Hypoglossal Research Articles

Olfactory and trigeminal routes of HSV-1 CNS infection with regional microglial heterogeneity.

Herpes simplex virus type 1 (HSV-1) primarily targets the oral and nasal epithelia before establishing latency in the trigeminal ganglion (TG) and other peripheral ganglia. HSV-1 can also infect and become latent in the central nervous system (CNS) independent of latency in the TGs. Recent studies suggest entry to the CNS via two distinct routes: the TG-brainstem connection and olfactory nerve; however, to date, there is no characterization of brain regions targeted during HSV-1 primary infection. Furthermore, the immune response by microglia may also contribute to the heterogeneity between different brain regions. However, the response to HSV-1 by microglia has not been characterized in a region-specific manner. This study investigated the time course of HSV-1 spread within the olfactory epithelium (OE) and CNS following intranasal inoculation and the corresponding macrophage/microglial response in a C57BL/6 mouse model. We found an apical to basal spread of HSV-1 within the OE and underlying tissue accompanied by an inflammatory response of macrophages. OE infection was followed by infection of a small subset of brain regions targeted by the TG in the brainstem and other cranial nerve nuclei, including the vagus and hypoglossal nerve. Furthermore, other brain regions were positive for HSV-1 antigens, such as the locus coeruleus (LC), raphe nucleus (RaN), and hypothalamus while sparing the hippocampus and cortex. Within each brain region, microglia activation also varied widely. These findings provide critical insights into the region-specific dissemination of HSV-1 within the CNS, elucidating potential mechanisms linking viral infection to neurological and neurodegenerative diseases.IMPORTANCEThis study shows how herpes simplex virus type 1 (HSV-1) spreads within the brain after infecting the nasal passages. Our data reveal the distinct pattern of HSV-1 through the brain during a non-encephalitic infection. Furthermore, microglial activation was also temporally and spatially specific, with some regions of the brain having sustained microglial activation even in the absence of viral antigens. Previous reports have identified specific brain regions found to be positive for HSV-1 infection; however, to date, there has not been a concise investigation of the anatomical spread of HSV-1 and the brain regions consistently vulnerable to viral entry and spread. Understanding these region-specific differences in infection and immune response is crucial because it links HSV-1 infection to potential triggers for neurological and neurodegenerative diseases.

Diagnosis and Management of Obstructive Sleep Apnea: Updates and Review

Obstructive sleep apnea (OSA) is a heterogenous disease process that cannot be adequately categorized by AHI alone. There is a significant prevalence of OSA in the general population with ongoing efforts to evaluate the risk factors contributing to OSA and its associated clinical implications. Only by improving our understanding of OSA can we advance our methods in the diagnosis and treatment of OSA. For this article, the authors reviewed keywords of obstructive sleep apnea diagnosis and therapy in the databases of Embase, Medline, and Medline ePub over the past 3 years, excluding any articles that only addressed sleep apnea in children under age 17 years. This review article is divided into three main sections. First, we will investigate the use of novel screening tools, biomarkers, anthropometric measurements, and novel wearable technologies that show promise in improving the diagnosis of OSA. There is mention of comorbid conditions seen in OSA patients since certain disease combinations can significantly worsen health and should raise our awareness to diagnose and manage those concomitant disorders. The second section will look at the current and developing treatment options for OSA. These include positive airway therapy (PAP), mandibular advancement device (MAD), exciting new findings in certain medications, orofacial myofunctional therapy (OMT), hypoglossal nerve stimulation therapy (HGNS), and other surgical options. We will conclude with a section reviewing the current Clinical Practice Guidelines for Diagnostic Testing in Adults with Obstructive Sleep Apnea from 2017, which strongly advises polysomnography (PSG) or home sleep apnea testing (HSAT), along with comprehensive sleep evaluation for uncomplicated patients with a clinical presentation of OSA.

Cost-Effectiveness of Hypoglossal Nerve Stimulation for Pediatric Severe Obstructive Sleep Apnea in Down Syndrome Patients.

