HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of Laryngoscope. 2016; 126 Suppl 7:S12-S16.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Contemporary Review

Updates of Operative Techniques for Upper Airway Stimulation

Clemens Heiser, MD; Erica Thaler, MD; Maurits Boon, MD; Ryan J. Soose, MD; B. Tucker Woodson, MD

Selective upper airway stimulation has been established as an additional treatment for obstructive sleep apnea (OSA). Essen- tial for the treatment is the precise placement of the cuff electrode for select branches of the hypoglossal nerve, which inner- vate the protrusors and stiffeners of the tongue. A direct approach to the distal hypoglossal nerve has been established to achieve this goal. For surgeons, detailed knowledge of this anatomy is vital. Another decisive step is the placement of the sensing lead between the intercostal muscles. Also, the complexity of follow-up care postoperatively should be kept in mind. The aim of this article is to provide the latest knowledge on the neuroanatomy of the hypoglossal nerve and to give surgeons a step-by-step guide on the current operative technique. Key Words: Obstructive sleep apnea, upper airway stimulation, sleep medicine, hypoglossal nerve, surgical treatment obstructive sleep apnea. Laryngoscope , 126:S12–S16, 2016

BACKGROUND The high prevalence of obstructive sleep apnea (OSA), the multifactorial and variable pathophysiology, and the suboptimal long-term adherence rates with posi- tive pressure and oral appliance therapy necessitate alternative treatment strategies in many OSA patients. Upper airway stimulation (UAS) therapy represents a novel and unique therapeutic approach that combines a surgical implant procedure with a titratable medical device to provide multilevel upper airway improvement via neuromodulation of the hypoglossal nerve. Tradi- tional upper airway reconstructive procedures for OSA exclusively target the anatomy and structural vulner- From the Department of Otorhinolaryngology–Head and Neck Surgery ( C . H .), Technische Universitaet Muenchen, Munich, Germany; the Department of Otolaryngology–Head and Neck Surgery ( E . T .), Uni- versity of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; the Depart- ment of Otolaryngology–Head and Neck Surgery ( M . B .), Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.; the Depart- ment of Otolaryngology ( R . J . S .), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A.; the Department of Otolar- yngology ( B . T . W .), Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A. Received April 18, 2016, Editor’s Note: This Manuscript was accepted for publication May 31, 2016. Clemens Heiser, MD, receives payment for travelling, research, and presentations from Inspire Medical Systems (Maple Grove, MN) and serves as a consultant for Inspire Medical Systems. Erica Thaler, MD serves as a consultant for Inspire Medical Systems. Maurits Boon, MD, has served as a consultant for Inspire Medical Systems. Ryan J. Soose, MD, has served as a consultant and study investigator (research sup- port) for Inspire Medical Systems. B. Tucker Woodson, MD, has served as a consultant and received payment for research from Inspire Medical Systems, Siesta Medical, Lingualflex, Cryosa, and Zelegent. He has served as a consultant and received royalties from Medtronic. The authors have no other funding, financial relationships, or con- flicts of interest to disclose. Send correspondence to B. Tucker Woodson, MD, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226. E-mail: bwoodson@mcw.edu

ability of the upper airway; however, increasing evidence demonstrates that neuromuscular compensation during sleep also plays a critical role in the sleep-disordered breathing pathophysiology of many OSA patients. 1 UAS differs from traditional OSA surgery for sleep apnea in several key ways. One element critical to the success of UAS therapy is its ability to provide multile- vel upper airway improvement with one procedure. In UAS responders, imaging, fluoroscopy, and drug-induced sleep endoscopy have shown enlargement of not only the retrolingual space but also the retropalatal portion of the airway, at least in part due to mechanical coupling of the tongue to the palate and pharyngeal walls. 2 UAS is also distinct from other OSA surgical procedures in that it does not alter upper airway anatomy and is tech- nically reversible. Unlike tongue base or pharyngeal sur- geries, the UAS surgical procedure is completely external to the pharynx, thus substantially reducing postoperative discomfort, recovery time, and potential adverse side effects of anatomy-altering procedures. 3–7 Similar to positive pressure or other OSA medical therapy, UAS also has the advantages of being an adjust- able medical device, which is important for a chronic long-term condition like OSA. The amplitude and other stimulation parameters can be titrated in the clinical or sleep laboratory setting to optimize both effectiveness and comfort across a longitudinal care model. Therapy titra- tion studies have shown a graded increase in airflow and airway measurements with increasing stimulation ampli- tudes. Yet, unlike the external interface and tethering of positive pressure therapy, which drives much of the posi- tive pressure therapy side effects and adherence con- cerns, the UAS components are completely subcutaneous. UAS therapy has established itself as a promising new addition to the OSA treatment armamentarium. A recent multicenter prospective trial reported significant

DOI: 10.1002/lary.26158

Laryngoscope 126: September 2016

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