Tonsillectomy Improves Outcomes of Hypoglossal Nerve Stimulation in Patients With Obstructive Lateral Wall Collapse

Hypoglossal nerve stimulation (HGNS) has become a popular second-line therapy after positive airway pressure (PAP) therapy for obstructive sleep apnea, and adherence rates are higher. However, oropharyngeal lateral wall (OLW) collapse can compromise HGNS efficacy.

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Since November 2020, Philip Huyett, MD, director of sleep surgery at Mass Eye and Ear, and colleagues have been studying whether adding concurrent tonsillectomy to HGNS implantation improves sleep apnea outcomes. In Otolaryngology–Head and Neck Surgery they report promising early results.

Methods

Patients at Mass Eye and Ear are eligible for HGNS and concurrent coblation tonsillectomy (HGNS+T) if they have partial or complete OLW collapse detected by drug-induced sleep endoscopy, which is performed routinely. Other eligibility criteria are 1+ or 2+ tonsils, apnea–hypopnea index (AHI) > 15 events/hour, failure of PAP therapy, <25% mixed/central AHI, and body mass index <35 kg/m².

Thirty patients underwent HGNS+T by a single surgeon between November 2020 and October 2023. This interim analysis includes the 19 who completed follow-up sleep testing by February 2024. The research team also studied a control group of 78 patients who met all the same eligibility criteria but did not undergo tonsillectomy and did not have any other surgical treatment before completing follow-up sleep testing.

Efficacy of the Combination Procedure

Entire-night AHI was used as the primary outcome because it includes both sub- and supratherapeutic amplitudes, as well as periods with therapy off, and is thus more conservative than optimal-setting AHI. Compared with HGNS alone, HGNS+T was associated with a 23% additional reduction in entire-night AHI (P=0.006) and a 14% additional reduction in optimal-setting AHI.

Treatment response was defined in three ways:

1. ≥50% reduction in entire-night AHI to <15 events/hour
2. ≥50% reduction in AHI to <10 events/hour
3. ≥70% AHI reduction

Compared with HGNS alone, the increased odds of treatment response after HGNS+T were:

• Definition (A)—8.6-fold (95% CI, 1.7–43.4; P=0.010)
• Definition (B)—13.5-fold (95% CI, 2.5–74.2)
• Definition (C)—12.0-fold (95% CI, 2.4–59.9)

Safety of the Combination Procedure

After adjustment for surgical experience (time from the first procedure), total OR time and recovery room time were longer with HGNS+T by 17 and 25 minutes, respectively, and the latter difference was not statistically significant. These figures are unlikely to negatively affect OR workflow or scheduling and are outweighed by the substantial improvements observed in sleep apnea.

In the HGNS+T group, no patient developed an infection and 2/30 (6.7%) experienced post-tonsillectomy hemorrhage requiring return to the OR. The control group had no complications.

Potential to Benefit Numerous Patients

This is the first study to present encouraging results of an adjunctive therapy to improve the success of HGNS in patients with OLW collapse. Palatine tonsillectomy, which should be part of the skillset of most or all HGNS providers, would expand HGNS access to many patients with OLW collapse who otherwise go untreated or undertreated.

HGNS+T requires only one recovery period, one exposure to general anesthesia, and one insurance copayment, so it is both efficient for the healthcare system and convenient for the patient.

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