819 A RARE CASE OF RESPIRATORY SENSE LEAD DYSFUNCTION IN A PATIENT WITH A HYPOGLOSSAL NERVE STIMULATOR

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A320-A320
Author(s):  
Omesh Toolsie ◽  
Rajesh Zacharias ◽  
Joel Oster ◽  
Peter Ostrow ◽  
Greg Schumaker ◽  
...  
Keyword(s):  
Hypoglossal Nerve ◽  
Pulse Generator ◽  
Lower Range ◽  
Stimulation Level ◽  
Cuff Electrodes ◽  
Obstructive Sleep ◽  
Increased Sensitivity ◽  
The Right ◽  
Structured Approach

Abstract Introduction In patients with moderate to severe obstructive sleep apnea (OSA) who are intolerant to PAP therapy, hypoglossal nerve stimulation (HGNS) is being increasingly considered as alternative treatment. Implantation involves placing cuff electrodes on inclusion branches of the hypoglossal nerve and a respiratory effort-sensing lead which is placed between the right intercostal muscle layers. These are connected to the implantable pulse generator which usually sits in a right infraclavicular pocket. Report of case(s) A 49-year-old male with severe OSA (AHI 30.8/hour) was implanted with a HGNS two years ago with successful activation a month later. He successfully up titrated his amplitude to the maximum stimulation level within his set range (0.9v – 1.7v). He underwent HGNS titration with AHI reduction to 13.9/hour at 2.1 volts and given a new higher range of 1.5 to 2.5 volts. This was accompanied by reduction in snoring, witnessed apneas and associated arousals with more consolidated sleep and improvement in his Epworth sleepiness score to 3 from 12 as noted prior to HGNS. The patient continued to up titrate over the next six months within his new range to 2.4 volts, when he reported increased sensitivity and intolerance at every stimulation level with recurrence of snoring and daytime sleepiness. He underwent interrogation of his device with subsequent awake endoscopy and change to his electrode configuration with a new lower range of 1.0 to 2.0 volts. However, he continued to have the same complaints. A second interrogation revealed increased impedance within the circuit of the respiratory sensing lead which was reproducible. The patient underwent sensing lead replacement in the operating room. He has since been able to increase stimulation levels without complaints and improvement in his OSA symptoms and is scheduled to have a follow-up hone sleep test (HST). Conclusion This case illustrates the importance of a structured approach in the evaluation of a reduced tolerance to HGNS. This includes assessing adherence, interrogation of the device’s circuitry, evaluating electrode configurations, stimulation thresholds with consideration for awake endoscopy. Repeating this process may be necessary to detect rare or delayed mechanical problems that may occur over time with HGNS. Support (if any):

scholarly journals 1220 A CASE OF HYPOGLOSSAL NERVE STIMULATOR CERVICAL LEAD CUFF DISLODGEMENT

SLEEP ◽  
2020 ◽  
Vol 43 (Supplement_1) ◽  
pp. A466-A466
Author(s):  
Hamed Ali ◽  
Sowjanya Duthuluru
Keyword(s):  
Hypoglossal Nerve ◽  
Pulse Generator ◽  
Rare Complication ◽  
Alternative Therapy ◽  
Distal Portion ◽  
Clinic Visit ◽  
Nerve Stimulator ◽  
Obstructive Sleep ◽  
The Right

Abstract Introduction Hypoglossal Nerve Stimulation (HGNS) has become an alternative therapy for moderate to severe obstructive sleep apnea (OSA) patients intolerant to PAP therapy. HGNS devices typically comprise of implantable pulse generator (IPG) placed surgically in an infraclavicular subcutaneous pocket. An electrode cuff attached to the IPG wraps around the distal portion of the of the hypoglossal nerve. This device has an implantable chest sensor that monitors the respiratory efforts. Report of Case A 76-year-old male with history of severe OSA (AHI 39 /hour) was intolerant to PAP therapy. HGNS was implanted in the right infraclavicular pocket under general anesthesia without any complications. Patient had successful tongue motion to stimulus per protocol intra- operatively in the OR. However, no tongue movement was noted despite maximum stimulation up to 4.5 V at follow up clinic visit. Follow up C spine x ray showed very low-lying HGNS cervical lead cuff, and possible dislodgement. Patient was taken back to the OR. Intraoperatively it was noted that the previously placed cervical lead cuff has folded back and was lying on the surface of the submandibular gland /digastric anchor site. It was dissected free and replaced on the distal inclusion branches of the hypoglossal nerve with loupe magnification and EMG confirmation (tongue deviation at 1.5 volts). Patient developed tongue neuropraxia with difficulty swallowing, difficulty speaking and right sided tongue deviation lasting for months, that gradually improved. Patient had successful HNS activation 6 months later using 2.2 V. Conclusion (HGNS) failure secondary to cervical lead cuff dislodgement is a rare complication and should be taken in consideration. Post-operative imaging and comprehensive clinical examination are crucial in detecting such problems. Temporary tongue neuropraxia post Hypoglossal nerve stimulator placement is another possible complication.

