Snoring

Overview

Snoring is estimated to affect up to 40% of the population, and patients commonly present to primary care, often encouraged by their bed partner.

The upper airway is made of either hard structures (such as the hard palate) or soft structures (like the back of the throat or the base of the tongue). Hard structures stay in place by themselves, but soft structures are held in place by muscles. As you sleep, these airway muscles relax causing the airway to narrow. This can cause turbulent airflow, which makes the soft structures vibrate (usually the soft palate and uvula), which we hear as snoring.

For some people it is simply due to the shape of their upper airway. Other anatomical factors include very large tonsils and a deviated nasal septum.

Risk factors include:

• Obesity, as more fat in the neck narrows the upper airway
• Smoking and allergies such as hayfever that causes inflammation and narrowing of the upper airway
• Alcohol and sedating medications that relax the upper airway muscles

New onset snoring may need investigation for an underlying cause.

Assessment

All patients who present with snoring should be assessed for symptoms of obstructive sleep apnoea.

Please see the Obstructive Sleep Apnoea (OSA) page for details and advice about when to refer.

Symptoms include:

• Episodes of stopping breathing during sleep (apnoeas)
• Gasping, choking or gagging during sleep
• Excessive daytime sleepiness (check Epworth Sleepiness Score)
• Morning headaches
• Poor concentration or memory problems
• STOP-BANG Score for Obstructive Sleep Apnea - MDCalc

You should examine the nose and upper airway to check for enlarged tonsils, nasal polyps and septal deviation.

Management

Initial advice will usually include lifestyle measures and simple management techniques

• Weight loss
• Smoking cessation
• Reduction in alcohol intake
• Advising patients to sleep on their side as the airway is narrower in the supine position (for example by sewing a tennis ball into the back of their pyjamas, or using a triangular pillow)

Medication

• Reducing sedating medications where possible
• Treating rhinitis with nasal steroids

Specific treatments

• Mouth snorers can find improvement with use of an elasticated chin strap that gently holds the mouth closed during sleep.  

• Nasal strips may help keep nasal passages open
• Mandibular advancement devices (oral appliances), which are also used as a treatment for mild to moderate OSA. The patient wears a gumshield over the top and bottom teeth that clips together and moves the lower jaw forward to open the airway. Patients can buy self-moulded devices or have them custom-made by a dentist. There usually needs to be good dentition.
• CPAP – if patients are diagnosed with OSA, then CPAP is also a highly effective treatment for snoring, although wouldn’t be indicated for simple snoring without OSA

http://www.sleeppro.com/ or here http://www.britishsnoring.co.uk/shop/mandibular_advancement_devices_MADs.php.

Surgery for Snoring

Surgery for Snoring is not routinely funded by the NHS unless there are exceptional circumstances. See the funding policy below:

• Snoring - Surgical Intervention for Simple Snoring - NHS BNSSG ICB

Snoring is always a tricky problem for which the ENT surgeons usually have little to offer.

Nasal obstruction rarely contributes significantly to snoring so fixing this rarely helps.

Most of the online evidence for surgery for snoring is for people with obstructive sleep apnoea - a Cochrane review in 2008 did not advocate its use. NICE [1] in January 2014 did publish their guidance on ablation of the uvula in which they also state evidence is poor.

A number of surgical treatments are available privately, with varying success:

• Laser-assisted uvulopalatoplasty (LAUP) to reduce tissue in the soft palate - Subject to the Uvula Removal Exceptional Funding Policy
• Somnoplasty – this uses radiofrequency ablation to shrink tissues around the soft palate and tongue
• Septoplasty straightens a deviated nasal septum - Subject to the Non Cosmetic Nasal Treatment Prior Approval Policy
• Tonsillectomy and adenoidectomy - Subject to the Tonsillectomy Policy - Adults with clinically diagnosed OSAHS can be referred via a Respiratory Consultant only

Resources

[1] NICE Guidance - Radiofrequency ablation of the soft palate for snoring

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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