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Snoring in adults

Snoring in adults
Author:
James A Rowley, MD
Section Editor:
M Safwan Badr, MD
Deputy Editor:
April F Eichler, MD, MPH
Literature review current through: Dec 2022. | This topic last updated: Apr 21, 2021.

INTRODUCTION — Snoring is a sound produced by vibration of the soft tissues of the upper airway during sleep. It usually occurs during inspiration, but can also occur during expiration. Habitual snoring is common, occurring in 44 percent of males and 28 percent of females who are between 30 and 60 years of age in the general population [1]. Occasional snoring is almost universal [2].

ASSOCIATED CONDITIONS — It is important to recognize the clinical features of conditions associated with snoring so that objective testing can be performed and treatment initiated, if indicated.

Obstructive sleep apnea (OSA) – Snoring is indicative of increased upper airway resistance and increased pharyngeal collapsibility. Snoring, particularly if loud and habitual, may indicate the presence of OSA, a sleep disorder characterized by obstructive apneas and hypopneas that occurs when upper airway resistance is sufficient to disrupt sleep. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)

Upper airway narrowing – Snoring can also be associated with conditions that narrow the upper airway, including obesity, nasal congestion, craniofacial abnormalities, hypothyroidism, acromegaly, and adenotonsillar hypertrophy. These conditions, in turn, may cause snoring without OSA, or snoring that occurs as a symptom of OSA.

PHYSIOLOGY — While the symptom of snoring is an acoustic phenomenon, the presence of snoring can indicate significant upper airway pathophysiology.

The anterior nasal valve is one of the airway segments with the smallest cross-sectional area, and it offers the greatest resistance to airflow during sleep (figure 1). Conditions that partially obstruct the already narrow airway (eg, allergic rhinitis, vasomotor rhinitis, anatomic factors) can further increase resistance and contribute to snoring. The negative pressure in the lower airways that is required to overcome high nasal resistance may promote partial or intermittent collapse of the pharynx, worsening snoring. A variety of interventions aim to improve nasal patency. (See 'Nasal patency' below.)

Snoring is also associated with upper airway narrowing, increased upper airway resistance, and pharyngeal collapsibility. (See "Pathophysiology of upper airway obstruction in obstructive sleep apnea in adults".)

At relatively low levels of upper airway resistance, there may be snoring without sleep disruption or symptoms of disturbed sleep.

As upper airway resistance increases, there is a compensatory increase in respiratory effort in order to maintain ventilation. The increased effort may be associated with transient arousals from sleep related to respiratory effort. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults", section on 'Respiratory effort-related arousals'.)

As upper airway resistance becomes more severe, obstructive apnea and hypopnea may occur, leading to more fragmented sleep, increased symptoms and signs of disrupted sleep, and oxyhemoglobin desaturation.

Although snoring is indicative of increased upper airway resistance, its absence does not exclude increased upper airway resistance or OSA. This is especially true among women and patients who have had a uvulopalatopharyngoplasty [3-6].

There is observational evidence that alcohol consumption is transiently associated with increased airway resistance and snoring [7-10]. The likely cause of the increased airway resistance during sleep is decreased tone in the pharyngeal dilator muscles [7].

It is not known why smoking is associated with snoring, but nightly nicotine withdrawal and nasal congestion have been proposed as etiologies.

NATURAL HISTORY — As snoring can be a marker of pathologic upper airway narrowing, progression of snoring to obstructive sleep apnea (OSA) is of clinical importance. While rates of progression have not been well studied prospectively, the available evidence suggests that progression is likely with weight gain. This was demonstrated by a retrospective cohort study of 160 middle-aged men with untreated snoring or OSA who were followed for a mean of five years [11]. The apnea-hypopnea index (AHI) increased with both weight gain and time in patients with untreated snoring, mild OSA, or moderate OSA. Weight gain had a seven-time larger effect on the AHI than time. A one-point gain in the body mass index over one year corresponded to an increase in the AHI of five events per hour.

