This study examines the benefit of an operation that targets the lateral pharyngeal wall. The double suspension sutures are, in essence, a suture through the palatopharyngeus muscle which is then tied around the hamulus in the retro molar area. This has the effect of preventing the lateral pharyngeal wall from collapsing medially, whilst also dragging the palate anteriorly, thereby increasing the retropalatal distance. The technique relies on scar tissue to hold the structures in this position long term, and it is not clear from this article how the authors decided to achieve this. The anterior palataoplasty was modified by not removing the uvula and, typically, this is considered a snoring operation unless the patient has an unduly long palate which is interfering with the retroglossal space. To my mind, the two major limitations of this study are that the effect of tonsillectomy was not controlled for, and there was only a six-month follow-up with polysomnography. The literature is very clear about the beneficial effect of tonsillectomy on obstructive sleep apnoea. Patients with grade 3 or 4 tonsils are likely to have a greater than 85% chance of success from a simple tonsillectomy. Of the 29 patients included in this study, 17 required a tonsillectomy, but there was no sub-cohort analysis for this group. Even so, the results at six months are rather good: mean AHI dropped significantly (p < 0.0001, t = 17.5024) from a mean of 28.6 ± 5.5 preoperatively to 8.3 ± 2.96 postoperatively. The improvements in Epworth score (14.5 ± 2.4 reduced to 3.4 ± 1), and a visual analogue score for satisfaction (7.9 ± 1.3 reduced to 1.9 ± 1.2), were also impressive. These values are similar to, if not better than, the improvement seen with the use of CPAP when total sleep time is factored into the calculation. The authors make the point that this technique requires no specialist equipment or specific training to perform (it is, in essence, an advanced tonsillectomy), and would therefore benefit financially restricted healthcare systems. There should have been a sub-cohort analysis, but this is useful data and adds favourably to the sleep surgery literature.

Modified anterior palatoplasty and double suspension sutures (with or without tonsillectomy) in selected patients with obstructive sleep apnea: a preliminary report.
Askar S, El-Anwar M, Awad A.
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Vik Veer

Royal National Throat, Nose & Ear Hospital and Queens Hospital, Romford, UK.

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