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Hypoglossal Nerve Stimulator Surgery, Part 2: Postoperative Care, Device Settings & Side Effects

Author Taylor Spurgeon-Hess covers Hypoglossal Nerve Stimulator Surgery, Part 2: Postoperative Care, Device Settings & Side Effects on BackTable ENT

Taylor Spurgeon-Hess • Apr 26, 2022 • 62 hits

After obstructive sleep apnea (OSA) patients undergo hypoglossal nerve stimulator (HNS) surgery, they can expect to work with their sleep pulmonologist for a few months in order to activate the device, to make adjustments to the device settings as needed to maximize comfort, and to measure the extent to which the device has reduced the severity of their OSA. While every surgery comes with risks, patients generally experience few side effects with HNS surgery and tolerate the procedure well.

Learn more about postoperative care, device settings, and the side effects that may occur after surgery. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Patients can return home the day of surgery and often leave with a prescription for a seven-day course of antibiotics and a few days worth of narcotics.

• Activation of the hypoglossal nerve stimulator device occurs one month after implantation. Patients should work with a sleep pulmonologist to ensure the stimulation settings remain comfortable and effective.

• Three months after activation, sleep pulmonologists should conduct a formal sleep study to determine the extent to which the patient’s AHI has decreased.

• Device infection is rare, but patients may experience a feeling of tightness when swallowing and thickness around the skin near the device for a short time after surgery. Other side effects may include mild jaw or ear pain, controlled with over the counter medications.

An illustration depicting the placement of a hypoglossal nerve stimulator.

Table of Contents

(1) Postoperative Care After Hypoglossal Nerve Stimulator Surgery

(2) Adjusting Hypoglossal Nerve Stimulator Device Settings

(3) Hypoglossal Nerve Stimulator Side Effects and Complications

Postoperative Care After Hypoglossal Nerve Stimulator Surgery

After the two-hour hypoglossal nerve stimulator surgery, patients can return home the same day. During recovery, the patient can expect to undergo a chest x-ray to ensure that the stimulator is properly placed and to confirm a lack of a pneumothorax. Often, the surgeon will prescribe a few days worth of narcotics along with a seven-day course of antibiotics. Often physicians do not prescribe anything to treat inflammation, like Medrol or Decadron, as it is controlled through intraoperative dosing during the procedure itself. Healing time ranges, but typically lasts four to five weeks, after which, the device can be activated and patients can begin use.

[Gopi Shah MD]
Do these patients then stay overnight. Do you have some that just go home the same day? Is this outpatient?

[Matthew Hensler MD]
It's outpatient. Generally the surgery, we schedule it for about maybe two hours or a little bit under that. And they go home afterwards. So we do the chest x-ray in recovery to make sure that the implant is sitting in a good spot and that they don't have a pneumothorax and just really to document its location. And we'll just see how they're doing, but it's an outpatient surgery. We don't plan for anybody to stay. And it's pretty well tolerated, particularly with a pain perspective. You get some tightness that happens up under the digastric. So they'll have some, maybe some jaw and ear and tongue pain, but nothing that's not controlled by oral pain medication at home.

[Gopi Shah MD]
So like Tylenol, Motrin, or do you ever have to do narcotics?

[Matthew Hensler MD]
We use narcotics. Yeah. We'll give them a short, a couple of days worth of that to help, but that's all it typically requires.

[Gopi Shah MD]
Do you ever do steroids or anything like that post-op? Does that help for inflammation or pain?

[Matthew Hensler MD]
Yeah, we do the intraoperative dosing, but we don't typically send them home on any Medrol or any Decadron. We just give them the intraoperative dose.

[Gopi Shah MD]
Do you have to do antibiotics since it's implants?

[Matthew Hensler MD]
Yeah, I normally do just, and just because you just kind of feel like okay, we're putting a device in, your in the mouth at some component of this. So I'd typically put them on a seven day course of antibiotics just to have that.

[Gopi Shah MD]
And do you just do like Augmentin or what's your go-to for this?