To examine the cost-effectiveness of hypoglossal nerve stimulation (HGNS) implantation at an early age in simulated pediatric cohorts with Down Syndrome (DS) and severe obstructive sleep apnea (OSA). Cost-utility analysis. Hypothetical cohort. A Markov model simulated 3 pediatric cohorts with DS and OSA beginning at age 4 years until 21 years. Cohorts received HGNS implants in early childhood, late childhood, or adulthood at age 4, 13 (current FDA-approved age), or 18 years, respectively. Input model parameters were obtained from the literature and our institution. Outcomes were measured with an incremental cost-effectiveness ratio (ICER), measured in dollars per quality-adjusted life-year (QALY). Deterministic 1-way sensitivity analyses were conducted to evaluate the effects of parameter uncertainty. Results (total costs; total QALYs) across the time horizon were determined for each cohort: early implantation ($83,300.35; 15.79), late ($48,319.09; 14.98), and adult ($38,721.07; 14.55). ICERs were $48,892.47 per QALY for early vs late implantation, $43,471.15 per QALY for early vs adult implantation, and $30,959.58 per QALY for late vs adult implantation. All ICERs were below a willingness-to-pay threshold of $50,000 per QALY. Varying the discount rate and utility expectedly varied the ICERs and cost-effectiveness. Threshold analysis showed early implantation to be cost-effective for a HGNS implantation cost up to $62,230 compared to late implantation. The current study suggests HGNS is a cost-effective treatment strategy for pediatric patients with DS and severe OSA. Our findings also suggest cost-effectiveness at ages younger than 13, the current age of FDA approval.

Hypoglossal nerve stimulation explantation in patients with obstructive sleep apnea - a systematic review.

Hypoglossal nerve stimulation explantation in patients with obstructive sleep apnea - a systematic review.

Upper Airway Stimulation for Children and Adolescents with Down Syndrome: Long-Term Follow-Up.

Hypoglossal nerve stimulation (HGNS) is safe and effective for patients with Down syndrome (DS) and severe persistent obstructive sleep apnea (OSA). Long-term outcomes for this patient population have not been evaluated. A prospective single-group multicenter cohort study with 1-year follow-up was conducted between 2015 and 2021 among 42 adolescent patients with DS and severe persistent OSA. Here, we evaluate long-term outcomes in this patient cohort. Patients were evaluated with polysomnogram (PSG) at three timepoints: pre-implantation (timepoint 1), 1-year post-implantation (timepoint 2), and long-term follow-up (timepoint 3). Long-term follow-up data were available for 33 of 42 patients. Mean (SD) of timepoint 3 was 4.0 (1.9) years after implantation. Using a therapy response definition of a 50% decrease in Apnea Hypopnea INdez (AHI) from timepoint 1, the response rate was 69.7% (23/33) at timepoint 2 and 87.9% (29/33) at timepoint 3. From timepoint 1, there was a mean (SD) decrease in AHI of 12.7 (13.4) events/h at timepoint 2 and 15.7 (13.1) events/h at timepoint 3. The mean percentage change in AHI between timepoints 1 and 2 was -51.1% (95% CI: -32.8% to -69.3%) and between timepoints 1 and 3 was -59.6% (95% CI: -42.0% to -77.3%). Patients with DS and severe persistent OSA who undergo HGNS implantation may continue to experience improvement in PSG parameters at long-term follow-up. Future studies are needed to assess additional long-term outcomes in this patient population, including neurocognition and quality of life. 3 Laryngoscope, 2024.

7357 Microscopic Papillary Thyroid Cancer Presenting with Cranial Nerve Palsies due to Metastatic Cervical Lymphadenopathy: A Case Report

