This book by leading international experts provides an evidence-based approach to electrical stimulation of the upper airway, beginning with patient selection, implant techniques, trouble shootings, patient pathways, titrations during daytime and sleep as also new innovative techniques such as stimulation of the ansa cervicalis and the phrenic nerve.
Key Features:
- · Superbly illustrated schematic drawings and full-colored photographs;
- · Step-by-step description of surgical concepts and techniques on all of the market available systems (Inspire, Nyxoah, LivaNova, Remede);
- · Complete online media library with videos on the surgical procedures;
- · New surgical steps presented for well established procedures (e.g. 2-incicions technique);
- · Discussion of outcomes, success rates, risks, and potential troubleshooting’s, where evidenced-based data are not available, expert opinion is provided.
Upper Airway Stimulation in Obstructive Sleep Apnea will be welcomed by residents, fellows, and board-certified surgeons in otorhinolaryngology and head and neck surgery.
Author(s): Clemens Heiser, Nico de Vries
Publisher: Springer
Year: 2022
Language: English
Pages: 338
City: Cham
Preface
Contents
Contributors
Chapter 1: The Burden of Obstructive Sleep Apnea: A Clarion Call to Act
Introduction
Global Burden
Health Implications
Obesity
Type 2 Diabetes Mellitus
Cardiovascular
Neurologic Disorders
Ophthalmic Conditions
Implications on Quality of Life
Economic Burden
Clinical Case Series and Cost-Effective Strategies: Diagnosis, Treatment and Reduction in Burden
Conclusion
References
Chapter 2: Treatment Options in Sleep Apnea
Background
Continuous Positive Airway Pressure (CPAP)
Surgery as Adjunct to CPAP
Tonsillectomy
Nasal Surgeries
Mandibular Advancement Devices (MADs)
Surgery as Alternative to CPAP
“Too Little Space”
Maxillo-Mandibular Advancement
Maxillary Expansion
“Too Much Tissue”
Simple Tonsillectomy
Lingual Tonsillectomy
Uvulopalatopharyngoplasty (UPPP)
Partial Glossectomy
“Tissue Too Lax”
Tongue Suspension
Hyoid Myotomy and Suspension
Radiofrequency Ablation (RFA)
Hypoglossal Nerve Stimulation
Tracheostomy
Summary
References
Chapter 3: Effect of Hypoglossal Nerve Stimulation on Cardiovascular Outcomes
Introduction
Mechanisms of OSA on Cardiovascular Disease
OSA Severity and Cardiovascular Outcomes
Treatment of OSA on Cardiovascular Outcomes
Impact of OSA Surgery on Cardiovascular Outcomes
Impact of HGNS on Cardiovascular Outcomes
Challenges to Future Studies
Summary
References
Chapter 4: History of Electrical Stimulation in Sleep Apnea
Electrical Stimulation of the Hypoglossal Nerve for Treatment of Obstructive Sleep Apnea: History, Current State and Future Perspectives
References
Chapter 5: Embryology of the Hypoglossal Nerve
Introduction and Background
Human Predisposition to OSA and Hypoglossal Nerve’s Unique Role in Treating OSA
Objectives for Detailed Anatomic Primer on Distal Ramifications of Human Hypoglossal Nerve
Basis for Selective Upper Airway Stimulation
Human Hypoglossal Neuromuscular Embryology
Muscles Relevant to Upper Airway Stimulation Implant Procedure
The Functional Breakpoint
Highly Relevant Anatomic Structures
Vena Comitans of the Hypoglossal Nerve
References
Chapter 6: Considerations of Facial Skeletal Morphology to Optimize Upper Airway Stimulation
Introduction
Recognizing Soft Tissue and Skeletal Anatomic Risk Factors of OSA
Anatomical and Physiologic Considerations of the Tongue
Genioglossus Muscle Dysfunction in OSA
Hypoglossal Nerve
Multilevel OSA Surgery
Maxillomandibular Advancement: Indications and Multilevel Effect
Upper Airway Stimulation: Indications and Multi-Level Effect
Combining MMA with UAS as a New Multi-Stage, Multi-Level Treatment Pathway
Conclusion
References
Chapter 7: The Hypoglossal Nerve and Its Anatomical Variability
Introduction
The Anatomic Variability of the Nerve
Latest Hyoglossus Muscle Branch
Transverse and Vertical Intrinsic Lingual Muscles (T/V)
First Cervical Nerve (C1)
Summary
Pathophysiology & Mechanisms of Stimulation
Velum
Oropharyngeal Wall
Tongue Base
Epiglottis
References
Chapter 8: Patient Selection, Including Drug Induced Sleep Endoscopy
Introduction
Inclusion Criteria Then and Now
Mixed Sleep Disturbances
POSA
BMI
Central and Mixed Apnea
Ethical Considerations
DISE
Commercial Implantation
Conclusion
References
Chapter 9: Overview of Different HN-Stimulation Systems: Inspire
Inspire
Introduction
Components of the System
Clinical Outcomes of Inspire System
Respiratory Parameters
Sleep Parameters
Comparative Clinical Trials of Inspire System with Anatomy-Altering Surgery
Patients’ Experience with the Inspire System
Procedures
References
Chapter 10: Overview of Different HN-Stimulation Systems: Livanova
Introduction
Targeted Hypoglossal Neurostimulation (THN) Concept and Design
Patient Selection
Surgical Technique
Postoperative Management
Complications
Clinical Trials
Future Perspectives
Summary
References
Chapter 11: Overview of Different HN-Stimulation Systems: Nyxoah
Introduction
The Device
Implantation Technique
Titration
Results
Conclusion
References
Chapter 12: Upper Airway Stimulation Therapy; an Evaluation of Outcomes
Introduction
Outcomes
