Success with Mandibular Advancement During Drug-Induced Sleep Endoscopy Correlates with Less Success in Hypoglossal Nerve Stimulation

by Linda Kossoff •

What is the association between the mandibular advancement (MA)’s effect on the velum and lateral walls during drug-induced sleep endoscopy (DISE) in relation to the improvement in the apnea-hypopnea index (AHI) with hypoglossal nerve stimulation (HGNS)?

BOTTOM LINE: Patients having significant airway improvement in the upper pharynx with MA during DISE appear less likely to succeed with HGNS.

BACKGROUND: Hypoglossal nerve stimulation is an effective treatment for select obstructive sleep apnea (OSA) patients. Otolaryngologists use DISE to evaluate patients’ candidacy for HGNS. Mandibular advancement during DISE is shown to predict successful treatment of OSA with a mandibular advancement device (MAD). The value of MA during DISE for evaluating HGNS success is not known.

STUDY DESIGN: Prospective case series.

SETTING: Division of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.

SYNOPSIS: Researchers examined 46 adult patients who had central or mixed respiratory events and failure of first-line therapy (CPAP or MAD) who underwent DISE with use of MA prior to HGNS implantation, received HGNS implantation, and underwent designated sleep studies. The degree of velum and lateral wall collapse was made as a comparison before and after application of MA during DISE, and the cohort naturally stratified into two groups. The group with a decreased opening of the lateral wall in response to MA demonstrated greater AHI improvement than those with an increased opening. In contrast to researchers’ alternative hypothesis, an inverse relationship between the degree of response of the velum and lateral walls with MA and successful HGNS therapy was identified. Moreover, worse baseline severity of collapse at the level of the lateral walls correlated with worse HGNS treatment outcomes. Study limitations included limited power to detect modest differences between groups and lack of standardization in preoperative diagnostic sleep testing types.

CITATION: Mulholland GB, Dedhia RC. Success of hypoglossal nerve stimulation using mandibular advancement during sleep endoscopy. Laryngoscope. 2020;130:2917-2921.