Abstract Disclosure: N.N. Mukhtar: None. C. Zuo: None. B.R. Haugen: None. Introduction: Tumors metastasizing to head and neck are considered a rare cause of cranial nerve palsy (CNP). In this report, we describe an unusual presentation of metastatic microscopic follicular variant papillary thyroid cancer (FVPTC) presenting with CNP. Case Summary: A 68-year-old previously healthy female presented to her primary care physician with a 6-week history of difficulty speaking and chewing food. She did not notice any dysphagia, change in voice or shortness of breath. Cranial nerve examination was evident for palatal asymmetry, left-sided uvular and right-sided tongue deviations suggesting right glossopharyngeal and hypoglossal nerve palsies. Neck examination revealed a normal thyroid gland without palpable nodules however, the patient had multiple enlarged painless right cervical lymph nodes (CLN). MRI of the brain was normal. CT of the neck and chest showed enlarged, calcified right level II and III CLN (largest 4x3.5 cm) compressing the right internal jugular vein. In addition, bilateral pulmonary nodules (largest 1.7x1.5 cm) suspicious for metastasis were seen. CT-guided biopsy of left upper lobe lung nodule was consistent with metastatic thyroid cancer (positive PAX-8 and TTF-1 immunostaining). Neck ultrasound did not show any thyroid nodules, but did confirm 4 enlarged right CLN (largest 2.9 cm). The patient was referred to our multidisciplinary clinic for further evaluation. Based on the duration of her symptoms (6 weeks), her CNP was most-likely irreversible and agreement to proceed with total thyroidectomy, central and right lateral neck dissection aiming for complete resection in preparation for future treatment with radioactive iodine. Preoperative thyroglobulin level was 30.7 ng/ml (1.6-50), thyroglobulin antibody 24 U/mL (<40) and TSH 0.6 mIU/L (0.4-4.6). Intra-operatively; the patient had extensive, bulky lymphadenopathy extending to surrounding neck muscles and completely encasing right jugular vein. Histopathological examination of the resected tissue showed a unifocal right thyroid lobe microscopic (6x4x3 mm) infiltrative follicular variant papillary thyroid cancer (FVPTC). No extrathyroidal extension, necrosis, angioinvasion or lymphatic invasion were identified. Mitotic index was 3/ 2mm2. 13 out of 36 lymph nodes were positive for metastatic thyroid cancer (3/3 level II, 2/17 level III, 8/16 level IV), largest was 4.6 cm with extra-nodal extension. The patient was discharged on suppressive dose levothyroxine. Molecular studies: Next generation sequencing of the lung biopsy was negative for BRAFV[6]00E mutation and further molecular analyses are ongoing. Conclusion: This case describes two unique presentations of thyroid cancer; a microscopic FVPTC associated with large lateral cervical lymph node metastasis and, CNP as the initial presentation of thyroid cancer which to our knowledge, has not been reported previously. Presentation: 6/2/2024

Implementing a Streamlined Hypoglossal Nerve Stimulator Pathway: Cost, Time to Surgery, and Outcomes.

To evaluate the costs, time to surgery, and clinical outcomes associated with implementing a streamlined hypoglossal nerve stimulator (HGNS) implantation pathway. Retrospective cohort study. Single tertiary care center in the United States from 2016 to 2023. Patients with a lack of complete concentric collapse of the velum during volitional snore on in-office laryngoscopy qualified for the streamlined HGNS pathway. This pathway consisted of confirmatory drug-induced sleep endoscopy (DISE) followed immediately by HGNS implantation during the same surgical encounter. Outcomes were compared to patients in the traditional pathway (standalone DISE followed by HGNS implantation on a later date). A total of 68 patients (13 streamlined, 55 traditional) with obstructive sleep apnea who underwent HGNS implantation were included. Patients were predominately male (70.6%) and White (95.6%) and had a mean (SD) age of 63.5 (10.0) years. The streamlined pathway was associated with a significant reduction in both hospital costs (mean difference $9258, 95% confidence interval [CI]: 3690-14,825; P = .002) and time to surgery (mean decrease of 3.82 months, 95% CI: 0.83-6.80 months; P = .013) compared to the traditional pathway. Patients in both groups had reduction in apnea-hypopnea index and Epworth Sleepiness Scale score, with no significant differences in comparisons between groups. In select patients, the streamlined HGNS pathway may expedite time to surgery and reduce hospital costs with comparable clinical outcomes to a traditional 2-stage pathway. Further research is warranted to validate patient selection and better understand longitudinal outcomes.

Comprehensive Analysis of Garcin Syndrome: A Systematic Review of the Etiology, Diagnosis, and Treatment.

