Is the Inspire device suitable for a patient with nasal problems, such as nasal polyps, deviated septum, or chronic rhinosinusitis, and obstructive sleep apnea (OSA)?

Inspire Device Suitability for Patients with Nasal Problems

The Inspire hypoglossal nerve stimulator can be used in patients with nasal problems, but anatomical nasal obstruction should be surgically corrected first to optimize outcomes and PAP therapy should be attempted before considering Inspire. 1

Patient Selection Criteria

The VA/DoD guidelines specifically recommend evaluation for hypoglossal nerve stimulation (Inspire) in patients with OSA who have an AHI of 15-65/h, BMI <32 kg/m², and cannot adhere to PAP therapy. 1 This is a weak recommendation, indicating that nasal problems alone do not disqualify patients, but PAP failure must be documented first.

Addressing Nasal Obstruction Before Inspire

Among patients with anatomical nasal obstruction as a barrier to PAP use, evaluation for nasal surgery should be performed first. 1 This sequential approach is critical because:

• Nasal obstruction from deviated septum, polyps, or chronic rhinosinusitis can impair PAP adherence 1
• Surgical correction of deviated nasal septum has demonstrated dramatic clinical improvement in obstructive sleep apnea, with reduction in apnea episodes 2
• Structural abnormalities including nasal septal deviation, nasal polyps, and middle turbinate deformity warrant otolaryngology consultation 1

Clinical Algorithm for Decision-Making

Step 1: Optimize Medical Management

• Treat underlying chronic rhinosinusitis with appropriate medical therapy including corticosteroids for nasal polyps 1
• Address allergic rhinitis if present with environmental control and pharmacotherapy 1
• Maximize medical treatment before proceeding with any surgical intervention 1

Step 2: Surgical Correction of Nasal Pathology

• If obstructing nasal polyps persist after medical therapy including oral corticosteroids, refer to otolaryngology 1
• Correct significant nasal septal deviation compressing the middle turbinate or obstructing sinus outflow 1
• Consider functional endoscopic sinus surgery for chronic rhinosinusitis with ostiomeatal obstruction despite aggressive medical management 1

Step 3: PAP Therapy Trial

• After nasal surgery, initiate or retry PAP therapy 1
• Use educational, behavioral, and supportive interventions to improve PAP adherence 1
• Document objective PAP failure (inability to tolerate or adhere despite interventions) 1

Step 4: Consider Inspire

• Only after documented PAP failure and correction of anatomical nasal obstruction should Inspire evaluation occur 1
• Ensure patient meets criteria: AHI 15-65/h, BMI <32 kg/m² 1

Important Caveats

Chronic rhinosinusitis patients have high OSAS prevalence (64.7%), but OSAS severity does not correlate with rhinosinusitis severity. 3 This means that treating nasal disease alone may not resolve OSA, making Inspire a reasonable option after appropriate nasal surgery and PAP failure.

Inspire complications include infection (34.2%), neuropraxia (15.1%), and device migration, with 42.3% of adverse events requiring reoperation. 4, 5 These risks must be weighed against benefits, particularly after nasal pathology has been optimized.

The presence of nasal polyps does not worsen sleep problems beyond the baseline effect of chronic rhinosinusitis 3, so polyps alone should not be considered an absolute contraindication to Inspire if other criteria are met and surgical correction has been attempted.