[Matthew Hensler MD]
Typically Keflex. I just put them on Keflex and again, knock on wood. And often we'll use antibiotic irrigations, like when you place the stimulator cuff, you'll kind of flush it with some antibiotic irrigation too, and again, ultimately we haven't had any major, we haven't had any infections of the device and we keep it pretty sterile. I shouldn't say pretty sterile. We keep it strictly sterile. We haven't had any issues with it, but putting them on antibiotics is really just to make it seem a little cleaner.

[Gopi Shah MD]
Okay. That's good to know. And then how long do you have to wait before they can start using it or turning it?

[Matthew Hensler MD]
Yeah. So.

[Gopi Shah MD]
Is there like a healing time?

[Matthew Hensler MD]
It's about four to five weeks after it's implanted. So they'll come in for a first post-op just to make sure the neck is healing well, and they're not having any complaints or issues and that it's sitting in a good spot. And then generally it's a waiting game. I will say it's important to note. We do check the device once it's implanted, so we'll make sure that it's working, that you're getting good tongue protrusion and that the tongue is not pulling back at all. Because it's really important when you place the device that you only include the branches of the hypoglossal nerve that pull the tongue forward. Cause you don't want to stimulate any of the retrusive branches. That's one of the potential down, not downfalls of the surgery, but it would be a limitation of it, if you start pulling the tongue back with stimulation. So we make sure of that, but then we turn it off and they'll get it activated with sleep about four to five weeks afterwards.

[Gopi Shah MD]
Okay. So in the OR before you close up, you activate and then make sure that when it's turned on, the tongue is getting pulled forward.

[Matthew Hensler MD]
Yeah, we make sure that we get a good sensing of respirations and that you don't have too much cardiac interference with the sense lead. And we also make sure that the tongue is in a good spot and stimulates nicely. And then you can go to a very low level of stimulation and not see any retrusion of the tongue.

Listen to the Full Podcast

Hypoglossal Nerve Stimulation for Adult OSA with Dr. Matthew Hensler on the BackTable ENT Podcast)
Ep 51 Hypoglossal Nerve Stimulation for Adult OSA with Dr. Matthew Hensler
00:00 / 01:04

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Adjusting Hypoglossal Nerve Stimulator Device Settings

About a month after implantation, the device is activated and patients can begin the process of working with a sleep pulmonologist to ensure the settings and configuration works well for that individual. Oftentimes, the original setting provides relief without issue, but the device can be adjusted to provide different patterns and levels of stimulation. After about three months, the pulmonologist will conduct a formal sleep study to determine the level of improvement the nerve stimulator has provided.

[Gopi Shah MD]
All right. So you've seen them, they look like they're healing. Now we're like post-op week four to six. They go back to pulm. And at that point they can then help guide them of starting to turn it on using the mouse, putting it on, the sensor portion or the lead in the chest. and they can start and they just put that on before they go to sleep at night.

[Matthew Hensler MD]
Yeah, and, you just kind of hold it over it, right? Like you just, you hold the device kind of on top of your chest where your processor is and then, and then you take it away. So it doesn't have to stay there all night.

[Gopi Shah MD]
Oh, okay. Okay.

[Matthew Hensler MD]
It is just kind of there to turn it on, to activate it.

[Gopi Shah MD]
And does the sleep pulmonologist then kind of adjust the settings. Are there certain settings or it just automatically kind of goes with your breathing?

[Matthew Hensler MD]
Right, And that gets a little bit out of our wheelhouse a little bit, cause sleep will manage a lot of those settings, but ultimately there are different configurations on the stimulator that they can adjust. So if you're not doing well with a particular pattern, they can change that. And in terms of the intensity or the duration, a lot of that is all modifiable. People often say, am I getting shocked in my base of tongue? It's not a shocking thing. It's more of just a tense kind of tightening sensation that they would feel. So they're able to make those adjustments and the device, about 70% of people, when they go for that initial activation, they're good to go, it works. They're getting a good level of stimulation. It's comfortable and they're sleeping and they're happy, but you do have an important percentage of people who, and that's another thing I try to stress preoperatively is don't think that we just put this in and you turn it on and sleep apnea is gone, you have to maybe work with it and calibrate it kind of when you get glasses for the first time, it's not like it's just easy for everybody. It takes some getting used to, even C-PAP for some people it takes getting used to. So, they'll work with sleep over time to maybe make modifications and rarely would we then see somebody back in the office who, hey, we've tried these different configurations, maybe the sleep study. We're not getting them exactly where we want with AHI. So let's, let's do a scope while they're under, turn on the device and see where our diff different stimulations are happening of the base of tongue. And you can kind of modify it that way too.