Garcin syndrome is a rare neurological condition characterized by progressive unilateral involvement of multiple cranial nerves, without typical intracranial hypertension. It is often linked with aggressive malignancies and invasive infections; hence, it presents significant diagnostic and therapeutic challenges. Despite the advances in medical technology, the prognosis still remains poor, and there is limited literature on comprehensive reviews regarding its etiology, diagnosis, and management. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review was performed in order to compile updated evidence related to Garcin syndrome. The PubMed and Scopus databases were comprehensively searched using the search terms "Garcin syndrome" AND ("etiology" OR "diagnosis" OR "treatment" OR "management"). Information was obtained from case reports and focused on common etiologies, clinical presentations, diagnostic methodologies, treatment protocols, and outcomes. The review discussed very diverse etiologies of Garcin syndrome. The most common among these were skull base tumors, metastatic lesions, and invasive infections like mucormycosis. Most of these were multiple cranial nerve (CN) involvements in which CN V (trigeminal nerve), CN VII (facial nerve), or CN XII (hypoglossal nerve) involvement was common. Advanced imaging, especially MRI, played a very crucial role in diagnosis, showing the presence of extensive bony destruction with the involvement of cranial nerves. Treatment was varied according to the etiology, ranging from chemotherapy and radiotherapy in neoplastic cases to active surgical intervention supported by antifungal therapy in infected cases. Garcin syndrome is a clinical challenge due to its diverse etiologies and complex management profile. While early diagnosis and intervention are emphasized, the prognosis remains grave, especially in cases presenting with metastatic disease or immunocompromised states. Future research should focus on better, more sensitive diagnostic modalities and the investigation of newer therapeutic approaches for Garcin syndrome patients.

The Emerging Role of Pharmacotherapy in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a prevalent pathology with current modalities of treatment including continuous positive airway pressure (CPAP), surgery, weight loss, hypoglossal nerve stimulation, and pharmacotherapy. While CPAP is the current standard treatment for OSA, lack of tolerance and side effects necessitate alternative modalities of treatment. Various pharmacologic agents exist with mechanisms that may target OSA. Early trials have demonstrated efficacy of noradrenergic-antimuscarinic combinations to stimulate the airway, promote pharyngeal muscle tone, and prevent airway collapse. These agents, which we discuss in detail, have demonstrated significant reductions in apnea-hypopnea index (AHI) and lowest oxygen saturations based on preliminary studies. Glucagon-like peptide 1 receptor agonists (GLP-1RA), which stimulate endogenous insulin, reducing glucagon release, and decreasing gastric emptying, have shown positive results for OSA patients through weight loss with reductions in AHI. In this narrative review article, we highlight the mechanisms, current data, and future potential for multiple drug classes, including respiratory stimulants and GLP-1RAs.

Baseline Characteristics Associated with Hypoglossal Nerve Stimulation Treatment Outcomes in Patients with Obstructive Sleep Apnea: A Systematic Review.

Hypoglossal nerve stimulation (HGNS) has emerged as an effective treatment for obstructive sleep apnea (OSA). Identifying baseline characteristics that prospectively could predict treatment outcomes even better is crucial for optimizing patient selection and improving therapeutic success in the future. A systematic review was conducted following PRISMA guidelines. Literature searches in Medline, Web of Science, and Cochrane databases identified studies assessing baseline characteristics associated with HGNS treatment outcomes. Inclusion criteria focused on studies with adult patients diagnosed with OSA, treated with HGNS, and assessed using full-night efficacy sleep studies. Risk of bias was evaluated using the NICE tool. Twenty-six studies met the inclusion criteria. Commonly reported baseline characteristics with predictive potential included BMI, site of collapse, and various pathophysiological endotypes. Most studies used the original Sher criteria to define treatment response, though variations were noted. Results suggested that lower BMI, absence of complete concentric collapse at the palatal level, and specific pathophysiological traits were associated with better HGNS outcomes. This review identified several baseline characteristics associated with HGNS outcomes, which may guide future patient selection. Importantly, patients were already preselected for HGNS. Standardizing response criteria is recommended to enhance the evaluation and effectiveness of HGNS therapy in OSA patients.

Analysis of Recent Sleep Surgery Fellowship Training.

