Hypoglossal Nerve Stimulation Surgery, Part 2: Postoperative Care, Device Settings & Side Effects

[Gopi Shah MD]
Do these patients then stay overnight. Do you have some that just go home the same day? Is this outpatient?

[Matthew Hensler MD]
It's outpatient. Generally the surgery, we schedule it for about maybe two hours or a little bit under that. And they go home afterwards. So we do the chest x-ray in recovery to make sure that the implant is sitting in a good spot and that they don't have a pneumothorax and just really to document its location. And we'll just see how they're doing, but it's an outpatient surgery. We don't plan for anybody to stay. And it's pretty well tolerated, particularly with a pain perspective. You get some tightness that happens up under the digastric. So they'll have some, maybe some jaw and ear and tongue pain, but nothing that's not controlled by oral pain medication at home.

[Gopi Shah MD]
So like Tylenol, Motrin, or do you ever have to do narcotics?

[Matthew Hensler MD]
We use narcotics. Yeah. We'll give them a short, a couple of days worth of that to help, but that's all it typically requires.

[Gopi Shah MD]
Do you ever do steroids or anything like that post-op? Does that help for inflammation or pain?

[Matthew Hensler MD]
Yeah, we do the intraoperative dosing, but we don't typically send them home on any Medrol or any Decadron. We just give them the intraoperative dose.

[Gopi Shah MD]
Do you have to do antibiotics since it's implants?

[Matthew Hensler MD]
Yeah, I normally do just, and just because you just kind of feel like okay, we're putting a device in, your in the mouth at some component of this. So I'd typically put them on a seven day course of antibiotics just to have that.

[Gopi Shah MD]
And do you just do like Augmentin or what's your go-to for this?

[Matthew Hensler MD]
Typically Keflex. I just put them on Keflex and again, knock on wood. And often we'll use antibiotic irrigations, like when you place the stimulator cuff, you'll kind of flush it with some antibiotic irrigation too, and again, ultimately we haven't had any major, we haven't had any infections of the device and we keep it pretty sterile. I shouldn't say pretty sterile. We keep it strictly sterile. We haven't had any issues with it, but putting them on antibiotics is really just to make it seem a little cleaner.

[Gopi Shah MD]
Okay. That's good to know. And then how long do you have to wait before they can start using it or turning it?

[Matthew Hensler MD]
Yeah. So.

[Gopi Shah MD]
Is there like a healing time?

[Matthew Hensler MD]
It's about four to five weeks after it's implanted. So they'll come in for a first post-op just to make sure the neck is healing well, and they're not having any complaints or issues and that it's sitting in a good spot. And then generally it's a waiting game. I will say it's important to note. We do check the device once it's implanted, so we'll make sure that it's working, that you're getting good tongue protrusion and that the tongue is not pulling back at all. Because it's really important when you place the device that you only include the branches of the hypoglossal nerve that pull the tongue forward. Cause you don't want to stimulate any of the retrusive branches. That's one of the potential down, not downfalls of the surgery, but it would be a limitation of it, if you start pulling the tongue back with stimulation. So we make sure of that, but then we turn it off and they'll get it activated with sleep about four to five weeks afterwards.

[Gopi Shah MD]
Okay. So in the OR before you close up, you activate and then make sure that when it's turned on, the tongue is getting pulled forward.

[Matthew Hensler MD]
Yeah, we make sure that we get a good sensing of respirations and that you don't have too much cardiac interference with the sense lead. And we also make sure that the tongue is in a good spot and stimulates nicely. And then you can go to a very low level of stimulation and not see any retrusion of the tongue.

[Gopi Shah MD]
Okay. Got it. And then, okay, so you see them, post-op, is it common to have a device infection or anything? What if you see redness or drainage at the chest, or under the mandible? How do you treat that, usually?

[Matthew Hensler MD]
Good question. I will say I haven't personally. I am just jinxing myself to death.

[Gopi Shah MD]
You're going to kill me after this.

[Matthew Hensler MD]
Yeah, no, no, it's all good. But really, we haven't had any device infections pneumothoraces. No, really the main complaint afterwards is pain. Or that people will say, wow, it's kind of tight up under here, I didn't think it would be that tight. And you'll see this mild kind of just thickening to the skin. And I think it's because you're doing a lot of muscle retraction when you're pulling on the digastric and the mylohyoid to get up along, you really have to go pretty distal on the hypoglossal nerve. So I think some of the retraction, and then you, you also attach the stimulator. Or at least part of it, you anchor it on the digastric. And I think there's some discomfort with that, that I really try to make sure I tell people beforehand and maybe they're like, “Okay. Yeah, it's tight when I swallow.” But you often give them reassurance. And, ultimately it goes away pretty quickly,

[Gopi Shah MD]
And this might be a silly question, but, no concerns about oral dysphagia, swallowing immediately post-op or-

[Matthew Hensler MD]
Right.

[Gopi Shah MD]
-weird sounds with articulation or anything like that from swelling or anything?

[Matthew Hensler MD]
Yeah, I know, you'd be surprised. The nerve is very robust. So seeing any weakness of the hypoglossal nerve is really rare. I always tell people it's a risk, but that's a rare thing to see. So most swallowing, I tell people to start maybe with soft diet at first. And once you see that that goes well you can go to a regular diet. Post-op day zero or whenever. You don't really hear of any issues with swallowing.