Aims. To evaluate thirteen years of hyoid suspension experience in multilevel OSAHS surgery, for which hyoidthyroidpexia represented the exclusive hypopharyngeal approach applied. Materials and Methods. From 1998 to 2011, a bicentric retrospective study was conducted: all adult patients with a diagnosis of OSAHS were enrolled. Specific eligible criteria were established. Pre-/postoperative data concerning ENT and sleep findings were recorded. Recruited subjects were surveilled for a follow-up range from 6 to 18 months. Results. A total of 590 hyoid suspensions were evaluated, but only 140 patients met the specific inclusion criteria. A success rate of 67% was obtained. No intraoperative adverse events or major complications occurred. Excessive daytime sleepiness was observed in 28% of nonresponders. Despite the homogeneous candidate anatomy, ENT awake findings changed differently after surgery. Statistical analysis revealed multilevel surgery to be more effective when AHI < 30. Postoperative AHI was statistically not influenced by preoperative BMI. Conclusions. Hyoid suspension in multilevel treatment is effective when short-term results are considered. The necessity of a more valuable anatomic-based diagnostic approach is crucial to guide the patient selection. Long-term followups and randomized prospective trials with case-control series are needed to increase the level of evidence of this surgery. 1. Introduction Sleep disordered breathing (SDB) surgery has taken its initial steps from the first tracheotomy  up to the pioneering applications of robotics in the new millennium . When Sher and colleagues published the unsatisfying results of surgery in patients with hypopharyngeal obstruction, they were probably still not aware that a great number of hypopharyngeal procedures would be developed . Despite the several techniques reported in the literature (e.g., surgical reduction of the tongue base, tongue base stabilization, genioglossus advancement, mortised genioplasty, tongue radiofrequency treatment, hyoepiglottoplasty, and hyoid suspension), many of them should be critically analyzed anyway because they are extremely invasive. The idea of restoring the retrolingual space acting on the hyoid bone was codified by Riley et al. in 1986 , but a few years before experimental attempts in animal models had already been demonstrated [5, 6]. Since then, hyoid suspension has been adopted by many authors finally turning into a stepping stone in SDB surgical management . We conducted a bicentric retrospective study to evaluate thirteen years of
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