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Fig. 21.12 (Video 21.2) Microlaryngoscopic view of the epiglottis at the end of the GEP procedure (► https://doi.org/10.1007/000-bfp)
M. Barbieri et al.
21.4 Postoperative Care
At the end of the procedure, the patient is extubated and transferred to the recovery
room for 30min and then directly to his room.
On the rst postoperative day, it is mandatory to evaluate the swallowing function with water and soft foods. If no disorders are detected, the patient can start to
drink and to eat a soft diet for 7 days. During hospitalization time, intravenous
antibiotics are generally administrated.
If no complications are observed, the patient is discharged in the second postoperative day, with oral antibiotics for 1week and analgesics if required.
Video laryngoscopic evaluation is performed after 1week to test the penetrationaspiration scale. After 3 weeks, postoperatively it is repeated and the stich is
removed under endoscopic guidance without the necessity of general or local
anesthesia.
Six months after the procedure, every patient is submitted to an additional polysomnography test to evaluate the efcacy of surgery.
21.5 Complications
In our experience, we treated 49 patients affected by OSA with primary collapse of
epiglottic. Complications occurred only in 2 out of 49 procedures. One patient had
suture breakage 7days after procedure but the exible trans-nasal video endoscopy
revealed a stability of the GEP.
The second complication was observed in a patient that developed a laceration of
the epiglottis by the sutures: the reason of that was the wire placed involving the
hyoid bone, because of the excessive tension created. Anyway, in this last case, we
did not observe bleeding, dysphagia, or aspiration and postoperative AHI improved
from 66 to 10.
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A potential complication is a slight bleeding during surgery that can be routinely
controlled with bipolar clamp. Theoretically, oedema of supraglottic region of the
larynx, dysphagia, or dysgeusia could be developed but the surgical technique
described herein is able to preserve laryngeal anatomy and physiology. Moreover, it
provides stable support to the epiglottis without interfering with its function during
swallowing and reinforcing the wall of the airway by creating a kind of “landslide
barrier” to prevent the falling down of the tongue base posteriorly.
References
1. Torre C, Camacho M, Liu SYC, Huon LK, Capasso R.Epiglottis collapse in adult obstructive
sleep apnea: a systematic review. Laryngoscope. 2016;126:515–23. https://doi.org/10.1002/
lary.25589.
2. Roustan V, Barbieri M, Incandela F, Missale F, Camera H, Braido F, etal. Glossoepiglottoplastica
con approccio trans-orale nel trattamento delle apnee ostruttive notturne nell’adulto. Acta
Otorhinolaryngol Ital. 2018;38:38–44. https://doi.org/10.14639/0392- 100X- 1857.
3. Monnier P.Pediatric airway surgery: management of laryngotracheal stenosis in infants and
children. Berlin: Springer; 2010.
4. Delakorda M, Ovsenik N.Epiglottis shape as a predictor of obstruction level in patients with
sleep apnea. Sleep Breath. 2019;23:311–7. https://doi.org/10.1007/s11325- 018- 1763- y.
5. Piazza C, Mangili S, Del Bon F, Paderno A, Grazioli P, Barbieri D, etal. Preoperative clini-
cal predictors of difcult laryngeal exposure for microlaryngoscopy: the laryngoscore.
Laryngoscope. 2014;124:2561–7. https://doi.org/10.1002/lary.24803.
Upper Airway Stimulation
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ClemensHeiser
22.1 Introduction
Hypoglossal nerve stimulation (HNS) or also called as upper airway stimulation (UAS)
has rapidly become a powerful and useful therapy option for patients, who are suffering
from obstructive sleep apnea (OSA) and who are non-adherent or non- compliant to the
standard treatment positive airway pressure (PAP) therapy [1]. In 1978, John Remmers
etal. described the main upper airway opener “the genioglossus muscle”, which is also
the main target during HNS [2]. Further trials from different research groups showed
that the stimulation of this muscle opens the pharyngeal airway during sleep [3–5].
That was the cornerstone for the further development of the different upper airway
stimulation systems of the hypoglossal nerve. Since more than 10 years, multiple,
international, prospective trails have shown the effectiveness of this therapy [6–9].