POTENTIAL CONSEQUENCES — Early, large epidemiologic studies suggested that snoring may be related to hypertension, cardiovascular disease, and cerebrovascular disease [12-15]. However, these studies did not distinguish the effects of snoring from the effects of obstructive sleep apnea (OSA), which often coexists and is known to have cardiovascular and cerebrovascular consequences. (See "Obstructive sleep apnea and cardiovascular disease in adults" and "Sleep-related breathing disorders and stroke".)

This limitation was addressed in subsequent studies, which are described below. It now appears that snoring may be associated with carotid artery atherosclerosis, but there is little evidence to support an independent relationship between snoring and either hypertension or ischemic heart disease.

Carotid atherosclerosis – An observational study categorized 110 patients with nonhypoxemic OSA into three groups according to the proportion of the total sleep time spent snoring: mild snoring (≤25 percent), moderate snoring (26 to 50 percent), or heavy snoring (>50 percent) [16]. Heavy snoring was associated with carotid artery atherosclerosis, even after adjustment for known confounders (odds ratio 10.5, 95% CI 2.1-51.8). In addition, there was a dose-response gradient, with the prevalence of carotid atherosclerosis being 20, 32, and 64 percent among those with mild, moderate, and heavy snoring, respectively. The apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) were unrelated to the prevalence of carotid artery atherosclerosis. This study suggests that snoring alone may be associated with carotid atherosclerosis. It is postulated that the endothelial cells in the carotid artery walls are subject to direct vibratory damage from heavy snoring, thereby contributing to plaque formation.

A subsequent study reported the results of 501 patients who had undergone carotid artery duplex scanning at one of three vascular laboratories [17]. The patients were asked if they had snoring using the Snoring Outcomes Survey. After correction for other covariates such as hypertension, smoking, and heart disease, snorers had a 74 percent increased risk of having >50 percent carotid stenosis. After removing patients who reported having OSA or using CPAP, snoring was no longer a significant risk factor for carotid stenosis, though there was an increased risk for bilateral carotid stenosis. While confirming a relationship between snoring and carotid atherosclerosis, this study also suggests that OSA likely confounds the relationship between the two.

The relationship between snoring and arterial stiffness as measured using blood pressure waveform analysis has also been investigated. In a study of 1476 nonpharmacologically treated individuals in the Brisigella Heart Study, the main independent predictors of pulse wave velocity were self-reported snoring, self-reported snoring with apnea, age, and mean arterial pressure [18]. This study corroborates the findings of the carotid studies.  

Hypertension – In an observational study, 1415 individuals who were referred to a sleep disorders center underwent polysomnography and blood pressure measurement [19]. Among individuals without OSA, hypertension was equally likely among heavy snorers and non-snorers (20 versus 18 percent for non-snorers) [19]. This study suggests that snoring alone is not associated with an increased risk of systemic arterial hypertension.

Ischemic heart disease – In an observational study of 5338 adults without known cardiovascular disease, self-reported habitual snoring, in the absence of a physician diagnosis of sleep apnea, was not associated with an increased risk of incident cardiovascular event and death rates compared with non-snoring over a median follow-up of 7.5 years [20]. This study, along with smaller observational studies, suggests that snoring alone is not independently associated with ischemic heart disease or all-cause mortality [21,22].

Disruption of the bed partner's sleep may also be a significant problem that can cause the bed partner to have daytime sleepiness and marital dissatisfaction [23-25].

EVALUATION — The primary purpose of evaluating patients who snore is to identify potential causes of increased upper airway resistance, particularly obstructive sleep apnea (OSA). In the Wisconsin Sleep Cohort, 34 percent of men with habitual snoring and 19 percent of women with habitual snoring met the minimum diagnostic criteria for OSA [1]. Other potential etiologies that should be considered include nasal congestion, adenotonsillar hypertrophy, craniofacial abnormalities, and obesity.

