Montefiore Einstein recently performed its first pediatric hypoglossal nerve implant procedure for obstructive sleep apnea (OSA). The surgery was led by otorhinolaryngologist Marc J. Gibber, MD, Director of the Division of Comprehensive Otolaryngology & Sleep Medicine, Montefiore Einstein, and Associate Professor of Otorhinolaryngology-Head and Neck Surgery at Albert Einstein College of Medicine. It was performed on a 17-year-old patient with Down syndrome, making this the first case of its kind in the Tri-State area. This approach offers an alternative for patients with OSA, particularly those unable to tolerate traditional therapies, such as continuous positive airway pressure (CPAP). 

Hypoglossal Nerve Implantation: A TargetedApproach to Airway Management in OSA

Obstructive sleep apnea occurs when the airway is blocked during sleep, often caused by the relaxation of the tongue and other muscles in the throat, leading to pauses in breathing. The hypoglossal nerve implant targets this issue by stimulating the muscles responsible for keeping the airway open during sleep.

“This surgery implants a device onto part of the hypoglossal nerve, the nerve that controls tongue movement, helping to prevent it from collapsing backward and obstructing the airway,” says Dr. Gibber. While CPAP remains a first-line therapy for OSA, many patients — particularly those with anatomical differences, like those seen in individuals with Down syndrome — can struggle to tolerate the device. For these patients, the hypoglossal nerve implant offers an alternative that doesn’t require wearing a mask. The nerve implant works via a small device implanted in the chest, which the patient activates before they go to sleep.

A First Pediatric Implant

Although hypoglossal nerve implants to treat OSA have been widely used in adults, the FDA only approved the procedure for pediatric patients with Down syndrome in 2022, following successful clinical trials. 

Dr. Gibber and his team have performed more than 60 hypoglossal nerve implant surgeries on adults during the past five years, but this was the first for a pediatric patient at Montefiore Einstein.

The patient, a 17-year-old with Down syndrome, faced several anatomical challenges that made the surgery more complex than those typically seen in adult cases.

"Patients with Down syndrome often have shorter and thicker necks, which can make it more challenging from an anatomical standpoint," says Dr. Gibber.

The surgery was successful, and the patient is on track for significant improvements in sleep quality and overall health.

In pediatric patients with Down syndrome, craniofacial features such as macroglossia, midface hypoplasia, and smaller airway diameter present unique surgical challenges.

“These anatomical considerations require precise intraoperative navigation, particularly in maintaining muscle integrity and ensuring optimal placement of the implant,” says Dr. Gibber.

A Team Effort and a Growing Program

Montefiore Einstein’s success is a testament to the strength of its collaborative ORL and Sleep Medicine programs, which have worked closely to develop innovative approaches to OSA treatment. 

“We’ve significantly increased our volume over the last two years, and our team is excited to continue growing our implant program,” says Dr. Gibber.

While the procedure is only approved for pediatric patients with Down syndrome at present, Dr. Gibber expects that the inclusion criteria for pediatric patients will expand over time as the therapy continues to show long-term efficacy and tolerability in younger patients.

Montefiore Einstein’s ORL team is committed to offering this treatment option to a broader range of pediatric patients, especially those who have not responded well to other OSA treatments.

A Lifelong Commitment to Patient Care

The hypoglossal nerve implant is a long-term solution for sleep apnea, with the device’s battery expected to last around 10 years. For pediatric and many adult patients, this will involve periodic battery replacements throughout their life.

“Replacing the battery is a simple procedure, but we hope future advances in technology will extend the battery life or even lead to permanent solutions that don’t require power supply management or updates,” says Dr. Gibber.

Dr. Gibber and Montefiore Einstein’s approach to using hypoglossal nerve implants emphasizes the importance of conservative patient selection and thorough preoperative evaluations as a means to ensure long-term success. 

"We're cautious about choosing the right candidates for the implant," says Dr. Gibber. “We take into account anatomical and other factors to make sure the surgery is the best option for each patient. If someone is going to have an implant for their entire life, particularly a young patient, we want to make certain that they can thrive with the device for decades.”

Broader Implications of Treating Pediatric and Adult OSA

Untreated OSA has significant long-term health implications, particularly in pediatric populations. The disorder contributes to cardiovascular, metabolic, and neurological comorbidities that can profoundly affect quality of life. Addressing OSA early in high-risk populations like patients with Down syndrome can mitigate these risks.

“We want to emphasize the importance of treating sleep apnea in children and adults,” says Dr. Gibber. “The long-term health risks of untreated OSA are often overlooked or shrugged off, but they can be quite significant. With options like the hypoglossal nerve implant, we can offer patients a way to dramatically improve their health and quality of life.”