Inspire Medical’s Upper Airway Stimulation therapy is a treatment option for many patients with obstructive sleep apnea who do not tolerate positive airway pressure therapy (for example, CPAP). There are a few steps to determining whether a patient is a good candidate, including performing drug-induced sleep endoscopy (DISE). If you are interested in more background on DISE, I have posted two videos on Youtube that explain DISE and present examples of DISE videos.
The STAR Trial was the major study showing Upper Airway Stimulation treated obstructive sleep apnea well, and all individuals in the study underwent DISE to make sure they did not have a specific DISE finding called complete concentric collapse related to the soft palate that is seen in about 1/3 of all patients with obstructive sleep apnea. It is not entirely clear why some individuals have this finding, although my own experience is that it is more likely with weight gain or enlarged tonsils. The important thing for patients considering Upper Airway Stimulation is that you would not be considered a good candidate.
What if you have this finding but still are interested in Upper Airway Stimulation?
Dr. Armin Steffen and colleagues at the University of Lubeck in Germany examined this question in a study published last year in the journal Sleep and Breathing. In a series of 14 individuals, he performed tonsillectomy with soft palate surgery using a conservative technique. The study included individuals who still had their tonsils, with moderate to severe obstructive sleep apnea (average apnea-hypopnea index 35), and who were in the overweight/obese range (body mass index 24-40 kg/m2). They compared DISE findings before and after surgery and showed that after soft palate surgery almost all of them (13/14) no longer had this finding of complete concentric collapse related to the soft palate.
What does this mean for patients?
If you have complete concentric collapse related to the soft palate, then you would not undergo implantation of the Upper Airway Stimulation system directly. However, other treatments such as soft palate surgery with tonsillectomy can be used to resolve the complete concentric collapse. If the soft palate surgery did address the complete concentric collapse but did not clear up the obstructive sleep apnea, then patients could be candidates for other treatments such as Upper Airway Stimulation. About 4 years ago, I performed soft palate surgery in exactly this scenario (complete concentric collapse and interested in Upper Airway Stimulation after soft palate surgery). He ended up achieving some really nice results with the soft palate surgery, feeling so much better that he was able to exercise more and lose weight, clearing up his sleep apnea without needing any other treatments.
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Bob Belan Jr. says:
I have a sedated endoscopy on August 12 with my Dr. Tucker Woodson in Milwaukee, WI. He believes that my epiglottis might be the issue where it blocks my airway while sleeping. How painful are the surgeries you mentioned in your article?
Thank you
Dr. Kezirian says:
The soft palate procedures I mentioned in this post can be fairly painful, but they would not be expected to treat the epiglottis. You are in excellent hands with Tucker Woodson. He is one of the world’s leaders in sleep surgery.
John Finkiewicz says:
I have a sedated endoscopy scheduled for tomorrow. I have Sleep apnea since I was a child and i am now 42. I have had multiple surgery when I was young including soft pallet, tonsils and in my nose. I have had CPAP and BIPAP and can not tolerate. If i am not a candidate for inspire is there other options?
Dr. Kezirian says:
There are definitely other options. A sleep surgeon should be able to discuss these with you.
JoAnne M. Haberkorn says:
I do have concentric collapse and, even though I’ve been approved for Inspire, my ENT does not think it would work with my diagnosis. He suggests surgery on the concentric collapse and remaining tonsils first. Honestly, I’m apprehensive about surgery knowing it can be painful for sometime. I’ve tried many different cpap masks and find that I’m spending more time adjusting them during sleep than is worth it. I live alone and wonder how long I’ll feel bad after surgery if I decide to have it. Just a little scared. 😰
Dr. Kezirian says:
It is normal to be scared before surgery. Surgery usually has pain over 2-3 weeks, but the idea is that you trade this pain for finally being on the right track to get some high-quality sleep. Good luck.
Greg Taylor says:
Thank you for the videos. Have not heard from my doctor yet, but I had this procedure done yesterday. All I know is my wife told me the doctor stated I was not a candidate for the surgery. What causes you not to be a candidate for surgery? Hopefully, there are other procedures available since not breathing 46 times during REM is not good and 26 times when not in REM. Tired of being tired when I wake up.
Dr. Kezirian says:
The most common finding to indicate that you would not be a candidate for Inspire Upper Airway Stimulation is what is called complete concentric collapse related to your soft palate.