History — It is useful to include the bed partner or a family member when evaluating a patient who snores because they may have greater insight into the problem than the patient. The patient, bed partner, and/or family member should be asked about symptoms or signs of OSA, including frequency and intensity of snoring, episodes of breathing cessation, periods of silence terminated by loud resuscitative snoring, restless sleep, and awakening with a sensation of choking, gasping, or smothering (table 1). Excessive daytime sleepiness may exist, but it is often unnoticed or underestimated because of its insidious onset and chronicity. Moodiness, poor concentration, and morning headaches may also be present. The clinical features of OSA are discussed in greater detail separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)

Symptoms and signs of conditions associated with increased upper airway resistance other than OSA should also be sought. Nasal congestion or a history of allergies, sinusitis, or sinus surgery may warrant further investigation, since inadequately treated nasal or sinus disease is a potential cause of snoring [26]. Frequent sore throats or mouth breathing may indicate adenotonsillar hypertrophy, especially among young patients. Fatigue, weight gain, cold intolerance, and constipation may be due to hypothyroidism. Craniofacial abnormalities and acromegaly are generally suspected on the basis of physical examination findings, rather than symptoms. (See "An overview of rhinitis" and "Clinical manifestations of hypothyroidism" and "Causes and clinical manifestations of acromegaly".)

The history should also cover sleep position, sleep deprivation, habits, and medication use that will have a bearing on snoring. Habits associated with snoring include smoking and alcohol use [7-10,27,28]. Benzodiazepine use has been demonstrated to cause snoring and increased upper airway resistance in healthy volunteers [29,30].

Physical examination — The patient should be examined for physical signs associated with OSA, including truncal obesity, a large neck circumference, and a crowded oropharynx (picture 1A-B). Physical findings associated with OSA are described in more detail separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Physical examination' and "Obstructive sleep apnea and cardiovascular disease in adults".)

Clinicians should also look for physical findings suggestive of other causes of snoring. Obesity, craniofacial abnormalities, nasoseptal deviation, adenotonsillar hypertrophy, and nasal polyps may be obvious. Patients with nasal congestion may have nasal turbinates that appear boggy and edematous. The mucosal tissue is often erythematous, or may have a pale bluish hue or pallor. The mucosa can also appear relatively normal. (See "Nasal obstruction: Diagnosis and management", section on 'Diagnosis'.)

Patients with acromegaly may manifest acral, articular, and soft tissue overgrowth, while patients with hypothyroidism may have delayed relaxation of deep tendon reflexes, bradycardia, coarse hair and skin, puffy facies, enlargement of the tongue, and hoarseness. (See "An overview of rhinitis" and "Clinical manifestations of hypothyroidism" and "Causes and clinical manifestations of acromegaly".)

Diagnostic testing — The primary purpose of diagnostic testing in a patient who snores is to confirm or exclude the presence of OSA, since OSA is associated with significant clinical consequences and requires long-term therapy. Further testing for OSA should be considered in patients with loud habitual snoring and witnessed apneas in association with excessive daytime sleepiness, obesity, heart disease, and the presence of suggestive craniofacial features. Screening tools such as the Berlin questionnaire (table 2 and table 3) or STOP-Bang questionnaire (table 4) can indicate a higher likelihood of OSA and the need for either in-laboratory polysomnography or home sleep apnea testing [31-33]. An approach for determining which patients are sufficiently likely to have OSA to warrant such diagnostic testing is described separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Diagnostic evaluation'.)

Diagnostic testing for suspected craniofacial abnormalities or adenotonsillar hypertrophy may include lateral cephalometric radiographs to provide information about the patency of the patient's upper airway. This is generally performed along with otolaryngology consultation. Factors that should prompt referral include a structural abnormality causing obstruction, cranial nerve dysfunction, severe epistaxis, or a mucosal abnormality that has been refractory to a trial of nasal inhaled glucocorticoid medication. (See "Nasal obstruction: Diagnosis and management", section on 'Referral'.)

Metabolic testing is indicated for suspected acromegaly or hypothyroidism, as described separately. (See "Diagnosis of and screening for hypothyroidism in nonpregnant adults" and "Diagnosis of acromegaly".)

TREATMENT

Indications — In the absence of obstructive sleep apnea (OSA), treatment of snoring is indicated for patients who want to minimize disruption to their bed partner's sleep or to relieve themselves of any embarrassment caused by the snoring (algorithm 1).

