Snoring

Primary snoring is snoring that is not accompanied by awakening or excessive arousals, limitation of airflow, oxygen desaturation, or arrhythmias during sleep and that occurs in people who do not have excessive daytime sleepiness. Arousals are brief transitions to lighter sleep or awakenings that last < 15 seconds and are usually not noticed.

Snoring is usually a symptom of sleep-disordered breathing, which covers a spectrum ranging from upper airway resistance syndrome to obstructive sleep apnea Obstructive Sleep Apnea Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more (OSA). Each has similar upper airway obstructive pathophysiology but differs in degree and clinical consequences of the airway obstruction. The clinical consequences involve mainly disturbances of sleep and/or airflow.

Patients with obstructive sleep apnea have ≥ 5 episodes of apnea or hypopnea (with each episode lasting at least 10 seconds) per hour during sleep (apnea/hypopnea index [AHI]) plus ≥ 1 of the following:

Obstructive sleep apnea can be categorized by severity:

Upper airway resistance syndrome (airflow limitation secondary to increased upper airway resistance or respiratory effort–related arousals [RERAs]) can cause excessive daytime sleepiness or other manifestations suggesting obstructive sleep apnea but with few episodes of apnea/hypopnea or oxygen desaturation and thus does not meet full criteria for obstructive sleep apnea.

Although snoring itself has no known adverse physiologic effects, obstructive sleep apnea may have consequences (eg, hypertension, stroke, heart disorders, diabetes).

Risk factors for snoring include

There may also be familial risk.

History of present illness should cover severity of snoring, including its frequency, duration, and loudness. Also, the degree that snoring affects the bed partner should be noted.

Review of systems should seek symptoms suggesting obstructive sleep apnea, such as the presence of sleep disturbance as indicated by

The Epworth Sleepiness Scale can be used to quantify daytime sleepiness. The STOP-BANG score (see table STOP-BANG Risk Score for Obstructive Sleep Apnea STOP-BANG Risk Score for Obstructive Sleep Apnea ) is a useful tool to predict risk of OSA for patients who snore.

Past medical history should note presence of disorders that may be associated with OSA, particularly hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more , coronary ischemia, heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more , stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more , gastroesophageal reflux disease Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more (GERD), atrial fibrillation Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more , depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , obesity Obesity Obesity is excess body weight, defined as a body mass index (BMI) of ≥ 30 kg/m². Complications include cardiovascular disorders (particularly in people with excess abdominal fat)... read more (especially morbid obesity), and diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more . Patients are asked how much alcohol they consume and when it is consumed in relation to bedtime. Drug history may identify sedating or muscle-relaxing drugs.

Examination should begin by measuring height and weight, with calculation of body mass index (BMI).

The rest of the examination should focus on inspecting the nose and mouth for evidence of obstruction. Signs include

A modified Mallampati score of 3 or 4 (only the base or none of the uvula is visible during oral inspection—see figure Mallampati scoring Modified Mallampati scoring ) suggests increased risk of OSA.

The following findings are of particular concern:

The clinical evaluation is not completely reliable for diagnosis of obstructive sleep apnea but can be suggestive. Red flag findings clearly correlate with OSA. However, all of these findings occur along a continuum, and there is no widespread agreement on cut-off points and relative weighting. Nonetheless, the more red flag findings a patient has and the more severe they are, the greater the likelihood of OSA.

Testing is done when a diagnosis of obstructive sleep apnea is suspected; it consists of polysomnography Testing (in a laboratory or at home). Polysomnography should be done when clinical suspicion for OSA is significant. Patients who should be tested include those who have red flag findings (particularly witnessed apnea), including those whose test scores (eg, STOP-BANG risk score for OSA) are not quite high enough for a diagnosis of OSA. However, because snoring is so common, polysomnography, particularly home testing, which is not as expensive, can be used more liberally and should be considered when clinical suspicion for OSA is lower.

People with no symptoms or signs of sleep disturbance other than snoring may not need to be tested but should be clinically monitored for development of such manifestations.

Several general measures can be used for primary snoring. Their efficacy has not been well-evaluated, primarily because perception of snoring is highly subjective; However, particular patients may benefit. Measures include

Bed partners may benefit from using earplugs or white-noise machines. Sometimes alternate sleeping arrangements (eg, separate rooms) are necessary.

Oral appliances are worn only during sleep; they include

These appliances should be fitted by specially trained dentists. They are helpful for patients with OSA and are generally regarded as effective for simple snoring, although studies in this area are scant.

Adverse effects include temporomandibular joint (TMJ) discomfort, dental misalignment, and excessive salivation, but most patients tolerate the devices well.

Mandibular advancement devices are most commonly used. These devices move the mandible and tongue forward relative to the maxilla and thus increase airway caliber during sleep. These devices can be adjusted incrementally after the initial fitting to optimize results.

Tongue-retaining devices use suction to maintain the tongue in an anterior position. Tongue-retaining devices are more uncomfortable than mandibular advancement devices.

A recently developed, removable tongue muscle stimulator is designed to be used during the day and to improve tongue muscle function in patients with snoring or OSA. However, more data are needed to confirm effectiveness.

CPAP devices Treatment Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more maintain a constant positive pressure in the upper airway via a small mask applied to the nose or nose and mouth. By increasing the caliber of the upper airway, CPAP prevents narrowing or collapse of the upper airway during sleep. It thus is very effective for OSA and is effective for primary snoring. However, patients may have difficulty tolerating CPAP, and its use in primary snoring is limited because third-party reimbursement for this use is lacking. Although patients are often willing to use a CPAP device nightly to avoid the significant symptoms and long-term consequences of OSA, they are less willing to use the device to manage primary snoring, whose consequences are primarily social.

Because reduced nasal patency promotes snoring, surgically correcting specific causes of airway compromise (eg, nasal polyps, hypertrophied tonsils, deviated septum) may be a reasonable way to decrease snoring. However, studies have not yet substantiated this theory.

Various pharyngeal surgical procedures that alter the structure of the palate and sometimes the uvula have been developed for obstructive sleep apnea. Some are also useful for nonapneic snoring.

Uvulopalatopharyngoplasty involves remodeling the uvula, palate, and pharyngeal walls to increase the size of the airway. It can be effective for snoring, although effects may not last beyond a few years. It is an inpatient procedure requiring general anesthesia; thus, its usefulness for snoring alone is limited.

Therefore, a number of outpatient palate-altering procedures requiring only a local anesthetic have been developed: