Abstract Introduction Obstructive sleep apnea (OSA) severity varies by sleep position and sex; however, it is not known whether these factors affect how well upper airway stimulation by hypoglossal nerve stimulation (HGNS) controls OSA. In our clinical practice, we have observed that patients often were more responsive to control of OSA with HGNS in the lateral compared to supine sleep position. Methods Our study examines HGNS control of OSA by sleep position, supine versus lateral, and sex. To enhance real-world clinical applicability of results and address concerns regarding appropriate postoperative sleep study criteria to evaluate HGNS outcomes, our study also proposes and utilizes a standardized positional HGNS titration study scoring protocol to assess apnea-hypopnea index (AHI). A retrospective cohort of adult patients was implanted with HGNS at a tertiary care center between January 2018 and June 2021. Outcome measures included surgical response rate by sleep position and sex using Sher criteria (reduction of AHI by at least 50% to 20/hr) and normalization of AHI ( 5/hr). Results Of 181 patients implanted, 113 patients met inclusion criteria with preoperative and postoperative sleep studies with positional data. Patients were primarily older (63.8 +/- 9.7 years), overweight (BMI 29.1 +/- 3.5), white (91.2%) males (67.3%) with severe OSA (median AHI 32.0). HGNS success by Sher criteria (or normalization of AHI) in lateral sleep was 77.0% (54.1%) compared to 52.9% (23.5%) in supine sleep. Females attained a greater supine AHI reduction and surgical response rate than males (p 0.05). In supplemental analyses, positional trends persisted even when patients who underwent multiple titration or postoperative sleep studies were excluded. Subgroup analyses for patients with full-night fixed-voltage sleep studies were limited by low counts. Conclusion Thus, our study demonstrated that HGNS therapy more effectively controls OSA for patients in the lateral sleep position and for females, especially in the supine position. Our findings suggest clinically meaningful differences by sleep position that may help patients with a preferred sleep position or a position-dominant type of apnea make more informed decisions when considering HGNS therapy over traditional sleep apnea therapies. Support (if any)
Shindhelm et al. (2026) studied this question.