A collapsible airway is often the common denominator in sleep-disordered breathing (SDB). The upper respiratory tract includes the nasal passage, nasopharynx, oral cavity, oropharynx, base-of-tongue region and the hypopharynx. It is believed that the highest amount of resistance in the upper respiratory tract is in the nasal cavities, and particularly the nasal valve. Most authors believe that when considering surgical options for patients with obstructive sleep apnoea (OSA) it is imperative to correct nasal pathology together with the other sites of airway obstruction. In this retrospective study, I sought to investigate the safety and efficacy of one-stage nasal and multi-level pharyngeal surgery. I compared two groups of patients: group 1, receiving one-stage nasal and multi-level pharyngeal surgery; and group 2, receiving only multi-level pharyngeal surgery. In group 1, nine out of 12 patients (75 per cent) met the criteria for surgical success, with a mean pre-operative apnoea-hypopnoea index (AHI) decreasing from 36.3 to 8.9 post-operatively (p<0.0002), while in group 2, 25 out of 40 patients met the surgical success criteria (62.5 per cent), with their mean AHI decreasing from 52.6 to 10.2 (p<0.0000). When comparing the surgical success rates between the two groups, it was not statistically significant, at p>0.106. There were no postoperative respiratory-related complications despite having bilateral nasal Merocel (tampon) packing in place (in group 1), and none of the patients in either group had any desaturation, hypoxaemia, apnoea or OSA-related complications. This series suggests that, with adequate post-operative monitoring, it is both safe and efficacious to perform both nasal and multi-level pharyngeal surgery in the one surgical session.

Mandibular advancement prosthesis (MAP) is infrequently used in the UK at present for snoring. First-line measures include dietary and weight modification for those that require it. Where such measures are unlikely to be useful or have already failed, surgery is sometimes utilized as a second-line treatment modality. We evaluate the use of MAP as an adjunct to first-line measures, with emphasis on efficacy, side-effects and patient compliance. Case notes of 30 snorers were reviewed and followed up with a questionnaire. Despite being useful in alleviating snoring, the prosthesis was poorly tolerated. Side-effects include increased salivation, temporomandibular joint pain, intra-oral and myofacial discomfort. Patients who persevered with the prosthesis found the early side-effects resolved after a few weeks and snoring reduced. MAP can be used in the initial management of snorers but patients need to be educated and encouraged, especially in the first few weeks.

At 65 years of age, a former coal miner, now 72-years-old, developed a progressive loss of concentration with daytime sleepiness and sleep disturbances. Work-up in pneumological and medical sleep centres resulted in diagnosis of chronic obstructive pulmonary disease (COPD), borderline obstructive sleep apnoea syndrome and, later, upper airway resistance syndrome. In addition, there was evidence of reduced efficiency of sleep. Neither the initial administration of theophylline nor the later use at night of hyperbaric respiration led to improvement in the patient's symptoms. Instead, the patient developed loud snoring, as well as the inability to sleep while in a lying position.

At age 71 years, otorhinolaryngological examination resulted in findings of age-related changes in the epiglottis, that completely blocked the hypopharynx upon inspiration. Polysomnography, which was possible only in a half-seated position, revealed reduction in deep sleep, with a maximum oxygen saturation of 77 per cent at an apnoea-hypopnoea index (AHI) of 4.8.

Partial resection of the epiglottis with laser surgery resulted in complete improvement of diurnal drowsiness and reduced stamina. Sleeping in a supine position again became possible. Polysomnography revealed normalization of sleep architecture, but unchanged, low efficiency of sleep.

This case underscores the importance of an interdisciplinary approach to the treatment of sleep-related breathing disorders.

We describe a case of lingual thyroid (LT) with primary hypothyroidism, presenting during pregnancy and continuing beyond it with oropharyngeal obstructive symptoms and sleep apnoea syndrome (SAS) of mixed type. Although SAS of a combined obstructive and central type should not be too surprising in a case of LT with hypothyroidism, we were unable to find such a documentation previously. Only four weeks of L-thyroxin treatment resulted in a dramatic improvement in dysphagia, disturbed phonation, haemoptysis, arterial desaturation, sleep apnoea and overall sleep efficiency, in conjunction with a regression in the size of the lingual mass. This case highlights the vagaries confronted in the management of such a case and focuses on efforts towards accurate diagnosis and treatment.

A surgical cure for adult obstructive sleep apnoea syndrome (OSAS) is an attractive alternative to nasal continuous positive airway pressure, but current research suggests that uvulopalatopharyngoplasty is not effective in all patients. No subgroup of these patients, who might benefit from surgery to the oropharynx, has as yet been identified. In this study we examined the results of tonsillectomy either as an isolated procedure or as part of uvulopalatopharyngoplasty in seven patients, who had tonsillomegaly. In all seven there was a short-term improvement between the pre-operative and post-operative apnoea/hypoapnoea (A/H) index (100-65 per cent), which could not be accounted for by change in the body mass index (BMI). In one patient a diagnosis of Non-Hodgkin's lymphoma was made from histological examination of the tonsils. The results suggest that adult patients with tonsillomegaly may represent a subgroup of patients with OSAS, who would benefit from surgery aimed at the oropharynx.