Snoring

• 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.
• 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.² 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

Cover the following questions:

• Duration of snoring?
• Frequency - every night?
• Is snoring more likely in any particular position (for most people it is worse when they sleep on back)?
• Any precipitants/modifiable factors - alcohol, sedatives, recent increase in weight?
• Any history of nasal problems/obstruction?
• Does it disturb the patient's sleep?
• Does it disturb the partner's sleep? Relationship effects?
• Has partner noticed any apnoeic episodes?
• Is there daytime somnolence? Use Epworth Sleepiness Scale (see separate article) - a figure of 10 of more is considered sleepy.³
• Are there any other symptoms suggestive of obstructive sleep apnoea including early morning headaches, choking episodes during sleep, accidents, inability to concentrate, irritability?

• Calculate body mass index (BMI): 50% of people with OSA have BMI > 30¹
• Record collar size: neck circumference > 43cm correlates with snoring and OSA¹
• Perform a good general examination: CVS, respiratory, thyroid
• Is the site of obstruction apparent: nasal (e.g. polyps, septal deviation), tongue, tonsils and oropharynx, mandible (retrognathia)?

• Arrange sleep studies (polysomnography) if OSA suspected, especially if surgery is contemplated for snoring (see 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 clarify level of obstruction. It can exclude upper airway tumours and cysts as a rare cause.⁴
• Perform thyroid function tests if hypothyroidism suspected.
• The British Snoring and Sleep Apnoea Association has devised some 'snore tests' to identify the cause of snoring. They can be referenced using the link below.

Non-surgical

• Encourage weight loss as appropriate.
• Lifestyle advice: more exercise, less alcohol, less sedatives, stop smoking.
• Posture adjustment and sleep position training: e.g. tennis ball taped to back to stop patient rolling onto back. Bed wedges and pillows may also help.
• Ear plugs for partner.⁵
• Decongestants and steroid nasal sprays can help nasal congestion.
• Devices that splay the nasal alae may help nasal obstruction.⁶
• Oral appliances can advance the soft palate, tongue or mandible and therefore open the airway.⁶ Mandibular advancement devices may help if snoring is generated from tongue base or in mouth breathers (best fitted by dentist).
• Continuous positive airway pressure (CPAP) often works well in most circumstances but may not be readily available for those without OSA.

Surgery

Those with normal anatomy and near normal BMI do best. Procedure performed depends on 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.⁷
  • Laser-assisted uvulopalatoplasty (LAUP): benefits may wane with time. 55% showed long-term benefit in one study.⁸
  • Radiofrequency electrosurgery: radiofrequency ablation (delivered using an electrode) reduces volume of palatal tissue and makes remaining palate more dynamically stable. Outpatient procedure. 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.⁹
  • Soft palate implants: implants are inserted to soft palate under local anaesthetic with aim to stiffen 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.¹⁰
• 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 contraindicated in patients with both snoring and OSA, except nasal surgery to facilitate CPAP.