Drug-induced sleep endoscopy is an evaluation procedure designed to evaluate the physical cause(s) of blockage in breathing in patients with obstructive sleep apnea. One of the reasons we are recognized around the world for our leadership is the scientific research we have led in this area. One of the major studies showed that specific findings from drug-induced sleep endoscopy are associated with outcomes of unilateral hypoglossal nerve stimulation with the Inspire Upper Airway Stimulation technology.

One of the key findings from that study was the decreased odds of responding fully in individuals with complete blockage of breathing related to collapse of the sides of the throat (lateral walls). This past month, Phillip Huyett, MD from Mass Eye and Ear – the first author on our publication above who started that work when he was a fellow with our team – published a study in the medical journal Otolaryngology – Head and Neck Surgery suggesting that performing tonsillectomy at the same time as implanting the hypoglossal nerve stimulation system was helpful. This study compared results in those having partial or complete collapse of the lateral walls who underwent implantation of the Inspire system, with (19 individuals) and without (78 controls) tonsillectomy performed at the same time. They found that there was a greater percentage improvement in sleep apnea (decrease in apnea-hypopnea index) with tonsillectomy and a greater odds of response with the combination of the two procedures.

Can this possibly be true?

Many surgeons dismissed this when Dr. Huyett first presented it at the International Surgical Sleep Society last year. We generally do not think removal of small tonsils (most had small tonsils) as contributing much in the presence of substantial collapse of the lateral walls. However, there was no reason to question the findings, given that Dr. Huyett is one of the most honest people I know. To me, this finding was intriguing, so I was looking forward to publication of their findings.

Given that I know well almost all of the coauthors on the paper, I have had a chance to communicate with them and ask a number of questions. The short answer is that the small sample of 19 individuals who underwent tonsillectomy at the same time as system implantation does not allow full evaluation. I wrote a letter to the editor outlining some questions for these authors and future studies, My goal in this letter was mainly to ask for a fuller description of results (including the actual change in sleep apnea, not just the percentage changes) and evaluating whether the improvement with tonsillectomy was related to the size of the tonsils and/or the extent of collapse of the sides of the throat.

All in all, I may consider tonsillectomy in some of my patients with Inspire implantation surgery, especially in those with tonsils that are at least normal in size (but maybe not the small ones just yet).

ADDENDUM (12/18/24): Dr. Huyett and his team published a formal response letter, sharing more information about their results. It appears that the benefit of tonsillectomy performed in conjunction with Inspire hypoglossal nerve stimulation is greater in those with complete airway obstruction related to the lateral walls. This is related to the fact that the improvement with Inspire therapy alone was very good in those with partial lateral wall collapse. There may also have been greater benefit in those with somewhat-larger tonsils (2+ in size) compared to small tonsils (1+), although the small sample of this study may it hard to say whether this was true or not.