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Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Introduction to Hypoglossal Nerve Stimulation

(2) History and Physical for Adults with Obstructive Sleep Apnea

(3) Obstructive Sleep Apnea Surgery for Pediatric Populations

(4) Determining Candidacy for a Nerve Stimulation Device

(5) Postoperative Care for Patients after Nerve Stimulator Implantation

(6) Dissecting on the Hypoglossal Nerve

(7) Hypoglossal Nerve Stimulator Settings, Adjustments & Outcomes

(8) Limitations of Placing a Nerve Stimulator

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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
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[Gopi Shah MD]
Hello everyone. And welcome to the BackTable ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field, but the hope that you can take something from our show to your practice.

Hey, everyone, really exciting news. Our listeners asked and we have answered. We now have CME available. You can get AMA category one CME for listening to BackTable, and then filling out a reflection. You can find the CME links on the episode pages at backtable.com or you can also find the CME links in these show notes. It's a small cost for the credit, much less than you would spend at a conference. And it helps support the show powered by CMEfy using AI technology to bring the right education to the right place at the right time. You can do this in just a few minutes. If you're already listening to BackTable might as well get a CME credit for it. Again, this helps support the show and allows us to keep bringing you great content. Now on with the episode.

My name is Gopi Shah, and I'm a pediatric otolaryngologist at UT Southwestern here in Dallas, Texas. And today I have a very special guest. I have Dr. Matthew Hensler. He's an otolaryngologist practicing at Christ Hospital Physicians ENT in Cincinnati, Ohio. And he is here to talk to us today about the hypoglossal nerve stimulator for adult OSA. Welcome to the show, Matt.

[Matthew Hensler MD]
All right. Hi. Thank you.

[Gopi Shah MD]
Matt can you first tell us a little bit about yourself and your practice, your training, your background?

[Matthew Hensler MD]
Sure. Yeah. So I am from Middletown, Ohio, so it's a little bit north here of Cincinnati, about 30 miles and born and raised there. Went to The Ohio State University for undergrad, and then did that for four years, went to Wright State up in Dayton for med school. And after that came to Cincinnati at UC for general ENT residency, I didn't do a fellowship. I just came straight out of training and joined Christ and that was 2015, which continues to get further and further away. I can't believe it's that long ago. So back in ‘15 and then, yeah, I do general ENT at Christ and we kind of work within Cincinnati and Northern Kentucky and that's about it. And we live in the city and we have kids and a dog and there you go.

[Gopi Shah MD]
Living the dream. So you went to University of Cincinnati, that means, were you in the same training period or would you have crossed over with Eric?

[Matthew Hensler MD]
Oh, Yeah, Eric. Yeah. Oh, we're great buddies. So Eric was ahead of me in training by a couple of years. So yeah, we're really good buddies. That's where we met.

[Gopi Shah MD]
Yeah, I love Eric. he was a partner with me for a little bit in Dallas, and of course is a colleague and friend that I love to continue to text and talk to.

[Matthew Hensler MD]
Yeah, no, he's done such a cool job of taking your training and being able to broaden what you do. And it's not just like the straightforward do surgery and clinic, he's really been able to broaden himself. It's a cool thing.

(1) Introduction to Hypoglossal Nerve Stimulation

[Gopi Shah MD]
Yeah, it is. All right. Well, let's get into it a little bit. Did you do a lot of hypoglossal nerve stimulators in your training? Cause I feel like this is something that's a little bit relatively new, right?

[Matthew Hensler MD]
Yeah. I know it is pretty new. I actually, I did not. I didn't do any in training. So I think the FDA approval came around like 2014 for the procedure. So when I finished in ‘15, I hadn't done them at all. And I actually got approached by one of the companies to consider doing it towards the end of 2019. And at that point, I'm somebody that, I like to see the results of something before I do it. Like if something's new or if it's a new medication or whatever, I like to see the outcomes. And this was hard to do because there weren't many patients running around with them at that point. And so after talking with a lot of former colleagues and people really encouraged me to look into it. And then from the company's perspective, since we work in Cincinnati and Northern Kentucky, I was doing more of a Northern Kentucky reach and they didn't have anybody around there offering it. So, I was able to provide that and I did the training course and it kind of took off from there.

