Understanding Hypoglossal Nerve Stimulation

Speaker 1 0:43

All right , hello everybody and welcome to School of Answers , expanding your Breath of Knowledge . And we are here with the wonderful Dr Pat McBride . Let's see if I need to lower my volume just a bit . I was having a little bit of echoing there . All right , thank you so much for being here , dr Pat McBride . Let me do a little intro about you .

Speaker 1 1:23

Dr Pat McBride has spent 41 years as a full-time clinician and educator in the fields of dentistry , respiratory medicine and sleep medicine . Her extensive experience in clinical , laboratory research and educational arenas has led to the development of interdisciplinary care model delivery systems used by physicians and dentists around the globe . Pat's publications span both medical and psychosocial spectrums . She has a unique ability to intervene in the inner stitches of global systems , developing protocols which can be translated across demographics and cultures into improved clinical outcomes . She sits on the board of directors for the American Academy of Physiological Medicine and Dentistry in New York and the AAPMD's Endeavor Pediatric Community . She continues to work hands-on in a clinical setting and as the executive director for the Foundation of Airway Health , while lecturing internationally on subjects relating to breathing and sleep medicine , dentistry and precision medicine systems to best benefit all patient populations . Serving the underserved and marginalized patient remains a passion and a priority for her .

Speaker 1 2:41

Thank you so much for joining us , dr McBride , today we're going to be talking about hypoglossal nerve stimulation , but I did want to talk really quickly about your beautiful backdrop that beautiful . That is not a fake screen . It's Pat's backyard , a photograph of your backyard , and it just I said it looks like Italy or you're in like a vineyard in France or something . So this is what , if I'm not working .

Speaker 2 3:06

If I'm not working , if I'm not writing , if I'm not working , if I'm not seeing patients , this is where you'll find me . So if you need to get , over .

Speaker 1 3:15

So it's just so lovely , what a great place , what a great space to have at your home . So I wanted to talk to you about hypoglossal nerve stimulation because I feel like it's a topic that I don't hear too much about in terms of tons of patients receiving this treatment and what exactly it is , how it works , and I know you have a specialty in this area . So can you talk about how you have a specialty working with the hypoglossal nerve stimulation and then we'll talk more about what exactly it is ? Sure , sure .

Speaker 2 3:48

So , being with the sleep apnea community , sleep apnea therapies , everybody is always looking for something new , different , novel , something other than , for instance , cpap , which is what has been the gold standard for sleep apnea therapy for so long , has been the gold standard for sleep apnea therapy for so long . And back in the early 2010s I had heard about this new stimulator that was being developed . Originally it was part of Medtronic and then it kind of went away and then it was a group of the guys took it out and started working on it independently , called Inspire , and they developed this neurostimulator . It's a means by which , like the pacemaker , they developed theoretically a pacemaker for breathing . So what that would do is allow patients who couldn't , wouldn't or didn't use CPAP for instance , didn't want to have craniofacial surgery , didn't want to have expansion orthodontics , which really were not in the heyday at that point it allows for a different kind of sleep apnea therapy for those patients that really fit the right model for it . So that was originally . I read about it . It got approval and was started early implants in 2013 in Europe , in Germany for the first part and then 2014, . It received FDA approval , so it was considered very novel in 2014 . Now , in 2024 , I would say it's part of Main's Day sleep apnea therapy . It's certainly not the first thing that's offered by sleep medicine doctors as a treatment paradigm for their patients . However , it has become part of the tool bag that is used for sleep apnea therapy . So , having said that , it's like a pacemaker . People do need to understand that . Hypoglossal nerve stimulator and or Inspire , which is the brand name of the product that's used here in the United States . That was the first product that received FDA approval . There are others that are coming up through the pipe now that would be competitors that use the same basic type of technology which allows for the hypoglossal nerve .

Speaker 2 6:00

If everybody sticks their tongue out , you stick your tongue out , your airway opens up . So when you stick your tongue out , that nerve signals fires the muscles that move the tongue forward . The goal when you have obstructive sleep apnea obstructive being the word that your tongue falls back and obstructs your airway , shuts off the oxygen to you whilst you're breathing . So if there's a means by which we could stimulate the tongue to move forward out of the airway and keep the airway open for the inhalation part of the breathing cycle , then if there was some sort of mechanism that could do that , then you could treat sleep apnea effectively using something other than forced air , for instance , which is so what hypoglossal nerve stimulation does is by virtue of a very small electrical cuff that's placed along the hypoglossal nerve . So this is surgery . So it's not something you stick out , pull out and stick on .

