, St. Cloud Ear, Nose, Throat Clinic, St. Cloud, Minnesota, U.S.A
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Colin Huntley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital
| | - David Kent
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Christopher Larsen
- Department of Otolaryngology-Head and Neck Surgery, Kansas University Medical Center, Andover, Kansas, U.S.A
| | - Shalini Manchanda
- Section of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, U.S.A
| | - 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, Pennsylvania, U.S.A
| | - Nico de Vries
- Department of Ear, Nose and Throat, OLVG, Department of Oral Kinesiology, ACTA Amsterdam, Amsterdam, The Netherlands
| | - Harneet K Walia
- Cleveland Clinic, Sleep Disorders Center, Neurological Institute, Cleveland, Ohio, U.S.A
| | - Erica Thaler
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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23
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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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24
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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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25
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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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Yalamanchi P, Mott N, Ali SA, Peddireddy NS, Kovatch KJ, Stanley JJ, Hoff PT. Evaluation of In-Office Volitional Snore as a Screening Tool for Candidacy for Hypoglossal Nerve Stimulation. Otolaryngol Head Neck Surg 2021; 166:595-597. [PMID: 34182856 DOI: 10.1177/01945998211023733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/15/2022]
Abstract
Candidacy evaluation for hypoglossal nerve stimulation (HGNS) is resource intensive. This proof-of-concept study investigates use of in-office volitional snore during flexible laryngoscopy as an efficient, cost-effective screening tool for HGNS evaluation. Adults with moderate to severe obstructive sleep apnea that failed continuous positive airway pressure treatment (n = 41) underwent evaluation for HGNS from 2018 to 2019. Volitional snore and drug-induced sleep endoscopy (DISE) data were collected and scored by VOTE classification (velum/palate, oropharynx, tongue base, epiglottis). A chi-square test of independence was performed that demonstrated a significant relationship between volitional snore and DISE (χ2 = 4.39, P = .036) for velum collapse pattern. Sensitivity and specificity of volitional snore for detecting velum collapse pattern were 93.6% (95% CI, 75.6%-99.2%) and 40% (95% CI, 12.2%-73.8%), respectively, illustrating its utility in screening for HGNS. Patients who demonstrate anterior-posterior velum collapse on volitional snore may be excellent candidates for confirmatory DISE at the time of HGNS implantation.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole Mott
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Syed Ahmed Ali
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nithin S Peddireddy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey J Stanley
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul T Hoff
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Rodríguez Hermosa JL, Calle M, Guerassimova I, Fernández B, Montero VJ, Álvarez-Sala JL. Noninvasive electrical stimulation of oropharyngeal muscles in obstructive sleep apnea. Expert Rev Respir Med 2021; 15:1447-1460. [PMID: 34038311 DOI: 10.1080/17476348.2021.1935244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Continuous positive airway pressure (CPAP) therapy remains the standard treatment for obstructive sleep apnea. However, its proven effect is useless if the patient does not tolerate the treatment. The electrical stimulation approach has been investigated for several decades now and it seems that the implantable devices for invasive electrical stimulation of hypoglossal nerve are viewed as effective with some of them already approved for human use.Areas covered: in this review, we intent to summarize the existing records of noninvasive stimulation in sleep apnea to make the scientific community aware of the details before deciding on its future. We believe that this is a battle still to fight and more could be done bearing in mind the safety of this method.Expertopinion: noninvasive electrical stimulation has been left behind based on few, small and inconsistent studies using different stimulation parameters. These studies are difficult to compare and to draw conclusions.Electrical stimulation is a field for research in the treatment of obstructive sleep apnea, with many aspects still to be discovered, and which may become a therapeutic alternative to the use of CPAP in certain patients.
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Affiliation(s)
- Juan Luis Rodríguez Hermosa
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Myriam Calle
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Ina Guerassimova
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | | | - Víctor Javier Montero
- Torytrans SL, Innovative and technological-based company, Almagro, Ciudad Real, Spain
| | - José Luis Álvarez-Sala
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
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Abstract
A 75-year-old man with body mass index of 30.5 kg/m² and severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 72 events/h was referred for upper airway stimulation (UAS) therapy. Past medical history was significant for cardiovascular disease including congestive heart failure due to ischemic cardiomyopathy with impaired left ventricular function and ejection fraction of 35%. Following evaluation of clinical and polysomnographic data, he was an appropriate candidate for UAS and underwent uncomplicated implantation. Three months postoperatively, polysomnography showed a titrated AHI of 0 events/h. Follow-up cardiac evaluation revealed ejection fraction increase to 47% since implantation. No interval change in medical management or body mass index had occurred. Given the high prevalence of OSA in patients with cardiovascular disease, UAS may become an important adjunct in the comprehensive multidisciplinary treatment of heart failure in patients with OSA. Further clinical studies are required to investigate the impact of UAS on treatment and prognosis of heart disease.