[Gopi Shah MD]
I see. Okay. So you put the implant in, then you've turned it on about a month later. When do they get a sleep study again with the device on, is that at that initial turn on or is it a couple of months later?

[Matthew Hensler MD]
They'll do about three months generally, just to make sure that the device is in, subjectively we're getting good improvement. And then you let them use that for a bit before you check the formal sleep study.

Hypoglossal Nerve Stimulator Side Effects and Complications

Postoperative device infection or redness at the site of incision both rarely occur in patients. Most commonly, patients complain of a feeling of tightness with swallowing as well as some thickening of the skin around the area of implantation. The tightness feeling often goes away quickly. Weakness of the hypoglossal nerve rarely occurs, so often patients find no issue with swallowing or dysphasia immediately post-op. Some patients may experience some mild jaw or ear pain that resolves with over the counter medication.

[Gopi Shah MD]
Okay. Got it. And then, okay, so you see them, post-op, is it common to have a device infection or anything? What if you see redness or drainage at the chest, or under the mandible? How do you treat that, usually?

[Matthew Hensler MD]
Good question. I will say I haven't personally. I am just jinxing myself to death.

[Gopi Shah MD]
You're going to kill me after this.

[Matthew Hensler MD]
Yeah, no, no, it's all good. But really, we haven't had any device infections pneumothoraces. No, really the main complaint afterwards is pain. Or that people will say, wow, it's kind of tight up under here, I didn't think it would be that tight. And you'll see this mild kind of just thickening to the skin. And I think it's because you're doing a lot of muscle retraction when you're pulling on the digastric and the mylohyoid to get up along, you really have to go pretty distal on the hypoglossal nerve. So I think some of the retraction, and then you, you also attach the stimulator. Or at least part of it, you anchor it on the digastric. And I think there's some discomfort with that, that I really try to make sure I tell people beforehand and maybe they're like, “Okay. Yeah, it's tight when I swallow.” But you often give them reassurance. And, ultimately it goes away pretty quickly,

[Gopi Shah MD]
And this might be a silly question, but, no concerns about oral dysphagia, swallowing immediately post-op or-

[Matthew Hensler MD]
Right.

[Gopi Shah MD]
-weird sounds with articulation or anything like that from swelling or anything?

[Matthew Hensler MD]
Yeah, I know, you'd be surprised. The nerve is very robust. So seeing any weakness of the hypoglossal nerve is really rare. I always tell people it's a risk, but that's a rare thing to see. So most swallowing, I tell people to start maybe with soft diet at first. And once you see that that goes well you can go to a regular diet. Post-op day zero or whenever. You don't really hear of any issues with swallowing.

Podcast Contributors

Dr. Matthew Hensler discusses Hypoglossal Nerve Stimulation for Adult OSA on the BackTable 51 Podcast

Dr. Matthew Hensler

Dr. Matthew Hensler is a practicing otolaryngologist in Cincinnati, Ohio.

Dr. Gopi Shah discusses Hypoglossal Nerve Stimulation for Adult OSA on the BackTable 51 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2022, March 1). Ep. 51 – Hypoglossal Nerve Stimulation for Adult OSA [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Podcasts

Hypoglossal Nerve Stimulation for Adult OSA with Dr. Matthew Hensler on the BackTable ENT Podcast)

Articles

The backtable setup for a hypoglossal nerve stimulator surgery.

Hypoglossal Nerve Stimulator Surgery, Part 1: Candidacy, Technique & Device Limitations

Topics

Hypoglossal Nerve Stimulation Procedure Prep
Obstructive Sleep Apnea (OSA) Condition Overview

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