Snoring is noisy breathing caused by vibration of relaxed soft tissues of the nose, soft palate or pharynx whilst sleeping or drowsy.
- Snoring affects around 40% of the UK population.[1, 2]
- It is more common in men although the ratio in the literature varies.
- It is most common between the ages of 40-60.
- Prevalence in children is lower, with rates between 1-20% being quoted in children of school age.In children it is most commonly due to adenotonsillar enlargement or craniofacial abnormalities. In the preschool age group, prevalence has been reported in one UK-based study as 7.9% for habitual snoring, with atopy and respiratory infections being common causes.Nearly 60% of the children in this study were reported as having snored at some point in the previous 12 months.
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.
There is lack of consistency in definitions used for snoring and sleep-related breathing disorders. However, essentially:
- Snoring is the description of the noisy breathing made during sleep.
- Simple snoring is the presence of snoring without irregular breathing and hypoxia causing daytime sequelae. However, there is evidence that it is not an entirely benign condition and may be associated with cardiovascular morbidity as well as psychological and social problems.
- Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is the presence of irregular breathing in the night followed by sleepiness during the daytime.[6, 7] There is total upper airway collapse, with cessation of airflow for at least 10 seconds, occurring >5 times per hour. Obstructive sleep apnoea/hypopnoea (OSAH) or obstructive sleep apnoea (OSA) is disrupted irregular breathing without daytime sleepiness. However, these terms are often used interchangeably within the literature.
- Most people with OSA snore. The prevalence of OSA in people who snore varies widely in the literature from 20-70%, reflecting differences in definition and diagnostic rates.
- It may well be that the two conditions are at opposing ends of a continuum.
- The upper airway resistance syndrome (UARS) has been described as potentially another condition on this spectrum where there are respiratory effort-related arousals during the night, but no associated hypoxia.
There is a separate article discussing Obstructive Sleep Apnoea.
Snoring is not usually due to an underlying disorder, but the following may predispose by causing narrowing of the upper airway:
- Obesity. There is a strong association between increasing weight and the prevalence of OSA. This association is present but less strong for snoring. Those with a body mass index (BMI) of over 40 kg/m2 have been calculated to have a 27 times increased risk of OSA.
- Nasal congestion, blockage or septal deviation.
- Enlarged tonsils and adenoids.
- Craniofacial abnormalities.
Other factors which may make snoring more likely include:
- Alcohol intake.
- Sedative medication.
- Supine position.
- Age (prevalence increases with age generally).
Cover the following questions:
- Duration of snoring?
- Frequency - is it every night?
- Is snoring more likely in any particular position? (For most people it is worse when they sleep on their back.)
- Any precipitants/modifiable factors - alcohol, sedatives, a recent increase in weight?
- Any history of nasal problems/obstruction?
- Does it disturb the patient's sleep?
- Does it disturb the partner's sleep? What are the relationship effects?
- Has the partner noticed any apnoeic episodes?
- Is there daytime somnolence? When using the Epworth Sleepiness Scale a figure of 10 or more is considered sleepy. This scale has been validated for OSA, which is important to be excluded.
- Are there any other symptoms suggestive of OSAHS, including early morning headaches, choking episodes during sleep, accidents, inability to concentrate, and irritability?
- Calculate BMI.
- Record collar size: neck circumference >43 cm correlates with snoring and OSA.
- Perform a good general examination: cardiovascular system, respiratory system, and thyroid.
- Note whether the site of obstruction is apparent: nasal (eg, polyps, septal deviation), tongue, tonsils and oropharynx, mandible (retrognathia).
- Arrange sleep studies (polysomnography) if OSA is suspected, especially if surgery is contemplated for snoring (see under 'Management', 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 to clarify the level of obstruction. It can exclude upper airway tumours and cysts as a rare cause.
- Perform TFTs if hypothyroidism is suspected.
There is limited evidence for all forms of management, both non-surgical and surgical. Ascertaining any cause or predisposing factors will be helpful in improving efficacy of the advice, device or procedure offered.
- Encourage weight loss as appropriate.
- Lifestyle advice: more exercise, less alcohol, fewer sedatives, stop smoking.
- Posture adjustment and sleep position training: for example, a tennis ball taped to the back of pyjamas to stop him or her rolling on to the back. Bed wedges and pillows may also help.
- Earplugs for the partner.
- Decongestants and steroid nasal sprays can help nasal congestion.
- Devices that splay the nasal alae may help nasal obstruction. Nasal strips and nasal dilators are available commercially. There has not been sufficient research to ascertain if these are beneficial, and if so which type is more effective.
- For those who snore due to mouth-breathing, chin straps (to keep the mouth closed) or vestibular shields (essentially closing off the mouth and forcing breathing through the nose) may be of benefit.
- Oral appliances can advance the soft palate, tongue or mandible and therefore open the airway. Mandibular advancement devices may help if snoring is generated from the tongue base or in mouth breathers. These are best fitted by a dentist but choice of device and adequate training of dentists are important for this form of treatment to be effective.[14, 15]
- Continuous positive airway pressure (CPAP) often works well but may not be readily available for those without OSA.