Speaker 2 6:58

This particular thing is surgery . They make a very small , five millimeter incision under usually kind of under the fold in here , locate the hypoglossal nerve and there is a cuff it's a silicon cuff with three gold electrodes that are that closes on itself . So if this is the nerve running this way , it has the nerve looks like this a hypoglossal nerve , so the fibers at the top of the nerve . So here's's the body , here's the break points are out here and this is where it all comes together . Okay , so if you're looking at this , then part of this nerve makes the tongue go forward and part of it makes it go backwards . Well , what you don't want to do is stimulate this nerve to go backwards , right ? You don't want the tongue being pulled into the throat .

Speaker 2 7:46

So what they do is , when they're going to put this little cuff under here internally , they isolate , they test the nerve , all these little branches and see which one of these , when they test it , goes backwards or which one goes forwards . Then , for instance , these bottom two go forward . They capture one of the cranial nerves number down here as well . They put this cuff . It just self-closes around the nerve like this . They keep the ones that make it go backwards out , the ones that basically go forward . When you stimulate it , so you stim it , then it goes forward .

Speaker 2 8:19

It opens the airway , so the cuff goes under the neck and then it's attached obviously to a wire , to a little feed cord that is fished under the skin , down to a generator pack that's placed just about the third rib height down . In the old days it used to be three incisions , it used to be . The electrode was under the neck , the generator , which is the battery pack , essentially like a pacemaker . It essentially looks exactly like a pacemaker . It essentially looks exactly like a pacemaker . So anybody who's seen a pacemaker before knows that it's a little battery pack . And then they used to have a respiratory sensory way down here between the fourth , fifth wrist .

Speaker 2 8:57

But that has been modified . That surgery has been modified and improved so that in the same place the generator goes in they're now able to put that sensor , the respite that senses when the breathing habits . So the respiratory sensor , which is the other little piece of equipment that goes underneath the battery , senses when the actual breathing cycle starts . So it senses the minute you start to breathe in . Well , as you start to breathe in , it sends that little signal up to the tongue to move backwards . Allow the air in , breathe in Wide open . Okay , as you finish inhaling , the respiratory sensor notes that you're starting to exhale . It stops the stimulation and allows the patient to exhale normally In Stimulation on , exhale off . So it goes . It sinks with the breathing cycle so that you can breathe normally while you're sleeping , and it stimulates enough . So as you inhale , instead of sucking your tongue down your throat , the tongue is being stimulated forward out of the airway , keeping it open .

Speaker 2 10:06

And the generator it's a battery that comes right here .

Speaker 1 10:11

Up on the third rib Right here . Yeah , okay .

Speaker 2 10:15

Now for some of these . There are some very cool surgeons who deal with women , who one of our patients was a ballroom dancer and who has their deflatage . You know that's very important . She kept and was thin , very thin movement , so we hid . You can hide the generators . I know that may not be on label , but there are plenty of surgeons who want to make sure the aesthetics piece is taken care of and they make their own decisions about that too , so that it's hidden . Nobody sees anything . Very , very thin people .

Speaker 2 10:43

One of the marathon runners that we got had an original one . The battery was twice the size on the ones in 2014 . Had his battery swapped out , I think in 2022 . But he'd also lost about 65 pounds , so he needed something different . It's actually very easy to put in very quick . It doesn't take very much time . It's no different time-wise as I've seen , having been in cases for over four years than putting a pacemaker in . It's quick , easy . You go in in the morning , you go home at lunch , it's all good . But it's a process . There's a way . You have to be qualified for it . That's the actual surgical implant itself , but whether or not it is the right surgical implant itself , but whether or not , it is the right treatment for the right patient at the right time is a very different thing .

Speaker 1 11:36

I have a lot of questions about that because I'm really curious . But a couple of questions about the implantation of this device . It's called the device right ? What is the size of the generator ? Like a few inches .

Speaker 2 11:53

I would say I used to have a sample here . I don't anymore . It is about two inches wide . Think of it kind of like two inches wide by two , by two maybe , and then maybe a quarter of an inch thick .

Speaker 1 12:08

And then it's just staying externally . How does it stay ?

Speaker 2 12:11

No , it doesn't stay externally . It's implanted on top of the muscle , under the skin , on top of the muscle .