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Affiliation(s)
- Sophia Rokkas
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin Huntley
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Maurits Boon
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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29
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Op de Beeck S, Wellman A, Dieltjens M, Strohl KP, Willemen M, Van de Heyning PH, Verbraecken JA, Vanderveken OM, Sands SA. Endotypic Mechanisms of Successful Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea. Am J Respir Crit Care Med 2021; 203:746-755. [PMID: 32970962 DOI: 10.1164/rccm.202006-2176oc] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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: 12/11/2022] Open
Abstract
Rationale: Approximately one-third of patients with obstructive sleep apnea (OSA) treated with hypoglossal nerve stimulation (HGNS) therapy are incomplete responders, despite careful patient selection based on baseline characteristics and drug-induced sleep endoscopy.Objectives: Here we use polysomnographic endotyping to assess the pathophysiological mechanisms underlying favorable versus incomplete responses to HGNS therapy.Methods: Baseline polysomnography data of the STAR (Stimulation Therapy for Apnea Reduction) trial were included. Raw baseline polysomnographic data from 91/126 patients were available for analysis. Traits-loop gain, arousal threshold, collapsibility, and muscle compensation-were calculated from the baseline polysomnography data according to Sands and colleagues (AJRCCM 2018, SLEEP 2018). Logistic regression assessed apnea-hypopnea index (AHI)-adjusted associations between HGNS response (>50% reduction in AHI to <10/h at 1 yr) and OSA traits.Measurements and Main Results: Overall, HGNS treatment reduced AHI from 30.7 (24.9-39.9) to 8.5 (4.0-19.5) events/h (P < 0.0001; median [quartiles 1-3]); N = 53/91 were responders. In adjusted analysis, a favorable response to therapy was independently associated with higher arousal threshold (odds ratio [95% confidence interval]: 6.76 [2.44-23.3], P = 0.001), greater compensation (odds ratio: 4.22 [1.70-12.55] per SD, P = 0.004), and lower loop gain (in milder collapsibility, per significant interaction, P = 0.003). The higher arousal threshold was evident in responders before adjusted analysis. Predicted responders had an approximately fourfold lower treatment AHI versus predicted nonresponders (4.9 [2.7-8.5] vs. 20.7 [10.9-29.7], P < 0.0001; median [quartiles 1-3]); differences remained significant after cross-validation.Conclusions: Favorable responses to HGNS therapy are associated with the pathophysiological traits causing OSA, particularly a higher arousal threshold. Along with established criteria, individuals with favorable traits could potentially be prioritized for precision HGNS therapy.This analysis was a secondary analysis of the STAR trial registered with clinicaltrials.gov (NCT01161420).
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Affiliation(s)
- Sara Op de Beeck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery.,Multidisciplinary Sleep Disorders Centre, and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Marijke Dieltjens
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery
| | - Kingman P Strohl
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Paul H Van de Heyning
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery
| | - Johan A Verbraecken
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, and.,Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery.,Multidisciplinary Sleep Disorders Centre, and
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
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Pawlak D, Bohorquez D, König IR, Steffen A, Thaler ER. Effect of Electrode Configuration and Impulse Strength on Airway Patency in Neurostimulation for Obstructive Sleep Apnea. Laryngoscope 2021; 131:2148-2153. [PMID: 33864394 DOI: 10.1002/lary.29530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hypoglossal nerve stimulation (HNS) has gained increasing interest for the treatment of patients with obstructive sleep apnea (OSA). Drug-induced sleep endoscopy (DISE) can both exclude improper airway collapse patterns and visualize airway changes under stimulation. Stimulation outcome effects depend on the impulse voltage and electric field resulting from the electrode configuration of the implanted device. The effects of various combinations of voltage and electric field on DISE airway patterns in contrast to awake endoscopy are unknown. STUDY DESIGN Cohort study. METHODS During therapy adjustment about 6 months after implantation, patients underwent a DISE and awake endoscopy with 100% and 125% of functional voltage in three typical electrode configurations (+ - +, o - o, - - -). All videos were analyzed by two separate persons for the opening of the airway at velum, tongue base, and epiglottis level. RESULTS Thirty patients showed typical demographic data. The opening effects were visible in all patients, but there were changes between different electrode configurations. Several demographic or therapeutic aspects such as obesity, OSA severity, or prior soft palate surgery were associated with changes arising from different electrode configurations, but none resulted in a consistently better airway opening. CONCLUSIONS In patients with poor results during the therapy adjustment, electric configuration changes can improve airway patency-an independent variable from increasing voltage. As these effects can only be seen in awake endoscopy or DISE, both endoscopies with live stimulation may be considered in cases with insufficient improvement in apnea-hypopnea index after initiation of HNS therapy. LEVEL OF EVIDENCE Prospective case series; level 4. Laryngoscope, 131:2148-2153, 2021.
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Affiliation(s)
- Dominik Pawlak
- Department of Otorhinolaryngology, University of Lubeck, Lubeck, Germany
| | - Dominique Bohorquez
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Inke R König
- Department of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Armin Steffen
- Department of Otorhinolaryngology, University of Lubeck, Lubeck, Germany
| | - Erica R Thaler
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Bachour A, Bäck L, Pietarinen P. No changes in nocturnal respiration with hypoglossal neurostimulation therapy for obstructive sleep apnoea. Clin Respir J 2021; 15:329-335. [PMID: 33184972 DOI: 10.1111/crj.13303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 10/13/2020] [Accepted: 11/08/2020] [Indexed: 06/11/2023]
Abstract
STUDY OBJECTIVES We initiated Hypoglossal Neurostimulation therapy (HGNS) at the Helsinki University Hospital in late 2014. Here, we report our experience. METHODS We included all 15 HGNS patients. All patients had previously failed both CPAP and oral appliance therapy for sleep apnoea. Overnight polysomnography parameters were analysed before and at 1.5 years with HGNS. RESULTS Mean ± SD patient age was 53 ± 6 years; 2 women and 13 men were included. Mean ± SD efficient CPAP level was 11.4 ± 3.4 cm H2 O. Implantation technically succeeded in all patients. There were no significant changes of AHI and ODI4 after HGNS [median (quartile) 29.2/h (19.8-38.7) versus 30.1/h (15.6-52.6) and 15.0/h (5.9-20) versus 12.5/h (6.9-30.2) respectively]. CONCLUSION We did not observe significant changes in AHI and ODI4 indices with HGNS therapy. Larger multicentre randomised controlled trials are necessary before wider international use of HGNS.
