Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis on Responder-Based...

Area of Science:

• * Sleep Medicine
• * Neurosurgery
• * Respiratory Medicine

Background:

• * Hypoglossal nerve stimulation (HNS) is a surgical option for moderate-to-severe obstructive sleep apnea (OSA) in patients unable to tolerate positive airway pressure (PAP).
• * Existing research shows response rates of 70-80%, but significant variability between studies and clinical settings remains poorly understood.
• * Previous meta-analyses focused on pooled continuous outcomes, limiting the interpretation of responder-based endpoints and the drivers of heterogeneity.

Purpose of the Study:

• * To systematically review and meta-analyze the efficacy and heterogeneity of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA).
• * To evaluate responder-based endpoints, specifically the Sher-defined response rate, and continuous outcomes.
• * To identify potential drivers of between-study heterogeneity in HNS treatment outcomes.

Main Methods:

• * A PRISMA-compliant systematic review and meta-analysis of studies published up to December 31, 2025.
• * Inclusion criteria: adults with OSA treated with implantable HNS, reporting Sher-defined response or continuous outcomes, and ≥20 patients.
• * Random-effects models were used to pool data, with heterogeneity assessed using I² and τ², and meta-regression exploring predictors like baseline AHI, BMI, and follow-up duration.

Main Results:

• * The pooled Sher response rate for HNS in OSA was 74.0% (95% CI 67.6-79.5%), with substantial heterogeneity observed.
• * HNS significantly improved continuous outcomes, including Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), and Oxygen Desaturation Index (ODI).
• * Meta-regression did not identify baseline AHI, BMI, or follow-up duration as significant predictors of response, explaining minimal variance.

Conclusions:

• * Hypoglossal nerve stimulation (HNS) is an effective treatment for approximately three-quarters of selected CPAP-intolerant obstructive sleep apnea (OSA) patients, offering durable clinical benefits.
• * The safety profile of HNS is favorable, with low revision (5%) and explantation (4%) rates.
• * Unexplained heterogeneity in treatment response highlights the need for more granular determinants of HNS efficacy beyond conventional predictors.