[Gopi Shah MD]
Yeah. And you said you have one of your partners that also it's the two of you guys that kind of work together.

[Matthew Hensler MD]
Yeah, Dr. Hellman and I, the two of us are the people within our group that offer the procedure. And we're both, like I said, we're both based in Cincinnati. We kind of go to multiple offices, but he and I are the people that, that do it with us.

[Gopi Shah MD]
That's awesome. It's nice to have good partners, especially when you're building a program.

[Matthew Hensler MD]
Yeah.

[Gopi Shah MD]
So, you said Northern Kentucky and then the kind of greater Cincy area, how did the patients get referred to you? Are patients coming in- do they just find you? They come to you, pulmonologist, how are they referred?

[Matthew Hensler MD]
That's an area that's still developing. So initially it was kind of hearsay that people would say I heard the ad on the radio, or I saw the commercial and that's still obviously happens. It's getting more commercial time. But now we've been able to kind of develop a little bit of a sleep, we have like a sleep coordinator within Christ now that works with pulmonology sleep medicine and can help kind of with care coordination so that we can optimized when patients show up.

So if they come in and they haven't had a sleep study, we were trying to avoid that and maybe get them to see sleep medicine first so they can get their sleep study and then work their way into us. So it's still developing, but it's any variety of primary care, cardiology is actually a developing area too, because of the impact of sleep apnea on heart health. And you're getting more patients who say, “Hey, my coworker got the implant. That looks pretty cool. I just want to check it out.”

(2) History and Physical for Adults with Obstructive Sleep Apnea

[Gopi Shah MD]
Yeah, I think that's great. So it's a little bit multidisciplinary as well in your practice. Sleep coordinator, pulmonology, cards. So just kind of getting into, a patient shows up in your clinic, like the adult that comes in for snoring, what's your initial history and physical look like? What are some of the most common complaints that you can see in adults with OSA?

[Matthew Hensler MD]
Snoring. Snoring is so common and it's really tough to kind of distill that down and figure it out well. Okay. Who needs a sleep study to begin with? Right. Because plenty of patients who come in, if they snore and they feel like they've got pauses in breathing when they're sleeping, then they should probably just go ahead and get a sleep study to begin with.

But it's a longer discussion, I think when it's just seemingly regular snoring without concerns for sleep apnea, because there are still a lot of patients with that, that have underlying sleep apnea. So aside from talking to them about their snoring or figuring out perhaps what medications they've tried to help snoring to see, is it more nasal or looking at their habits. Is it because they don't sleep enough? They sleep heavier or they have a heavy alcohol intake, so they sleep heavier. Those are impactful things. Aside from that, checking out the impact on their life. Is it just the sound of the snoring? So it's their spouse that's getting annoyed by it or is it actually that they don't get good sleep and they don't feel well rested. And I think trying to really guide that discussion more into do we need to do the sleep study if they haven't already had it. And that's where I try to go. And then physical exam, you try to see if there’s an obvious anatomical issues, which could contribute. Snoring tends to be a multi-level process. So it's not often that you just see a deviated septum and you say, oh, well, if we fix that, you're going to be better. You try to look at all of the potential areas for obstruction and address those as needed. Or again, often the sleep study is really a key piece to all of it.

[Gopi Shah MD]
Yeah. Would you say that most patients then, before you're doing any sort of surgery for sleep apnea, you have a sleep study on them, pretty much?

[Matthew Hensler MD]
Yeah, absolutely. Yeah. I mean, there are a few patients perhaps that, like, let's say they're snoring and maybe they also get really bad tonsil stones and they have huge tonsils and maybe a pretty open throat. And you kind of think, okay, well maybe we could address your tonsils now because they already know they want those addressed because of their tonsil stones. And perhaps you will get the added benefit of improved snoring. So there's a couple instances like that, but most of the time, if you're going to do surgery with any intent of improving snoring, it's good to find out if they're a primary snorer without sleep apnea, or if they have some underlying apnea.

[Gopi Shah MD]
Okay. And then when you do your physical exam, are you scoping, all these patients in clinic? Do you ask if they've tried, do you try Breathe Right strips on them? Do you have them try Flonase? How does that kind of play into some of this?