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Affiliation(s)
- Adel Bachour
- Sleep Unit, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Leif Bäck
- Head and Neck Center, ENT Department, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Petra Pietarinen
- Head and Neck Center, ENT Department, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Flynn J, Boyd C, Yalamanchali S, Rouse D, Goodwin S, Penn J, Larsen C. The Effect of Lateral Pharyngeal Collapse Patterns on Therapy Response in Upper Airway Stimulation Surgery. Ann Otol Rhinol Laryngol 2021; 130:985-989. [PMID: 33455440 DOI: 10.1177/0003489420987979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/16/2022]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. METHODS A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. RESULTS About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, P = .001), AHI (29.8 vs 5.4, P < .001) and minimum oxygen saturation (79% vs 83%, P < .001). No DISE findings significantly predicted AHI response after UAS. Specifically, multiple types of lateral pharyngeal collapse patterns did not adversely effect change in AHI or AHI response rate. CONCLUSION Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. LEVEL OF EVIDENCE VI.
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Affiliation(s)
- John Flynn
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Christopher Boyd
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Sreeya Yalamanchali
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - David Rouse
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Sara Goodwin
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Joseph Penn
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Christopher Larsen
- Department of Otolaryngology-Head and Neck Surgery, The University of Kansas School of Medicine, Kansas City, KS, USA
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Huyett P, Kent DT, D'Agostino MA, Green KK, Soose RJ, Kaffenberger TM, Woodson BT, Huntley C, Boon MS, Heiser C, Birk A, Suurna MV, Lin HS, Waxman JA, Kezirian EJ. Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study. Laryngoscope 2021; 131:1676-1682. [PMID: 33443811 DOI: 10.1002/lary.29396] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 07/16/2020] [Revised: 12/03/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN Cohort study. METHODS A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1676-1682, 2021.
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Affiliation(s)
- Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Mark A D'Agostino
- Southern New England Ear, Nose and Throat Group, Middlesex Hospital, Middlesex, Connecticut, U.S.A.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Ryan J Soose
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Thomas M Kaffenberger
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Maurits S Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Amelie Birk
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, U.S.A
| | - Ho-Sheng Lin
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Jonathan A Waxman
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Eric J Kezirian
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, California, Los Angeles, U.S.A
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Abstract
Hypoglossal nerve stimulation (HGNS) therapy was approved in 2014 for the treatment of obstructive sleep apnea in patients who are intolerant to continuous positive airway pressure (CPAP) therapy, which is reported in up to 40-60% of patients. This therapy works via direct neurostimulation of the hypoglossal nerve in synchrony with respiration, to open the airway via tongue stiffening and protrusion. Studies have demonstrated significant reductions in both respiratory parameters such as disordered breathing indices, as well as subjective sleep complaints, such as daytime sleepiness, with the use of this therapy. This has increased the repertoire of treatment options for sleep providers to recommend to those patients that are intolerant to CPAP therapy.
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Affiliation(s)
- Michael D Olson
- Department of Otolaryngology, Head and Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Mithri R Junna
- Center for Sleep Medicine, Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Stewart M, Estephan L, Thaler A, Zhan T, Connors K, Malkani K, Hunt P, Boon M, Huntley C. Reduced Recovery Times with Total Intravenous Anesthesia in Patients with Obstructive Sleep Apnea. Laryngoscope 2020; 131:925-931. [PMID: 33141982 DOI: 10.1002/lary.29216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/25/2020] [Revised: 09/10/2020] [Accepted: 10/15/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES/HYPOTHESIS There is currently no standard of care in terms of anesthesia modality for patients receiving upper airway surgery with comorbid obstructive sleep apnea (OSA). Although both total intravenous anesthesia (TIVA) and volatile gas anesthesia are commonly utilized in ambulatory otolaryngology surgery, it is currently unclear if there are any advantages with one modality over the other. We hypothesize that patients receiving upper airway surgery with comorbid OSA will have quicker recovery times with TIVA. STUDY DESIGN Retrospective chart review from January 2019 to December 2019. METHODS All patients aged 18 and older receiving upper airway surgery (upper airway stimulation, nasal surgery, modified uvulopalatopharyngoplasty) were included. Patients were excluded when there was incomplete or missing data in the electronic medical record. RESULTS Eighty-six patients received gas anesthesia and 62 patients received TIVA. Phase I recovery times were significantly reduced by surgery and by severity of OSA: nasal surgery, upper airway stimulation, and modified uvulopalatopharyngoplasty had a reduction of 35.5 minutes (P < .001), 42.5 minutes (P < .001), and 36 minutes (P = .022), respectively. In terms of severity, mild, moderate, and severe OSA had reductions of 23.5 minutes (P = .004), 52 minutes (P = .004), and 47 minutes (P < .001), respectively. The severity of OSA generally correlated with increased time spent in Phase I: as severity increased, Phase I time increased by 16.8 minutes for the gas cohort (P < .001), whereas in the TIVA cohort, it increased only 4.3 minutes (P = .489). CONCLUSION Patients having upper airway surgery with comorbid OSA that received TIVA (propofol and remifentanil) spent significantly less time in Phase I and the recovery room overall compared to those receiving volatile gas anesthesia in the form of sevoflurane, and this correlated with the severity of OSA. LEVEL OF EVIDENCE 3. Laryngoscope, 131:925-931, 2021.
