Mount Sinai sleep surgeons perform a large number of hypoglossal nerve stimulators for obstructive sleep apnea. In order to be a candidate for this procedure, the primary area of obstruction should be the back of the tongue, or tongue base. There is a device in the chest much like a pacemaker with a stimulator lead that wraps around the hypoglossal nerve and a sensing lead in the intercostal muscles. When a patient breathes in, the sensing lead communicates with the stimulation lead, causing the tongue to protrude and relieving the anatomic obstruction. Other treatment for sleep apnea includes cervical pillows, mouthguards, CPAP (continuous positive airway pressure), and maxillomandibular advancement among others. For more information, go to: https://www.mountsinai.org/care/ent/services/sleep-surgery
Fred Lin, MD Assistant Professor, Otolaryngology, Sleep Medicine Chief of Sleep Surgery Mount Sinai Health System Courtney T. Chou, MD Assistant Professor, Otolaryngology, Sleep Medicine New York Eye & Ear Infirmary of Mount Sinai Gregory P. Tsai, MD Assistant Professor, Otolaryngology Mount Sinai Health System Zachary G. Schwam, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery Division of Otology-Neurotology, Lateral Skull Base Surgery Mount Sinai Health System The Mount Sinai Oto Laryngology Surgical video series presents placement of the inspire hypoglossal nerve stimulator for obstructive sleep apnea. This procedure is performed by our division of sleep surgery. This video was edited by Zachary. The procedure will consist of three parts. First, a neck incision will be made. The hypoglossal nerve identified and a stimulating lead placed around the portion of the nerve that controls the tongue protrusives. Next, a superficial pocket is made in the chest for the generator. Lastly, a respiratory sensing lead is placed in the chest between the external and internal intercostal muscles. We begin first with the neck incision. A 15 blade is used to cut through the skin and subcutaneous tissue. The plasma is incised on a broad plane using the belly of the blade. The Faure over the submandibular gland is exposed and subsequently dissected off the gland. The inferior portion of the gland is visible and the rest of the fash is incised care must be taken not to enter the marginal mandibular branch of the facial nerve. A finger is used to bluntly dissect over the gland and the gland is retracted superiorly to expose the digastric just under the fascia, the Faure over the digastric is released, exposing the muscle and tendon. A yellow fish hook is used to attract the digastric inferiorly. The hypoglossal nerve should be just deep to the digastric crossing, superficial to the carotid artery. A kitner sponge is used to bluntly dissect in this area and the hypoglossal nerve is visualized along with a few large raining veins faster over the mylohyoid muscles seen anteriorly, the mylohyoid muscle is then partially split. In order to be able to trace the hypoglossal out distally. This is a diagram showing the muscular components of the tongue as well as their innervation. The genioglossus anchors the majority of the tongue to the mandible and acts as a protrusive, the styloglossus and hyoglossus retract the tongue as does the geniohyoid. The hypoglossal nerve and yellow sends branches to all of these muscles. The stimulator should wrap around the portion of the nerve that stimulates protrusion without also stimulating the retractors, retracting branches of the nerve should ideally be excluded. The X marks an ideal location for the stimulating lead. We are now looking at the same view under an operative microscope. The mylohyoid has been cut and the digastric is visible just inferior to the hypoglossal fasher over the nerve is then released. A few different branches are isolated. The branch of the hyoglossus will retract the tongue. So this will be excluded from stimulation. The same goes for C one which will go to the geniohyoid the middle branch will go to the genioglossus and is the main protrusive branch of the nerve. The innervation of each branch is confirmed with the nerve stimulator electrodes were placed in the tongue. At the beginning of the case, the branch to the genioglossus is then dissected out with a right angle. Clamp, a fair amount of space is necessary for the stimulating lead to fit the stimulating lead is then brought in and unfurled around the nerve. The stimulation contact will face the nerve. The proximal portion of the stimulation lead is then anchored to the digastric tendon with two silk sutures. We now start the chest pocket. An incision is made in the upper chest down to the level of the pectoralis major muscle. The skin and soft tissue are then elevated off the peck inferiorly until three of the surgeons fingers can fit the pectoralis major muscles then incised and an intercostal space is found the external intercostal has fibers pointing immediately and inferiorly. The external intercostal muscles then split and the respiratory sensing lead is placed laterally between the external and internal intercostal muscles. The proximal aspect of the respiratory sensing lead is then anchored to the peck muscle with silk sutures. The stimulating lead must then be passed from the neck to the chest so that it can be plugged into the generator. This is done with a long flexible passer. The passer is placed in the subq plane into the upper chest. The stimulator lead is then threaded into the back of the passer and the whole thing delivered into the chest. There are now two leads in the chest that must be plugged into the generator. The leads are placed in the generator and secured with a small screw. The generator is placed into the pocket and then secured with a silk suture to ensure the implant is working and programmed, a device is placed over the generator, look closely at the mouth and you can see sustained repetitive tongue protrusions. The way form is confirmed using company software. The incisions are closed and an x-ray is obtained in the recovery area to confirm device placement and absence of pneumothorax.