Speaker 1 12:16

Oh , so you're going to see sort of .

Speaker 2 12:19

For some people . It's usually down far enough that if you have enough fatty tissue to cover it on the top . So it's external , except for the remote control which looks a whole lot like any , um , like a large computer . It looks like a mouse . I would say remote control looks like either a glorified television changer or a garage door opener or a mouse . It's kind of that shape and size and that's external because you have to be able to turn it on and off externally .

Speaker 1 12:49

So mouthful day , awful

Understanding Inspire Hypoglossal Nerve Stimulation

Speaker 1 12:51

day . When you go to sleep , you turn it on . When patients take a nap , they're probably supposed to turn it on .

Speaker 2 12:57

It depends on how long their delay is . So patients stay healed for a month to six weeks , and then they go back and the doctor turns it off Okay , and that's a whole process in and of itself too . Turns it off Okay , and that's a whole process in and of itself too . And so , but in order to use it and use it effectively , you need to be able to have it on most of the night . And patients , for instance , who have problems going to sleep at night for instance their delay you can have it set to not turn on for 45 minutes . Let's say , I take 45 minutes to fall asleep . You don't want to . You don't lay down and just turn this thing on when you're wide awake .

Speaker 1 13:32

Yeah , that would be weird , because then you would breathe in , your tongue would come forward . Yeah , it would be moving .

Speaker 2 13:37

So what they do is they find kind of the sweet spot for when you do fall asleep . Let's say you fall asleep for 20 minutes , they'll set it for 25 minutes to turn on , for 25 minutes to turn on . So for the first 20 minutes your partner may go to bed and be snoring their head off because it hasn't kicked in . They think , let's say , they fell asleep at 10 minutes instead of 25 . So for 15 minutes they're snoring their head off and then it kicks in and then they're quiet .

Speaker 1 14:02

So it can't actually sense when the person's asleep . It does not have artificial intelligence ?

Speaker 2 14:07

No , it can't . It can't .

Speaker 1 14:09

It senses the rhythmic cycle once that it's turned on , has to be on activated , okay , don't you think maybe that's going to be connected to like a sleep image ring or something at one point , and it's going to wirelessly or something . Sense when the person starts to act when they have actually falsely , but automatically turns on . Well , that would be . That was just all of a sudden my brain went to like the next level , we think that would be presumptuous for us to think of that .

Speaker 2 14:37

Yeah , I sleep image . You know that's cardiopulmonary coupling . It's now considered a level three sleep diagnostic , like a home sleep test . They give us an idea of what's going on , then you'll .

Speaker 1 14:50

They're not pinpoint accurate yeah , so this is just at a set amount of time . Um , it'll turn off 20 minutes . Whatever it always is going to automatically turn on , it's going to kick in you cannot change your delay .

Speaker 2 15:03

You have to have there's a programmer that's used , your um . It used to be , at least back when I was doing it and I was working with the doctors directly in it . You'd have the um , inspire a clinical person there with the programmer while you program the patient and you've got a feel for what their sleep patterns were like and then you dial in the . You know you dial in the needs and , but the patient just can't change when their on-off time is they have to go to the clinic and somebody has to hook them up to the programmer and have it connect and then make those changes . So you want to take your time and make sure you dial it in . There are a lot of things . Any kind of stimulator , neurostim therapy tends to have an algorithm . Okay , well , most medicine has algorithms . Your a1c gets to be this level . You get put on metformin . I mean it's like , okay , get in line . Okay , sleep is so complex sleep apnea is . There are complexities about it that go with each and every person that make programming inspire inspire far more difficult than people actually think that it is Really good .

Speaker 2 16:14

Providers are really good at this . Other providers are less good at it because of time constraints , because it takes time . These people , they come into your practice , the ones who they advertise . They switch it on and they go merrily on their way and their apnea is cured and they advertise that . You know . They switch it on and they go merrily on their way in there , apnea is cured and they're fine forever and ever .

Speaker 2 16:33

Amen , that's great , wonderful . I'm so happy for you . That's not everybody , and sometimes any provider who's going to listen to this , who is in any specialty of any kind , will tell you it's that 10 to 15 people , 10 to 15% of the people that you see are the people that keep you up at night and are your time sucked during the day and are and make doing what you do very difficult because it's not easy for them . Yeah , and so you have to have a reasonable amount of perspective when you do any kind of therapy like this . I will definitely never , ever , say this is not good therapy . I think it is excellent therapy for the right patient at the right time , for the right reasons .