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Affiliation(s)
- Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Leonard Estephan
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Adam Thaler
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Kevin Connors
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Kabir Malkani
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Patrick Hunt
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Maurits Boon
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Colin Huntley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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Sturm JJ, Lee CH, Modik O, Suurna MV. Intraoperative identification of mixed activation profiles during hypoglossal nerve stimulation. J Clin Sleep Med 2020; 16:1769-1774. [PMID: 32677611 DOI: 10.5664/jcsm.8694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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 The effectiveness of hypoglossal nerve stimulation (HGNS) in the treatment of obstructive sleep apnea (OSA) depends on the selective stimulation of nerve fibers that innervate the tongue muscles that produce tongue protrusion (genioglossus) and stiffening (transverse/vertical) while avoiding fibers that innervate muscles that produce tongue retraction (styloglossus/hyoglossus). Postoperative treatment failures can be related to mixed activation of retractor and protrusor muscles, despite intraoperative efforts to identify and avoid nerve fibers that innervate the retractor muscles. This study describes a novel intraoperative protocol that more optimally identifies mixed activation by utilizing an expanded set of stimulation/recording parameters. METHODS This study was a case series in a university hospital setting of patients undergoing unilateral hypoglossal nerve stimulation implantation for obstructive sleep apnea. Data included electromyographic responses in the genioglossus and styloglossus/hyoglossus to intraoperative stimulation with an implantable pulse generator using unipolar (- - -, o-o) and bipolar (+-+) settings. RESULTS In a subset of patients (3/55), low-intensity unipolar implantable pulse generator stimulation revealed significant mixed activation of the styloglossus/hyoglossus and genioglossus muscles that was not evident under standard bipolar implantable pulse generator stimulation conditions. Additional surgical dissection and repositioning of the electrode stimulation cuff reduced mixed activation. CONCLUSIONS A novel intraoperative neurophysiological monitoring protocol was able to detect significant mixed activation during hypoglossal nerve stimulation that was otherwise absent using standard parameters. This enabled successful electrode cuff repositioning and a dramatic reduction of mixed activation.
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Affiliation(s)
- Joshua J Sturm
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York
| | - Clara H Lee
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York
| | - Oleg Modik
- Department of Neurology, Division of Clinical Neurophysiology, Weill Cornell Medicine, New York, New York
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York
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Bellamkonda N, Shiba T, Mendelsohn AH. Adverse Events in Hypoglossal Nerve Stimulator Implantation: 5-Year Analysis of the FDA MAUDE Database. Otolaryngol Head Neck Surg 2020; 164:443-447. [PMID: 32957866 DOI: 10.1177/0194599820960069] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 12/24/2022]
Abstract
OBJECTIVE Use of hypoglossal nerve stimulator implantation has dramatically improved the surgical treatment of multilevel airway collapse during obstructive sleep apnea (OSA). Understanding causes of adverse events and their impact on patients undergoing stimulator implantation will help improve patient preparation and surgical practices to avoid future complications. STUDY DESIGN This study is a retrospective review of the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, a publicly available voluntary reporting system. SETTING National patient event database. METHODS The MAUDE database was searched for reports associated with the terms "hypoglossal nerve stimulator" and "Inspire," being the only currently FDA-approved system for upper airway stimulation for OSA. All records were searched with the events limited in dates between May 2014 and September 2019. RESULTS A total of 132 patient reports were identified over the 5-year inclusion period, containing 134 adverse events. The reported adverse events resulted in 32 device revision procedures as well as 17 explantations. Device migration and infection were 2 of the most commonly reported adverse events. Complications not witnessed in previous large-scale clinical trials included pneumothorax, pleural effusion, and lead migration into the pleural space. CONCLUSION Previous data have demonstrated hypoglossal nerve stimulator implantation results in reliable OSA improvement. However, a number of technical difficulties and complications still exist during the perioperative period, which should be communicated to patients during the surgical consent process.
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Affiliation(s)
- Nikhil Bellamkonda
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Travis Shiba
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Abie H Mendelsohn
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Larsen C, Boyd C, Villwock M, Steffen A, Heiser C, Boon M, Huntley C, Doghramji K, Soose RJ, Kominsky A, Waters T, Withrow K, Parker N, Thaler E, Dhanda Patil R, Green KK, Chio E, Suurna M, Schell A, Strohl K. Evaluation of Surgical Learning Curve Effect on Obstructive Sleep Apnea Outcomes in Upper Airway Stimulation. Ann Otol Rhinol Laryngol 2020; 130:467-474. [PMID: 32924533 DOI: 10.1177/0003489420958733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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 An increasing number of facilities offer Upper Airway Stimulation (UAS) with varying levels of experience. The goal was to quantify whether a surgical learning curve exists in operative or sleep outcomes in UAS. METHODS International multi-center retrospective review of the ADHERE registry, a prospective international multi-center study collecting UAS outcomes. ADHERE registry centers with at least 20 implants and outcomes data through at least 6-month follow-up were reviewed. Cases were divided into two groups based on implant order (the first 10 or second 10 consecutive implants at a given site). Group differences were assessed using Mann-Whitney U-tests, Chi-squared tests, or Fisher's Exact tests, as appropriate. A Mann-Kendall trend test was used to detect if there was a monotonic trend in operative time. Sleep outcome equivalence between experience groups was assessed using the two one-sided tests approach. RESULTS Thirteen facilities met inclusion criteria, contributing 260 patients. Complication rates did not significantly differ between groups (P = .808). Operative time exhibited a significant downward trend (P < .001), with the median operative time dropping from 150 minutes for the first 10 implants to 134 minutes for the subsequent 10 implants. The decrease in AHI from baseline to 12-month follow-up was equivalent between the first and second ten (22.8 vs 21.2 events/hour, respectively, P < .001). Similarly, the first and second ten groups had equivalent ESS decreases at 6 months (2.0 vs 2.0, respectively, P < .001). ESS outcomes remained equivalent for those with data through 12-months. CONCLUSIONS Across the centers' first 20 implants, an approximately 11% reduction operative time was identified, however, no learning curve effect was seen for 6-month or 12-month AHI or ESS over the first twenty implants. Ongoing monitoring through the ADHERE registry will help measure the impact of evolving provider and patient specific characteristics as the number of implant centers increases.
