BackTable / ENT / Podcast / Episode #51
Hypoglossal Nerve Stimulation for Adult OSA
with Dr. Matthew Hensler
In this episode we talk with Dr. Matthew Hensler about Hypoglossal Nerve Stimulation for treating Adult Obstructive Sleep Apnea (OSA), including how he learned the procedure, patient selection, procedure tips, and advice on building a successful program.
BackTable, LLC (Producer). (2022, March 1). Ep. 51 – Hypoglossal Nerve Stimulation for Adult OSA [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Matthew Hensler
Dr. Matthew Hensler is a practicing otolaryngologist in Cincinnati, Ohio.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
First, Dr. Hensler explains the initial workup for a snoring patient. In this history, he addresses the impact snoring has on the patient’s quality of life and also assesses the environmental factors that may be responsible for the snoring, such as lack of sleep and alcohol consumption. Then, during the physical exam, he checks for anatomical reasons for snoring, such as large tonsils and a deviated septum. From the history and physical exam, he is able to classify patients into two categories: primary snorers (without sleep apnea) and snorers with sleep apnea. He recommends that all patients complaining of snoring obtain a sleep study.
Dr. Hensler then explains his criteria for choosing good hypoglossal nerve stimulator candidates. He recommends choosing patients with an Apnea Hypopnea Index (AHI) score between 15-65, a BMI of less than 31, and patients who have less than 25% of apnea attributed to mixed and central apnea. Because the CPAP machine is still the gold standard treatment for treatment of OSA, he usually only recommends this surgery to patients who have failed CPAP treatment already.
Next, Dr. Hensler explains the mechanics behind the hypoglossal nerve stimulator, which only treats obstructive sleep apnea. During the implantation surgery, the first incision is made in the right chest for placement of the processor. The processor is attached to a sensor lead that feeds into the rib cage space between the external and internal intercostal muscles. A second submandibular incision is made below the submandibular gland to place the stimulator lead. When the sensor lead in the rib cage senses the patient breathing, it relays a message to the stimulatory lead, which stimulates the protrusive branches of the hypoglossal nerve to fire and push the tongue outwards. The surgery can be performed in an outpatient setting andlasts less than 2 hours. Patients can start turning on the device before they sleep 3-5 weeks after implantation. Finally, Dr. Hensler obtains a 3 month follow up sleep study in order to monitor improvement in AHI scores.
Post-operative complications like infection and pain are possible. Dr. Hensler prescribes his patients with a short duration of narcotics for submandibular pain and a 7-day course of antibiotics to prevent infection. Because of chest involvement during surgery, a pneumothorax is another post-operative complication. A chest X-ray should always be ordered after surgery to rule out this possibility. Finally, it is important to note that patients with a hypoglossal nerve stimulator are unable to undergo MRI scans involving their right chests because of the battery in the processor.
[Matthew Hensler MD]
Fit the mold for it. Yeah. So again, you want to at least see moderate sleep apnea. So AHI over 15, we have implanted people over 65 and I think that's an important thing as we get into outcomes, that you have to consider like, what were the initial parameters and how did you get the outcomes for that? And then if you start implanting people with a super high AHI, you can't really have the same expectation that they're going to get as low afterwards. But, so generally it's been 15 to 65 was the AHI. And BMI. We like to see that less than 35. And that's variable too. Because it depends on their insurance. Some insurances require lower. Some really don't have any guidelines for that. But generally we want to see that they're not too overweight, when you're considering it.
And another really important piece to it is to make sure on their sleep study, that they're not having a lot of central apneas or mixed apneas. And so the difference there, obstructive is that your something's blocking off your airway, whereas central you're not trying to breathe. And so if you're not trying to breathe, it's not going to matter if you stimulate the base of tongue, you're not going to breathe. So you really don't want to implant anybody that's got central or mixed apnea greater than 25% of their sleep study. And the last thing is, as you mentioned, C-PAP so we really want to see that they've failed C-PAP because it is still the gold standard of managing sleep apnea. And it has great results if people use it regularly, but there are plenty of people who just don't tolerate use. Whether it's claustrophobia or they're swallowing air, or you could go on and on, or they're caught up in the inconvenience of using C-PAP. That's part of it. It's pretty rare that we'll implant somebody that hasn't tried C-PAP. I mean, I think there's a few situations where you could consider it, but it gets me back to that point where I say, I really try to talk people out of surgery sometimes because if C-PAP’s working, that's great. And I get it can be inconvenient, but it's still a device that's implanted in you. It's a battery there's limitations afterwards in terms of MRIs, whatnot. So just a lot of things to consider rather than just, I've got sleep apnea, C-PAP annoys me and I want to put this device in.
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