Previous Surgery and Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

2019 ◽  
Vol 161 (5) ◽  
pp. 897-903 ◽  
Author(s):  
Eric J. Kezirian ◽  
Clemens Heiser ◽  
Armin Steffen ◽  
Maurits Boon ◽  
Benedikt Hofauer ◽  
...  
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Nerve Stimulation ◽  
Hypoglossal Nerve ◽  
Therapy Response ◽  
Apnea Hypopnea Index ◽  
Previous Surgery ◽  
Hypoglossal Nerve Stimulation ◽  
Obstructive Sleep

Objective To examine whether previous palate or hypopharyngeal surgery was associated with efficacy of treatment of obstructive sleep apnea with hypoglossal nerve stimulation. Study Design Cohort (retrospective and prospective). Setting Eleven academic medical centers. Subjects and Methods Adults treated with hypoglossal nerve stimulation were enrolled in the ADHERE Registry. Outcomes were defined by the apnea-hypopnea index (AHI), in 3 ways: change in the AHI and 2 definitions of therapy response requiring ≥50% reduction in the AHI to a level <20 events/h (Response20) or 15 events/h (Response15). Previous palate and hypopharyngeal (tongue, epiglottis, or maxillofacial) procedures were documented. Linear and logistic regression examined the association between previous palate or hypopharyngeal surgery and outcomes, with adjustment for age, sex, and body mass index. Results The majority (73%, 217 of 299) had no previous palate or hypopharyngeal surgery, while 25% and 9% had previous palate or hypopharyngeal surgery, respectively, including 6% with previous palate and hypopharyngeal surgery. Baseline AHI (36.0 ± 15.6 events/h) decreased to 12.0 ± 13.3 at therapy titration ( P < .001) and 11.4 ± 12.6 at final follow-up ( P < .001). Any previous surgery, previous palate surgery, and previous hypopharyngeal surgery were not clearly associated with treatment response; for example, any previous surgery was associated with a 0.69 (95% CI: 0.37, 1.27) odds of response (Response20 measure) at therapy titration and a 0.55 (95% CI: 0.22, 1.34) odds of response (Response20 measure) at final follow-up. Conclusion Previous upper airway surgery was not clearly associated with efficacy of hypoglossal nerve stimulation.

Ansa Cervicalis Stimulation Increases Pharyngeal Patency in Patients with Obstructive Sleep Apnea

2021 ◽  
Author(s):  
David T. Kent ◽  
William C. Scott ◽  
David Zealear ◽  
Alan R. Schwartz
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Hypoglossal Nerve ◽  
Cross Sectional Area ◽  
Sectional Area ◽  
Cross Sectional ◽  
Ansa Cervicalis ◽  
Obstructive Sleep ◽  
The Right ◽  
Stimulation Of

