Abstract Introduction Hypoglossal nerve stimulation (HNS) is an alternative treatment for obstructive sleep apnea (OSA) in patients who are unable to tolerate continuous positive airway pressure (CPAP). This case describes a patient with extremely severe OSA and a BMI slightly above typical eligibility cutoffs who experienced substantial improvement after HNS therapy. Report of case(s) A 51-year-old man (BMI 35 kg/m²) was evaluated for long-standing loud snoring and marked daytime sleepiness. Home sleep apnea testing on 11/16/2022 showed very severe OSA with an apnea–hypopnea index (AHI) of 92.3 events/hour, oxygen saturation nadir of 74%, and 27.2% of total sleep time below 89% saturation. Several trials of auto-adjusting positive airway pressure (APAP) were unsuccessful because of pressure intolerance and mask discomfort. Drug-induced sleep endoscopy on 5/17/2024 revealed partial anteroposterior tongue-base collapse without concentric palatal collapse, supporting candidacy for HNS. The patient underwent HNS implantation on 11/12/2024, with device activation on 12/30/2024. Titration polysomnography on 7/22/2025 demonstrated a reduction in AHI to 6.9 events/hour at a stimulation amplitude of 2.6 V. The oxygen saturation nadir improved to 89%, with only 0.1% of sleep time below 89%. Sleep efficiency was 74.6%, REM sleep accounted for 8.7% of total sleep time, and the periodic limb movement index was 0. Mean nightly HNS use was 6 hours 56 minutes, with 100% adherence (4 hours/night). The Epworth Sleepiness Scale score improved from 18 to 4, and both snoring and daytime sleepiness resolved. BMI remained stable (35→34 kg/m²). No perioperative complications occurred, and improvements persisted at 10-month follow-up. Conclusion This case highlights the sustained benefit of HNS in a patient with extreme OSA severity and a BMI above 34 kg/m². Careful DISE-guided selection and consistent device use resulted in marked physiologic and symptomatic improvement. This experience supports the real-world effectiveness of HNS for selected patients who fall slightly outside traditional BMI cutoffs. Support (if any) None.
Bam et al. (Fri,) studied this question.