Routine treatment cannot be justified at this time to improve daytime symptoms, hypertension, or risk of ischemic heart disease because these findings do not appear to be more common among snorers than non-snorers [22,34]. There is evidence that snoring may contribute to carotid artery atherosclerosis; however, this needs to be confirmed before treatment is suggested for the purpose of preventing carotid disease. (See 'Potential consequences' above.)

Conservative approaches

Weight loss — Weight loss is recommended for patients with obesity who snore since it may improve snoring and has additional health benefits. (See "Obesity in adults: Overview of management", section on 'Importance of weight loss'.)

While most patients who lose weight will have a reduction in snoring frequency, improvement is not universal and cannot be predicted [35]. Additional support for the concept that weight loss reduces snoring comes from the observation that weight loss improves OSA [36,37]. Since OSA and snoring are both due to increased upper airway resistance, any intervention that improves one can reasonably be expected to improve the other. (See "Management of obstructive sleep apnea in adults", section on 'Weight loss and exercise'.)

Avoidance of tobacco and alcohol — Smoking cessation is recommended for all patients. Elimination of alcohol consumption, especially during the several hours prior to bedtime, is recommended for patients who snore. Both interventions may reduce snoring and have numerous other potential health benefits. (See "Benefits and consequences of smoking cessation", section on 'Benefits of smoking cessation'.)

The effect of smoking cessation on snoring has not been tested in randomized trials or observational studies. There is observational evidence that current smoking, and possibly former smoking [27,28], is associated with snoring.

The impact of reducing or eliminating alcohol consumption on snoring has not been evaluated in randomized trials or observational studies.

Sleep position — Sleeping in the lateral position is a low-risk intervention that warrants a trial in most patients who snore, although the evidence that this approach durably improves snoring is limited and inconsistent [38-40].

A number of devices have been developed to reduce the likelihood of sleeping in the supine position, including posture alarms, special pillows, and modified nightshirts. A simple device that can be made at home is a snug-fitting T-shirt with a pocket sewn over the spine and tennis balls placed in the pocket. Patients with obesity may benefit from a harder type of ball, such as a baseball. The discomfort associated with rolling into the supine position is generally enough to prompt the patient to roll back into the lateral position without awakening.

One trial compared a head positioning pillow with a normal pillow in patients with mild, supine-dependent OSA (supine apnea-hypopnea index [AHI] more than double the lateral position AHI) [41]. The head positioning pillow was designed to help maintain airway patency in both the supine and lateral positions. Compared with a normal pillow, the head positioning pillow was associated with significant reductions in subjective snoring intensity and frequency, but not with objective measures of snoring. A study that evaluated that use of a pillow that changes head position in response to snoring (as detected by built-in microphones) confirmed similar decreases in snoring intensity [42].

Nasal patency

Decongestants for acute rhinosinusitis — When snoring arises in association with acute sinusitis or rhinosinusitis, symptomatic measures to reduce nasal congestion before bedtime, such as saline nasal irrigation or intranasal decongestants, may help alleviate snoring. Intranasal (topical) decongestants are less likely to cause systemic side effects than oral decongestants. However, topical decongestant use should be limited to two to three days because more prolonged use can induce rebound nasal congestion and rhinitis. (See "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment", section on 'Symptomatic management'.)

Of note, one trial tested the use of pseudoephedrine, alone or in combination with the prokinetic agent, domperidone, for severe snoring in patients not screened for sleep apnea [43]. Compared with placebo, pseudoephedrine resulted in more nights rated as having "no" or "mild" snoring. However, given the small size of the trial and the known side effects of regular use of pseudoephedrine, this medication cannot be recommended for regular use of snoring reduction.