[Matthew Hensler MD]
Yeah. I think if somebody hasn't had a sleep study, I definitely entertain all of those thoughts. And I ask them and many patients have tried a lot of different remedies by the time they show up, with Breathe Right strips. We'll definitely see if we can improve nasal breathing with like nasal steroids or decongestants for a little time frame to see if that offers improvement. Scopes, it's not that every patient gets a scope, I would say. I think it's more directed based on the exam or perhaps somebody snoring and everything looks totally normal. And you're like, well, why would this person snore? Or if they report nasal obstruction or other head and neck complaints, which could suggest something that you're not seeing directly, then I think you jump to a scope.

[Gopi Shah MD]
Okay. All right. That makes sense. Cause in pediatric, sleep apnea, we're lucky in the sense that we have guidelines right. Of who should definitely get a sleep study before. And for us it's mostly TNA in kids, right? That's we're not jumping or thinking as much multi-level. Although many kids have residual OSA after a TNA and many kids it's other reasons, right? From poor tone to lingual tonsils, to large tongue base, as well. And so I always feel like, well, at least in the pediatric ENT stuff, I have some guidelines that can help me out. With adults and again, I don't treat adults, but I feel like I'm always kinda curious, like, okay, how different is it? Or what are the nuances? And it always seems a lot more complex.

[Matthew Hensler MD]
Yeah. I mean back in the day and I say back in the day, like, let's go like 10, 15 years ago. A lot of people were just getting uvulopalatopharyngoplasty and it was just the, well, take the tonsils and uvula out and we'll trim you up and see if the tightening helps. And it's just been over time that we've seen with the different classifications of pharyngeal anatomy and outcomes that that kind of cookie cutter approach to it isn't working for everybody. So, particularly with the nerve stimulator, they have some guidelines that they've set to try to guide you down that. But with regards to working up sleep apnea or snoring, like you were saying, adults, you really just want to get that sleep study to find it.

[Gopi Shah MD]
Okay. Are your patients mostly going to like an outpatient sleep lab? Do some of them get home sleep studies? Is your pulmonologist reading it? How does that work?

[Matthew Hensler MD]
It's a good mix. We don't, as an ENT office, we don't do our own sleep studies. So there is a sleep group within Christ that will kind of team up with, and there are a couple other community sleep centers that we’re also, not partnered with, but whether it's referring patients back and forth, but we'll get patients that way. And then sometimes you get patients who had a sleep study at a random sleep center and whether it was home or a facility, depending on the amount of data from the study, you're able to use that. Dentists too, actually, we've seen a lot of overlap with dentistry and sleep apnea. And so that's been another source.

(3) Obstructive Sleep Apnea Surgery for Pediatric Populations

[Gopi Shah MD]
Yeah, no, I think that's a great point. One, with the sleep lab. So in kids, we don't usually do home sleep studies in children. And most of our kids we'll get them within like children's, however, we will have kids that come with outside sleep studies and every once in a while, I just always ask the families, do we feel like it? And some families can't travel. Like it's asking for a lot because you need the parent, the kid to come stay overnight. They have other children at home, childcare. It's a big to-do, but I always ask if they're gonna do something locally, just make sure it's at a place where they're used to doing sleep studies in kids, the hookup process, all that. As well as, I would assume that whoever's reading it, they're also reading pediatric sleep studies as well. And so that at least in pediatric, that can kind of be a little tricky, because every once in a while, it's hard to know how to put that into context, I guess.

Yeah, and then the dental point is very interesting too, because we are seeing a lot more, I think our pediatric dentists screen a lot more for pediatric OSA, because they use sedation in their clinics. And I'm thankful that they're [screening] because a child with severe OSA in an outpatient dental setting, potentially could have a complication from sedation and things like that. So they're very vigilant about that.

[Matthew Hensler MD]
Yeah, that's a good point.

[Gopi Shah MD]
Yeah. And so I think they do play a role, in terms of screening as well as, other, potential treatment options. I think it's important to also include them at the table so we can figure out how to continue to have evidence-based and where different things play into the sleep algorithm, I guess.

