Inclusion of the first cervical nerve does not influence outcomes in upper airway stimulation for treatment of obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Upper airway stimulation (UAS) has demonstrated efficacy in the management of obstructive sleep apnea (OSA). Branches of the hypoglossal nerve that selectively activate tongue protrusor and stiffener muscles are included within the stimulation cuff electrode. The first cervical nerve (C1) is often also included to stimulate additional muscles contributing to tongue protrusion and stabilization. The purpose of this study was to determine whether inclusion of the C1 translates into treatment efficacy, decreased voltage requirement, and improved outcomes in patients utilizing UAS. STUDY DESIGN: Single-center, retrospective cohort study. METHODS: One hundred fourteen patients who received a UAS implant at our institution and underwent posttreatment polysomnography were evaluated. Stimulation cuff electrodes in 87 patients included the C1; those in the remaining 27 patients did not include the C1. Demographic data, voltage data, and pre- and posttreatment apnea-hypopnea index (AHI), O2 nadir, and Epworth Sleepiness Scale (ESS) data were collected for all patients. RESULTS: There was no significant difference in stimulation voltage, or posttreatment AHI, O2 nadir, and ESS between the two cohorts. Treatment success, as measured by posttreatment AHI < 20 with a 50% reduction, was similar regardless of C1 inclusion. The same was seen for the percent of patients with AHI < 15 and AHI < 5 after treatment. The distributions of age and body mass index, as well as pre-treatment AHI, O2 nadir, and ESS were also not significantly different between treatment groups. CONCLUSIONS: The current study has demonstrated that inclusion of the C1 in the stimulation cuff electrode of the upper airway stimulator may not provide any additional benefit in therapy for OSA. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E382-E385, 2020.

Dysfunctional hypoglossal nerve stimulator after electrical cardioversion: A case series.

OBJECTIVES/HYPOTHESIS: Upper airway stimulation has demonstrated marked improvements in apnea-hypopnea index, oxygen desaturation index, and quality-of-life measures in patients with moderate to severe obstructive sleep apnea (OSA) who cannot tolerate continuous positive airway pressure. Cardiac arrhythmias are common in patients with OSA and can require electrical cardioversion. We describe the first four reported cases of hypoglossal nerve stimulator (HGNS) dysfunction after electrical cardioversion and illustrate our operative approach to device troubleshooting and repair. STUDY DESIGN: Retrospective case series. METHODS: A retrospective review of 201 HGNS implantations performed at two academic institutions revealed four cases of HGNS device dysfunction after electrical cardioversion requiring surgical revision. Preoperative and postoperative device performance metrics and electrical cardioversion specifications were retrospectively assessed and compiled for this case series. The senior authors (R.J.S., M.S.B.) detail operative planning and approach for HGNS implantable pulse generator (IPG) replacement. RESULTS: At least two patients with HGNS device dysfunction had received cardioversion via anterolateral electrode pad placement. Three patients had received multiple shocks. All four patients experienced a change in device functionality or complete cessation of functionality after electrocardioversion. Operatively, each patient required replacement of the IPG, with subsequent intraoperative interrogation revealing proper device functionality. CONCLUSION: Counseling for patients with HGNS undergoing external electrical cardioversion should include possible device damage and need for operative replacement. Anteroposterior electrode pad placement should be considered for patients with HGNS who require electrocardioversion. Operative replacement of an HGNS system damaged by electrocardioversion begins with IPG replacement and intraoperative device interrogation. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1949-1953, 2019.

The Impact of Upper Airway Stimulation on Swallowing Function.

OBJECTIVE: To evaluate the impact of upper airway stimulation therapy (UAS) on swallowing function in patients with obstructive sleep apnea. STUDY DESIGN: Prospective cohort study. SETTING: Academic medical center. PARTICIPANTS AND OUTCOME MEASURES: We recorded demographic, preoperative polysomnogram (PSG), operative, and postoperative PSG data. We assessed the patients swallowing function using the Eating Assessment Tool (EAT-10) dysphagia questionnaire. This was administered both pre- and postoperatively. The postoperative EAT-10 survey was administered at least 3 months after UAS implantation. RESULTS: During the study period, 27 patients underwent UAS implantation, completed the pre- and postoperative EAT-10 questionnaire, met inclusion/exclusion criteria, and were included in the study. The cohort consisted of 16 men and 11 women with a mean age of 63.63 years. The mean preoperative BMI, Epworth Sleepiness Scale (ESS), and Apnea Hypopnea Index (AHI) were 29.37, 10.33, and 34.90, respectively. The mean postoperative ESS and AHI were 5.25 and 7.59, respectively. These were both significantly lower than the preoperative values (P = .026 and P < .001). The mean pre- and postoperative EAT-10 scores were 0.37 and 0.22, respectively (P = .461). CONCLUSION: Our data suggest that UAS likely does not lead to postoperative dysphagia.

