The gold standard treatment for
obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP). But CPAP therapy is notoriously difficult to stick with long term.
If you’ve struggled with this treatment, nerve stimulation may offer a path forward.
Previously, people with moderate to severe OSA “who were intolerant to CPAP machines had no other treatment options,” says Aparajitha Verma, MD, a sleep neurologist at UTHealth Houston. “So this is bridging a valuable gap.”
Hypoglossal nerve stimulation involves surgically implanting a medical device that delivers gentle electrical pulses to the nerve that controls the muscles of your tongue. With OSA, the muscles in your tongue and at the back of your throat can relax while you’re asleep, causing your tongue to block your airway. Stimulating the hypoglossal nerve moves your tongue forward so you can breathe normally.
Research shows that hypoglossal nerve stimulation is a highly effective treatment for moderate to severe OSA. In studies tracking patients over multiple years, it reduced the apnea-hypopnea index (AHI), which measures the severity of OSA by counting your breathing interruptions, by an average of almost 16 events per hour.
“That’s very significant,” says Joyce Lee-Iannotti, MD, a neurologist and the director of Barrow Neurological Institute's Sleep Center in Phoenix. “It can take you from having moderate sleep apnea to not having sleep apnea at all.” Patients also reported improvements in daytime sleepiness — a hallmark symptom of OSA.
Nerve stimulation may be a good option if you meet these criteria:
- Have moderate to severe sleep apnea (an AHI score of 15 to 100)
- Have a body mass index of 40 or less
- Haven’t been able to tolerate CPAP therapy after trying for at least three months
- Can safely undergo implantation surgery
- Are age 22 or older (though patients as young as 13 may be eligible in some cases.)
If you are a candidate, your doctor will refer you to a sleep surgeon or an otolaryngologist (a doctor who specializes in the ears, nose, and throat) for a drug-induced sleep endoscopy (DISE). DISE is a minimally invasive procedure performed under anesthesia. A thin flexible tube with a camera is inserted into your nose to view your airway and determine the way it collapses during sleep.
“The physician wants to see what type of collapse is happening in the upper airway — anteroposterior or complete concentric,” Dr. Verma says. If you have an anteroposterior collapse, your airway narrows from front to back, typically caused by your tongue dropping back toward your throat — a pattern that responds well to nerve stimulation. But if you have a complete concentric collapse, meaning your airway narrows from all sides simultaneously, the device is unlikely to help.
If the doctor determines that you have an anteroposterior collapse and would likely benefit from nerve stimulation, they will submit a request to your insurance company to approve the device.
The most commonly used device is the Inspire upper airway stimulation system, which was approved by the U.S. Food and Drug Administration in 2014.
A second device, called the Genio system, was approved in August 2025.
The key difference between the two devices is that Inspire provides unilateral (one-sided) stimulation to the nerve, while Genio delivers bilateral (two-sided) stimulation. “The theory is, if you can move the tongue even more by stimulating both sides, you’ll see faster results and more significant improvements,” says Dr. Lee-Iannotti. However, early data from a small group of people showed similar outcomes.
The Inspire device includes a small sensor implanted in your chest that monitors your breathing. When you inhale, the sensor signals a pulse generator, implanted below your collarbone, to send a mild electrical pulse to a tiny electrode attached to your hypoglossal nerve. You control when the stimulator is active using a handheld remote or device attached externally, turning it on before bed and off when you wake up. Inspire runs on a battery that must be replaced roughly every 11 years.
The Genio device consists of a single implant attached to the hypoglossal nerves on both sides of the muscle that controls your tongue. It’s battery-free, powered and controlled by a rechargeable activation chip that’s connected to an adhesive patch you wear under your chin while you sleep.
Hypoglossal nerve stimulation implant surgery is an outpatient procedure done under general anesthesia. It typically takes two to three hours.
To implant the Inspire device, the surgeon will make an incision under your jaw to wrap the stimulation electrode around the hypoglossal nerve, then a second incision in your chest to place the breathing sensor and pulse generator. A wire is tunneled under the skin to connect the parts.
The Genio procedure requires a single incision under your chin to implant the nerve stimulator.
Neither device is activated immediately after the procedure. For Inspire, you’ll typically wait six weeks to allow the implant site and surrounding nerve to heal, Verma says. For Genio, you’ll wait eight weeks.
The Inspire device is usually activated in the sleep medicine physician’s office. “We slowly introduce a very minimal voltage and see what the patient’s reaction is. Are they sensing it? Then we slowly advance the settings until the patient can feel it,” Verma says. You’ll use that setting as a baseline and gradually increase the voltage by one setting per week.
If the next week’s setting feels too intense — you may feel your tongue is being pulled too hard — Verma advises staying at the lower setting for a couple more days before trying again. "It's like training a muscle in the gym,” she says. “The more you lift a weight, the more you get used to it.”
It takes approximately six to eight weeks from the date of activation for people to reach their final setting, though some people may need three or four months, she adds.
Similarly, the Genio is activated and fine-tuned by specially trained technicians in consultation with your doctor, although you can make some adjustments yourself using an app.
“Overall, hypoglossal nerve stimulation is considered safe, but as with any surgical procedure, there are risks,” Lee-Iannotti says, including infection, bleeding, lasting pain, nerve injury, and device displacement, which may require revision surgery.
Some temporary side effects are normal in the weeks after surgery — including tongue discomfort, mild difficulty swallowing, and changes in speech — and should resolve on their own as you heal.
Contact your doctor if you experience the following:
- Fever higher than 100.5
- Excessive swelling or redness at the incision site
- Bleeding from incisions
- Slurred speech or difficulty breathing or swallowing that doesn’t improve
A few months after surgery, you’ll undergo a sleep study to see how well the device is working and whether it needs to be adjusted.
After that, you’ll see your doctor once or twice a year for device monitoring, compliance checks, and any setting adjustments. When the time comes, battery replacement for the Inspire device is a minor outpatient procedure. “It’s not as extensive as the initial implantation,” Verma says.
Because sleep apnea is closely tied to weight, significant weight gain after surgery can reduce the device's effectiveness.
Follow-up appointments help your doctor track changes in your weight and identify any issues before they affect your treatment outcomes.
