Management of Comorbid Insomnia and Obstructive Sleep Apnea in Patients Referred for Hypoglossal Nerve Stimulation: Evaluation, Treatment Pathways, and Clinical Outcomes

Comorbid insomnia and obstructive sleep apnea (COMISA) are common and associated with worse sleep-related symptoms, impaired quality of life, and challenges with treatment adherence. Hypoglossal nerve stimulation (HNS) has emerged as an effective treatment for selected patients with obstructive sleep apnea (OSA), particularly those unable to tolerate positive airway pressure (PAP) therapy. Insomnia is frequently underrecognized in OSA patients referred for HNS, despite its influence on symptom attribution, treatment expectations, perioperative counseling, and postimplant outcomes. To review current evidence regarding COMISA patients referred for HNS, summarize diagnostic and therapeutic considerations for COMISA in this population, and propose a clinical framework for integrating insomnia assessment and treatment into HNS evaluation and follow-up. A narrative review of published literature addressing COMISA in patients referred for upper airway stimulation. Evidence from clinical trials, observational studies, guideline statements, and expert recommendations were synthesized, with emphasis on implications for patient selection, treatment sequencing, and outcomes in HNS candidates. Insomnia symptoms are common among patients referred for HNS, although HNS-specific data remain limited. In this population, insomnia may contribute to PAP intolerance, exaggerate nocturnal symptom burden, and persist despite successful treatment of upper airway obstruction. Comprehensive evaluation should include screening for insomnia severity as well as other sleep disorders. Cognitive behavioral therapy for insomnia (CBT-I) remains first-line treatment for chronic insomnia and may be beneficial before, during, or after HNS evaluation depending on symptom severity and care logistics. HNS may improve respiratory-related sleep fragmentation, but it should not be expected to resolve nonrespiratory causes of insomnia. Routine insomnia screening should be incorporated into HNS referral pathways. Recognition and treatment of COMISA may improve patient counseling, refine expectations, and optimize posttreatment symptom outcomes. Future prospective studies are needed to define the prevalence of insomnia in HNS referral populations and determine whether targeted insomnia treatment improves HNS-related outcomes.