Hyoid suspension is a procedure to stabilise the retrolingual space in obstructive sleep apnoea. Using the Hörmann technique, a steel wire is slung around the body of the hyoid and fixed to the upper rim of the thyroid cartilage. It was observed, however, that the steel wire may lie very superficially to the pharyngeal mucosa. Evaluation of computed tomography (CT) scans showed a mean distance between the hyoid and the pharynx of only 3 mm. A modification is presented by threading a steel wire through a hole that is drilled through the hyoid bone. Thus pharyngeal exposure of the steel ligature and possible perforation of the mucosa is avoided.

Within the last 10 to 15 years, a significant amount of research in tonsil surgery has focused on reduction of post-operative pain and recovery time. In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as ‘tonsillotomy’, specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy. More recently, surgeons have used terms such as partial tonsillectomy, partial intracapsular tonsillectomy or subtotal tonsillectomy to describe their procedure and have employed a variety of modern instrumentation. This return to a ‘partial’ procedure has generated a debate similar to that which occurred amongst tonsil surgeons about 100 years ago, when tonsillotomy was the most commonly performed procedure. Today, concerns about regrowth and problems with infection of the remaining tonsillar tissue have been raised. Such concerns, combined with an incomplete understanding of why the ‘partial’ procedure was abandoned in the early twentieth century, may explain why tonsil surgeons hesitate to change their approach to patients with OSDB due to adenotonsillar hypertrophy. These issues can be addressed in a meaningful way only through a detailed review of the evolution of tonsil surgery, which is presented here. This information, along with a summary of the last 10 years' experience with these techniques, supports the use of a ‘partial’ procedure in children with OSDB due to adenotonsillar hypertrophy. Future areas of research are also discussed.

Laser-assisted uvulopalatoplasty (LAUP) is an established treatment for snoring. Our institution has been using a modification of the Kamami technique since 1995. Between January 1995 and December 2001, 469 patients underwent LAUP for snoring. A telephone survey of these patients and their partners was conducted retrospectively. One hundred and sixty-eight patients and their partners were interviewed and the findings analysed.

Of the 168 patients, 122 had LAUP alone, 42 had LAUP and tonsillectomy and four had LAUP and septoplasty. The median follow-up time was 59 months (range 19 to 98 months).

Seventy-four per cent reported improvement at six weeks, 69 per cent reported improvement at nine months and 55 per cent reported improvement at the time of interview. To assess the degree of improvement, patients and their partners were asked to grade any improvement in percentage terms. The mean subjective improvement scores were 57 per cent at six weeks (95 per cent confidence interval (CI) 50–64 per cent), 45 per cent at nine months (95 per cent CI 38–59 per cent) and 30 per cent at the time of interview (95 per cent CI 23–35 per cent). Patients who reported weight gain since surgery did not have a poorer outcome than those who reported no weight change or weight loss. Neither did weight loss predict a better outcome. The procedure was generally well tolerated, with only 30 patients (18 per cent) reporting complications (mainly minor).

The benefits of LAUP wane with time and the results are best in the first 12 months following surgery. Our study suggests that 55 per cent of patients selected after sleep studies and sleep nasendoscopy will enjoy long-term benefit.

Potentially serious complications have been documented in patients undergoing upper airway surgery for obstructive sleep apnoea (OSA). Consensus is lacking regarding peri- and post-operative monitoring and identification of those patients likely to suffer post-operative complications.

This retrospective review of 118 patients treated and 152 surgical procedures undertaken, from January 1998 to December 2003, addresses this issue. The overall peri- and post-operative complication rate was 13.8 per cent, with one patient experiencing upper airway compromise, five patients experiencing post-operative oxygen desaturation within 150 minutes of extubation, six patients experiencing persistent hypertension and four patients suffering secondary haemorrhage. All patients were treated accordingly and recovered well, with no mortality. From these results, it is concluded that patients with severe OSA (apnoea–hypopnoea index > 60 and lowest oxygen saturation <80 per cent) are at higher risk of post-operative oxygen desaturation. Post-operative hypertension is more likely in patients with a prior history of hypertension. Routine post-operative admission to an intensive care unit for all OSA patients is unnecessary (including patients with severe OSA). However, all patients with OSA should be closely monitored in the post-anaesthesia care area for at least three hours after surgery; based on the outcome of this period and the clinical judgment of the clinician, the patient can then be observed overnight in either the high dependency unit or on a general ward. Patients with mild OSA may be admitted to the 23-hour ambulatory unit post-operatively. Use of continuous positive airway pressure in the immediate post-operative period can reduce the incidence of post-operative respiratory compromise and complications and is strongly recommended.