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Affiliation(s)
| | | | - Mark Villwock
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Armin Steffen
- University Clinic Schleswig-Holstein, Lubeck, Germany
| | | | - Maurits Boon
- Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | | | | | | | | | - Noah Parker
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erica Thaler
- University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Eugene Chio
- The Ohio State University, Columbus, OH, USA
| | | | - Amy Schell
- University Hospitals, Cleveland, OH, USA
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Steffen A, König IR, Baptista PM, Abrams N, Jeschke S, Hasselbacher K. Home Sleep Testing to Direct Upper Airway Stimulation Therapy Optimization for Sleep Apnea. Laryngoscope 2020; 131:E1375-E1379. [PMID: 32865831 DOI: 10.1002/lary.29043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 03/04/2020] [Revised: 07/26/2020] [Accepted: 07/31/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES/HYPOTHESIS Selective upper airway stimulation (sUAS) is a well-established treatment option for obstructive sleep apnea (OSA). This study aimed to determine if there are benefits in performing a home sleep test (HST) to evaluate postoperative sUAS effectiveness after patient acclimatization compared to the generally used polysomnography (PSG) titration, as measured by long-term follow-up outcomes. STUDY DESIGN Retrospective comparative cohort analysis. METHODS We conducted an analysis of consecutive patients at our center who had completed a 6-month follow-up (month 6 [M6]) and recorded data from M6, month 12 (M12), and month 24 (M24). After device activation, we performed an HST with the patient's stimulation settings, and measured the apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and device usage. These values were compared to patients who had undergone PSG-based device titration. RESULTS Baseline values of the initial 131 patients show high ESS and moderate OSA. At the 2-month time point of the HST, nearly half of the patients (46.2%) reached an AHI ≤15/hr, and approximately a fifth (19.2%) reached <5/hr. The PSG and HST groups differed in median ESS at M24, but no other differences were observed for ESS at M6 and M12. Both groups showed similar AHI, oxygen desaturation, and usage hours per week. CONCLUSIONS Adjusting therapy by using the HST technique after device activation and acclimatization has clinical and economic advantages. These advantages are contingent on several conditions being met when deviating from the standard device protocol, including precise communication with the referring sleep medicine physicians, especially their role in helping with long-term follow-up. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1375-E1379, 2021.
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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
| | - Peter M Baptista
- Department of Otorhinolaryngology, Navarra University Hospital, Pamplona, Spain
| | - Nils Abrams
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Stephanie Jeschke
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
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Jenks CM, Yu JL, Schmitt KA, Schwab RJ, Thaler ER. Prospective Determination of Airway Response to Upper Airway Stimulation: A New Opportunity for Advanced Device Titration. Laryngoscope 2020; 131:218-223. [PMID: 32557705 DOI: 10.1002/lary.28758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Response to upper airway stimulation (UAS) is associated with the degree of airway opening during stimulation. UAS programming may affect this opening. The objective of this study was to examine airway changes in response to five different electrode configurations programmable within the Inspire UAS system. STUDY DESIGN Prospective single-arm cohort study. METHODS Subjects who underwent UAS implantation were recruited for a prospective single-arm cohort study during UAS device activation. Functional thresholds were recorded for all settings. Awake nasopharyngoscopy was performed to examine the retropalatal (RP) and retroglossal (RG) regions at rest and during activation with all settings at their functional thresholds. Cross-sectional measurements were made by two blinded reviewers and reported as percent change in airway size. RESULTS Sixteen patients were included. The standard setting (+-+) resulted in the greatest change in RP area in 43.8% of patients. An alternative setting resulted in greatest change in 56.2% of patients (--- and o-o in 18.8% each, -o- in 12.5%, and -+- in 6.3% of patients). Average response to all five settings was utilized to classify degree of palatoglossal coupling. Most patients had some enlargement (20%-70% change in RP area, 43.8%) or no enlargement (<20% change, 43.8%), whereas a minority of patients (12.5%) had marked enlargement (>70% change). RP and RG expansion were not correlated. CONCLUSION Degree of RP expansion varied among patients and settings. Although the standard setting resulted in greatest RP change in a plurality of patients, over half had a greater response to an alternative setting. Future studies should address whether choice of setting based on RP expansion results in improved outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 131:218-223, 2021.
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Affiliation(s)
- Carolyn M Jenks
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason L Yu
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Division of Sleep Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Katherine A Schmitt
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Richard J Schwab
- Division of Sleep Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Erica R Thaler
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Steffen A, Sommer JU, Strohl K, Hasselbacher K, Suurna MV, Hofauer B, Heiser C. Changes in breath cycle sensing affect outcomes in upper airway stimulation in sleep apnea. Laryngoscope Investig Otolaryngol 2020; 5:326-329. [PMID: 32337364 PMCID: PMC7178441 DOI: 10.1002/lio2.334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/25/2019] [Revised: 09/20/2019] [Accepted: 11/01/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Upper Airway Stimulation (UAS) is a well-established therapy option for obstructive sleep apnea (OSA). AIMS There are no data on whether respiratory sensing contributes to successful UAS therapy. MATERIALS & METHODS After initial measurements of 3 implanted patients (M1), the sensing signal was inverted (M2) without changing other parameters. Two weeks later, the signal was converted back again, and the sensitivity of breathing cycle detection was turned to a very low state (M3). RESULTS At M2 and M3, the apnea-hypopnea index and oxygen desaturation index increased. DISCUSSION Correct respiratory sensing is important for controlling OSA using UAS. CONCLUSIONS Therefore, implant centers should should optimize respiratory sensing placement and adjustment.