22.2 Available Technologies
Nowadays, three technologies, in different stages of development with regard to
clinical data, are available in Europe and the United States with different clinical
data: Inspire, LivaNova (former: ImThera) and Nyxoah [1, 10]. These three devices
differ from each other mainly in two points such as (Table22.1):
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-34992-8_22. The videos can be accessed individually by clicking
the DOI link in the accompanying gure caption or by scanning this link with the SN More Media App.
C. Heiser (*)
Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum Rechts der Isar,
Technical University of Munich, Munich, Germany
Translational Neurosciences, University of Antwerp, Antwerp, Belgium
e-mail: clemens.heiser@tum.de
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_22
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Table 22.1 Different systems for upper airway stimulation and their differences regarding the
anatomical location on the hypoglossal nerve and stimulation dependence regarding the breathing cycle
Anatomical
location on the
hypoglossal nerve
Breathing cycle Breathing cycle
Unilateral distal
selective placement of
the stimulation cuff
dependent
Unilateral main trunk
placement of the
stimulation cuff
Non-dependent Duty cycle dependent
Bilateral distal
selective placement of
the stimulation paddles
C. Heiser
1. Anatomical location of the stimulation side on the hypoglossal nerve.
2. Breathing cycle dependency.
22.3 The Anatomy oftheHypoglossal Nerve andits
Anatomical Stimulations Sides
The hypoglossal nerve and its terminating branches can be divided into two main
groups such as [11, 12]:
• Lateral branches: supplying the main retractors of the tongue (styloglossus mus-
cle and hyoglossus muscle).
• Medial branches: supplying the main protrusions of the tongue: horizontal and
oblique part of the genioglossus muscle.
The Genio and Inspire system, which are placed selectively at the protruding bers
of the tongue, actively open the upper airway during stimulation [13–15]. The
Aura6000 system, which also includes the lateral bers of the nerve, is placed at the
main trunk of the HN.The system has multiple contacts with the opportunity to
increase the permutations for selective activation of the nerve bers [16]. The effect
of stimulation is not an active upper airway opening; its mode of action is more a
stiffening and re-shaping of the tongue, with only a small amount of protrusion.
22.4 Active Hyoid Suspension
Active opening of the lower upper airway can be achieved by an “active hyoid suspension” [17–19]. Moving the hyoid bone actively forward helps to open obstructions on the lower hypopharyngeal levels. Pengo etal. could show that stimulation
of the genioglossus and geniohyoid muscle reduces the resistance of the upper airway [20]. The epiglottis is the upper part of the larynx and attaches to the hyoid
bone via the hyoepiglottic ligament, which is an elastic-like band (Fig.22.1). The
petiolus of the epiglottis is attached to the thyroid cartilage through the thyroepiglottic ligament. The hyoid bone can be moved forward by the contraction of the
geniohyoid muscle (Fig.22.2) [21, 22].
Pulling the hyoid bone forward is normally needed during deglutition. The geniohyoid muscle is narrow, and its insertion is to the medial border of the mylohyoid muscle.
This muscle originates from the inferior mental spine on the inner side of the mandible
and runs slightly downwards to its insertion at the anterior part of the hyoid bone.
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Fig. 22.1 The geniohyoid
muscle is attached to the
mental spine on the inner
side of the mandible and
runs to the anterior part of
the hyoid bone. The hyoid
bone is connected through
the hyoepiglottic ligament
(grey bar) to the epiglottis.
GH geniohyoid muscle,
HB hyoid bone
Fig. 22.2 Active
contraction of the
geniohyoid muscle moves
the hyoid bone forward
and puts the epiglottis in a
more perpendicular
position (compare with
Fig.22.1). Grey bar
hyoepiglottic ligament, GH
geniohyoid muscle, HB
hyoid bone
283
22.5 Anatomical Variations oftheFirst Cervical Nerve (C1)
The innervation of this muscle is done by the rst cervical nerve (C1), which is running next to the HN and leaves the main trunk at its distal branches (Fig.22.3) [21].