[Matthew Hensler MD]
And, and to that point, there's plenty of people that come in to see me with this. And feel like I talk more people out of surgery than I do into surgery, right? I mean, dentistry is a big component to that, dental appliances. And it's not like it works for everybody, but I do think that's become a more important piece to just consider the big picture of sleep apnea. So finding somebody within your community or finding other people who perhaps do a good job of making appliances has been a useful thing.

[Gopi Shah MD]
Yeah, no for sure. And I think that, in the last, probably three to four years, even in the pediatric population, the role of dental appliances, it's not well-defined, but that option is becoming there. And I think that patients you're not going to, it's not like a ton of patients because one, insurance doesn't cover it, so it's cash. And two, these are kids and they have to wear something every night. But you're gonna have a handful. And I literally say a handful, per year. Maybe one or two per year. So it's not a ton in my practice that might come and ask me what my thoughts are on oral appliance and like in a seven-year-old with OSA. And the question is I don't really know because it's not like we know, do you do it after a TNA? Do you do it as an alternative to TNA? If you do it, like who? Is it moderate to severe OSA, mild OSA. Do you get a sleep study at some point? Like how long do you do it for? And so there's so many different questions I feel with that piece. And so I think opportunities at some point to kind of figure out, because I think that is something that's there and we just have to figure out how it fits in.

[Matthew Hensler MD]
Right. Well then also, with like mandibular development and dentition and occlusion and all of that in a kid who’s still continuing to grow. That's a whole nother factor to it. Yeah. I can imagine there's a lot.

[Gopi Shah MD]
But it seems better established, I think, in the adults though, in terms of the dental option. Do you perform DISE then? So let's say you get a patient, they have OSA, let's say it's moderate or maybe let's say not even moderate, let's say like 10, mild, right? But still enough to where there's something. Do you think about DISE? Do you DISE everybody? Do you get cine MRIs? Then how do you kind of work them up?

[Matthew Hensler MD]
Yeah. So for the nerve stimulator, the criteria is to have an AHI of like 15 to 65 was the original criteria. And there are people that do fall outside of those parameters on a pretty rare basis, but that's at least where we kind of start with it. So if they're less than 15, I don't really do DISE procedures unless you've said, okay, we've tried an oral appliance, we've tried sleep apnea if you're really getting into the deeper workup, for those patients. But more often the DISE is reserved for when we're kind of going down the pathway of we're going to do surgery. What's that gonna look like? Whether it's for the nerve stimulator or if you're going to consider something else like tonsillectomy or UPPP.

[Gopi Shah MD]
And then is that something you do as a separate or you DISE, you think you're gonna do a TNA or you think you're gonna do a U triple P you do the DISE and then you go ahead and proceed with surgery at the same time, or is it always a separate procedure?

[Matthew Hensler MD]
Typically a separate.

[Gopi Shah MD]
So you get all the information.

[Matthew Hensler MD]
Yeah. Particularly for the nerve stimulator, it comes down to approval with insurance and making sure that patients are meeting criteria. And sometimes if you have questions about their candidacy, based on the scope you can upload them to the cloud and get second opinions on where their collapses are happening and if they're a good candidate for the nerve stimulator or not. So we typically make that its own procedure and that way patients know it's a pretty simple in and out. You go to sleep, you're awake pretty quickly and you get answers.

[Gopi Shah MD]
Yeah. Okay. And do y'all do cine MRIs in adults?

[Matthew Hensler MD]
No, at least not with the nerve stimulator, it hasn't been a main piece to the workup. It's really just been made more off the DISE.

[Gopi Shah MD]
All right. That makes sense. So I guess before we get into like criteria and who's a good candidate, how does the nerve stimulator work? What's the goal of it?

(4) Determining Candidacy for a Nerve Stimulation Device

[Matthew Hensler MD]
Sure. That's a great question because I think a lot of people hear what it is and then when they hear actually how it works, it's a little different. It's two incisions and you implant typically on the right because we reserved the left if somebody would need a pacemaker and we stay away from the heart. So you go on the right and you put a processor in the chest that has a battery and there's a sensor lead that feeds off of it, down into the rib cage so that it can sense when they’re breathing. And then there's a stimulator that runs, it's a little wire that kind of comes up the neck and there is a second incision kind of under the jawline. And that's how you place the stimulator lead on the hypoglossal nerve.