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Affiliation(s)
- Armin Steffen
- Department of OtorhinolaryngologyUniversity of LübeckLübeckGermany
| | - J. Ulrich Sommer
- Helios University Hospital Wuppertal, University Witten/HerdeckeWuppertalGermany
| | - Kingman Strohl
- University Hospitals Cleveland Medical Center, Case Western Reserve UniversityClevelandOhio
| | | | - Maria V. Suurna
- Department of Otolaryngology‐Head and Neck SurgeryWeill Cornell MedicineNew YorkNew York
| | - Benedikt Hofauer
- Department of Otorhinolaryngology, Head and Neck SurgeryUniversity of FreiburgFreiburg im BreisgauGermany
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck SurgeryTechnische Universität MünchenMunichGermany
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Patel J, Daniels K, Bogdan L, Huntley C, Boon M. Effect of Gender, Age, and Profound Disease on Upper Airway Stimulation Outcomes. Ann Otol Rhinol Laryngol 2020; 129:772-780. [PMID: 32172600 DOI: 10.1177/0003489420911656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [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 To evaluate treatment outcomes of upper airway stimulation (UAS) in obstructive sleep apnea (OSA) patients based on patient age, gender, and preoperative disease severity. METHODS Retrospective chart review of patients undergoing UAS from 2014 to 2018 at a tertiary care center. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. Profound OSA was defined as AHI >65 and age ≥65 was considered advanced age. The primary outcome measured was initial treatment response, defined as a post-operative AHI <20 with a >50% reduction from baseline. RESULTS 145 patients underwent UAS at our institution including 98 males and 47 females with a mean age of 61.7 ± 11.5 years, mean BMI of 29.1 ± 3.9 kg/m2, and mean preoperative AHI of 34.1 ± 18.2 events/hour. After surgery, patients had a significantly lower mean AHI of 8.6 ± 15.0 events/hour (<0.001). Older patients had a lower initial treatment response rate (78%) when compared to their younger counterparts (94%) (P = 0.005). Male gender and profound disease status did not significantly impact treatment response rates; young age was the only variable found to predict early treatment response on multivariate analysis (P = 0.003). CONCLUSION Although the overall OSA population showed significant postoperative AHI reduction with UAS, patients age ≥65 years were less likely to have an initial response to treatment, when compared to their younger counterparts. A larger proportion of elderly patients and patients with profound OSA had residual moderate disease (AHI > 15) after UAS. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kelly Daniels
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren Bogdan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Mulholland GB, Dedhia RC. Success of Hypoglossal Nerve Stimulation Using Mandibular Advancement During Sleep Endoscopy. Laryngoscope 2020; 130:2917-2921. [PMID: 32108345 DOI: 10.1002/lary.28589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 10/24/2019] [Revised: 01/24/2020] [Accepted: 02/04/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hypoglossal nerve stimulation (HGNS) effectively treats obstructive sleep apnea in select patients. Drug-induced sleep endoscopy (DISE) is required for HGNS candidacy. Data suggest that mandibular advancement (MA) devices and HGNS share similar target populations. We aimed to test the association between MA's effect on the velum and lateral walls during DISE in relation to the improvement in the apnea-hypopnea index (AHI) with HGNS. STUDY DESIGN Prospective case series METHODS: All patients completed preoperative polysomnography or home sleep study, DISE with MA prior to HGNS implantation, and full-night efficacy sleep tests. Adult patients with body mass index (BMI) ≤ 35 and AHI ≥ 15 were included. Two independent reviewers scored DISE videos. RESULTS Forty-six patients were included from October 2015 to January 2019. Mean BMI (standard deviation) was 28.5 (3.7) kg/m2 . Patients with a reduced airway response to MA had greater AHI improvement than patients with a robust response (21.7, 95% confidence interval [CI]: 14.4 to 29.0 vs. 4.9, 95% CI: -8.9 to 18.6; P = .03). Patients with complete baseline collapse at the velum and lateral walls (n = 11) had less response compared to those with partial collapse (n = 35) (AHI reduction of 4.4 [95% CI: -8.6 to 17.4] vs. 22.3 [95% CI: 15.1 to 29.6; P = .02]). CONCLUSIONS Patients having significant airway improvement in the upper pharynx with MA during DISE appear less likely to succeed with HGNS. This phenomenon might be secondary to the worsened baseline obstruction of the upper pharynx in such patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2020.
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Affiliation(s)
- Graeme B Mulholland
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Raj C Dedhia
- Division of Sleep Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.,CPAP Alternatives Clinic, Penn Sleep Center, Penn Medicine, Philadelphia, Pennsylvania, U.S.A
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Abstract
OBJECTIVE Demonstrate the potential of the 4K-3D exoscope during upper airway stimulation surgery (UAS). METHODS A proof-of-concept study was performed to evaluate the feasibility of the exoscope during three consecutive UAS. RESULTS The exoscope was employed during UAS including cuff electrode and sensing lead placement. Three cases were successfully completed without adverse perioperative event; mean operative time was 200 minutes (range 188-218 minutes) with a successive reduction in operative time. CONCLUSION This experience demonstrates the potential viability of the exoscope for UAS; it is a safe, innovative, and effective alternative or adjunct to existing visualization modalities. Notable advantages include improved ergonomics, unobstructed surgical field access, wide depth of field visualization, and short learning curve. Future technological enhancements could allow the exoscope to become a promising next-generation tool in the armamentarium of the contemporary sleep surgeon.
