Introduction

Snoring is noisy breathing caused by vibration of relaxed soft tissues of the nose, soft palate or pharynx whilst sleeping or drowsy.

• It affects up to 40% of the UK population.^[1]
• It is more common in men although evidence suggests that the condition in women is under-reported.^[2]
• A Swedish study found that pregnant women who snore habitually have a higher risk of hypertension, pre-eclampsia and intrauterine growth restriction and that low Apgar scores were more common in their babies.^[2]
• Obstructive sleep apnoea (OSA) occurs in 1% of people who snore: there is total upper airway collapse, with cessation of airflow for at least 10 seconds, occurring >5 times per hour.^[3] There is a separate article discussing Obstructive Sleep Apnoea.
• The snoring sound can be generated at one or more levels:
  • In the nose.
  • At the level of the soft palate and uvula.
  • At the level of the pharyngeal wall and tonsils.
  • At the base of the tongue.

History

Cover the following questions:

• Duration of snoring?
• Frequency - is it every night?
• Is snoring more likely in any particular position? (For most people it is worse when they sleep on their back.)
• Any precipitants/modifiable factors - alcohol, sedatives, a recent increase in weight?
• Any history of nasal problems/obstruction?
• Does it disturb the patient's sleep?
• Does it disturb the partner's sleep? What are the relationship effects?
• Has the partner noticed any apnoeic episodes?
• Is there daytime somnolence? When using the Epworth Sleepiness Scale^[4] a figure of 10 of more is considered sleepy.^[2]
• Are there any other symptoms suggestive of obstructive sleep apnoea (OSA), including early morning headaches, choking episodes during sleep, accidents, inability to concentrate, and irritability?

Examination

• Calculate body mass index (BMI): 50% of people with obstructive sleep apnoea (OSA) have a BMI >30.^[1]
• Record collar size: neck circumference >43 cm correlates with snoring and OSA.^[1]
• Perform a good general examination: cardiovascular system, respiratory system, and thyroid.
• Is the site of obstruction apparent: nasal (eg polyps, septal deviation), tongue, tonsils and oropharynx, mandible (retrognathia)?

Investigations

• Arrange sleep studies (polysomnography) if obstructive sleep apnoea (OSA) is suspected, especially if surgery is contemplated for snoring (see under 'Management', below) as palatal surgery may reduce the options for OSA treatment.
• Nasendoscopy (awake, sedated and/or asleep) or acoustic analysis of the snoring usually helps to clarify the level of obstruction. It can exclude upper airway tumours and cysts as a rare cause.^[5]
• Perform thyroid function tests if hypothyroidism is suspected.
• The British Snoring & Sleep Apnoea Association has devised some 'snore tests' to identify the cause of snoring. See Document reference below which includes these tests.^[6]

Management

Nonsurgical

• Encourage weight loss as appropriate.
• Lifestyle advice: more exercise, less alcohol, fewer sedatives, stop smoking.
• Posture adjustment and sleep position training: for example, a tennis ball taped to the patient's back to stop him or her rolling on to the back. Bed wedges and pillows may also help.
• Earplugs for the partner.^[7]
• Decongestants and steroid nasal sprays can help nasal congestion.
• Devices that splay the nasal alae may help nasal obstruction.^[8]
• Oral appliances can advance the soft palate, tongue or mandible and therefore open the airway.^[8] Mandibular advancement devices may help if snoring is generated from the tongue base or in mouth breathers. These are best fitted by a dentist but choice of device and adequate training of dentists is important for this form of treatment to be effective.^[9]
• Continuous positive airway pressure (CPAP) often works well in most circumstances but may not be readily available for those without obstructive sleep apnoea (OSA).
• Patients with OSA who drive should inform the DVLA. Full details, including a link to the DVLA guidelines, are available from the separate Obstructive Sleep Apnoea article.

Surgical

Those with normal anatomy and near normal BMI do best. The procedure performed depends on the level of obstruction:

• Nasal surgery.
  • Septoplasty.
  • Polypectomy.
  • Turbinate reduction.
  • Sometimes the above procedures are carried out in combination.
• Palatal surgery ± tonsillectomy
  • Uvelopalatopharyngoplasty (UPPP): involves tonsillectomy, reorientation of the anterior and posterior tonsillar pillars and excision of the uvula and posterior rim of the soft palate.^[10]
  • Laser-assisted uvulopalatoplasty (LAUP): benefits may wane with time. 55% showed long-term benefit in one study.^[11]
  • Radiofrequency electrosurgery: radiofrequency ablation (delivered using an electrode) reduces volume of palatal tissue and makes the remaining palate more dynamically stable. It is an outpatient procedure. National Institute for Health and Clinical Excellence (NICE) guidance in 2005 noted lack of evidence of short-term efficacy and long-term outcomes and suggests that, if used, there should be arrangements for audit, consent and research.^[12] One series following up 29 patients concluded that the procedure produced long-term benefits in one in four patients and that patient selection may be improved by prior electromyography of the palatoglossus muscle.^[13]
  • Soft palate implants: implants are inserted to the soft palate under local anaesthetic with the aim of stiffening the soft palate over weeks, due to fibrosis. NICE guidance in 2007 suggests that this procedure should only be carried out in context of research, due to lack of well controlled evidence.^[14] One series of 21 patients concluded that the procedure was a safe and easy one which resulted in a high degree of patient satisfaction.^[15]
• Tongue base procedures.
  • Tongue base reduction (laser).
  • Mandibular advancement and osteotomy.
• Other points:
  • Uvulectomy may help patients with a large uvula.
  • Tracheostomy is occasionally performed in extreme cases.
  • Tonsillectomy with adenoidectomy may be helpful in children.
  • Surgery is contra-indicated in patients with both snoring and obstructive sleep apnoea, except nasal surgery to facilitate continuous positive airway pressure.