Since 2011, otolaryngologists aiming to become certified in sleep medicine have had to complete an ACGME accredited sleep medicine fellowship. In addition to standard sleep medicine and sleep surgery fellowships, several institutions have developed hybrid ACGME sleep medicine programs that incorporate sleep surgery training. Our primary aims were to understand the balance between sleep medicine and surgical training requirements and the surgical volume of recent graduates across the three pathways. Our secondary aim was to assess their employment post-graduation. An improved understanding of the current state of sleep surgeon training could better inform both applicants and programs and be used to guide fellowship curriculum development. Between 2017 and 2023, we identified 26 surgeons who completed a sleep focused fellowship. An anonymous survey was developed and emailed to them. The survey assessed clinic and operating balance, procedures completed during fellowship, and comfort with these procedures as attendings. Finally, the survey assessed the job prospects of graduates. Data were analyzed with Prism 10. There were 19 respondents with 52.6% completing a hybrid fellowship, 21.3% completing a sleep medicine fellowship, and 31.6% completing a sleep surgery fellowship. Approximately 84.8% completed ACGME accredited otolaryngology training prior to fellowship. The three most common surgeries were hypoglossal nerve stimulators, pharyngoplasty, and nasal surgeries. Respondents on average received 2.4 job offers, 55% returned to their residency institution, and 89.5% were in academics. Our survey demonstrates a wide variability in sleep-focused fellowships for surgeons, but the employment market for these trainees is robust. N/A Laryngoscope, 2024.

Radiographic and neurological outcomes of Gamma Knife radiosurgery for lower cranial nerve schwannomas: a single-institution experience.

Gamma Knife radiosurgery (GKRS) is widely used for treating small- to medium-sized or postoperative residual, recurrent lower cranial nerve schwannomas (LCNSs). This study aimed to evaluate the radiographic and neurological outcomes of GKRS for LCNS. A total of 60 patients with 47 jugular foramen schwannomas (JFSs) and 13 hypoglossal nerve schwannomas (HNSs) who underwent GKRS were included. Dysphagia (40.4%) and hoarseness (23.4%) were the most common preexisting symptoms associated with JFS, whereas tongue deviation (53.8%) was prevalent in HNS. The median tumor volumes were 3.2 cm3 and 2.2 cm3 for JFSs and HNSs, respectively. The median marginal dose administered to the tumor was 13 Gy (range 12-15 Gy). The median follow-up duration was 52.8 months. Local tumor control was achieved in 91.5% of JFSs and 92.3% of HNSs. The preexisting neurological symptoms improved in 48.9% of patients with JFS and remained stable in 29.8%. However, 10 patients (21.3%) experienced exacerbation of symptoms associated with cranial nerves VII, VIII, IX, X, and XI. Among these, 3 patients (6.4%) exhibited persistent symptomatic deterioration. Patients with HNSs demonstrated a stable trajectory without symptom aggravation. Larger tumor volume and cystic portion were significantly associated with tumor progression (p = 0.017 and 0.003, respectively), and post-GKRS transient swelling was associated with neurological deterioration (p = 0.044). GKRS is an alternative treatment option for LCNS that reduces surgical morbidity and enhances tumor control. However, GKRS can potentially lead to neurological deterioration, necessitating extreme caution throughout the procedure, specifically for JFSs.

What are the Predictors of Success with Hypoglossal Nerve Stimulation?

Obstructive sleep apnea (OSA) affects up to 4% of the adult population. Hypoglossal nerve stimulation (HNS) was approved by the FDA in 2014 as a treatment option for patients with moderate to severe OSA who cannot tolerate CPAP and, since that time, studies have focused on predicting response to this therapy. This review summarizes the relevant literature assessing factors that predict HNS success including therapeutic response and device adherence.