During selective HN surgery, this ber should be carefully identied [23–25].
Heiser etal. were the rst to describe this anatomical diversity and developed a new
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C. Heiser
Fig. 22.3 This schematic drawing of the hypoglossal nerve (HN) shows the different anatomical
stimulation sites of the three different HNS systems. Aura6000 (LivaNova) is placed at the main
trunk of the HN and the two other systems (Inspire & Genio system Nyxoah) are placed selectively
distal on the hypoglossal nerve. The red circle includes all the lateral branches of the HN, which
are responsible mainly for tongue retractors and elevators. The green circle includes all the medial
branches of the HN, which are responsible for protruding the tongue. N.XII nervus hypoglossus,
SL superior longitudinal nerve bers, HG hyoglossus muscle nerve bers, T/V intrinsic transversal
and vertical muscle nerve bers, l-XII lateral nerve bers, m-XII medial nerve bers, C1 rst cervical nerve, GGo genioglossus (oblique) nerve bers, GGh genioglossus (horizontal) nerve bers
surgical classication system [12]. Three different types of C1 have been established, mainly depending on the point where C1 leaves the main trunk. In 60% of
the cases (type a, Fig.22.4a), C1 runs parallel to the main trunk of the HN and
leaves the trunk in an acute sharp angle. In 10% of the cases, C1 leaves the main
trunk very proximal and in a blunt angle (type b, Fig.22.4b). Leaving the main
trunk very distally and late in a blunt angle occurs in 30% of the cases (type c,
Fig.22.4c).
The importance of C1 and hyoid movement could be shown during an ultrasound
study from Hofauer etal. [17]. A video of active and passive contractions of the
geniohyoid muscle and hyoid bone movement during stimulation is attached to this
chapter (Fig.22.5a, b).
abc
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Fig. 22.4 (a–c) Different anatomical variations of the rst cervical nerve (C-1, blue line) leaving
the main trunk of the hypoglossal nerve at different anatomical sides. N.XII nervus hypoglossus,
SL superior longitudinal nerve bers, HG hyoglossus muscle nerve bers, T/V intrinsic transversal
and vertical muscle nerve bers, C-1 rst cervical nerve, GGo genioglossus (oblique) nerve bers,
GGh genioglossus (horizontal) nerve bers
285
ab
Fig. 22.5 (Video 22.1) (a) Passive contractions of the geniohyoid muscle (GH) and hyoid bone
during stimulation of the hypoglossal nerve visualized with an ultrasound. The tongue is contracting but not the GH muscle. (b) Active contractions of the geniohyoid muscle (GH) and hyoid bone
during stimulation of the hypoglossal nerve visualized with an ultrasound. The tongue and the GH
is contracting and moving the hyoid actively forward (► https://doi.org/10.1007/000-bfs)
22.6 Scientific Evidence ofActivating C1
Sixteen patients, who received an implantation of Inspire II Upper Airway
Stimulation System (Maple Grove, USA), were examined with ultrasound (US)
after the initiation of therapy [17]. Different planes for US were used, and hyoid
protrusion was measured and correlated to the reduction of the apnea hypopnea
index (AHI). The extent of the hyoid protrusion did not correlate with the
improvement of AHI or oxygen desaturation index (ODI). One major limitation
of the study was that non-responders to HNS therapy were NOT included. Just
patients with signicant improvements in objective parameters were asked to
participate in this study [17]. In addition, the US examinations were performed
2months after surgery while already using the effective stimulation amplitude
that was dened in an overnight titration polysomnography in the sleep laboratory. In another retrospective study in 114 patients, Kumar et al. examined
whether C1 had been included or not during implantation [26]. In 87 patients,
C1 seemed to be included in the stimulation cuff, while 27 patients did not have
C1 included. No objective measurement such as ultrasound was performed to
check the inclusion of this nerve ber. The authors could not nd any correlation between C1 inclusion and non-inclusion regarding the AHI and
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C. Heiser
a
Fig. 22.6 (Video 22.2) (a) Floppy epiglottis during drug induced sleep endoscopy (DISE).