Upper Airway Stimulation in Patients Who Have Undergone Unsuccessful Prior Palate Surgery: An Initial Evaluation.

Upper airway stimulation therapy (UAS) is a new option for treatment of obstructive sleep apnea (OSA) in patients unable to tolerate continuous positive airway pressure (CPAP). We set out to evaluate the effectiveness of UAS in patients who have undergone prior palate surgery. We designed a retrospective review and evaluated patients undergoing UAS at 2 academic centers. We recorded demographic and pre- and postoperative polysomnogram (PSG) data. We compared the cohort of patients who had undergone prior palate surgery, "prior surgery," to the cohort who had not, "no prior surgery." A total of 164 patients were included in the study: 23 in the prior surgery and 141 in the no prior surgery groups. The mean age was significantly higher in the no prior surgery group ( P = .020). There were no other significant differences when comparing demographic, quality of life, or PSG variables between cohorts. UAS therapy is an option to treat OSA in patients having undergone unsuccessful prior palate surgery.

Personally Modifiable Risk Factors Associated with Pediatric Hearing Loss: A Systematic Review.

BACKGROUND: Pediatric hearing loss is an increasingly recognized problem with significant implications. Increasing our quantitative understanding of potentially modifiable environmental risk factors for hearing loss may form the foundation for prevention and screening programs. OBJECTIVE: To determine whether specific threshold exposure levels of personally modifiable risk factors for hearing loss have been defined, with the overarching goal of providing actionable guidance for the prevention of pediatric hearing loss. DATA SOURCES: A systematic review was performed. Computerized searches of PubMed, EMBASE, and the Cochrane Library were completed and supplemented with manual searches. REVIEW METHODS: Inclusion/exclusion criteria were designed to determine specific threshold values of personally modifiable risk factors on hearing loss in the pediatric population. Searches and data extraction were performed by independent reviewers. RESULTS: There were 38 criterion-meeting studies, including a total of 50,651 subjects. Threshold noise exposures significantly associated with hearing loss in youth included: (1) more than 4 hours per week or more than 5 years of personal headphone usage, (2) more than 4 visits per month to a discotheque, and (3) working on a mechanized farm. Quantified tobacco levels of concern included any level of in utero smoke exposure as well as secondhand exposure sufficient to elevate serum cotinine. CONCLUSIONS: Specific thresholds analyses are limited. Future studies would ideally focus on stratifying risk according to clearly defined levels of exposure, in order to provide actionable guidance for children and families.

Societal-level Risk Factors Associated with Pediatric Hearing Loss: A Systematic Review.

OBJECTIVE: To determine if the current body of evidence describes specific threshold values of concern for modifiable societal-level risk factors for pediatric hearing loss, with the overarching goal of providing actionable guidance for the prevention and screening of audiological deficits in children. DATA SOURCES: Three related systematic reviews were performed. Computerized PubMed, Embase, and Cochrane Library searches were performed from inception through October 2013 and were supplemented with manual searches. REVIEW METHODS: Inclusion/exclusion criteria were designed to determine specific threshold values of societal-level risk factors on hearing loss in the pediatric population. Searches and data extraction were performed by independent reviewers. RESULTS: There were 20 criterion-meeting studies with 29,128 participants. Infants less than 2 standard deviations below standardized weight, length, or body mass index were at increased risk. Specific nutritional deficiencies related to iodine and thiamine may also increase risk, although data are limited and threshold values of concern have not been quantified. Blood lead levels above 10 µg/dL were significantly associated with pediatric sensorineural loss, and mixed findings were noted for other heavy metals. Hearing loss was also more prevalent among children of socioeconomically disadvantaged families, as measured by a poverty income ratio less than 0.3 to 1, higher deprivation category status, and head of household employment as a manual laborer. CONCLUSIONS: Increasing our understanding of specific thresholds of risk associated with causative factors forms the foundation for preventive and targeted screening programs as well as future research endeavors.

Spontaneous calcific coronary embolus from a degenerative calcific aortic valve-a rare cause of acute ST segment elevation myocardial infarction.

This case report describes pathology-proven spontaneous coronary embolization from a calcific aortic valve resulting in an acute ST segment elevation myocardial infarction. It serves as an important reminder that, especially for elderly patients with coexisting aortic valvular disease, initial treatment for abrupt coronary artery occlusion with aspiration thrombectomy catheterization is standard of care.