Intranasal glucocorticoids for chronic nasal congestion — For patients with chronic nasal congestion and snoring, we suggest a trial of intranasal (topical) glucocorticoid therapy. Those patients whose snoring improves may benefit from chronic therapy. However, at least one study in which nasal steroids were tested on a group of snoring subjects (in which OSA was not objectively ruled out) did not show any improvement in snoring [44]. (See "Chronic nonallergic rhinitis", section on 'Efficacy of glucocorticoid sprays' and "Pharmacotherapy of allergic rhinitis", section on 'Glucocorticoid nasal sprays'.)

Nasal dilators — For patients who continue to snore despite conservative therapy and relief of any nasal congestion, we suggest a trial of an external nasal dilator.

Nasal dilators are devices that attempt to dilate the anterior nasal valve. External and internal dilators exist, and the impact of each on snoring has been evaluated. Given the low risk and burden of the intervention, a trial of using an external dilator is reasonable for most individuals who have snoring that is not associated with OSA and who continue to snore despite the conservative interventions described above.

An external nasal dilator is a stiffened adhesive strip that is applied externally across the nasal alae. It retracts and stabilizes the nasal alae, dilating the anterior nasal valves. External nasal dilators increase nasal cross-sectional area and decrease nasal airflow resistance, but these effects are highly variable [45].

A systematic review on nasal dilators identified several small studies that measured snoring subjectively before and after use of a nasal dilator [46]. All studies reported a decrease in either snoring frequency or intensity. However, the one study that included an objective measure of snoring obtained during polysomnography did not find a decrease in snoring.

Nasal surgery — Surgical procedures to improve nasal patency have been tried in an effort to treat snoring, but supporting data are sparse and inconsistent. Given the lack of evidence, nasal surgery to treat snoring cannot be recommended at this time.

One study found a reduction in subjective snoring in 64 individuals undergoing septoplasty [47]. There was no relationship between the severity of septal deviation and improvement in snoring. Another study found no improvement in objective measures of snoring in 40 individuals who underwent septoplasty with or without partial resection of the inferior turbinates [48].

Mechanical approaches

Oral appliances — Oral appliances, which are customized oral devices prescribed and fitted by dentists, increase the size of the upper airway during sleep, which decreases snoring. They typically work by advancing the mandible, changing the position of the soft palate, retracting the tongue, or a combination of these mechanisms. Practice guidelines from the American Academy of Sleep Medicine recommend oral appliances for patients who fail conservative measures and request treatment of their snoring [49]. (See "Oral appliances in the treatment of obstructive sleep apnea in adults".)

Oral appliances may be highly effective for snoring when used properly. In one study of 23 patients with primary snoring (no evidence of OSA on polysomnography), a crossover design was used to study the effect of a mandibular advancement device in either the advanced or non-advanced position [50]. In the advanced position, both snoring intensity (as rated by bed partners) and the number of snores per hour (during recorded home study) were reduced [50].

Indirect evidence in patients with OSA also supports the hypothesis that oral appliances can reduce snoring. A systematic review of oral appliances for snoring with or without OSA identified 18 studies that evaluated snoring before and after treatment with an oral appliance [51]. There was significant heterogeneity across studies in how snoring was defined, how snoring was measured, and the severity of OSA. Snoring frequency and snoring intensity were reduced in most studies, including the four that had identified individuals meeting criteria for primary snoring. Other studies of patients with both snoring and OSA also suggest that oral appliances can reduce snoring [52,53].

During the period of initial use, side effects are common (up to 80 percent in some studies) and include excessive salivation, mouth dryness, difficulty chewing in the morning, tooth pain, gum irritation, headaches, and temporomandibular joint discomfort [49,54]. These side effects are generally minor and self-limiting. Long-term side effects, seen in up to 15 percent of patients, include occlusal changes such as changes in the degree of overjet and overbite and changes in the dental arch. (See "Oral appliances in the treatment of obstructive sleep apnea in adults", section on 'Evaluate adverse effects'.)

Oral appliances should be fitted by dentists with expertise in sleep-related breathing disorders. Fitting includes fabrication in a dental laboratory from impressions of the patient's bite or custom molding from a prefabricated device. Follow-up polysomnography is not necessary when snoring alone is treated with an oral appliance. Regular long-term follow-up for side effects is recommended [49].