Rationale: Hypoglossal nerve stimulation (HNS) is an alternative treatment option for obstructive sleep apnea (OSA) that reduces pharyngeal collapsibility, but HNS non-responders often demonstrate continued retropalatal and lateral pharyngeal wall collapse. Recent evidence suggests that caudal pharyngeal traction with sternothyroid muscle contraction via ansa cervicalis stimulation (ACS) can also stabilize the pharynx, but the underlying mechanisms have not been elucidated. Objectives: To evaluate the effect of ACS on pharyngeal patency during expiration when the airway is most hypotonic. Methods: Eight participants with OSA underwent sustained ultrasound-guided fine-wire stimulation of the medial branch of the right hypoglossal nerve with and without transient stimulation of the branch of the ansa cervicalis nerve plexus innervating the right sternothyroid muscle during drug-induced sleep endoscopy. Airway cross-sectional area and expiratory airflow (VE) were measured from endoscopy video with ImageJ and pneumotachometry, respectively. Measurements and Main Results: ACS significantly increased retropalatal cross-sectional area (CSArp) to 211% [159-263] of unstimulated CSArp (p<0.05). Adding ACS to HNS increased CSArp from baseline by 341% [244-439] (p<0.05), a 180% [133-227] increase over isolated HNS (p<0.05). ACS increased VE from baseline by 177% [138-217] (p < 0.05). Adding ACS to HNS increased VE by 254% [207-301], reflecting decreases in pharyngeal collapsibility. Conclusions: Combining ACS with HNS increased retropalatal cross-sectional area and increased expiratory airflow, suggesting decreases in pharyngeal collapsibility. Our findings suggest that ACS exerts caudal traction on the upper airway through sternothyroid muscle contraction, and that it may augment HNS efficacy in patients with OSA.

Intracerebral foreign body granuloma caused by a resorbable plate with passive intraosseous translocation after cranioplasty

2013 ◽  
Vol 12 (6) ◽  
pp. 622-625 ◽  
Author(s):  
Yoko T. Katsuragi ◽  
Akira Gomi ◽  
Ataru Sunaga ◽  
Kunio Miyazaki ◽  
Hideaki Kamochi ◽  
...  
Keyword(s):  
Foreign Body ◽  
Sleep Apnea Syndrome ◽  
Clinical History ◽  
Foreign Body Granuloma ◽  
Left Behind ◽  
Contrast Enhanced ◽  
Obstructive Sleep ◽  
Intracranial Foreign Body ◽  
The Right

Numerous reports have demonstrated the usefulness of bioresorbable materials, but few have described severe complications caused by delayed degradation. The authors present the case of an intracranial foreign body granuloma caused by plates made of unsintered hydroxyapatite (uHA) particles and poly-l-lactide (PLLA; Super Fixsorb MX, Takiron) after cranioplasty. This 1-month-old boy presented to the authors' department with Pfeiffer syndrome. He had multiple-suture synostosis causing turribrachycephaly, Chiari malformation Type 1, and obstructive sleep apnea syndrome. At 6 months old, the child was treated with multidirectional cranial distraction osteogenesis. The uHA-PLLA plates were applied as base stones to reinforce the pins. After 16 days of distraction and 3 weeks of consolidation, the pins were removed. Seventeen months postoperatively, the plate on the right temporal bone showed passive intraosseous translocation (PIT), and by 2 years postoperatively, the plate was completely left behind in the cerebrum. At 3.5 years postoperatively, MRI disclosed a contrast-enhanced mass with surrounding brain edema at the site of the plate. The lesion was resected. The clinical history and histological specimens led to a diagnosis of foreign body granuloma surrounding the nonabsorbed resorbable plate in the dura mater. Resorbable plates are clearly useful resources in cases in which delayed absorption will not prove problematic, but careful application and follow-up is required when dealing with the growing skull given the possibility of intracranial displacement after PIT.

Hypoglossal Nerve Stimulation Usage by Therapy Nonresponders

2021 ◽  
pp. 019459982110368
Author(s):  
Kimberly K. Coca ◽  
Clemens Heiser ◽  
Colin Huntley ◽  
Maurits Boon ◽  
Nico de Vries ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Nerve Stimulation ◽  
Hypoglossal Nerve ◽  
Apnea Hypopnea Index ◽  
Long Term Effects ◽  
Hypoglossal Nerve Stimulation ◽  
Obstructive Sleep ◽  
International Multicenter

Objective The purpose of this study is to examine differences in therapy usage and outcomes of therapy between responder (R) and nonresponder (NR) groups in an international, multicenter prospective registry of patients undergoing hypoglossal nerve stimulation for obstructive sleep apnea (OSA). Study Design Database analysis (level III). Setting International, multicenter registry. Methods The studied registry prospectively collects data pre- and postimplantation, including sleep parameters, Epworth score, patient experience, and safety questions, over the course of 12 months. Patients are defined as a “responder” based on Sher criteria, which require a final apnea-hypopnea index (AHI) of ≤20 and a final AHI reduction of >50% at their 12-month follow-up. Results Overall, there were 497 (69%) R and 220 (31%) NR. Most patients in both groups experienced improvement in quality of life following implantation (96% of R; 77% of NR) with reductions in oxygen desaturation index and Epworth score. At final follow-up, the R group demonstrated significantly better adherence to recommended therapy (>4 hours/night) (P = .001), average hours of nightly use (P = .001), final Epworth scores (P = .001), and degree of subjective improvement (P < .001). Conclusion Patients classified as NR to upper airway stimulation continue to use therapy with improvement in percent time of sleep with O2 <90%, reduction in daytime sleepiness, and improvement in quality of life. Therefore, ongoing usage of the device should be encouraged in NR patients who note improvement while integrating additional strategies to lower the long-term effects of OSA.

