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Acknowledgements to reviewers

Snoring must be the most subjective of symptoms that otolaryngologists have to manage. In the absence of apnoea, it is the patient’s sleeping partner that is affected unless the bedroom door is left open or the walls are not acoustically insulated. Intervention is almost always centred on the snorer rather than the partner, trying to reduce the frequency or loudness of the snoring. So if one wishes to assess the technical effect of such interventions, objective snoring measures should be used and hopefully these will be translated to improvement in the partner’s report of the snoring. It is therefore surprising that in the Health Technology Assessment systematic review, (whose abstract and Executive Summary is reproduced on pages 240 to 244) none of the 25 studies that investigated surgical intervention (including uvulopalatoplasties, radiofrequency ablation and palatal stiffening) reported objective outcomes. Such surgery usually improved subjective outcomes in this short-term but these lessened with time. The benefit could be entirely due to an expectation effect of surgery but this cannot be investigated because of the lack of objective measures in these studies. On the other hand in the three studies that looked at mandibular advancement splints and continuous positive airway pressure, objective snoring outcomes improved. Unfortunately, of the three studies reported subjective measures something that must be done in future studies on these mechanical devices. However in the meantime, mechanical means have been shown to be of technical benefit, are considerably cheaper at ~£200 than surgery as well as being reversible. As such in patients they should be perhaps tried first and persisted with to overcome initial discomfort before surgical intervention is even contemplated.