Trends in Management
of Snoring
Deepak Gupta
Department of Otolaryngology
The Great Western Hospital
&
The Ridgeway Hospital
Swindon
Snoring
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Definition:
Rough, noisy breathing during sleep, due to vibration
of uvula and soft palate, maybe tongue
Mechanism:
Obstructive air flow leading to turbulence which
vibrates soft tissue in the mouth and throat
to produce sound.
Incidence:
Men 24% - 50%, women 14% -30%
Sleep-Disordered Breathing (SDB)
Simple Snoring
Upper Airway Resistance Syndrome (UARS)
Mild Obstructive Sleep Apnea Syndrome (OSAS)
Severe Obstructive Sleep Apnea Syndrome (OSAS)
Collapsible Portions of Upper Airway
Consequence of Snoring
• Social – the sound of Snoring may lead to
marital disharmony or social embarrassment
• Sleep disturbance and fragmentation lead to
excessive daytime sleepiness
e.g. traffic accidents
• Sore throat
Quantifying Snoring
• Frequency
• Position sensitivity
• Witnessed apnoeic episodes
• Duration
• Degree of disruption
Clinical Assessment
• Obesity – Neck Circumference
• Alcohol
• Smoking
• Daytime Sleepiness
• Witnessed Apnoeas
• Abnormal nocturnal motor activity
• Other nocturnal events
• Epworth
Clinical Examination
• Body Mass Index (BMI)/Neck
• Nasal Obstruction
• Oral cavity/Oropharynx
• Laryngoscopy
Signs/Symptoms of Sleep Apnea
• Breathing sounds during sleep
• Excessive daytime sleepiness
• Fatigue
• Changes in alertness, memory, personality
• Hypertension/CHF
• Impotence
• Headaches
• Bedwetting
Assessment of Sleep Apnea
• Epworth Sleepiness Scale
• Nocturnal oxygen saturation
• Home sleep testing -Apneagram
• Polysomnography
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Epworth Sleepiness Scale
0-24
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour
Resting in the afternoon
Sitting and talking to someone
Sitting after lunch without alcohol
In a car while stopping for a few minutes in traffic
Chance of dozing
0=never
1=Slight
2=moderate
3=High
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How to assess the region of obstructions
• To determine a surgical procedure it is valuable
to know the location of the nocturnal
obstruction.
Deciding on a Treatment Option
General Treatment for SDB
• Control of body weight
• Behavioral modification
• avoid full dinner and excess alcohol
• sleep in lateral or prone position
Patient Administered Treatments
Worth a Fortune!
Oral Appliances
• Mandibular repositioning devices(MRD)
• Tongue retaining devices
MRD
•Good compliance
•Reduce frequency,
intensity and duration of
snoring
•Xerostomia
•TMJ pain
•Dental pain
•Myofacial pain
•Bite change
Nasal CPAP
•Very effective
•Low compliance when
used for snoring alone
•70% prefer less effective
MRD
•http://www.dailymail.co.uk/
health/article-81411/Tensnoring-cures.html
Surgical Interventions
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Nasal Surgery – poor prediction of success
Adenoid/Tonsil Surgery
Palatal Surgery
50-95% short term success
45-75% long term success
Poor correlation between objective
decrease in intensity and subjective
improvement
Maintenance of fall in snoring volume
Tongue base surgery
Jaw advancement
Hyoid myotomy and suspension
Tracheostomy
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Why should we operate
• May be the only tolerable option
• Only ‘permanent’ option
• Good results
• Mimimal complications
Why not to operate
• Variable success
• Insufficient evidence base
• May make future CPAP use difficult
• Recurrence with time and age
Intra Palatal Surgery
•Diathermy
•Cold steel
•Radiofrequency
•Laser
•Injection Sclerosis
•Intra palatal devices
•Low morbidity
•LA
•Out-Patient Procedure
•Repeatable
•UPPP still possible
•SR 30-80% in short term
•Possible decrease in
long term
Best for BMI less than
25,Tonsil grade 1 & 2,
AHI less than 25
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Radiofrequency Ablation RFA
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Snoring, mild/moderate OSAS
Interstitial volume reduction
and stiffening
Local anaesthesia/out patient
Day procedure
Anti-snoring device (ASD implants)
• Pi Medical (Minnesota, USA)
• Year 2000
• Increase stiffness of soft palate
• Permanent implant
Uvulopalatopharyngoplasty
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Laugh and the world laughs with you
snore, and you snore alone Mark Twain
Thank You – and sleep well