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Personalized multi-modal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device

This case highlights the adaptability of OSA treatment to best fit patients’ needs and preferences while optimizing AHI and nocturnal oxygenation and decreasing self-reported symptoms of snoring and sleepiness. While many patients respond favorably to HGNS, a proportion of patients is unable to achieve AHI < 10 events/h even after 5 years. There are others who have difficulty tolerating side effects of HGNS. Prior literature has shown that long-term utilization of HGNS for more than 12 months has resulted in up to 12%–13% of patients having tongue discomfort with stimulation.Post-implantation strategies include adjusting amplitudes and electrical configurations as well as utilizing additional OSA treatment modalities like positional therapy, MAD, and PAP to improve effectiveness and tolerability. Our case is the first demonstrating personalized therapy utilizing 3 modalities, HGNS, MAD, and positional therapy, in order to improve adherence, comfort, and effectiveness.

Different treatment modalities have previously been combined to help individualize OSA treatment for patient comfort and treatment success. For patients who are intolerant of high PAP pressures and experience an inadequate response to mandibular advancement, hybrid therapy can reduce the need for such high PAP levels and improve the patient experience. Liu and colleagues showed that hybrid therapy with MAD and CPAP lowered the residual AHI to < 5 events/h while reducing the required CPAP from 19 to 9.8 cm H2O. Similarly, MAD and HGNS have also been combined to achieve adequate control of OSA. In a case of a patient with severe OSA who had a residual AHI of 11.6 events/h and continued bothersome snoring after HGNS surgery, MAD successfully reduced the AHI to 2.1 events/h and resolved snoring. It is hypothesized that mandibular advancement added to genioglossus stimulation lowers the critical closing pressure of the upper airway thus dilating the oropharynx and improving airflow.



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