A Tongue Pacemaker for Sleep Apnea: Hope or Hype?

One of the most common questions I get asked by patients and my online community is, “What’s the newest or cutting edge option for treating obstructive sleep apnea?” Internally, I cringe at this question, since it’s like asking what’s the best way to get from your home to work? The answer is…it depends. You can walk, use a skateboard, cycle, drive a car, or even fly there by helicopter. Even the car answer can range from a basic Toyota subcompact to a Lamborghini. All these options have their pros and cons. Some are not very practical, such as flying by helicopter.

It’s understandable that people with obstructive sleep apnea are always looking for better ways of treating OSA, not having to use a pressurized mask (CPAP) for the rest of their lives. Others are reluctant to consider surgery, even when they are good candidates. There are also too many good dental options to choose from. All these mainstream treatment options work to various degrees with various pros and cons.

One recent option that’s been available to sleep apnea patients in the past few years is the tongue nerve pacemaker. The official term is called hypoglossal nerve stimulation, where a pacemaker-like device is implanted in the right upper chest wall, and an electrical cuff is placed around the nerve that protrudes your tongue (the hypoglossal nerve). A sensor lead is placed below the pacemaker device to detect breathing efforts. The device senses when you are making an effort to breathe, and creates an electrical signal to push your tongue forward, opening up your airway being the tongue and soft palate. Click here to see a graphic.

This sounds like a novel idea, but it was first described many years ago by Johns Hopkins researchers in the 1990s. It didn’t take hold for mass sleep apnea treatment until 3 start-up companies were created in the United States in 2006 years of 2007. ImThera is being used in Europe and is currently in clinical trials in the United States. Inspire and Apnex performed clinical studies in the early 2010s. I had the privilege of being involved in the early studies with Apnex. 

Inspire received FDA approval in 2014. In their landmark New England Journal of Medicine publication, they found that in the 126 patient study, the average AHI at 12 months dropped from 29.3 to 9.0, a 68% difference. The overall response rate (> 50% drop in AHI and final AHI < 20) was 66%. The Epworth Sleepiness Score dropped from 11.6 to 7 (< 10 is considered normal). Functional Outcome of Sleep Questionnaire (FOSQ) scores increased from 14.3 to 17.3 (>2 point improvement is considered clinically significant). Currently, Inspire is the only hypoglossal nerve stimulation technology that is approved for patient use in the United States.

Being a bit skeptical about new devices coming out in our field, I waited to see how Inspire performed, especially with long term outcomes, as well as complication rates. I was pleased to see that they published numerous long-term follow-up studies, even up to the 5 year mark. For the most past, all their studies showed improvements seen initially persist up to the 5 year mark. A systematic review and meta-analysis of all available studies in 2019 found that overall, the AHI dropped 21 points, Epworth Sleepiness Score dropped 5 points, and the FOSQ increased 3 points. More and more insurances are now beginning to cover this new technology. Well over 90% of patients are satisfied with the procedure, snoring elimination, and prefer it to CPAP.

Based on all these positive results, here’s the bad news: You have to meet very specific criteria to be eligible for this treatment. Specifically, these are the requirements:

  • Refuse or can’t tolerate CPAP
  • BMI < 32
  • Age > 22
  • AHI between 15 and 65
  • And sleep endoscopy showing front to back palate collapse only.

You can also imagine that some people just won’t like the idea of an implant of any kind in the chest wall, with small incisions in the neck and chest walls. Unfortunately, many people won’t meet the weight cutoff of 32. Even if you meet all the other criteria, you still need to undergo drug-induced sleep endoscopy to confirm if you are a candidate. This is a short procedure that’s performed in the operating room using an IV infusion of a sleep-inducing medication, with a flexible fiberoptic camera placed through the nose to look at your throat while you’re sleeping. To be a candidate, your soft palate must collapse in a front-to-back manner, and not in a pursestrings-like manner. In my experience, not too many people will qualify based on this particular test. Lastly, you could be in the 10-20% where you don’t get the result that you want, or suffer from serious complications (which are low at 2%). These include device failure, infections or nerve injury. 

The procedure is performed as an outpatient procedure, taking about 2 hours to perform. The battery lasts about 10 years. You will be given a remote control to turn it on or off, as well as to control various settings. One post-op visit is needed to see your surgeon. Four weeks later, you will see your sleep doctor in a designated Inspire trained sleep lab to turn on the device, after which a final overnight sleep study is performed to fin-tune the device, like a CPAP titration. Contrary to what you may think, the nerve stimulation level is similar to what your brain sends to your tongue, so you won’t feel any “shocks.”  For more information about the Inspire procedure, please visit Inspiresleep.com. One the website, you will be able to find an Inspire surgeon or sleep lab in your local area.

If you don’t meet the criteria for this procedure, there are various other ways of treating this condition, including other surgical procedures, dental appliances, and ways of getting you to improve your CPAP experience. Whatever you do, don’t give up, especially if you have moderate to severe obstructive sleep apnea. I generally recommend trying non-surgical options first, especially dental options. However, some people can’t tolerate CPAP or don’t have success with dental appliances. This new procedure is definitely not hype, but can be a hopeful option in some selective patients. 

If you have any further questions, please feel free ask in the comments area below.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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16 thoughts on “A Tongue Pacemaker for Sleep Apnea: Hope or Hype?

  1. I had the Inspire surgery and it was the best decision I ever made. I just wish it would have been available when I was first diagnosed 25 years ago.

  2. Marty,

    Sorry, but the systems are completely different and can’t be used interchangeably. Many people with cardiac pacemakers can undergo the Inspire procedure on the right side of the chest and neck.

  3. How does this work if you exercise a lot and lift weights (bench presses, rows, shoulders, etc.)? Would you have to refrain from weightlifting?

  4. If insurance won’t cover it or you don’t have insurance, it can range in multiple tens of thousands of US dollars, depending on the hospital.

  5. Victor,

    For routine exercises, even weight lifting, it should be fine after a few weeks of healing. But if you’re involved with contact sports, it’s probably not a good idea.

  6. Dr Park,

    You should tell people that once they get this device implanted, they will never be abe to get an MRI. So people who have other long term problems where an MRI might be needed someday, may want to avoid this

  7. Dear Dr Park,
    Could you tell me what makes a person a good candidate for surgery, such as UPPP?
    Ms Jacqui Hatz

  8. Beautiful article Dr. Steve. I knew about the hypoglossal stimulation but had zero knowledge about candidate selection. This endeavor reminds a lot like losing weight and reducing wrinkles. Endless suggestions in spite of just doing the obvious simple things.
    I have success with the TRD but don’t push it over MAD.
    Hope you and Cathy are well.

    your friend, jim hales 3-24-20

  9. Mr. Hatz,

    Ideally, the soft palate should be the only area of obstruction, but this is not too common. This is why the overall UPPP success rate is not too good. But in general, the larger your tonsils, the better the results. Also, the more overweight you are, the less likely the UPPP will be successful.

    I only offer UPPP as an option once CPAP has been tried and refused. More recently, I’ll recommend a drug-induced sleep endoscopy to see what’s obstructing in the throat to make surgical recommendations, including the Inspire procedure.

  10. It is my understanding that the inspire device will prohibit you from MRI use which is a terrible drawback. Is this true and how does one find out which particular dental device or surgery option is right for their particular anatomy.

  11. It’s currently approved for MRI of the head and neck and extremities only.

    Many of the newer cardiac pacemakers are MRI safe for all areas of the body, and the expectation is that with time, the Inspire will likely strive for full-body MRI approval.