CASE REPORT: SURGICAL MANAGEMENT OF LUMBAR COMPRESSION FRACTURE

2019 ◽  
Vol 1 (4) ◽  
Author(s):  
Yustinus Robby Budiman Gondowardojo ◽  
Tjokorda Gde Bagus Mahadewa
Keyword(s):  
Spinal Cord ◽  
Left Lung ◽  
Lumbar Vertebrae ◽  
Compression Fracture ◽  
High Mobility ◽  
Early Mobilization ◽  
Cord Injury ◽  
Cardiothoracic Surgeon ◽  
The Right

The lumbar vertebrae are the most common site for fracture incident because of its high mobility. The spinal cord injury usually happened as a result of a direct traumatic blow to the spine causing fractured and compressed spinal cord. A 38-year-old man presented with lumbar spine’s compression fracture at L2 level. In this patient, decompression laminectomy, stabilization, and fusion were done by posterior approach. The operation was successful, according to the X-Ray and patient’s early mobilization. Pneumothorax of the right lung and pleural effusion of the left lung occurred in this patient, so consultation was made to a cardiothoracic surgeon. Chest tube and WSD insertion were performed to treat the comorbidities. Although the patient had multiple trauma that threat a patient’s life, the management was done quickly, so the problems could be solved thus saving the patient’s life. After two months follow up, the patient could already walk and do daily activities independently.

Upper instrumented vertebra to the right of the lowest instrumented vertebra as a predictor of an increase in the main thoracic curve after selective posterior fusion for the thoracolumbar/lumbar curve in Lenke type 5C adolescent idiopathic scoliosis: multicenter study on the relationship between fusion area and surgical outcome

2019 ◽  
Vol 31 (6) ◽  
pp. 857-864 ◽  
Author(s):  
Hiroki Oba ◽  
Jun Takahashi ◽  
Sho Kobayashi ◽  
Tetsuro Ohba ◽  
Shota Ikegami ◽  
...  
Keyword(s):  
Adolescent Idiopathic Scoliosis ◽  
Idiopathic Scoliosis ◽  
Cobb Angle ◽  
Posterior Fusion ◽  
Main Thoracic ◽  
Lowest Instrumented Vertebra ◽  
Line Tilt ◽  
The Right ◽  
Upper Instrumented Vertebra

OBJECTIVEUnfused main thoracic (MT) curvatures occasionally increase after selective thoracolumbar/lumbar (TL/L) fusion. This study sought to identify the predictors of an unacceptable increase in MT curve (UIMT) after selective posterior fusion (SPF) of the TL/L curve in patients with Lenke type 5C adolescent idiopathic scoliosis (AIS).METHODSForty-eight consecutive patients (44 females and 4 males, mean age 15.7 ± 2.5 years, range 13–24 years) with Lenke type 5C AIS who underwent SPF of the TL/L curve were analyzed. The novel “Shinshu line” (S-line) was defined as a line connecting the centers of the concave-side pedicles of the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) on preoperative radiographs. The authors established an S-line tilt to the right as S-line positive (S-line+, i.e., the UIV being to the right of the LIV) and compared S-line+ and S-line− groups for thoracic apical vertebral translation (T-AVT) and MT Cobb angle preoperatively, early postoperatively, and at final follow-up. The predictors for T-AVT > 20 mm at final follow-up were evaluated as well. T-AVT > 20 mm was defined as a UIMT.RESULTSAmong the 48 consecutively treated patients, 26 were S-line+ and 22 were S-line−. At preoperative, early postoperative, and final follow-up a minimum of 2 years later, the mean T-AVT was 12.8 mm (range −9.3 to 32.8 mm), 19.6 mm (range −13.0 to 41.0 mm), and 22.8 mm (range −1.9 to 68.7 mm) in the S-line+ group, and 10.8 mm (range −5.1 to 27.3 mm), 16.2 mm (range −11.7 to 42.1 mm), and 11.0 mm (range −6.3 to 26.9 mm) in the S-line− group, respectively. T-AVT in S-line+ patients was significantly larger than that in S-line− patients at the final follow-up. Multivariate analysis revealed S-line+ (odds ratio [OR] 23.8, p = 0.003) and preoperative MT Cobb angle (OR 7.9, p = 0.001) to be predictors of a UIMT.CONCLUSIONSS-line+ was defined as the UIV being to the right of the LIV. T-AVT in the S-line+ group was significantly larger than in the S-line− group at the final follow-up. S-line+ status and larger preoperative MT Cobb angle were independent predictors of a UIMT after SPF for the TL/L curve in patients with Lenke type 5C AIS. Surgeons should consider changing the UIV and/or LIV in patients exhibiting S-line+ during preoperative planning to avoid a possible increase in MT curve and revision surgery.