So once you're done with that, at night, when they go to sleep, they take a device that kind of looks like a mouse for a computer and you turn the device on and, you can change this, but after a certain period of time, it will begin working so that every time the patient breathes- so whenever it senses that there's chest wall, expansion or movement- that will gently stimulate the base of tongue to push forward and tighten up. So it's not just working when you snore, it's not just working when you have apneas, it's doing it with every single breath, it's pushing the tongue forward. And you can turn it on and off at night. If you wake up and you need to use the restroom or something, you can turn it off and turn it back on. But that's generally how it works.

[Gopi Shah MD]
Okay. And so it's pulling the tongue forward. So what are the criteria now? Like who's a good candidate? Do they have already had to try C-PAP first a certain number of time? I think you'd mentioned a range of AHI, height, weight. Who are the people that kind of fit the potential?

[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.

[Gopi Shah MD]
Yeah.

[Matthew Hensler MD]
Yeah. So those are the main criteria.

[Gopi Shah MD]
So in your practice, do you have them try C-PAP for like six months, three months? Do you feel like you kind of have a timeframe that you want them to at least keep trying? And do you work with your pulmonologist with that? Or how do you help that part of it?

[Matthew Hensler MD]
Yeah, we work pretty well with pulmonology. So often we'll at least try a month and they're able to look at the device and see how much they're using it. How long at night, how much adherence they're having to using the device. And you kind of take that all in perspective and really, it just boils down to if they've tried the C-PAP and they're just not doing well with it. If we get to that point of the discussion, that's when we just say, okay, you could consider the implant.

[Gopi Shah MD]
So you described, two incisions, one in the chest and one kind of right, maybe submandibular area. Do you monitor the marg for that? Or do you just go below the gland or, is that a concern, how do you monitor?

[Matthew Hensler MD]
For sure. So it's really interesting you bring that up. I feel like in training, we're always taught two finger breadths below the mandible to avoid the marg. We avoid that nerve at all cost and the way that this was taught to implant, you end up making an incision a lot closer to the mandible. It's more like a finger breath because you kind of, you're trying to find the hyoid and you find the midline and you try to split the difference and kind of extend it back from there. So you end up being, I think, a little bit closer anatomically to the marg. I don't specifically monitor it during surgery, but you can see their mouth in view when you have them prepped out. So you're able to tell if you're getting stimulation or if you're getting close, I've never had anybody that's had marg weakness afterwards. Because I still, even though the incision is high, I still aim really low to get down on the bottom part of the submandibular gland, just so you're not close to it. And then you work your way up.

[Gopi Shah MD]
And then for the chest incision, are you below the pec and the nipple? Where is that? And are you going down to rib? Like, do you have to worry about pneumothorax? Like how does that work?

[Matthew Hensler MD]
So when I first started doing the procedure, it was three incisions and the one incision was a couple of finger breadths below the collarbone. So that was for the device. And then the sense lead was down kind of along like if you come down under their armpit and you come across just kind of like a bra line, it would sit down along the ribs there. So that was the third incision, but we really don't do that anymore because now you're placing the sense lead within that a higher incision. So it's two finger breadths below the collar bone. And you, once you've made a pocket for where the implant is going to sit, you just kind of go through pec major and you'd bluntly divide it until you're getting down to the intercostals and you try to find the nice plane between the internal and external intercostals. In training, look, I never was dissecting down onto the ribs. So initially it was always a very like, oh my gosh, we're near the lung, it's right through there. And, you're definitely cognizant of it. It's got some really, really good safe anatomy to get to that level. And you develop a pocket between the two muscles between the intercostals and you feed the sense lead there. So as you said, pneumothorax is one of the reported risks of the procedure. I personally, knock on wood, haven't been affected by it. And again, I think it's, you're just, you're smart when you get down to that point and you're delicate as you work between the muscles to avoid that complication. And we do a chest x-ray afterwards to make sure there's no issue with pneumothorax, especially.