Continuous positive airway pressure — Continuous positive airway pressure (CPAP) is an effective, safe, and reversible therapy for snoring, although the effects of snoring have been primarily studied in patients with some degree of OSA [55-57]. However, many patients without daytime symptoms do not accept CPAP because of its inconvenience, and most insurance policies do not cover the cost of CPAP for patients if snoring is the only indication. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea".)

Oral appliance versus CPAP — Oral appliance therapy and CPAP were compared in a crossover study in which 20 snorers (by clinical assessment only) received three months of each therapy [58]. Both therapies were associated with significant improvement in patient and partner assessments of snoring. The oral appliance was chosen more frequently for long-term use (eight patients chose an oral appliance, five chose CPAP, and seven decided against further therapy).

Palatal surgeries — Surgery for snoring has been widely studied. However, the quality of the evidence is limited due to multiple factors:

Most studies are case series or case control studies with a small number of patients, including some with mild OSA

Most studies use subjective outcomes to measure snoring pre- and post-surgery

Many studies combine nasal and upper airway techniques

Most studies have short follow-up times

Studies that have measured long-term outcomes consistently find that the initial effect on snoring is not sustained over time

Because of these limitations, surgical treatment of snoring should only be considered in patients who have tried and failed conservative approaches, including weight loss, tobacco and alcohol avoidance, sleep position, efforts to improve nasal patency, and mechanical approaches. One guideline further recommends that only minimally invasive techniques, such as radiofrequency ablation or palatal implants, be considered for snoring [59].

Uvulopalatopharyngoplasty — Uvulopalatopharyngoplasty (UPPP) involves surgically removing tissue from the soft palate and tonsillar pillars. It can be done through traditional surgical techniques or laser-assisted, which allows for outpatient therapy.

Multiple studies have shown that UPPP or laser-assisted uvulopalatoplasty (LAUP) can be used to decrease snoring intensity as measured by patient or bed partner report [60-63]. However, the effect does not appear to be long lasting, as demonstrated by the following studies:

UPPP – Long-term subjective outcomes were assessed via questionnaire in 203 patients who had undergone UPPP for snoring [60]. The immediate postoperative success rate (defined as a 50 percent or greater reduction in snoring by self-report) was 76 percent. By two years after surgery, the success rate had decreased to 45 percent. The majority of patients (62 percent) indicated that they would not have the surgery again if offered.

LAUP – A follow-up interview at 19 to 98 months post-surgery was performed in 122 patients who had undergone LAUP for snoring [62]. Seventy-four percent of patients reported improvement at six weeks postoperative, 69 percent at nine months, and 55 percent at the time of the interview. Mean subjective improvement scores decreased from 57 percent at six weeks to 30 percent at the time of the interview.

UPPP is initially painful and there are potential complications, including nasal reflux, pharyngeal stenosis, dysphonia, infection, bleeding, and transient velopharyngeal insufficiency. In addition, UPPP or LAUP may reduce snoring without eliminating the risk for OSA, potentially masking current or future OSA.

Patients who undergo UPPP require periodic evaluation by a sleep specialist to be evaluated for the development of OSA and to determine whether treatment is indicated. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)

Radiofrequency palate surgery — Radiofrequency palate surgery, or somnoplasty, involves temperature-controlled radiofrequency tissue volume reduction of the palate.

A systematic review of radiofrequency ablation found that this technique was safe and effective for snoring [64]. However, the evidence consisted primarily of case series. In the only controlled trial, 26 patients with snoring were randomized to undergo radiofrequency palate surgery or sham surgery [65]. Subjective snoring assessment at six to eight weeks post-procedure demonstrated greater improvement in snoring among patients who underwent radiofrequency palate surgery compared with those who underwent sham surgery; however, only two patients had a successful surgery as defined by near elimination of snoring. The remaining case series uniformly found improvement in snoring scores reported either by the patient or bed partner [64]. The review also concluded that radiofrequency palate surgery is generally less painful than LAUP or UPPP.

Similar to UPPP and LAUP, however, the long-term effects of radiofrequency palate surgery are less promising.