Speaker 1 17:21

Okay , well , let's talk about who is the right patient . So who would be eligible or recommended for the Inspire hypoblastal nerve stimulation ?

Speaker 2 17:31

So from the adult , population , of course , that 18 , up from the 18 years old and up , moderate to severe sleep apnea , which means your apnea can be as low as 15 , as high as 100 . So , moderate to very severe apnea 15% Can or be morbidly obese , however they have . It used to be . The BMI had to be under 32 . That was when the FDA approval came through and then slowly it started shifting a little bit in 2023 . I think it came out that the indicator changed , one of the indications changed for BMI of 40 . The indicator changed one of the indications changed for BMI of 40 . However , I think the caveat for that is there are many surgeons who do not feel putting a patient on the operating table for any reason whatsoever unless it is a dire emergency when their BMI is 40 .

Speaker 2 18:22

Yes , there are safety issues , higher risk for lots of different things when you're dealing with somebody who is morbidly obese . They cannot have more than 25% of their apnea be central sleep apnea . So you're like so what's that ? What's central sleep apnea ? Central sleep apnea is essentially a kind of complexity to obstructive sleep apnea . It's different in that the brain has bailed . The brain simply doesn't send the signal to the respiratory system to drive you to take that breath . So this is a stimulus for you . It moves your tongue out of the way to fix your obstruction . It had in no way shape and form can help anything that's happening neurologically in your brain . So it's not meant for people who have central sleep apnea . It's not meant for people who have , for instance , some neurological degenerative disease processes Parkinson's disease . We've had many , many patients who develop dementia over time , who have it , and as long as they have good hair caregivers , they're in a good home where they're either being cared for or their loved ones are with them .

Speaker 2 19:38

Somebody else can manage turning it on and off . You don't have to be able to manage turning it off and on and off . Finding the remote might be your biggest problem because you don't know where somebody's put it . Um , so I think I've got't know where somebody's put it . So I think I've got that one . It's the obesity . It's 15 to a hundred . They have to have tried and failed . Cpap , okay , which is the gold standard . Insurance companies want to see that you at least gave it the college try . So what does that mean ? Well , there's no real specific guidelines . You either have to be intolerant to it .

Speaker 2 20:12

Can't , won't , don't is the words that I use for the patients . I can't do this . I'm suffocating . I feel like I'm going to die . Okay , I won't do this . There is no way in God's good earth I'm putting that thing on my face . Okay , and don't is I rip it off through the night . I can't keep it on for more than 20 minutes . I find it in the floor every morning . That's not somebody who's doing well with it .

Speaker 2 20:34

Or how about the person who puts on their CPAP religiously every night , religiously , wears it all night long and in the morning still feels like crap . They still feel terrible . So they're not deriving clinical benefit from CPAP for a number of reasons . You don't have to specify what those reasons are . You just can't , won't and you don't Don't get clinical benefit . So those are the perfect patient .

Speaker 2 21:01

And they don't want to have craniofacial corrective surgery . Okay , many sleep apnea patients have craniofacial corrective surgery because the box is too small , the jars are too far back , their bites are off , there's all kinds of stuff wrong , a craniofacial fix that's been going on for years and years and years that maybe they don't want to have double jaw surgery . Maybe they don't want or can't afford to have orthodontic expansion and some of these interventions that are on the market , that are out there that are fee-free service . Your dental insurance isn't going to pay for them and your health insurance certainly isn't going to pay for it .

Speaker 2 21:38

This is this hypervascular stimulator implant , like c-pap , like oral appliance to a small extent are covered into your health care . There are very few carriers that will not pay for it anymore . It used to be in the early days case-by-case basis . You had to fight for it , but once Medicare realized that they could save billions of dollars on heart attack and stroke care , they approved it . And once it was on Medicare's formulary , all of the insurance companies basically were forced to finally get on board . They didn't have a choice . They couldn't say 10 years into the pipe , it's experimental , it is not , it's been around long enough . There are hundreds of thousands of people with this , just like there are pacemakers .

Speaker 1 22:24

Really Hundreds of thousands of people . This is not a rare treatment .

Speaker 2 22:29

No , there's patients all over Europe . They're in Japan now , they're in Singapore now . It's a harder slug to get this in an NIH system . So , for instance , trying to get it in England or Canada is tough and a lot of doctors who live way up north in the United States see a lot of patients who come across the border and pay cash and get it here because they can't get it on the NIH .