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Affiliation(s)
- Vijay A Patel
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Neerav Goyal
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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Hong SO, Poomkonsarn S, Millesi G, Liu SYC. Upper airway stimulation as an alternative to maxillomandibular advancement for obstructive sleep apnoea in a patient with dentofacial deformity: case report with literature review. Int J Oral Maxillofac Surg 2019; 49:908-913. [PMID: 31870520 DOI: 10.1016/j.ijom.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 12/15/2018] [Revised: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnoea (OSA) is characterized by repeated upper airway collapse leading to oxygen desaturation resulting in cardiovascular and neurocognitive sequelae. Upper airway surgeries such as palatopharyngoplasty, tongue base surgery, and maxillomandibular advancement can improve patient tolerance of continuous positive airway pressure, quality of life, and the severity of OSA. Upper airway stimulation (UAS) of the hypoglossal nerve is a contemporary US Food and Drug Administration-approved treatment modality for OSA with a fundamentally different mechanism. We report the case of a 65-year-old male with a high body mass index, hypertension, diabetes, dentofacial deformity, and severe OSA. He presented with a respiratory distress index (RDI) of 89.1 events per hour, apnoea-hypopnoea index (AHI) of 82.7 events per hour, and minimum oxygen saturation of 75%. He chose to undergo UAS. Initially, complete concentric collapse of the velum was found during drug-induced sedation endoscopy, which was converted by palatopharyngoplasty to meet inclusion criteria for UAS. The patient achieved surgical cure with postoperative RDI and AHI of 2 events per hour with minimum oxygen saturation of 83%, and resolution of daytime somnolence. UAS is an effective surgical option to broaden the surgeon's ability to treat OSA, especially if facial skeletal surgery is contraindicated or declined by the patient with dentofacial deformity.
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Affiliation(s)
- S O Hong
- Department of Oral and Maxillofacial Surgery (Dentistry), International St. Mary's Hospital, Catholic Kwandong University, Incheon, South Korea
| | - S Poomkonsarn
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA; Center of Excellence in Otolaryngology Head and Neck Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - G Millesi
- Department of Craniomaxillofacial and Oral Surgery, University Hospital, Medical University of Vienna, Vienna, Austria
| | - S Y C Liu
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA.
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Abstract
OBJECTIVE To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA). METHODS Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients. RESULTS In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS. CONCLUSION Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Thaler E, Schwab R, Maurer J, Soose R, Larsen C, Stevens S, Stevens D, Boon M, Huntley C, Doghramji K, Waters T, Kominsky A, Steffen A, Kezirian E, Hofauer B, Sommer U, Withrow K, Strohl K, Heiser C. Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy. Laryngoscope 2019; 130:1333-1338. [PMID: 31520484 PMCID: PMC7217178 DOI: 10.1002/lary.28286] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [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: 03/25/2019] [Revised: 07/15/2019] [Accepted: 08/19/2019] [Indexed: 01/20/2023]
Abstract
Objective/Hypothesis The ADHERE Registry is a multicenter prospective observational study following outcomes of upper airway stimulation (UAS) therapy in patients who have failed continuous positive airway pressure therapy for obstructive sleep apnea (OSA). The aim of this registry and purpose of this article were to examine the outcomes of patients receiving UAS for treatment of OSA. Study Design Cohort Study. Methods Demographic and sleep study data collection occurred at baseline, implantation visit, post‐titration (6 months), and final visit (12 months). Patient and physician reported outcomes were also collected. Post hoc univariate and multivariate analysis was used to identify predictors of therapy response, defined as ≥50% decrease in Apnea‐Hypopnea Index (AHI) and AHI ≤20 at the 12‐month visit. Results The registry has enrolled 1,017 patients from October 2016 through February 2019. Thus far, 640 patients have completed their 6‐month follow‐up and 382 have completed the 12‐month follow‐up. After 12 months, median AHI was reduced from 32.8 (interquartile range [IQR], 23.6–45.0) to 9.5 (IQR, 4.0–18.5); mean, 35.8 ± 15.4 to 14.2 ± 15.0, P < .0001. Epworth Sleepiness Scale was similarly improved from 11.0 (IQR, 7–16) to 7.0 (IQR, 4–11); mean, 11.4 ± 5.6 to 7.2 ± 4.8, P < .0001. Therapy usage was 5.6 ± 2.1 hours per night after 12 months. In a multivariate model, only female sex and lower baseline body mass index remained as significant predictors of therapy response. Conclusions Across a multi‐institutional study, UAS therapy continues to show significant improvement in subjective and objective OSA outcomes. This analysis shows that the therapy effect is durable and adherence is high. Level of Evidence 2 Laryngoscope, 130:1333–1338, 2020
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Affiliation(s)
- Erica Thaler
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Schwab
- Penn Sleep Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joachim Maurer
- Sleep Disorders Center, University Hospital Mannheim, Mannheim, Germany
| | - Ryan Soose
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christopher Larsen
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Suzanne Stevens
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Damien Stevens
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Karl Doghramji
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Tina Waters
- Cleveland Clinic Health System, Cleveland Clinic, Cleveland, Ohio
| | - Alan Kominsky
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Armin Steffen
- Department of Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Eric Kezirian
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine at University of Southern California, Los Angeles, California
| | - Benedikt Hofauer
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Ulrich Sommer
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Kirk Withrow
- Department of Otolaryngology, University of Alabama School of Medicine, Birmingham, Alabama
| | - Kingman Strohl
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Clemens Heiser
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Walia HK, Thompson NR, Strohl KP, Faulx MD, Waters T, Kominsky A, Foldvary-Schaefer N, Mehra R. Upper Airway Stimulation vs Positive Airway Pressure Impact on BP and Sleepiness Symptoms in OSA. Chest 2020; 157:173-83. [PMID: 31299245 DOI: 10.1016/j.chest.2019.06.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/19/2019] [Accepted: 06/27/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Positive airway pressure (PAP) and upper airway stimulation (UAS) are approved OSA treatment options. Although the effect of PAP on improvement in BP and daytime sleepiness (defined according to the Epworth Sleepiness Scale [ESS]) has been established, the impact of UAS on BP remains unclear. This study hypothesized that PAP and UAS will confer improvements in BP and daytime sleepiness. METHODS Clinic-based BP and ESS scores were compared between 517 patients with OSA (apnea-hypopnea index, 15-65) and BMI ≤ 35 kg/m2 initiating PAP therapy (2010-2014) at the Cleveland Clinic and 320 patients with UAS implantation (2015-2017) via an international registry with 2- to 6-month follow-up. Mixed effect models were used to compare outcomes in 201 patients in each arm following propensity matching. RESULTS PAP showed greater improvement in diastolic BP (mean difference of change between groups, 3.7 mm Hg; P < .001) and mean arterial pressure (mean difference of change between groups, 2.8 mm Hg; P = .008) compared with UAS. UAS showed greater improvement in ESS scores vs PAP (mean difference of change between PAP and UAS groups, -0.8; P = .046). UAS therapy usage was 6.2 h/week greater than PAP-treated patients (95% CI, 3.3-9.0). Results were consistent following adjustment for therapy adherence. CONCLUSIONS PAP showed greater improvement in BP, potentially reflecting an enhanced ability of PAP to exert beneficial mechanical intrathoracic cardiac and vascular influences. BP measurement error in the UAS group may also have accounted for findings. Greater improvement in sleepiness symptoms was noted with UAS compared with PAP.