(5) Postoperative Care for Patients after Nerve Stimulator Implantation

[Gopi Shah MD]
Yeah. 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.

(6) Dissecting on the Hypoglossal Nerve

[Gopi Shah MD]
Do you have any special landmarks or techniques to help you feel like your sensor is where it should be? How do you know?

[Matthew Hensler MD]
Well, when you're dissecting on the hypoglossal nerve, there are a couple little landmarks. Really the main one is, you're just looking for what we call it, the break point, where you can see these retrusive ranches kind of extending up. And so we will use a nerve stimulator for that and kind of stimulate the inclusion branches and your exclusion branches. And you'll kind of tell when you'll isolate the nerve, maybe put a vessel loop around it to say, here's the branches we want to include. And then you use a little probe to stimulate them and make sure that your inclusion branches are stimulating well. And that you're not including any of the retrusor branches.

[Gopi Shah MD]
Ah, I see. That's pretty neat. Okay. I didn't realize. And is that, this might be a dumb question. Is that just like a NIMs monitor then when you're doing that? It's just like the straight up NIMs that we use for things like a parotid or a thyroid or whatever? It's just that.

[Matthew Hensler MD]
Yeah.

[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.

[Gopi Shah MD]
You gotta love a robust nerve.

[Matthew Hensler MD]
I know. I know. Yeah, it is a very good nerve to work on for sure.

(7) Hypoglossal Nerve Stimulator Settings, Adjustments & Outcomes

[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.

[Gopi Shah MD]
So let's say you have the repeat sleep study at three months. What's a good outcome? I mean, you kinda mentioned the AHI range, the indication is 15 to 65 and the higher, I would imagine, you start with, in terms of resolution, the less that's going to be. I mean, it's the same way with OSA in kids, the more severe you start, the harder it is to resolve it or completely “cure it” to an AHI of less than whatever the minimum is. So what's a good outcome or how do you talk to patients about that?

[Matthew Hensler MD]
Yeah. Great question. So there were a lot of studies that have looked at these different registries where they followed a lot of patients to see generally, where are we starting with an AHI, generally though they’ll report median AHIs, and then you see where they wind up afterwards. And so they're still developing a lot of that longer term follow-up, but generally they've brought people from let's go the low mid thirties of an AHI, median AHI, and it brings them down to about six to nine. So just over 90% of people are brought down to no sleep apnea or mild sleep apnea. Right. So that's really good. And again, it's still to tell people, don't think that we're going to put this in and that all snoring is gone and you don't have sleep apnea. It's more, this is your further down the line procedure to consider. So if somebody is not tolerating C-PAP and they're just sitting at home with an AHI of 65 and not doing anything. Yeah. If you can bring them down to mild sleep apnea, that would be awesome. It's really going to improve their long-term health. So I think the education upfront is important with regards to that.

But another parameter they follow is the Epworth sleepiness scale. So the perception by patients is really good. I think it brings them from perceiving daytime sleepiness to a lower number. So you're getting good outcomes with regards to that. And a lot of these devices have a really good patient network that if you have a patient interested in the device, you can set them up with somebody who's already been implanted and they can talk to them and see what it's like. It's kind of like cochlear implants. I feel like that. Or a lot of the other implantable devices, it's important to talk to others who have had it and hear it firsthand from them.

[Gopi Shah MD]
Yeah, that's a good point. I think that's pretty cool that that network and community or support is there for patients and families.

[Matthew Hensler MD]
Oh yeah. Yeah, it's really hard to see your long-term results. And that's what's been cool to work with sleep medicine and have now a coordinator. We're following our own patients long-term and seeing our outcomes, which are the same as what you're getting on a national level. And it's pretty cool too, because when you operate on somebody and you don't see them back, it's generally because they're better, but you never get to see your patients that are doing better back, it's if you have issues. So it is nice to get some of that feedback and follow up.

[Gopi Shah MD]
One other question, or actually in terms of a candidacy, do you feel that the patients that do have lingual tonsils, for example, or maybe have a slight maybe some sort of elongation of the soft palate or do you have to do those surgeries first and then consider staging, or at that point, if you're thinking about putting a stimulator in you've already bypassed all that. Are there certain patients you're like, your lingual tonsils are huge, we just need to get those out.