Adherence to Therapy
Predictors of Success
UAS Vs Traditional Sleep Surgery
Physiologic Outcomes
Complications
Summary
References
Chapter 13: Surgical Techniques in Upper Airway Stimulation
Surgical Techniques
Introduction
Implant Technique
Breath-Synchronized Stimulation System
Inspire 1 System
Inspire 2 and 4 Systems
Tonic Stimulation System
LivaNova, former: ImThera Aura 6000 System
Bilateral Hypoglossal Nerve Stimulation System
Nyxoah
Advanced NIM Techniques
Summary
Literature
Chapter 14: Treatment Pathway
Overview: HNS Clinical Care Pathway
Preoperative Evaluation
Patient Selection/Indications/Screening
Perioperative Care
Implant Procedure
Postoperative Course
Post-Implant Therapy Management
Device Activation
Therapy Titration
Therapy Adherence
Therapy-Related Side Effects
Long-Term Follow-Up
MRI Restrictions and Battery Life
Therapy Optimization
References
Chapter 15: Trouble Shooting
Trouble Shooting During Implantation
Advanced Candidates for Surgery
Gender-Specific Peculiarities
Left-Sided Implantation
Other Implantable Medical Devices
Intraoperative Situations
Implantation and Placement of the Stimulation Cuff
Tunneling of the Leads
Implantation and Placement of the IPG
Implantation and Placement of the Sensing Lead
Telemetric Checks
Early Postoperative Complications
Postoperative Bleeding and Hematoma
Wound Infection
Dislocation of Components of the Stimulation System
Paralysis of the Hypoglossal Nerve
Trouble Shooting Situations in the Postoperative Pathway
Activation
No or Only Instable Connection to the Implant Can Be Established Via Telemetry
Abnormal or Homonymous Impedances Occur
No Tongue Motion at Several Electrode Configurations Despite Highest Voltage and Normal Impedances
No Tongue Motion at Specific Electrode Configurations Despite Highest Voltage and Abnormal Impedances
Abnormal High Voltages for Thresholds
Only Submental Activation Without Tongue Protrusion
Low Amplitudes in Respiratory Sensing
Irregular Pattern in Respiratory Sensing
Synchronic Existence with Cardiac Implantable Electronic Devices
Early Therapy Adaption Phase
Problems with Handling the Remote
Subjectively Low or No Stimulation in the Morning
Impulses That Are Too Weak or Too Strong Despite Unchanged Voltage Settings Within the First Weeks
More Snoring Than Before
Coexisting Insomnia
Unwanted Results
Other Technical Observations
References
Chapter 16: Hypoglossal Nerve Stimulator in Pediatric Down Syndrome Patients
Introduction
Surgical Technique and Pediatric Modifications to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Preparation and EMG Placement
Incision Modification for Pediatric Patient
IPG Pocket Modification
Sensor Lead Insertion Modifications
Stimulation Lead Insertion Technique
Lead Tunneling, IPG Insertion, and Closure
References
Chapter 17: Daytime Polysomnography in Upper Airway Stimulation
Introduction
Methods
Polysomnography
Scoring
Titration
Discussion
Appendix
Appendix 1 Excluded Patients for Analysis (n = 4)
Appendix 2 UAS Device Polarity Setting and Amplitude Outcome
References
Chapter 18: Phrenic Nerve Stimulation in Central Apnea
Background of Phrenic Nerve Stimulation
Phrenic Nerve Stimulator Device Implantation
Therapy Application
Central Sleep Apnea and Phrenic Nerve Stimulation
Prevalence of Central Sleep Apnea
Diagnostic of Central Sleep Apnea
Mechanisms and Clinical Impact of Central Sleep Apnea
Clinical Trials and Outcome Parameters on Phrenic Nerve Stimulation with the Remedē® Device
Phrenic Nerve Stimulation and Nocturnal Hypoxia
Phrenic Nerve Stimulation and Physical Capacity
Device Specific Aspects
Battery Longevity and Exchange Procedure
Challenges in Implantation Procedure
Conclusion and Outlook
References
Chapter 19: Stabilizing Sleep Through Closed-Loop Acoustic Stimulation; Implications for Obstructive Sleep Apnea Treatment
References
Chapter 20: Special Cases in Hypoglosal Nerve Implantation
Introduction
Selection of Adequate Candidates for a Hypoglossal Nerve Stimulator Implant
HNS and Sleep Disorders Related with OSA
Sleep Disorders
Insomnia
Central Sleep Apnea (CSA)
Hypersomnolence
Circadian Rhythm Disorders
Bruxism, Periodic Limb Movements (PLM) and Restless Legs Syndrome (RLS)
Parasomnias
Psychiatric Disorders
Neurologic Disorders
Cognitive Impairment
Migraine
Parkinson’s Disease
Cardiovascular Disorders
Special Considerations
Other Implantable Devices
Placement in Children with Down Syndrome
Surgical Technique
Post-Operative Care
HNS and Head and Neck Cancer
Other Surgical Considerations
Other Special Problems
Positional Sleep Apnea and HNS
Titration
References
Chapter 21: Ansa Cervicalis Stimulation for Obstructive Sleep Apnea
Introduction
Radial Dilation of the Upper Airway
Biomechanical Factors Affecting Airway Collapse
Caudal Tracheal Traction in Animals
Caudal Tracheal Traction in Humans: The Role of End-Expiratory Lung Volume
Infrahyoid Muscle Contraction in Animals
Human Infrahyoid Muscles and the Ansa Cervicalis: Relevant Anatomy
Ansa Cervicalis Stimulation for Obstructive Sleep Apnea
Conclusions
References
Chapter 22: Future Perspective of Electrical Stimulation in Sleep Apnea
Will UAS Become Cheaper?
Different Companies
Combination Therapy
Conclusion
Index
