Hypoglossal Nerve Stimulator Implantation: 2-Incision Technique Authors: Cheryl Yu, MD1; Nilan Vaghjiani, BS1; Ryan Nord, MD1 1Virginia Commonwealth University School of Medicine, Department of Otolaryngology/ Head and Neck Surgery, Richmond, VA
Background:
Obstructive sleep apnea is a worldwide health problem that affects all groups. Given its systemic associations with comorbid diseases, it ultimately increases lifetime risk of mortality and thus, should not be a disorder taken lightly. Although continuous positive airway pressure is thoroughly acknowledged as the gold standard for treating OSA with studied efficacy, adherence remains challenge. Given such, hypoglossal nerve stimulation therapy presents a revolutionary alternative for those with moderate to severe degrees of OSA who are unable to tolerate standard CPAP therapy. It has been studied to be very efficacious in treating the disorder, with reductions in apneas up to 70-80%. The surgery itself is less invasive, now even more so with the 2-incision technique, when compared to other surgical options such as mandibular advancement or other upper airway surgery, with decreased post-operative pain and healing times. Adherence to therapy is generally superior as the majority prefer it over traditional positive airway pressure therapy. Overall, hypoglossal nerve stimulator implantation is an effective, tolerable long-term alternative treatment option for those with OSA.
Case Overview: 84-year-old female with BMI of 31 with past medical history significant for hypertension, atrial fibrillation, and obstructive sleep apnea and inability to tolerate CPAP. Polysomnography revealed severe OSA with an AHI of 33 and minimal central or mixed apneas. Preoperative drug induced sleep endoscopy was performed noting complete anterior-posterior collapse of the velum, no collapse at the oropharynx, complete anterior-posterior collapse of the tongue base, and no collapse at the epiglottis. Patient was subsequently deemed an appropriate candidate for hypoglossal nerve stimulator implantation and elected to proceed with the procedure. The following video demonstrates her hypoglossal nerve stimulator implantation via the 2-incision technique detailing the procedure’s anatomic landmarks and corresponding steps.
A modified 3cm incision is made in the right upper neck half way between the mandible and the hyoid bone starting 1cm off midline. Dissection is then carried down through the subcutaneous tissue and platysma. The anterior border of the submandibular gland and the gland is retracted posterosuperiorly. The anterior belly the digastric is identified and dissection is performed to expose the tendon which is then retracted inferiorly. The mylohyoid is then separated from its attachments to the submandibular gland and retracted superomedially. Once the space between submandibular gland and mylohyoid is entered, the hypoglossal nerve and ranine vein are identified. Overlying fascia is dissected off the nerve at the suspected breakpoint. Intrusor and retrusor branches are identified and confirmed with the NIM. Next, a vessel loop is placed around the intrusor branches and dissection proceeds anteriorly to the anterior aspect of the hyoglossus to ensure no missed exclusion branches. A window is created under the inclusion branches and the stimulation cuff is placed around the nerve. The outer flange should then be noted to be in contact with all three electrode points and the inner flange should fully around the nerve and c1. Once the cuff is appropriately seated, it is irrigated with saline.
The procedure then turns to the chest. A second 4.5cm incision is made in the right upper chest 3cm from the medial border of the sternum overlying the second intercostal space. Dissection is carried down through subcutaneous tissues to the pectoralis muscle. An inferior pocket is then created deep to the subcutaneous layer and superficial to the pectoralis muscle. Next, blunt dissection is carried through the pectoralis muscle until the intercostals are visualized. Next, a 3-0 silk suture with an air knot is tied to the free edge of the external intercostal muscle to serve as the anchoring stitch for the impending sensing lead. A right angle dissector was used to carefully identify the plane below the external and above internal intercostal muscles along the intercostal space starting 5mm from the free edge of the external intercostal and following the trajectory of the rib towards the right shoulder. The sensing lead is then place into this pocket gently and secured to the external muscles. Care should be taken to only grasp the sensor at the reinforced section of the sensing lead which is distal on the sensor in respect to the flexible wiring portion which is easily damaged. A pocket is created deep and medial to the pectoralis major muscle to allow a coil of the sensing lead to bend and turn back without kinking and the second anchor is secured under the pectoralis major muscle with 3 3-0 silk sutures. The pectoralis major muscle is then closed.