[Matthew Hensler MD]
Yeah. Yeah. This actually just yeah, this happened pretty recently. I had a patient who they're on kind of this track to consider the implant and you do your DISE. And truly during this DISE, the tonsils, the amount of collapse that was just lateral wall collapse and purely tonsil and everyone else looks fine. You're kind of like, look, you don't fit the mold for needing a tonsillectomy. I totally get it. But, if you're younger or if maybe their AHI is 16, and you're just creeping into candidacy. If I was young, and that was me, I would say, okay, well then let's try the tonsillectomy or the lingual tonsillectomy. So I think you'll pick up on that with the dice to make sure that there isn't a very exaggerated contribution to their sleep apnea or if it's just the normal, multilevel collapse and you go about it that way.

[Gopi Shah MD]
So I think that's a great point because in kids, tonsil size, always, isn't a predictor. You'll see kids in clinic with two, four, plus kissing tonsils, abnormal sleep studies or kids with one plus two plus that you don't think much is there and you might get a sleep study and be like, oh, okay. And then you take the tonsils out and they actually get a little bit better. And I always tell families, they’re kind of like belly buttons, I think when they sleep, they'll fall out, like fall into the pharynx when, when sometimes they're asleep and maybe we just don't always appreciate it.

One other question for you is, right now in kids, I think, we do the TNA, they might still have residual, moderate to severe OSA. They might need C-PAP, maybe they can't tolerate it for like six months. Maybe you do a DISE or a cine MRI, depending on where you practice and what you prefer. We will do, I feel like, because it's not approved obviously, and under 18 yet, tongue based surgery or lingual tonsillectomy, if that tissue is there. In terms of adult basic tongue surgery, is the stimulator replacing that then like a posterior midline glossectomy or tongue-based reduction. Is this in lieu of that?

[Matthew Hensler MD]
I would say, I don't do a lot of lingual tonsillectomies. And it's not because I'm biased towards doing the implant. I think there are patients where I'll say, look, there's hyoid suspension, you can do these procedures to tighten up the pharynx in various ways or reduce the base of tongue. And I think they're all things to consider doing. And you kind of walk them through. And I've even referred people to other physicians that do those procedures to say, why don't you talk to them about it, before you get this implant, because I still put the implant as being far enough down the line right now that we want to make sure that it's either a specific area that you can't control, like tonsils or their palate or the base of tongue, or make sure you know of all of the other non implantable procedures you could do, look at their outcomes and, and make that decision sometimes for yourself. But, yeah. I think if again, if somebody's got exaggerated lingual tonsils, and that's what's collapsing on their DISE, it's totally worth trying to do that rather than, if there's somebody that can go through it medically based on their medical history or their age. Yeah. I think that's still something important to remember that this hasn’t just gone from C-PAP to nerve stimulator.

[Gopi Shah MD]
Yeah. Yeah. Yeah. And I think the questions I keep asking is because I still find it so hard to identify the level of obstruction. Right. It's multilevel, and it's hard to know exactly where, and then what procedures going to help.

[Matthew Hensler MD]
Well, yeah. And that's an important point that you bring up because on the DISE, really, the main thing we're looking for for the nerve stimulator is that they don't have lateral wall collapse. Because if you think, if you're going to stimulate your base of tongue to go forward and they're primarily getting a concentric or lateral collapse, you're not helping that with the device. So the DISE is sometimes more important from an exclusion perspective, as opposed to, oh, this is your level. So we should do this procedure.

[Gopi Shah MD]
Right.

[Matthew Hensler MD]
So that's an important point.

(8) Limitations of Placing a Nerve Stimulator

[Gopi Shah MD]
Yeah, no, that's very helpful. In terms of, you had mentioned battery and MRI, how do you talk to patients about the battery and potential needs of MRI? What are the limitations?

[Matthew Hensler MD]
That's kind of a moving target I would say. The MRI indications, generally I tell people expect that you're not going to be able to get an MRI of the right chest or kind of right upper extremity kind of this area, because that's where the battery is going to be. Now there are, as the device continues to change, the companies continue to send out, here are the MRIs that are allowed or the regions that are allowed, but ultimately it's good to make sure that people understand upfront there may be limitations. We haven't done any like removals of a device so that somebody could get an MRI that we haven't ever run into that. The battery itself lasts currently about 11 years. So we tell people expect that in 11 years, if and when the battery is not working, you can do an outpatient surgery just to replace the processor with the battery.