The blue arrow marks how the epiglottis gets sucked to the pharyngeal wall. (b) The oppy
epiglottis during drug induced sleep endoscopy (DISE) is solved by upper airway stimulation
(► https://doi.org/10.1007/000-bfr)
b
summarized that inclusion of C1 may not provide any additional benet [26].
The major limitations of this study were the retrospective study design, no
objective measurement of C1 inclusion and using a titrated AHI during a titration night. Heiser etal. responded in a letter to the editor to take exception to an
overreaching claim that C1 is not inuencing clinical outcomes [19]. The major
problem is that the C1 branch is sometimes difcult to detect during surgery due
to its high variable branching patterns (Fig.22.4a–c) [12]. In addition, in some
cases, the intraoperative neuromonitoring (NIM), which is used during implantation, can be misleading [12, 24]. Furthermore, intraoperative muscle contractions, which can be seen during stimulation with the NIM, can be weak and
obviously tongue motions do not reveal if C1 is included or not. One solution to
answer these questions could be to perform an electromyogram (EMG) of the
geniohyoid muscle during surgery, or as already mentioned, to perform an ultrasound in a larger cohort trial. Hofauer etal. have done this in a pilot study [17].
Heiser showed in a case report how a oppy epiglottis can be treated with
advanced titration (Fig.22.6a, b) [18].
In sum, inclusion of the small C1 ber can be challenging. In some cases, surgeons may miss this part of the wider hypoglossal nerve. Changing stimulation
settings from unipolar to monopolar for example could result in a broader and
deeper eld of electrical activation [18].
22.7 Conclusion
Moving the hyoid bone forward helps to solve obstruction at the level of the epiglottis. An “active hyoid suspension” can be achieved by the activation of the associated
geniohyoid muscle, which is innervated by C1. In combination with the active opening of the upper airway at the level of the tongue base by stimulating the horizontal
bers of the genioglossus muscle, additional forces on the whole lower pharyngeal/
hypopharyngeal level are released. Therefore, to obtain optimal clinical outcome,
precise and selective cuff placement is necessary during surgery and identifying of
all nerve structures by NIM, muscle contractions and tongue motions are needed.
C1 should always be included in selective HNS.
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References
1. Heiser C, Hofauer B.Addressing the tone and synchrony issue during sleep: pacing the hypoglossal nerve. Sleep Med Clin. 2019;14(1):91–7.
2. Remmers JE, etal. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol Respir
Environ Exerc Physiol. 1978;44(6):931–8.
3. Miki H, etal. Effect of electrical stimulation of genioglossus muscle on upper airway resistance in anesthetized dogs. Tohoku J Exp Med. 1987;153(4):397–8.
4. Miki H, etal. Effects of submental electrical stimulation during sleep on upper airway patency
in patients with obstructive sleep apnea. Am Rev Respir Dis. 1989;140(5):1285–9.
5. Hida W, et al. Submental stimulation and supraglottic resistance during mouth breathing.
Respir Physiol. 1995;101(1):79–85.
6. Heiser C, et al. Outcomes of upper airway stimulation for obstructive sleep apnea in a
Multicenter German Postmarket Study. Otolaryngol Head Neck Surg. 2017;156(2):378–84.
7. Heiser C, etal. Post-approval upper airway stimulation predictors of treatment effectiveness in
the ADHERE registry. Eur Respir J. 2019;53(1):1801405.
8. Thaler E, etal. Results of the ADHERE upper airway stimulation registry and predictors of
therapy efcacy. Laryngoscope. 2019;130:1333.
9. Steffen A, etal. Long-term follow-up of the German post-market study for upper airway stimulation for obstructive sleep apnea. Sleep Breath. 2020;24(3):979–84.
10. Hofauer B, Heiser C. The use of selective upper airway stimulation therapy in Germany.
Somnologie. 2018;22(2):98–105.
11. Heiser C, Knopf A, Hofauer B.The terminal hypoglossal nerve and its anatomical variability.
HNO. 2019;67(4):242–50.
12. Heiser C, Knopf A, Hofauer B.Surgical anatomy of the hypoglossal nerve: a new classication
system for selective upper airway stimulation. Head Neck. 2017;39(12):2371–80.