The tunneler is then bent over the patient to accurately gauge the appropriate shape. Up in the neck a tonsil is used to develop a subplatysmal plane as far as possible under direct visualization. The tunnel is then passed from the neck to the chest incision with careful guidance to maintain the subplatysmal plane but passing above the clavicle. The stimulation lead is then passed from the neck to the chest by aid of the tunneler.
Next, we attach the IPG to the sensing and stimulation leads into the lower and upper holes respectively. The wire is then coiled under the IPG and the unit is placed into the chest pocket.
The device is then tested. A waveform is run for three minutes to assess physiologic waveform with care to observe for any current leakage. Stimulation is then tested at +-+ and 0-0 and -0- settings and tongue motion is assessed.
The IPG is then secured to the pectoralis fascia using 2-0 silk suture with an air knot. All the wounds are then copiously irrigated with saline and antibiotic irrigation. The wounds are then closed in multilayered fashion.
- Adults 18 years or older with moderate OSA (AHI range 15-65 with <25% central apneas)
- CPAP intolerance/failure (inability to use greater than 5 nights (at least 4 hours per night) per week
- <18 years of age
- AHI <15 or >65
- Central apneas >25%
- Concentric collapse at palate
- BMI >32 (not FDA approved)
- Pregnancy
General anesthesia is induced and nasotracheal intubation is performed. Preoperative antibiotics are given. The patient is then turned 180 degrees. A shoulder roll is placed. Prep beginning with Betadine scrub and paint is performed which was then blotted and followed by chlorhexidine. The patient is then draped off in usual sterile fashion which includes excluding the mouth with a 10-10 drape, toweling off the surgical site and placing ioban over the exposed field. 18mm NIM electrodes are then placed in the genioglossus (blue) and hyoglossus (red) muscle and connected to the NIM box for intraoperative nerve monitoring.
- Polysomnogram to evaluate AHI and assess for degree of central apneas
- Drug induced sleep endoscopy to evaluate levels and dynamic patterns of collapse (velum, oropharynx, tongue base, epiglottis)
NECK:
- Mandible, hyoid bone, submandibular gland for neck incision
- Free edge of mylohyoid muscle
- Hypoglossal nerve anatomy identification: GGo and GGh to the oblique and horizontal genioglossus fibers, transverse and vertical branches to intrinsic muscles and C1 to the geniohyoid as well as exclusion branches to hyoglossus and styloglossus
CHEST:
- Sternum, clavicle, second intercostal space along right chest for chest incision
- Pectoralis fascia and muscle
- External and internal intercostals, placement of sensing lead in the plane in between the intercostals
Advantages:
- Alternative for those with OSA who are unable to tolerate CPAP
- Single-stage outpatient procedure with resulting effect at multiple airway levels
- Easy to use with high adherence
Disadvantages:
- Foreign body with risk of device intolerance/malfunction/infection and need for removal
- Battery life of device approximately 10 years
Advantages:
- Alternative for those with OSA who are unable to tolerate CPAP
- Single-stage procedure with resulting effect at multiple airway levels
- Easy to use with high adherence
Disadvantages:
- Foreign body with risk of device intolerance/malfunction/infection and need for removal
- Battery life of device approximately 10 years
Ryan Nord, MD: Consultant for Inspire Medical Systems
N/A
Olson MD, Junna MR. Hypoglossal Nerve Stimulation Therapy for the Treatment of Obstructive Sleep Apnea. Neurotherapeutics. 2021 Jan;18(1):91-99. doi: 10.1007/s13311-021-01012-x. Epub 2021 Feb 8. PMID: 33559036; PMCID: PMC8116425.
Mashaqi S, Patel SI, Combs D, Estep L, Helmick S, Machamer J, Parthasarathy S. The Hypoglossal Nerve Stimulation as a Novel Therapy for Treating Obstructive Sleep Apnea-A Literature Review. Int J Environ Res Public Health. 2021 Feb 9;18(4):1642. doi: 10.3390/ijerph18041642. PMID: 33572156; PMCID: PMC7914469.
Lin C, Olson MD, Huyett P, Chio EG. Implantation of the hypoglossal nerve stimulator via left sided, 2-incision approach. J Clin Sleep Med. 2021 Dec 30. doi: 10.5664/jcsm.9856. Epub ahead of print. PMID: 34964436.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Hypoglossal Nerve Stimulator Implantation: 2-Incision Technique.