{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,4,11]],"date-time":"2025-04-11T04:14:26Z","timestamp":1744344866084,"version":"3.40.4"},"reference-count":12,"publisher":"American Medical Association (AMA)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Otolaryngol Head Neck Surg"],"published-print":{"date-parts":[[2025,4,1]]},"abstract":"<jats:sec id=\"ab-obr240007-4\"><jats:title>Importance<\/jats:title><jats:p>Allergic contact reactions to medical implants are underrecognized and incompletely understood, particularly in hypoglossal nerve stimulation (HGNS), an increasingly popular and effective alternative to positive airway pressure therapy for patients with obstructive sleep apnea (OSA).<\/jats:p><\/jats:sec><jats:sec id=\"ab-obr240007-5\"><jats:title>Objective<\/jats:title><jats:p>To document a rare case of allergic contact reaction in a patient following implantation of an HGNS device for OSA.<\/jats:p><\/jats:sec><jats:sec id=\"ab-obr240007-6\"><jats:title>Design, Setting, and Participant<\/jats:title><jats:p>In this case report, the patient presented to a quaternary care academic medical center with localized erythema, swelling, and pustular drainage at the right neck incision site approximately 2 months following HGNS device implantation.<\/jats:p><\/jats:sec><jats:sec id=\"ab-obr240007-7\"><jats:title>Exposure<\/jats:title><jats:p>This patient underwent serial, bilateral HGNS device implantation and subsequent explantation.<\/jats:p><\/jats:sec><jats:sec id=\"ab-obr240007-8\"><jats:title>Main Outcome and Measure<\/jats:title><jats:p>The main outcomes were the findings from symptom monitoring and allergy patch testing.<\/jats:p><\/jats:sec><jats:sec id=\"ab-obr240007-9\"><jats:title>Results<\/jats:title><jats:p>A 64-year-old male patient with severe OSA (Apnea-Hypopnea Index, 54 events\/h) underwent implantation of an HGNS device. His recovery was uneventful for 2 months until he reported localized erythema, swelling, and pustular drainage at the right neck incision site. HGNS device extrusion at the neck was noted approximately 3 months postoperatively, prompting device explantation. The patient underwent subsequent HGNS reimplantation in the left neck and chest 3 months after right-sided explantation. At postoperative day 10, swelling, erythema, and purulence were noted from neck and chest incisions. The device was re-explanted with odorless purulence noted in the chest and neck. The wound cultures were negative for infection, and at this time, the patient underwent allergy patch testing, which demonstrated a strong positive reaction to isophorone diisocyanate. Patch testing confirmed an allergy to isocyanates, evidenced by a strong positive reaction to isophorone diisocyanate, 1.0%, in petrolatum. This finding was further validated by the manufacturer, which confirmed isocyanates were used in the polyurethane components of the HGNS device.<\/jats:p><\/jats:sec><jats:sec id=\"ab-obr240007-10\"><jats:title>Conclusions and Relevance<\/jats:title><jats:p>Isocyanates are low\u2013molecular weight compounds used in the production of polyurethanes, which are commonly found in medical devices. HGNS is a widely available implantable medical device for treatment of patients with OSA. The literature regarding isocyanate allergies with medical implants is limited, and this may be the first confirmed case with an HGNS device. This case report highlights the importance of noninfectious causes of device reactions, especially when occurring outside of the postoperative wound infection window. Patch testing for isocyanate and other components can inform both patient and clinician regarding the cause of device implantation failure and have implications for future implantable devices.