Certain medical conditions may affect one's ability to drive safely. In the United Kingdom, the Driver and Vehicle Licensing Agency (DVLA) issues guidelines outlining which medical conditions drivers must notify them of. In order to assess our knowledge of, and ability to apply, the current DVLA guidelines with regard to otolaryngological conditions, a postal survey was sent to all otolaryngologists in Scotland. The responses obtained suggest that the current DVLA guidelines are not well understood or easily applied, and it is recommended that all otolaryngologists familiarize themselves with these guidelines in order to better advise their patients with regard to driving.

We report here a very rare case of bilateral congenital choanal atresia untreated for the 27 years after birth. A 27-year-old Japanese man complaining of long-term nasal obstruction, snoring and daytime sleepiness visited our hospital. He exhibited the characteristic appearances of long face and bilateral hypoplastic cheeks. Examination by flexible fiberscopy and computed tomography led us to diagnose him with bilateral choanal atresia. Subsequent polysomnography revealed the number of apnoea or hypopnoea episodes per hour (apnoea—hypopnoea index, or AHI) to be over 10. On the basis of these observations, we modified the diagnosis to obstructive sleep apnoea syndrome (OSAS) secondary to congenital choanal atresia.

Nasal continuous positive airway pressure (CPAP) is the mainstay of treatment for patients with moderate to severe obstructive sleep apnoea (OSA). However, tolerance and compliance are poor.

An audit using the Christchurch Hospital ORL surgery database identified patients who underwent upper airway surgery for OSA. Tracheostomy and bimaxillary advancement patients were excluded. Adults with moderate to severe OSA (Desaturation Index (DI) >10 n.h-1), who had failed atrial of nasal CPAP, and had pre-operative and post-operative sleep study data were identified. Objective (DI) and Subjective (Epworth Sleepiness Score (ESS)) outcome measures were recorded.

The database identified 69 patients who underwent surgery for snoring or OSA; of these, 25 patients formed the study group. Sixteen out of 25 improved (64 per cent) after surgery, seven out of 25 showed no change (28 per cent), two patients (eight per cent) showed deterioration in their DI. Forty-eight per cent of patients had >50 per cent post-operative improvement in DI. Fourteen out of 25 (56 per cent) had a post-operative DI <20 n.h-1. Seven out of 25 (28 per cent) had a post-operative DI <10 n.h-1. Upper airway surgery has a role in the managementof selected patients with OSA who cannot tolerate nasal CPAP.

As a result of a previous audit on the management of sleep apnoea hypopnoea syndrome (SAHS) which showed long waiting times that were primarily due to unnecessary interspecialty referrals, a change in practice was adopted. All referrals are now sent a questionnaire about symptoms suggestive of SAHS, the Epworth Sleepiness Scale score and their body mass index (BMI) which when returned are categorized into having a high, intermediate or low risk of SAHS. Those patients with a high probability have home overnight oximetry and those with intermediate probability have video oximetry. Those with a low probability are referred directly to ENT. We audited the first 100 patients referred. All were General Practitioner referrals to either ENT or respiratory medicine. Only two patients had a low probability score and were seen directly in ENT. Following sleep study analysis, 10 patients were referred directly to ENT with no respiratory medicine follow-up and nine were discharged back to the General Practitioner with no apnoea or snoring. Eighty-one patients were followed up by respiratory medicine. Of these, 49 received a trial of nasal continuous positive airway pressure (nCPAP) and six were referred to ENT. Therefore the majority justified an investigation to exclude SAHS in the first instance and an unnecessary initial ENT appointment was avoided. We have reduced the average waiting times to sleep study by approximately 90 days and to nCPAP trial by 32 days, mostly due to decreased delays in interspecialty referrrals. We have also demonstrated a greater than 50 per cent reduction in ENT clinic visits, a small increase in the number of sleep studies but no increase in respiratory clinic workload.