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Huntley C, Vasconcellos A, Mullen M, Chou DW, Geosits H, Doghramji K, Boon M. The Impact of Upper Airway Stimulation on Swallowing Function. Ear Nose Throat J 2019; 98:496-499. [PMID: 31142163 DOI: 10.1177/0145561319853519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] Open
Abstract
OBJECTIVE To evaluate the impact of upper airway stimulation therapy (UAS) on swallowing function in patients with obstructive sleep apnea. STUDY DESIGN Prospective cohort study. SETTING Academic medical center. PARTICIPANTS AND OUTCOME MEASURES We recorded demographic, preoperative polysomnogram (PSG), operative, and postoperative PSG data. We assessed the patients swallowing function using the Eating Assessment Tool (EAT-10) dysphagia questionnaire. This was administered both pre- and postoperatively. The postoperative EAT-10 survey was administered at least 3 months after UAS implantation. RESULTS During the study period, 27 patients underwent UAS implantation, completed the pre- and postoperative EAT-10 questionnaire, met inclusion/exclusion criteria, and were included in the study. The cohort consisted of 16 men and 11 women with a mean age of 63.63 years. The mean preoperative BMI, Epworth Sleepiness Scale (ESS), and Apnea Hypopnea Index (AHI) were 29.37, 10.33, and 34.90, respectively. The mean postoperative ESS and AHI were 5.25 and 7.59, respectively. These were both significantly lower than the preoperative values (P = .026 and P < .001). The mean pre- and postoperative EAT-10 scores were 0.37 and 0.22, respectively (P = .461). CONCLUSION Our data suggest that UAS likely does not lead to postoperative dysphagia.
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Affiliation(s)
- Colin Huntley
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam Vasconcellos
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Mullen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - David W Chou
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Haley Geosits
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Karl Doghramji
- Jefferson Sleep Disorders Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Withrow K, Evans S, Harwick J, Kezirian E, Strollo P. Upper Airway Stimulation Response in Older Adults with Moderate to Severe Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2019; 161:714-719. [PMID: 31084350 DOI: 10.1177/0194599819848709] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of age on safety, efficacy, and usage of upper airway stimulation (UAS). STUDY DESIGN Multicenter observational study. SETTING Thirteen US hospitals and 3 German hospitals. SUBJECTS AND METHODS The ADHERE registry is a multicenter database enrolling patients undergoing UAS implantation from October 2016 to April 2018. Outcome measures included the Epworth Sleepiness Scale, apnea-hypopnea index (AHI), therapy usage, and complications. Data were segmented by age (<65 vs ≥65 years). RESULTS Younger adults (n = 365) were a mean ± SD 52.7 ± 7.9 years old and 82% male, with a body mass index of 29.6 ± 3.8. Older adults (n = 235) were 71.1 ± 4.8 years old and 71% male, with a body mass index of 28.8 ± 3.8. Baseline AHI was similar (younger, 36.2 ± 15.9; older, 36.1 ± 14.8). Both groups had lower AHI at 12 months versus baseline (P < .001), but the older group showed a greater reduction (7.6 ± 6.9 vs 11.9 ± 13.4, P = .01). The Epworth Sleepiness Scale score decreased from 12.3 ± 5.4 to 7.1 ± 4.8 (P < .001) among younger adults and from 10.7 ± 5.7 to 6.3 ± 4.4 (P < .001) among older adults. Usage was slightly higher among older adults (6.0 ± 2.0 vs 5.4 ± 2.1 hours/night, P = .02). Surgical time was similar between younger patients (2.4 ± 0.7 hours) and older patients (2.3 ± 0.7 hours, P = .40), with comparably low complications. CONCLUSION AHI reduction and therapy usage were found to be somewhat higher among patients aged ≥65 years who were treated with UAS. Surgical complications were low, in contrast to traditional sleep surgery.
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Affiliation(s)
- Kirk Withrow
- University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Sean Evans
- University of Alabama Birmingham, Birmingham, Alabama, USA
| | - John Harwick
- University of Florida, Gainesville, Florida, USA
| | - Eric Kezirian
- University of Southern California, Los Angeles, California, USA
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