Preliminary Efficacy and Safety of Bilateral Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

Purpose Bilateral hypoglossal nerve stimulation (biHNS) is an emerging neurostimulation alternative for obstructive sleep apnea (OSA). This systematic review and meta-analysis aims to analyze the reported preliminary outcomes of biHNS. Methods PubMed, Embase, and Scopus were searched through February 2026. Primary metrics included mean changes in Apnea-Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), and Epworth Sleepiness Scale (ESS), alongside Sher responder and adverse event rates. Case reports were reviewed qualitatively. Results Six studies were included (n = 122), with three cohort studies included in the meta-analysis (n = 119). Treatment with biHNS was associated with pooled mean changes in AHI of -16.31 events/hour (95% CI -22.08 to -10.54), ODI of -14.80 events/hour (95% CI -20.57 to -9.04), and ESS of -3.49 points (95% CI -4.31 to -2.66). The pooled Sher responder rate was 62% (95% CI 53% to 69%). The serious treatment-related adverse event rate was 8%, the device-related serious adverse event rate was 3%, and the pooled explantation rate was 6%. Qualitative review of three case reports highlighted biHNS feasibility in complex cases, including complete concentric collapse and craniofacial syndromes. Conclusion In this analysis, biHNS was associated with improvements in OSA severity and daytime sleepiness. Given the limited sample size, substantial heterogeneity in respiratory outcomes, and early safety signal, biHNS should be viewed as an emerging alternative neurostimulation approach whose role relative to unilateral HNS remains to be defined.