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamaoto.2024.5446","type":"journal-article","created":{"date-parts":[[2025,2,27]],"date-time":"2025-02-27T16:32:27Z","timestamp":1740673947000},"page":"401","source":"Crossref","is-referenced-by-count":0,"title":["Allergic Contact Dermatitis Following Hypoglossal Nerve Stimulator Implant"],"prefix":"10.1001","volume":"151","author":[{"given":"Akshay","family":"Tangutur","sequence":"first","affiliation":[{"name":"Department of Otorhinolaryngology\u2013Head & Neck Surgery, University of Pennsylvania, Philadelphia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katherine K.","family":"Brown","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University of Pennsylvania, Philadelphia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Raj C.","family":"Dedhia","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology\u2013Head & Neck Surgery, University of Pennsylvania, Philadelphia"},{"name":"Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","reference":[{"issue":"6","key":"obr240007r1","doi-asserted-by":"publisher","first-page":"1435","DOI":"10.1016\/j.chest.2018.08.1070","article-title":"Neurostimulation treatment of OSA.","volume":"154","author":"Fleury Curado","year":"2018","journal-title":"Chest"},{"issue":"2","key":"obr240007r2","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1056\/NEJMoa1308659","article-title":"Upper-airway stimulation for obstructive sleep apnea.","volume":"370","author":"Strollo","year":"2014","journal-title":"N Engl J Med"},{"issue":"2","key":"obr240007r3","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1177\/0194599820960069","article-title":"Adverse events in hypoglossal nerve stimulator implantation: 5-year analysis of the FDA MAUDE database.","volume":"164","author":"Bellamkonda","year":"2021","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"6","key":"obr240007r4","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjoto.2020.102616","article-title":"Adverse events associated with the Inspire implantable hypoglossal nerve stimulator: a MAUDE database review.","volume":"41","author":"Bestourous","year":"2020","journal-title":"Am J Otolaryngol"},{"issue":"3","key":"obr240007r5","doi-asserted-by":"publisher","first-page":"130","DOI":"10.1097\/DER.0b013e31824a648d","article-title":"Isocyanates.","volume":"23","author":"Wenk","year":"2012","journal-title":"Dermatitis"},{"issue":"2","key":"obr240007r6","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1056\/NEJM199507133330207","article-title":"Occupational asthma.","volume":"333","author":"Chan-Yeung","year":"1995","journal-title":"N Engl J Med"},{"issue":"5","key":"obr240007r7","doi-asserted-by":"publisher","first-page":"414","DOI":"10.1111\/cod.14187","article-title":"Isocyanates may contribute to allergic contact dermatitis from diabetes devices and wound dressings.","volume":"87","author":"Dendooven","year":"2022","journal-title":"Contact Dermatitis"},{"issue":"5","key":"obr240007r8","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1097\/DER.0000000000000621","article-title":"American Contact Dermatitis Society Core Allergen series: 2020 update.","volume":"31","author":"Schalock","year":"2020","journal-title":"Dermatitis"},{"issue":"1","key":"obr240007r9","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1007\/s12016-018-8707-y","article-title":"Allergy to surgical implants.","volume":"56","author":"Pacheco","year":"2019","journal-title":"Clin Rev Allergy Immunol"},{"key":"obr240007r10","doi-asserted-by":"publisher","first-page":"96","DOI":"10.2500\/aap.2012.33.3561","article-title":"Chapter 28: classification of hypersensitivity reactions.","volume":"33","author":"Uzzaman","year":"2012","journal-title":"Allergy Asthma Proc"},{"issue":"1","key":"obr240007r11","doi-asserted-by":"publisher","first-page":"211","DOI":"10.5664\/jcsm.11370","article-title":"Allergic reaction to hypoglossal nerve stimulator: a case report.","volume":"21","author":"Gouldman","year":"2024","journal-title":"J Clin Sleep Med"},{"issue":"4","key":"obr240007r12","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1111\/cod.12809","article-title":"Sensitization and cross-reactivity patterns of contact allergy to diisocyanates and corresponding amines: investigation of diphenylmethane-4,4'-diisocyanate, diphenylmethane-4,4'-diamine, dicyclohexylmethane-4,4'-diisocyanate, and dicylohexylmethane-4,4'-diamine.","volume":"77","author":"Hamada","year":"2017","journal-title":"Contact Dermatitis"}],"container-title":["JAMA Otolaryngology\u2013Head &amp; 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