Surgery

March 14, 2026

For people with obstructive sleep apnea (OSA) who are unable to tolerate continuous positive airway pressure (CPAP) therapy or other nonsurgical treatments, the next consideration is usually surgery. Hypoglossal nerve stimulation has provided patients with a less invasive treatment option for their OSA, and continued innovation has led to the approval of a new technology.

The first hypoglossal nerve stimulation device was approved by the U.S. Food and Drug Administration (FDA) in 2014. In this treatment, three components — a pulse generator in the chest, a breathing sensor in the ribs and an electrode stimulator in the upper neck — are surgically placed under the skin. The pulse generator is connected to the sensor and electrode with thin wires. It's turned on before sleep with a hand-held remote. During sleep, the sensor detects when breathing stops and signals the pulse generator, which sends an electrical pulse to the electrode in the neck. This pulse activates one side of the hypoglossal nerve, which stimulates the tongue muscles to move the tongue forward and open the airway.

"Hypoglossal nerve stimulation therapy has grown in popularity over the last decade," says John M. Nathan, M.D, D.D.S., an oral and maxillofacial surgeon and sleep surgery specialist at Mayo Clinic in Rochester, Minnesota. "In August 2025, another implantable device option received FDA approval."

Innovation in hypoglossal nerve stimulation

Bilateral hypoglossal nerve stimulation requires only one small incision under the chin to implant the stimulator. An external, rechargeable device called an activation chip is worn under the chin during sleep. It sends signals to the stimulator at routine intervals. These signals activate both sides of the hypoglossal nerve, which moves the tongue forward to allow air into the throat.

The key differences in this new technology are:

• Increased airway opening with bilateral nerve stimulation instead of unilateral stimulation.
• External activation device affixed to the skin with an adhesive patch instead of an implanted pulse generator.
• Less invasive procedure with a single incision instead of 2 to 3 incisions.
• Single operation without the need for battery changes every 8 to 10 years.

The eligibility criteria include:

• Age 22 or older.
• Apnea-hypopnea index (AHI) of 15 to 60. The AHI is the number of times a person stops breathing or has a partial blockage in airflow during an hour of sleep.
• Body mass index (BMI) up to 35.
• Inability to use CPAP therapy.

"This new treatment gives patients another option. If they're interested in hypoglossal nerve stimulation, we provide information about both devices and help them choose based on their sleep habits, lifestyle and personal preferences," says Dr. Nathan.

There's also movement toward advancing this new treatment. Future changes may eliminate the need for a sleep endoscopy to evaluate the soft palate. Additionally, the wearable piece that signals the stimulator may be replaced by a pad positioned under the pillow.

Streamlining care for hypoglossal nerve stimulation therapy

Evaluations for patients seeking hypoglossal nerve stimulation therapy include a review of prior sleep studies and sleep apnea treatments before the patient comes in. During the first visit, the surgeon discusses all treatment options. For patients traveling for care, the team can also schedule any workup needed for the procedure, including a sleep endoscopy.

"For the battery-free device, I'll send the patient home with stickers so they can see how it feels to wear the stickers at night and to make sure there's no skin allergy," says Dr. Nathan.

Surgical placement is a short outpatient procedure. After a recovery period, the patient works with the team to activate the device and ensure it's working properly.

Other surgical treatments for obstructive sleep apnea

Other types of surgery also are used to treat OSA. Although more invasive, these procedures can address the underlying condition and provide a more permanent solution. An evaluation for surgery typically involves X-ray imaging and a nasal endoscopy to look inside the throat.

Maxillomandibular advancement is a common OSA surgery used to move the upper and lower jaws and connected soft tissues forward. New techniques have nearly eliminated the need to wire shut the jaw after surgery. The use of nerve blocks also significantly reduces postsurgical pain.

In addition to treating OSA, maxillomandibular advancement can improve a patient's bite and facial appearance.

Other less common types of OSA surgery include:

• Hyoid suspension. This procedure involves looping a suture around the hyoid bone and connecting it to the lower jaw to enlarge the airway and provide stability.
• Lingual tonsillectomy. In this procedure, the surgeon removes the tonsils and sometimes a portion of tongue tissue to create more space in the throat.
• Nasal surgery. Endoscopic nasal surgery removes obstructions in the nasal passages.
• Surgically assisted rapid palatal expansion. This procedure widens the upper jaw, reducing nasal airflow resistance.

Determining the right obstructive sleep apnea treatment

There are many factors to consider when choosing an OSA treatment. For most patients, physicians typically recommend CPAP therapy, the least invasive method, first. A mandibular advancement device also is an option. This oral appliance moves the lower jaw and tongue forward to keep the airway open. If those treatments are not effective, the next option is hypoglossal nerve stimulation therapy or surgery.

"At Mayo Clinic, oral and maxillofacial surgeons offer both hypoglossal nerve stimulators and the full range of obstructive sleep apnea surgery options. We evaluate patients for all options and help them decide the right path forward," says Dr. Nathan.

For more information

Refer a patient to Mayo Clinic.