In a study that included 29 patients with disruptive snoring and an AHI <10 events per hour of sleep by full-night polysomnography who underwent radiofrequency ablation, only 25 percent of patients were satisfied with the outcome of the procedure after three to four years, and another 25 percent had sought additional therapy [66].

In another long-term follow-up study that included 77 patients who had undergone radiofrequency ablation for snoring, 49 percent of patients had undergone additional surgical treatments for snoring over a mean follow-up of seven years [67]. Among 39 patients who underwent radiofrequency ablation alone, only 17 percent felt that their condition was still improved compared with their preoperative baseline. For most of the patients whose snoring was the same or worse, there had been an increase in body mass index over the follow-up period.

Palatal implants — The pillar procedure involves the deployment of braided polyester filaments into the soft palate through a needle. It is generally performed as an outpatient procedure.

A systematic review found seven case series (173 patients) and no controlled studies evaluating palatal implants for snoring [68]. In all seven studies, subjective snoring was reduced postoperatively compared with preoperative baseline scores [68]. However, a subsequent study of 29 patients with simple snoring or mild OSA found no changes in objective measures of snoring at three to six months post-surgery despite significant decreases in subjective snoring [69]. Another uncontrolled study using barbed sutured implants found a small but statistically significant decrease in scoring as measured by visual analog scale at 90 and 180 days post-procedure compared with baseline [70].

Similar to other surgical techniques, the long-term success of palatal implants is less clear.

An observational study followed 40 patients who had undergone the pillar procedure for one year [71]. Snoring was assessed preoperatively and at 90, 180, and 360 days postoperatively via snoring recordings, and several subjective measures. Bed partner assessment using the subjective visual-analog scale indicated improvement in snoring at 90 days that continued for one year. Objective measures of snoring did not improve, however.

A long-term follow-up study of 26 patients followed prospectively after pillar procedure found that after four years, snoring was again louder per bed partner report [72]. Only 22 percent of patients said that they would recommend the procedure to a friend.

Comparative studies — There have been no high quality studies comparing various surgical treatments for snoring with one another. Examples of prospective studies include the following:

A prospective, nonrandomized study compared LAUP with radiofrequency ablation in 30 patients with habitual snoring or mild OSA [73]. While both LAUP and radiofrequency ablation decreased snoring at two months compared with preoperative baseline scores, both success rate (defined by a visual analogue score <3) and satisfaction rates were higher in the radiofrequency ablation group [73].

A small trial in 30 patients with habitual snoring or mild OSA randomized patients to receive either palatal implant or a single session of radiofrequency ablation. At three months, snoring was improved in both groups compared with baseline, but the success rate (defined by a visual analogue score <3) was higher in the palatal implant group (79 versus 21 percent) [74].

In a single-center prospective study of 195 patients presenting for evaluation and treatment of snoring, 116 patients received some form of treatment; 28 percent were treated with CPAP, 26 percent were treated with an oral appliance, and 46 percent underwent surgery (septoplasty, UPPP, or radiofrequency ablation). All three modalities resulted in similar rates of improvement in subjective snoring scores at both six weeks and six months [56].

In a single-center retrospective analysis of 84 patients, several surgeries including tonsillectomy, septoplasty, somnoplasty, bimaxillary osteotomy, and UPPP were compared [75]. The patients were mostly males, with a mean age of 43 years and mean body mass index (BMI) of 26 kg/m2. Among procedures, osteotomy or UPPP were associated with the greatest improvement in snoring scores.

Upper airway exercises (myofunctional therapy) — Limited data in patients with snoring and/or OSA suggest that upper airway exercises may provide some benefit in motivated individuals.

One small trial examined the effects of 30 minutes of oropharyngeal exercises for the soft palate, tongue, and facial musculature in a group of 31 patients with moderate OSA [76]. The group randomly assigned to perform oropharyngeal exercises had improvements in subjective and objective measures of snoring frequency and intensity.

In a second trial, oropharyngeal exercises were simplified to take only about eight minutes per day [77]. Patients had either primary snoring or mild OSA. Both subjective and objective measures of snoring decreased in the group performing the exercises compared with the control group.