Improvement in Obstructive Sleep Apnea (OSA) in Super Morbidly Obese Patients After Bariatric Surgery

2020 ◽  
Vol 103 (8) ◽  
pp. 725-728
Keyword(s):  
Bariatric Surgery ◽  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Lifestyle Modification ◽  
Apnea Hypopnea Index ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Obstructive Sleep ◽  
Objective Evidence

Background: Lifestyle modification is the mainstay therapy for obese patients with obstructive sleep apnea (OSA). However, most of these patients are unable to lose the necessary weight, and bariatric surgery (BS) has been proven to be an effective modality in selected cases. Objective: To provide objective evidence that BS can improve OSA severity. Materials and Methods: A prospective study was conducted in super morbidly obese patients (body mass index [BMI] greater than 40 kg/m² or BMI greater than 35 kg/m² with uncontrolled comorbidities) scheduled for BS. Polysomnography (PSG) was performed for preoperative assessment and OSA was treated accordingly. After successful surgery, patients were invited to perform follow-up PSG at 3, 6, and 12 months. Results: Twenty-four patients with a mean age of 35.0±14.0 years were enrolled. After a mean follow-up period of 7.8±3.4 months, the mean BMI, Epworth sleepiness scale (ESS), and apnea-hypopnea index (AHI) significantly decreased from 51.6±8.7 to 38.2±6.8 kg/m² (p<0.001), from 8.7±5.9 to 4.7±3.5 (p=0.003), and from 87.6±38.9 to 28.5±21.5 events/hour (p<0.001), respectively. Conclusion: BS was shown to dramatically improve clinical and sleep parameters in super morbidly obese patients. Keywords: Morbid obesity, Bariatric surgery, Obstructive sleep apnea (OSA)

Persistent Apical Periodontitis: Bacterial Taxonomic Analysis and Treatment Through Intentional Replantation

2020 ◽  
Author(s):  
Fernando Eduardo Coria-Valdiosera
Keyword(s):  
Antibiotic Therapy ◽  
Root Canal ◽  
Resistance Mechanisms ◽  
Apical Periodontitis ◽  
Infectious Process ◽  
Identification Of Bacteria ◽  
The Right ◽  
Apical Lesions ◽  
Endodontic Retreatment

Introduction: The microorganisms own different resistance mechanisms that allow them to resist the chemo-mechanical cleanliness of root canal and antibiotic therapies causing the persistence of apical lesions. Methods: This clinical case describes a male patient diagnosed with pulp necrosis in the right lower central incisor due to trauma, which developed apical periodontitis manifesting itself extra orally. Root canal treatment along with antibiotic therapy was performed, but because the infectious process persisted, endodontic retreatment and a new antibiotic therapy were carried out, however, the clinical evolution was not favorable. For this reason, the intentional replantation was chosen as the outright treatment, performing apicectomy and curettage of the periapical lesion, from which the isolation and taxonomic study of microorganisms were carried out, with the respective antibiogram. Results: In the 10-day clinical follow-up, the extraoral infectious process disappeared almost completely and 6 months later, a complete repair of the bone tissue was observed on the tomography. Conclusion: A better understanding of the persistence of apical periodontitis was achieved by taxonomic identification of bacteria and the intentional replantation allowed to remove the apical biofilm gaining an excellent wound healing.

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