Abstract
Hypoglossal nerve stimulation (HNS) is a new procedure offered for the treatment of moderate-to-severe obstructive sleep apnea (OSA) that has been shown to decrease the severity and symptoms of OSA in select patients. We report on a case of a patient with persistent symptoms and findings of OSA despite a history of multiple multilevel procedures, including an uvulopalatopharyngoplasty (UPPP) with revision, a genioglossus advancement, and a maxillomandibular advancement. The patient then underwent HNS with significant improvement of his symptoms and severity. The success of this patient’s HNS surgery demonstrates that we need to examine where HNS fits into the approach to surgery for OSA. There could be benefit to considering cranial nerve stimulation earlier than conventional approaches for select patients.
1
Introduction
Hypoglossal nerve stimulation (HNS) is a recently FDA approved procedure offered for the treatment of moderate-to-severe obstructive sleep apnea (OSA). This procedure has been shown to decrease the severity and symptoms of OSA in select patients . We report a case of a patient with persistent symptoms and findings of OSA despite a history of multiple multilevel procedures. The patient then underwent HNS with significant improvement of his symptoms and severity.
2
Case report
A 61-year-old male with a twenty-year history of OSA presented for evaluation for HNS. He did not tolerate continuous positive airway pressure treatment due to claustrophobia and thus sought out alternative options. His past procedures included an uvulopalatopharyngoplasty (UPPP) with revision, two septoplasties, an inferior turbinate reduction, genioglossus advancement, and lastly, a maxillomandibular advancement. He also tried an oral appliance and a Winx® (Apnicure, CA) machine.
Despite these numerous procedures and devices, the patient was left with moderate obstructive sleep apnea. The patient still reported extreme daytime sleepiness and unrefreshing sleep with six to seven awakenings per night and snoring. He scored a nine on the Epworth sleepiness scale. A polysomnogram showed an AHI of 28 with minimal central apnea and lowest oxygen saturation of 85%.
His body mass index was 21. Physical examination revealed a straight septum, lateralized turbinates, normal sized tongue, a long thick neck with long vertical face and no retrognathia. His palate was Friedman IV with absent tonsils. He had an angle class II occlusion with lateral wall scar tissue tethered to the posterolateral pharynx. In-office fiberoptic laryngoscopy demonstrated obstruction at the soft palate level with mild base of tongue fullness with the Muller’s maneuver. The nasopharynx was normal with no adenoidal hypertrophy. Drug induced sleep endoscopy (DISE) showed collapse of the velopharynx in an anterior–posterior direction with tongue base obstruction during an apneic episode. There was central tongue depression as a result of the genioglossal advancement.
Following surgery, the patient recovered well. The device was turned on one-month postsurgery. He then underwent a titration period in which the stimulation level was increased. A titrated sleep study was performed five months postoperatively ( Table 1 ). When stimulation was turned on and the voltage progressively increased, the AHI was progressively reduced to 8.5 over both REM and non-REM period with an acceptable saturation of 90 percent. At the same time, his Epworth sleepiness scale score was three.
| Pre-Surgery | 5 Months Postoperative | |
|---|---|---|
| Baseline | Therapeutic Stimulation (1.7V) | |
| AHI | 28 | 8.5 |
| LSAT (%) | 85 | 90 |
Lateral cephalometric radiographs were obtained with the patient awake ( Fig. 1 ). One was obtained with the device turned off. A second radiograph was obtained with the device at a low stimulation level. A final radiograph was obtained with the stimulation turned to the patient’s titrated functional level. This sequence of three radiographs demonstrated forward movement of the soft tissue at the base of the tongue and hypopharynx with increasing stimulation. These radiographs also reveal the hardware from his new nerve stimulator and previous hyoid sling and maxillary-mandibular advancement.
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