Speaker 1 22:57

And is this calibrated with a sleep study ? So after it's implanted , everybody ?

Speaker 2 23:02

has to have a sleep study . You have to have a sleep study that's less than two years old . That says you're having it is this you don't have central sleep apnea .

Speaker 1 23:09

Okay , when they calibrate it to set the voltage , how does that work ?

Speaker 2 23:14

well , the voltage is set based on what , what they clinically see , because everybody's nerves are different and they're sensitive . But one of the other things I might not have mentioned was um , this the c-pap trying and feeling the c-pap . The other thing was the um . I just had it and I forgot it . There was something I missed as one of the indicators . It'll come back to me in a minute . I just it flew out of my brain . So you have to have tried and failed .

Speaker 2 23:38

Cpap . You can't have complete concentric collapse of your airway , okay . So what does that mean ? Your airway ? If you think of a person lying on their back and you see those pictures of the air where the toggle falls back and it pitches the airway closed . If you think of that , the airway is like somebody stepping on a banana . Right , it collapses from front to back . You know , here's your neck and here's your back of your head . Your airway collapses like a banana . But what happens if your airway collapses like a camera shutter ? Okay , the stimulation is less effective on this kind of a collapse .

Speaker 2 24:15

Concentric collapse Does that mean that patient can't ever get inspired ? No , not anymore , because ear , nose and throat doctors who really want to provide the best for their patients often do something called a modified UPPP or an expansion pharyngoplasty . Called a modified UPPP or an expansion pharyngoplasty , which is a nice way of saying we're going to take your camera , shutter and turn you into a banana . Okay , the lateral walls . It's a surgery that tightens up the lateral walls , that allows that stiffening of the sidewalls so that the airway collapses front to back instead of like a camera okay , so in combination that could work .

Speaker 2 24:52

So patients can have , um , soft tissue surgery that fails . Lots of times they say , oh , I had a duvulectomy and I had my tonsils and my adenoids and lots of soft tissue surgery . Um , and over time it fails and we ask why ? Okay , so why does it fail ? They told me it would fix my sleep apnea . Well , every day you're a day older , every single day you are one day older and your tissues are different today than they were yesterday .

Speaker 2 25:21

And as we age , flaxity , laxity , all of these things , a little bit extra weight , laxity of the tissues , all of that , so that soft tissue surgery you had 10 years ago is no longer helping you with your sleep apnea and so you got to do something else . So soft tissue surgery is a piece of the pie . Lots of times you can do combination therapies to get patients over the finish line . Like I said , sleep apnea and therapy is extremely complex . I have provider sleep docs that are friends of mine , good friends of mine , that over their dead body do they think surgery is a good idea , unless it's tonsils and adenoids for children ? That's just their thinking .

Speaker 1 26:02

Tell me about okay before we go to the combination therapy , because I want to learn about that . I've heard that special populations , like patients with Down syndrome , may qualify who are younger 18 . 13 to 18 for Down syndrome patients Okay , so age 13 to 18 .

Speaker 2 26:19

Because at 18 , they become an adult . Then they go into the adult parameters .

Speaker 1 26:23

Okay . So if you have Down syndrome or if your patient has Down syndrome in the ages range of 13 to 18 , they can qualify for Inspire .

Qualifying for Inspire Therapy

Speaker 2 26:33

And there are certain facilities around the country that do lots and lots of down stations , especially the kids .

Speaker 1 26:40

Wow , that's . That's really interesting . When did that occur ? Were they allowed that to push to like that special population at a young age , like that they were working on ?

Speaker 2 26:51

children from the get go they wanted to have . There are children with Marfan's . There are all kinds of disorders that children in particular have . That Down's was the one that seemed to be the best first target and they had been working on that all the way back into the 2015-16 .

Speaker 1 27:09

Are there any other special populations that can qualify at a younger age than 18 ?

Speaker 2 27:14

Not , as that I've seen on the FDA approval sheets as of yet they will come . They will come and remember every single change you make to any kind of therapy that requires FDA approval . Each change or indication requires the whole brand new FDA approval for it . Yeah , it's a very lengthy , very expensive , very time-consuming process to get therapy to the table for people to actually have access to and not limited access , but open access to . Unfortunately , medicare pays for this . Medicaid does not . Sadly , they don't pay for quite a few things . That's where part of our healthcare system just fails . You don't know with what you have .

