ENT Referral for Inspire Hypoglossal Nerve Stimulation
An otolaryngology-head-and-neck surgeon (ENT) should refer patients for Inspire hypoglossal nerve stimulation, not primary care physicians, as this is a specialized surgical procedure requiring comprehensive upper airway surgical examination, drug-induced sleep endoscopy (DISE), and technical expertise in head and neck surgery that falls squarely within the ENT scope of practice.
Why ENT Should Make the Referral
Specialized Surgical Assessment Required
Hypoglossal nerve stimulation requires detailed upper airway surgical examination and drug-induced sleep endoscopy (DISE) to assess collapse patterns, which are essential for proper patient selection and cannot be performed in primary care settings 1.
The surgical placement of the Inspire device involves four principal steps requiring head and neck surgical expertise: placement of the stimulation lead on the hypoglossal nerve, placement of the sensing lead, tunneling with connection to the implantable pulse generator, and intraoperative functional testing 2.
This is a standardized head and neck surgery procedure using familiar anatomy and techniques within an otolaryngologist's repertoire, not a procedure that primary care physicians would refer patients to directly 2.
Patient Selection Complexity
Proper patient selection requires assessment of multiple specialized parameters: OSA severity via polysomnography, BMI criteria (≤32-35 kg/m²), upper airway collapse pattern during DISE, anatomic features of the upper airway, and previous failure or intolerance of CPAP therapy 1, 3.
The ENT surgeon must determine if patients have appropriate anatomic features through clinical assessment with sleep endoscopy before determining surgical candidacy 3.
FDA-established stringent criteria must be verified, including moderate to severe OSA, CPAP failure/intolerance, and specific BMI thresholds, which requires specialized sleep surgery expertise 3.
The Primary Care Role
Initial Evaluation and ENT Referral
Primary care physicians should identify patients with OSA who have failed or are intolerant of CPAP therapy and refer them to an ENT/sleep surgeon for evaluation of surgical options including hypoglossal nerve stimulation 4.
When referring to ENT, primary care should document: duration of OSA diagnosis, CPAP adherence issues or intolerance, results of sleep studies, BMI, relevant comorbidities, and patient's general health status 5.
Not a Direct-to-Device Referral
Primary care does not refer "for Inspire" directly—they refer to ENT for surgical OSA management evaluation, and the ENT surgeon then determines candidacy and arranges device placement if appropriate 1, 2.
The ENT specialist performs the comprehensive evaluation, DISE assessment, patient selection, surgical implantation, and postoperative device titration and management 1, 2.
Common Pitfalls to Avoid
Do not bypass ENT evaluation: Primary care cannot determine Inspire candidacy without specialized upper airway surgical assessment and DISE 1.
Do not refer patients who have not failed CPAP therapy first: Hypoglossal nerve stimulation is a second-line treatment for CPAP-intolerant or non-adherent patients 4, 3.
Do not assume all OSA patients are candidates: Specific anatomic features, collapse patterns, and BMI criteria must be met, requiring ENT surgical expertise to assess 1, 3.