I had the opportunity to attend the 2025 International Surgical Sleep Society (ISSS) and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) meetings in Indianapolis, this past week. These academic sessions are always a unique opportunity to reconnect with colleagues across the nation (and internationally!), hear exciting new research developments, and discuss practice dynamics. This year’s meetings felt particularly rich: from the long-awaited shake-up in hypoglossal nerve stimulation to a new wave of early-stage technologies and evolving frameworks for care, the field of sleep surgery remains poised for ongoing growth.

Here are my key takeaways from this year’s conferences.

1. The Hypoglossal Nerve Stimulation Wars Have Begun

For more than a decade, Inspire has been the dominant — and essentially only — player in hypoglossal nerve stimulation (HNS) in the U.S. That monopoly has now ended. Nyxoah has received FDA approval and has begun its U.S. launch, while LivaNova reiterated its compelling data and expected FDA approval soon. This development was the dominant discussion item amongst surgeons: how will these new players reshape treatment workflows?

1. Optimizing Long-Term Success: There was general agreement that neither new entrant represents a ‘paradigm change’ in surgical management. Because of this, there was increased emphasis on patient selection factors (via drug-induced sleep endoscopy DISE, thorough review of multiple non-surgical & surgical options, and having long-term follow-up protocols to manage) for all HNS candidates. This was heartening as a comprehensive sleep surgeon: implantation is just one tool for managing this burdensome chronic disease.
2. Market Positioning / Patient Decision Making: Having said that, there is excitement about additional options. Nyxoah’s incision placement, external battery patch, and bilateral stimulation present a differentiated choice to the surgeon/patient; they have also highlighted their supine sleep data. Similarly, LivaNova’s proximal nerve cuff technology seems to offer some uniqueness as well, and their published OSPREY study didn’t require DISE to rule out complete concentric collapse, which could provide a workflow change to the current Inspire-DISE default. Efficacy appears roughly identical amongst the 3, so we expect some of these form-factor and workflow differences to influence surgical decision making. We look forward to learning more with these devices in the ‘real world.’
3. Inspire V: While there is excitement about new options, the discussions regarding Nyxoah/LivaNova pros/cons are a reminder that Inspire has 10+ years of established use cases. Inspire V has now launched nationwide, and the company presented data affirming its promises: shorter case times, reliable respiratory monitoring without a sensor, and solid patient adherence. The company is clearly not planning on relinquishing its dominance.

2. The Next Wave Is Coming — But It’s Early

Several new companies are on the horizon. Whether via new technology, novel applications to the hypoglossal nerve, or approaching a new nerve target, there is ongoing excitement in improving patient options/outcomes and decreasing invasiveness. Many are still in ‘stealth’ mode/hypothetical, others are starting to enroll in trials. A few I’m keeping an eye on, and look forward to discussing further in my newsletter in the future:

1. Lunair Medical
2. Cryosa, Inc.
3. StimAire
4. Somnaire

Cautious optimism surrounds this next wave — it took a lot of time and work to reach three HNS devices to market, and we expect the same is true with these new entrants.

3. Rethinking Metrics and Management

The meetings reinforced treating obstructive sleep apnea (OSA) as a chronic disease, not just a condition to “cure” with surgery or CPAP. Beyond that, there was robust discussion about ‘phenotyping’ patients and utilizing multiple metrics to assess patients’ long-term disease risk.

Across sessions, there was consensus that AHI (apnea–hypopnea index) is an imperfect metric, particularly for capturing physiologic stress and cardiovascular risk. Alternative measures — such as hypoxic burden and time below 90% oxygen saturation (T90) — are gaining traction as better indicators of disease impact and treatment response.

The work by Dr. Ali Azarbarzin and Dr. Ed Weaver weighs on a lot of these discussions: that there is a distinctly at-risk OSA group (more severe, more hypoxic burden) and that surgery has a very real impact in mitigating that risk (on big outcomes like mortality), respectively.

4. ENT’s Role in OSA

A final and recurring theme was the critical role of ENT’s in caring for CPAP-intolerant patients.

We’re uniquely positioned to offer a comprehensive pathway:

1. Optimizing CPAP through nasal surgery and airway interventions
2. Discussing medical and non-surgical therapies, including oral appliances and even emerging pharmacologic options (GLP-1s included)
3. And when indicated, offering the full range of surgical treatments, from palatal or HNS to skeletal procedures

For many patients, the ENT becomes the last stop before giving up — and the one provider who can realistically address anatomy, physiology, and adherence together.

At the same time, there’s acknowledgment that general otolaryngologists face competing demands, and sleep may not always rise to the top of the list. As sleep apnea prevalence grows and awareness of surgical solutions expands, ENT’s relevance in this space will only deepen. This makes sleep education essential to our field moving forward.

Closing Thoughts

If there’s a single takeaway from this year’s meetings, it’s that sleep surgery is entering a new phase of maturity — diversifying beyond a single device, refining how we define success, and reaffirming the importance of collaborative, chronic-disease care.

It’s an exciting moment for the field — and a reminder that innovation is as much about how we care for patients as it is about the tools we use.

Dr. Gouveia has no conflicts of interest to report.

Image by GoodStudio / Shutterstock