Contributed by Tereza Cervenka, MD
A 60-year-old female patient with a history of sleep problems sought an evaluation with a University of Minnesota Health ENT surgeon for possible therapy via upper airway stimulator implantation. She had been diagnosed with severe obstructive sleep apnea (OSA) in 2003 and had tried a continuous positive airway pressure (CPAP) device but could not tolerate it. She had tried other treatment methods. Weight loss helped her sleep better, but symptoms returned with weight regain. An oral appliance was not tolerated because of preexisting severe temporomandibular joint disorder. Sleeping on her side helped somewhat. She weighed 161.8 lbs; her BMI was 27.
Diagnosis and Treatment
A review of patient history revealed continuing daytime sleepiness and naps on weekends. The patient reported that she snored loudly, awoke frequently with dry mouth, and had morning headaches 3 to 4 times a week. She was getting adequate hours of sleep.
A sleep study was conducted, and it showed severe OSA, with the patient experiencing 46 episodes of apnea and partial apnea per hour. Sleep apneas were more frequent when the patient was sleeping supine, less frequent with side sleeping. Upper airway evaluation revealed a velopharynx with 100% anteroposterior collapse, 30% lateral oropharynx narrowing, 50% anteroposterior collapse of the tongue base, passive epiglottis, and soft palate that opened with jaw thrust and appeared open in the left lateral position.
The patient was deemed a good candidate for upper airway stimulation therapy and underwent a right hypoglossal nerve stimulator placement. The patient’s hypoglossal nerve stimulator device was activated after she had completely healed. The care team educated the patient about the device and use of the remote control. The providers advised increasing the voltage by 0.1 V every third day as tolerated. Once she reached the maximum effective voltage, she could remain at that level.
About 2 weeks later during a second postoperative visit, she reported being at level 3 of the 11 levels of voltage settings ramp-up and had difficulty with higher settings. Pausing the device when she awakened during the night to take her dog out caused stimulation that was too strong. Her team advised her that normal sleep with the device could take up to 6 months and suggested turning the device off when getting up for longer periods and then turning it on when returning to bed.
At 4 weeks postactivation, titration PSG determined the best settings to be 2.3 to 2.6 V, at which episodes of apnea and partial apnea fell to the normal range. Snoring resolved at higher voltages. One month later, the patient reported increasing device voltage as recommended, and her current setting is 2.2 volts.
The device allowed the patient to fall asleep, but during occasional awakening, she noted a throbbing at the back of her throat, sometimes preventing her from returning to sleep. She has significantly less excessive daytime sleepiness and much improved restful sleep. She also planned to purchase an adjustable bed, which will allow her to elevate the head of her bed. She has had no other significant health changes.
An estimated 50 to 70 million U.S. adults have sleep disorders, and nearly half of these experience sleep apnea. New devices and coordinated care approaches are providing new hope for relief.Continue reading