13. Saruddin F, etal. Effect of upper-airway stimulation for obstructive sleep apnoea on airway
dimensions. Eur Respir J. 2015;45(1):129–38.
14. Heiser C, etal. Cross motor innervation of the hypoglossal nerve-a pilot study of predictors for
successful opening of the soft palate. Sleep Breath. 2021;25(1):425–31.
15. Heiser C, etal. Palatoglossus coupling in selective upper airway stimulation. Laryngoscope.
2017;127(10):E378–83.
16. Meadows PM, Whitehead MC, Zaidi FN.Effects of targeted activation of tongue muscles on
oropharyngeal patency in the rat. J Neurol Sci. 2014;346(1–2):178–93.
17. Hofauer B, etal. Sonographic evaluation of tongue motions during upper airway stimulation
for obstructive sleep apnea-a pilot study. Sleep Breath. 2017;21(1):101–7.
18. Heiser C.Advanced titration to treat a oppy epiglottis in selective upper airway stimulation.
Laryngoscope. 2016;126(Suppl 7):S22–4.
19. Heiser C, Hofauer B.In reference to inclusion of the rst cervical nerve does not inuence
outcomes in upper airway stimulation for treatment of obstructive sleep apnea. Laryngoscope.
2020;130(7):E454.
20. Pengo MF, Steier J.Emerging technology: electrical stimulation in obstructive sleep apnoea. J
Thorac Dis. 2015;7(8):1286–97.
21. Mu L, Sanders I.Human tongue neuroanatomy: nerve supply and motor endplates. Clin Anat.
2010;23(7):777–91.
22. Sanders I, Mu L.A three-dimensional atlas of human tongue muscles. Anat Rec (Hoboken).
2013;296(7):1102–14.
23. Heiser C, etal. Updates of operative techniques for upper airway stimulation. Laryngoscope.
2016;126(Suppl 7):S12–6.
24. Heiser C, etal. Nerve monitoring-guided selective hypoglossal nerve stimulation in obstructive sleep apnea patients. Laryngoscope. 2016;126(12):2852–8.
25. Heiser C, et al. Technical tips during implantation of selective upper airway stimulation.
Laryngoscope. 2018;128(3):756–62.
26. Kumar AT, etal. Inclusion of the rst cervical nerve does not inuence outcomes in upper airway
stimulation for treatment of obstructive sleep apnea. Laryngoscope. 2020 May;130(5):E382–5.
https://doi.org/10.1002/lary.28256.
Tongue Base Surgery
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VikasAgrawal, VijayaKrishnan, andSrinivasKishore
23.1 Introduction
Obstructive sleep apnea (OSA) is a disorder caused by repetitive collapse of the
upper airway during sleep, resulting in either partial or complete airow obstruction
[1, 2]. In the adult population, the prevalence of OSA is 22% in men and 17% in
women [3]. The morphology of upper-airway structures plays a major role in the
pathogenesis of OSA.
Treatment of OSA with continuous positive airway pressure (CPAP) is still considered as the “gold standard”; however, despite its proven efcacy, a signicant
number of patients cannot tolerate the device and require therapeutic alternatives
such as surgery, oral appliances, and/or positional devices.
In the past, the prevalence of epiglottis collapse evaluated by clinical examination was estimated to be 12% in OSAS patients, although nowadays, it is possible to
show that the prevalence of epiglottis collapse in determining the airway obstruction is actually much higher, thanks to the introduction of drug-induced sedation
endoscopy (DISE) [4–6].
DISE has been previously described in the adult and pediatric populations for the
purpose of evaluating the dynamic airway in the supine position during a sleep-like
state [7–9]. It is an increasingly useful tool in the evaluation of children with
V. Agrawal (*)
Speciality ENT Hospital, Mumbai, Maharashtra, India
e-mail: doctor@enthospital.com
V. Krishnan
Department of Snoring & Sleep Disorders, Madras ENT Research Foundation,
Chennai, Tamil Nadu, India
S. Kishore
AIG Hospitals, Hyderabad, Telangana, India
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_23
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