One trial used a smartphone application to deliver a daily upper airway exercise regimen lasting about 15 minutes [78]. The participants had a BMI ≤32 kg/m2 and an AHI ≤14/hour. Snoring was recorded using the smartphone application. Compared with the group who did not do the regimen, participants in the exercise regimen group had an absolute decrease in snoring rate (defined as the number of snores louder than 60 dB per hour) after two weeks. Bed partners also reported satisfaction with the reduction in snoring.

The effects of didgeridoo playing on snoring and AHI severity were studied in 25 patients with moderate OSA [79]. Playing the didgeridoo, an indigenous wind instrument from Australia, requires circular breathing, which in theory strengthens upper airway muscles. Patients in the didgeridoo group had a significant improvement in partner-rated sleep disturbance compared with the control group.

A meta-analysis of nine studies in a total of 211 patients reported outcomes for snoring after myofunctional therapy [80]. The specific exercises varied by study but generally included exercises involving the tongue and soft palate; most studies involved three months of therapy before re-evaluation. The meta-analysis showed decreases in snoring intensity as measured by either visual analogue scale or Berlin questionnaire; in addition, time spent snoring during sleep also decreased.

Ineffective therapies — Nasal sprays that lubricate the upper airway are not recommended at this time for the routine management of snoring because they have not been shown to improve snoring in heterogeneous populations of snorers [45,81,82].

SUMMARY AND RECOMMENDATIONS

Snoring is a sound produced by vibration of the soft tissues of the upper airway during sleep. Habitual snoring is common in adults, and occasional snoring is almost universal. Snoring can be a sign of a condition associated with increased upper airway resistance, or it can occur independently. (See 'Introduction' above.)

Snoring has been independently associated with carotid artery atherosclerosis, but there is little evidence to support a relationship between snoring and either hypertension or ischemic heart disease. Disruption of the sleep of the bed partner may be a significant problem. (See 'Potential consequences' above.)

The primary reason to evaluate patients for snoring is to identify obstructive sleep apnea (OSA), which is associated with excessive daytime sleepiness and cardiovascular comorbidities. If OSA is not identified, evaluation of the snoring may yield a treatable cause such as obesity, enlarged tonsils, deviated nasal septum, or chronic nasal congestion. (See 'Evaluation' above.)

Conservative therapies should be encouraged for all patients who snore. These include smoking cessation, weight loss, alcohol avoidance several hours before bedtime, and sleeping in the lateral position (algorithm 1). (See 'Conservative approaches' above.)

Decreased nasal patency can contribute to snoring.

For patients with chronic nasal congestion, we suggest a trial of intranasal glucocorticoids (Grade 2C). Patients who respond may benefit from chronic intranasal glucocorticoid therapy. (See 'Intranasal glucocorticoids for chronic nasal congestion' above.)

For patients who continue to snore despite conservative therapy and relief of any nasal congestion, we suggest a trial of an external nasal dilator (Grade 2C). (See 'Nasal dilators' above.)

Nasal surgery is not recommended for most patients who snore and do not have OSA. An exception is patients who have significant anatomical obstruction (eg, septal deviation). (See 'Nasal surgery' above.)

For patients who continue to snore despite both conservative therapy and interventions to improve nasal patency, we suggest a trial of an oral appliance (Grade 2C). Oral appliances should be fitted by a dentist with experience in treating sleep-related breathing disorders. (See 'Oral appliances' above.)

Other surgical approaches involving the palate should be used as a last resort for patients who do not want to receive chronic mechanical therapy, such as an oral appliance, and who continue to snore despite both conservative therapy and interventions to improve nasal patency (algorithm 1). Patients should be made aware that initial improvements in snoring are infrequently sustained over time. (See 'Palatal surgeries' above.)

Limited data support a trial of upper airway exercises (myofunctional therapy) to decrease snoring intensity among interested patients.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges William Beninati, MD, and William Frey, MD, who contributed to an earlier version of this topic review.

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Topic 7703 Version 25.0

References