Respiratory pathology in the TDP-43 transgenic mouse model of amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease that results in death within 2-5years of diagnosis. Respiratory failure is the most common cause of death in ALS. Mutations in the transactive response DNA binding protein 43 (TDP-43) encoded by the TARDBP gene are associated with abnormal cellular aggregates in neurons of patients with both familial and sporadic ALS. The role of these abnormal aggregates on breathing is unclear. Since respiratory failure is a major cause of death in ALS, we sought to determine the role of TDP-43 mutations on the respiratory motor unit in the Prp-hTDP-43A315T mouse model - a model that expresses human TDP-43 containing the A315T mutation. We assessed breathing using whole-body plethysmography, and investigated neuropathology in hypoglossal and phrenic respiratory motor units. Postmortem studies included quantification of hypoglossal and putative phrenic motor neurons, activated microglia and astrocytes in respiratory control centers, and assessment of hypoglossal and phrenic nerves of TDP43A315T mice. The male TDP43A315T mice display an early onset of rapid progression of disease, and premature death (less than 15weeks) compared to control mice and compared to female TDP43A315T mice who die between 20 and 35weeks of age. The TDP43A315T mice have progressive and profound breathing deficits at baseline and during a respiratory challenge. Histologically, hypoglossal and putative phrenic motor neurons of TDP43A315T mice are decreased and have increased microglial and astrocyte activation, indicating pronounced neurodegeneration and neuroinflammation. Further, there is axonopathy and demyelination in the hypoglossal and phrenic nerve of TDP43A315T mice. Thus, the TDP-43A315T mice have significant respiratory pathology and neuropathology, which makes them a useful translatable model for the study of novel therapies on breathing in ALS.

Combination Tonsillectomy and Hypoglossal Nerve Stimulation for Sleep Apnea Patients With Oropharyngeal Lateral Wall Collapse.

The efficacy of hypoglossal nerve stimulation (HGNS) therapy is limited by obstruction of the oropharyngeal lateral walls (OLWs). Our objective was to investigate the effect of palatine tonsillectomy on HGNS efficacy in obstructive sleep apnea (OSA)patients with OLW collapse. Case-control study of patients with moderate-to-severe OSA, complete-or-partial OLW collapse, and small tonsils (1 - 2+). Concomitant palatine tonsillectomy and HGNS (HGNS+T) were compared against a control group of patients who underwent HGNS alone. Single academic institution. Study outcomes were measures of HGNS efficacy defined asa %reduction in apnea-hypopnea index (AHI) (primary) and successful treatment response (50% AHI reduction to <15/h, logistic regression), respectively. Regression analyses quantified the additional effect of tonsillectomy (HGNS+T vsHGNS alone, independent variable) on HGNS efficacy. Analyses were adjusted for OLW collapse severity (complete vspartial), tonsil size, age, sex, body mass index, and baseline AHI. Nineteen patients underwent HGNS+T and had follow-up sleep testing for the current analysis. The control group (HGNS alone) consisted of 78 patients. Baseline demographics and OSA severity were similar between the groups, except HGNS+T group had increased prevalence of complete OLW collapse. Linear regression demonstrated that adding tonsillectomy resulted in an additional 22.9% [7.5, 35.2] reduction in AHI [95% confidence interval, CI] (P = .006), and 8.6 [1.7,43.4] (P = .010) greater odds [95% CI] of a successful treatment response with HGNS. Compared to historically poorer outcomes of HGNS in patients with OLW collapse, these early results suggest combining tonsillectomy with HGNS may represent a promising strategy to improve success rates.

How we measure hypoglossal nerve stimulator outcome matters: titration versus single amplitude efficacy sleep studies.

Hypoglossal nerve stimulation (HGNS) is a common treatment for obstructive sleep apnea (OSA). Objective assessment of HGNS efficacy measures apnea-hypopnea index (AHI) by multi-amplitude titration polysomnography (tPSG) and/or a single amplitude efficacy sleep study (eHST). Both tests have been used to determine efficacy despite significantly different protocols. This project's aim was to determine differences in objective outcomes in HGNS patients who underwent both tPSG and eHST post-operatively. Data from 379 consecutive HGNS patients were retrospectively reviewed. Inclusion requirements were a pre-operative sleep study, a post-operative tPSG, and then an eHST, which at our institution is a type 3 home study. AHI mean and differences were calculated. Wilcoxon rank sum tests were used to analyze differences between tPSG and eHST. Sher15 criteria (post-operative AHI≤15 events/hour and ≥50% reduction from baseline) was calculated and compared by χ2 tests. Ultimately 61 patients met inclusion criteria with an average pre-operative AHI=33.2. When comparing the subject's tPSG versus eHST, tPSG AHI was significantly lower (AHI=8.8 versus AHI=17.6; respectively, p<0.001). There was also a difference in the percentage of patients that met Sher15 criteria when using tPSG (80.3%) versus eHST AHI (45.9%). HGNS patient's postoperative tPSG AHI was significantly lower than their eHST outcome. This work highlights the importance of reporting the type of post-operative study used in evaluating HGNS efficacy and the need for single amplitude, full-night studies to assess HGNS efficacy more accurately.