[Gopi Shah MD]
And that's just your chest incision.

[Matthew Hensler MD]
Yeah. The high chest incision. Yep. Yep. So you just go through that and so we'll get to that point someday once you get there, but the device also continues to, like I said, it evolves a lot in terms of what battery it is, what the MRI compatibility is. So it's just good to make sure that patients ask about that and see what the most recent guidelines are and limitations.

[Gopi Shah MD]
Yeah. As we are slowly wrapping up, are there any other final pearls or things that you've found in your experience, whether it's surgical or just managing these patients that you have for our listeners.

[Matthew Hensler MD]
Okay, this is I think a really good point. So I look pretty young, but I'm also still pretty early in practice. Right. So, and I'm sure you get this too, that when people come in, a very common question is how many of these have you done? Or, are you comfortable doing this? And I now enjoy the question because I used to always think, oh gosh, they're asking again. Yes, I know I'm young. But I remember when I first started doing this, initially people would come in like how many have you done? And I said, you're going to be my first patient. And I wouldn't hold back, but I wasn't trying to freak them out, but I'm like, well, ultimately, Dr. Hellman, my partner that does these, he was really, it was great to work with him initially because I was able to do several cases with him. See how he does it and learn from any mistakes that he's had, or if he's found certain pearls that work really well for it. Really really important. This goes, not just obviously for the surgery, but anybody that's wanting to start a new procedure, trying to find somebody else that does it, that you trust, that you can work with is really, really important because you see like, oh, I don't know anything about this. It is okay. I can do this. This is a straightforward thing. So getting those discussions with patients initially was really tough because there were plenty of people that go, “Thanks. I'm going to go talk to somebody else.” I'm like, I got, I got it. And fighting through the frustrations initially of, oh my gosh. People come to me and I can't do the surgery because I haven't done it. How am I going to even get experienced? And eventually, everybody's had good outcomes.

And so even the first lady that I implanted, I remember I told her, I was like, well, you'll be the first. And she said, great. You're not going to mess it up. And I'm like, okay. Yeah. And from there it's been fine, you get to a point where you can comfortably say you've done. I think I've done upwards of 30 of them now, which factoring in COVID where we weren't even operating for a period of time, that's been a good number to do over a year and a half or two years or so. I think the parole from that is for anybody that– I didn't do it in training. You hear about it. It's interesting, but you can't figure out a way to see the outcomes of patients. So talk to other people who are experts in the field and get the encouragement from them. And then when you have the encouragement, try to find somebody that does it and, and just kind of take it one step at a time and eventually the practice builds from there.

[Gopi Shah MD]
Yeah. Well, thank you so much for coming on the show, Matt and sharing your experience. Congratulations on just building your practice and just being a pioneer. Thank you for just being open with us. You can find Matt at the Christ Hospital Physicians ENT in Cincinnati. Matt, are you on any social media where if our listeners wanted to find out more about you, they can get in touch with you?

[Matthew Hensler MD]
Nope. I mean, you know.

[Gopi Shah MD]
Okay. They can listen to this podcast and that’s how they’re going to figure it out.

[Matthew Hensler MD]
Yeah, no, I don't have any other platforms that I utilize for that. I lay low.

[Gopi Shah MD]
I hear you. All right, well, thank you to our listeners for tuning in for our new listeners. Thank you for joining us. And of course, any returning listeners, thank you for stopping by again. You can find us on SoundCloud, Spotify, iTunes, Apple, and Gaana. Please follow us on Instagram and Twitter at underscore back table ENT.
We'd love feedback. Reach out to us for topics, ideas as speakers, or if you ever want to come on a show. And I think that's a wrap. Thanks.

[Matthew Hensler MD]
Appreciate it.

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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Articles

An illustration depicting the placement of a hypoglossal nerve stimulator.

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The backtable setup for a hypoglossal nerve stimulator surgery.

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Topics

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