A case is presented of a neonate with Hirschsprung's disease, associated with congenital central hypoventilation syndrome. After an ileostomy (at 2 days) and a stoma revision (at 10 days), postoperative pain management was established by continuous intravenous infusion of morphine, which caused severe postoperative respiratory depression. At 6 weeks a reexploration and stoma revision was performed using postoperative epidural analgesia with bupivacaine. This caused no respiratory depression. A colectomy under epidural analgesia at 8 months was also uneventful. Respiratory difficulties in children with congenital central hypoventilation syndrome associated with Hirschsprung's disease are discussed in relation to the technique of choice for postoperative pain management.

Nasal continuous positive airway pressure (nCPAP) is now the treatment of choice for patients with sleep apnoea syndrome. Side-effects and adverse reactions have been described in isolated reports with this device. We have, therefore, systematically studied the side-effects of nCPAP therapy in 300 consecutive patients referred to the London Chest Hospital Ventilatory Support Unit. Ninety-six per cent of patients complained of at least one side-effect resulting from the therapy, with 45 per cent complaining of a side-effect specific to the nasal mask. There was no correlation between the side-effects and level of pressure used during nCPAP. The rate of compliance remained high in spite of the side-effects, with a daily use of 7.8 hours (SD 8.05) and with 83 per cent of the patients using the device every night. Although nCPAP treatment remains acceptable to most patients there exists a high incidence of adverse effects.

This paper presents the long-term effect of restricted surgery for snoring and sleep apnoea. Patients with obstructive sleep apnoea (OSAS) (19) or heavy snoring (HS) (36) were studied prospectively for five to seven years after uvulopalatopharyngoplasty without tonsillectomy performed by regular surgical technique using local anaesthesia (LUPP). Five years after surgery, 90 per cent answered a questionnaire. All OSAS patients were offered a polysomnography, and the HS patients were offered a sleep study. Eighty per cent still showed a positive effect on daytime somnolence, and 77 per cent on snoring. Sideeffects were reported by 40 per cent; most common was choking (20 per cent) the first year. Eighteen per cent had local problems such as globus sensation. The polysomnography showed that 80 per cent were still ‘responders’ with an apnoea index (AI) reduction of >50 per cent. None of the HS patients had developed OSAS. In conclusion, LUPP in selected patients with OSAS or HS has a good long-term effect. Sideeffects are common, but diminish with time.

Obstructive sleep apnoea syndrome (OSAS) is caused by obstruction or narrowing of the airway at various levels. The repair of one site only will not alleviate the syndrome if there are obstructions in other sites. Epiglottis prolapse during inspiration is an unusual cause of airway obstruction and a rare cause of OSA.

Twelve cases of OSAS due to an abnormal epiglottis are presented. We present our approach to the diagnosis using fibre-optic examination of the hypopharynx, and our treatment using endoscopic carbon dioxide laser partial epiglottidectomy.

We found in our series that in 11.5 per cent of patients who failed the uvulopalatopharyngoplasty procedure, the reason was a narrow airway at the hypopharyngeal level caused by an abnormal epiglottis. It is our suggestion that in these cases a laser partial epiglottidectomy should be performed. The results of this study show that partial epiglottidectomy can increase the cure rate of patients with obstructive sleep apnoea syndrome by 10–15 per cent.

A questionnaire was sent to consultant Otolaryngologists (483) throughout the UK to identify any mortality associated with uvulopalatoplasty and other forms of palatoplasties for snoring and/or obstructive sleep apnoea. The response rate was 76.8 per cent (371). Six intra- and post-operative deaths were reported and four were known to have obstructive sleep apnoea. Life-threatening morbidity occurred in at least seven patients (three known apnoeic), two required immediate tracheostomy and two were managed in the intensive care unit. This suggests that the apnoeic patients undergoing palatoplasties experienced significant mortality and morbidity. Pre-operative sleep study should be performed in all snoring patients to identify the apnoeic subgroup. Continuous positive airway pressure, management of excessive obesity, elective tracheostomy and other strategies should be first considered before palatoplasties in these patients.

We present a case of obstructive sleep apnoea in a child that is caused by papillomatosis of the post-nasal space.

The case of an elderly male with Shy-Drager syndrome is presented. His presentation to the Sleep Clinic for assessment of snoring illustrates bilateral abductor vocal fold palsy as a rare presentation of the syndrome. This case emphasizes the need for thorough investigation of all patients with sleep-related breathing disorders with video and sound recordings prior to anaesthesia and surgery.