Speaker 1 28:06

But most other , like regular PPOP insurance , doesn't cover . Isn't it hard to qualify ? So I know you've named all the factors to qualify for this treatment . Is it hard to get that approval ? Or what doctor recommends this ? What are the next steps when somebody's interested ?

Speaker 2 28:24

Well , most of the time the patients start at the sleep medicine doctor , their primary care might send them over to get their sleep study done with the board certified sleep medicine doctor . A lot of dentists are , if their state permits them , to do home sleep testing and or refer up for sleep testing . So patients are starting there as well . They end up with a diagnosis from the board-certified sleep doctor . They have to go in see somebody , talk to somebody , see if they fit the qualifications . You have to qualify and you have to have it documented that you tried and failed CPAP or you're intolerant . You have to have it documented that you don't have . Then that person gets you to the ear , nose and throat doctor . Whoever that sleep doctor is that says I want to inspire , I don't want to do this anymore , I want to inspire . Most implant physicians are ENTs ear , nose and throat doctors , although there are some OMFS doctors who do it . That's oral maxillofacial surgeons who do it . Oral maxillofacial surgeons , though , however , cannot do Medicare patients At least that's the last I had heard . So as long as they do anybody but Medicare , they're fine . And the ear , nose and throat surgeon then will do a comprehensive evaluation , review the sleep studies , possibly rerun sleep studies that they've seen Many patients who come in with a home sleep study and they have very strong symptoms .

Speaker 2 29:43

We know that the home sleep study gives us an idea , gives us an idea that there's something going on . At what level ? Lots of them are scored at 4% , which is , they're saying , that's the new rule . What that does is allow the insurance companies not to treat you because 4% versus 3% is huge , it's a huge difference . But they run . They may need a test that's more specific .

Speaker 2 30:05

What really is your issue here and how severe are you ? I really personally feel with patients , especially the patients that we treat . Now I want to know . I don't want an idea . I want to know what is the severity and burden of your disease and what complexity are you as an individual bringing to the table for us to work with .

Speaker 2 30:26

This home sleep study says 14 . We've now put you in the lab and added the rear eyes , which is respiratory effort related arousals , which is a lot of upper airway resistance type and things that the insurance doesn't want to hear about . That made that number of 14 into 41 . 14 is oh , you can kind of sort of go . You know you need antidepressants and it's your problem . You don't really have a sleep problem . Now we're looking and going . Okay , you have the potential for a very serious sleep problem that has a number of layers , like an onion that we need to peel back and decide what piece of this is going to be the obstruction that's going to be taken care of with the Inspire and what piece of it is it not .

Speaker 1 31:10

Yes , and do they have to do a dice or do they tend to do this ? The ?

Speaker 2 31:14

next step then , after the comprehensive evaluation and proper testing is done , if that doctor wants anything more specific than just a home test . Every doctor has their own guidelines . I tend towards the doctors who will want very specific and detailed work . Other people want numbers . It just depends on how you run your practice , and the drug-induced sleep endoscopy is a requirement , and so it's a means by which they mimic sleep with a medication .

Speaker 2 31:43

In an outpatient it's an outpatient surgery center , for instance they put a little camera down your nose and a scope down your nose and while you're under the medication that they give you , that mimics sleep . They're able to see how your airway at the top , the velo fairings , that's up at the top how it collapses does it collapse front to back or does it collapse like a camera shutter ? That's when they'll say yes , you qualify , no , you don't . Okay . That's the majority of people , I think . In my I did more than 700 dice easily in four years and I would say only about 7% were concentric . Okay , small population . Most everybody was yeah , it's fine , it's okay , you're good .

Speaker 2 32:25

Okay , it was very straightforward , very easy . You might have , but you do also find , okay , there's quite a bit of redundant tissue here , or people don't realize they have tonsils at the top and they also have tonsils down below . And lingual tonsils , which are the ones down below , can really be a problem . They can really block a lot of the airway and the stimulation isn't going to fix what a lingual tonsils are sitting in the middle of . So those drug-induced sleep endoscopies give us tons of information . Is it used as a diagnostic ? No , it's used to rule out consent or collapse . And when it's used by other practitioners , they're seeing how the airway behaves . So they can gauge , for instance , whether maxillomandibular advancement surgery is going to work , because they can advance the jaw and see where , at what point , you get good opening of the airway . So it's a great tool , it's a really good tool .

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Speaker 3 33:22

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