An Unusual Case of Contralateral Hypoglossal and Recurrent Laryngeal Nerve Palsies Following Endotracheal Intubation.

We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.

Comparison of Home Sleep Devices and Sleep Study Testing in Hypoglossal Nerve Stimulation Patients.

Hypoglossal nerve stimulation (HGNS) is an implantable therapy for obstructive sleep apnea (OSA). Therapy efficacy is currently confirmed by a formal sleep study after empiric adjustment by the patient at home based on their subjective experience with the device. Home-based longitudinal apnea hypopnea index (AHI) measurements have the potential to refine HGNS therapeutic amplitude selection with objective data. Our objective was to compare AHI derived from routine sleep studies and two different home sleep devices in new HGNS recipients. Prospectively enrolled patients receiving HGNS therapy were provided a Sleep Tracking Mat (Withings, Issy-les-Moulineaux, France) and NightOwl peripheral arterial tonometry (PAT) sensor (Ectosense, Leuven, Belgium) for longitudinal, home AHI monitoring from 1 to 6 months post-implant. Therapy efficacy was assessed at 3 and 6 months post-implant using in-lab polysomnography (PSG) or home sleep apnea test (HSAT). The sleep mat and PAT sensor AHI were compared against PSG and HSAT for accuracy of OSA severity identification. Sixty patients were enrolled across 5 centers and followed for 6 months. The sleep mat had sensitivity and specificity for identifying AHI <15 of 61% and 82% and AHI <30 of 77% and 100%. The PAT device had sensitivity and specificity for identifying AHI <15 of 57% and 77% and AHI <30 of 81% and 80%. The sleep mat and PAT sensor demonstrated high sensitivity and specificity for detection of mild and moderate OSA in patients with HGNS therapy and may enable longitudinal objective monitoring of HGNS efficacy in the home setting. 3 Laryngoscope, 2024.

Transoral Robotic Surgery Versus Hypoglossal Nerve Stimulation for OSA: A Cost Analysis Study.

Transoral robotic surgery (TORS) lingual tonsillectomy and hypoglossal nerve stimulation (HGNS) are effective surgical interventions for well-selected patients with obstructive sleep apnea (OSA) intolerant to continuous positive airway pressure (CPAP) therapy. Previous publications have demonstrated that HGNS patients have a lower postoperative apnea-hypopnea index (AHI) and length of hospital stay than TORS patients. No prior study has investigated the differences in costs between HGNS and TORS. This study aims to compare surgery-related costs in patients undergoing HGNS versus TORS lingual tonsillectomy for OSA intolerant to CPAP. A retrospective study on OSA patients intolerant to CPAP that underwent HGNS or TORS from 2015 to 2022 at a tertiary care center. Cost was defined as the dollar amount associated with providing a specific service prior to the application of insurance. This study included 395 patients (375 UAS and 20 TORS). Average total cost was significantly higher in the UAS group than the TORS group (UAS: $25,582.60; TORS: $5832.60; p < 0.001). Operating room costs were also significantly higher in the UAS group (UAS: $1978.20; TORS: $1490.90; p = 0.001). The TORS cohort averaged higher costs for pharmacy (UAS: $201.30; TORS: $416.60; p < 0.001) and anesthesia (UAS: $139.00; TORS: $307.60; p < 0.001). The total cost was significantly higher in the UAS group compared to the TORS group. When making management decisions, it is important to consider the cost of care provided as well as patient-centered outcomes to optimize the value of care. N/A Laryngoscope, 2024.

Combined hypoglossal and lingual nerve palsy: An unrecognized complication after orotracheal intubation for general anaesthesia. A case report of a day surgery patient and a literature review

Cranial nerve injury after orotracheal intubation is a rare complication, which has varied etiology. We present a case of combined unilateral hypoglossal and lingual nerve palsy after orotracheal intubation. The current literature was reviewed for the diagnostic, treatment, follow-up, and preventive measures of this complication.