- Some people find acupressure rings worn on the fingers help. These are advertised commercially, but there are no robust trials into their efficacy.
Those with normal or near-normal BMI do best. The procedure performed depends on the level of obstruction:
- Turbinate reduction.
- Sometimes the above procedures are carried out in combination.
- The most frequent surgical treatment for snoring in children but used for those children who also have OSA or recurrent tonsillitis.
- Also done in adults where enlarged tonsils are demonstrably the cause of snoring.
- Uvulopalatopharyngoplasty (UPPP): involves tonsillectomy, reorientation of the anterior and posterior tonsillar pillars and excision of the uvula and posterior rim of the soft palate.
- Laser-assisted uvulopalatoplasty (LAUP): benefits may wane with time. 55% showed long-term benefit in one study.
- Radiofrequency electrosurgery: radiofrequency ablation (delivered using an electrode) reduces volume of palatal tissue and makes the remaining palate more dynamically stable. It is an outpatient procedure usually under local anaesthetic. National Institute for Health and Care Excellence (NICE) guidance in 2014 noted lack of evidence for long-term outcomes, but sufficient evidence for short-term efficacy.NICE suggests that patient selection is important and, if used, there should be arrangements for audit, consent and research. One series following up 29 patients concluded that the procedure produced long-term benefits in one in four patients and that patient selection may be improved by prior electromyography of the palatoglossus muscle.
- Soft palate implants: implants are inserted in the soft palate under local anaesthetic with the aim of stiffening 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. One series of 21 patients concluded that the procedure was a safe and easy one which resulted in a high degree of patient satisfaction.
Tongue base procedures
- Tongue base reduction (laser).
- Mandibular advancement and osteotomy.
- Uvulectomy may help patients with a large uvula.
- Tonsillectomy with adenoidectomy may be helpful in children.
- Surgery is not usually recommended in patients with both snoring and OSA, except nasal surgery to facilitate CPAP. This is due to lack of evidence and the efficacy of CPAP.
Owing to the variation in the literature of definitions and prevalence rates of snoring and OSA, it is difficult to ascertain the complications which arise from snoring alone. Some term it a benign condition but there is some evidence that it may cause the following complications.
- Marital/relationship problems.
- Embarrassment in social situations, staying with friends, holidays.
- Difficulty concentrating.
- Anxiety and depression. It is difficult to ascertain how prevalent this is for simple snoring without OSA but there does appear to be some increase in symptoms of anxiety or depression.[21, 22]
- Sleepiness due to sleep disruption.
- Sleepiness in others being disturbed by snoring.
- There is evidence that habitual snoring may carry an increased risk of coronary heart disease and stroke.However it remains contentious whether this applies to snoring alone, or to snoring in the presence of OSA. It appears that those who snore have a higher risk of carotid atherosclerosis than those who do not.
- Effect on safe driving. Patients with OSA who drive should inform the Driver and Vehicle Licensing Agency (DVLA). Full details, including a link to the DVLA guidelines, are available from the separate article Obstructive Sleep Apnoea.
Further reading and references
Main C, Liu Z, Welch K, et al; Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs. Health Technol Assess. 2009 Jan13(3):iii, xi-xiv, 1-208.
Stuck BA, Abrams J, de la Chaux R, et al; [S1 guideline on the "diagnosis and treatment of snoring in adults"]. HNO. 2010 Mar58(3):272-8. doi: 10.1007/s00106-010-2103-0.
Epidemiological study of snoring from a random survey of 1075 participants; British Snoring and Sleep Apnoea Association
Parker RJ, Hardinge M, Jeffries C; Snoring. BMJ. 2005 Nov 5331(7524):1063.
Fitzgerald NM, Fitzgerald DA; Managing snoring and obstructive sleep apnoea in childhood. J Paediatr Child Health. 2013 Oct49(10):800-6. doi: 10.1111/jpc.12421.
Kuehni CE, Strippoli MP, Chauliac ES, et al; Snoring in preschool children: prevalence, severity and risk factors. Eur Respir J. 2008 Feb31(2):326-33. Epub 2007 Nov 21.
Deary V, Ellis JG, Wilson JA, et al; Simple snoring: Not quite so simple after all? Sleep Med Rev. 2014 May 9. pii: S1087-0792(14)00047-1. doi: 10.1016/j.smrv.2014.04.006.
Management of obstructive sleep apnoea/hypopnea syndrome in adults; Scottish Intercollegiate Guidelines Network - SIGN (2003)
Sleep apnoea syndrome; NICE CKS, January 2009 (UK access only)
Keropian B, Murphy N; The prevalence of OSA in snorers presenting with various chief complaints: a pilot study. Cranio. 2014 Jul32(3):217-8. doi: 10.1179/0886963414Z.00000000032. Epub 2014 Apr 14.
Pepin JL, Guillot M, Tamisier R, et al; The upper airway resistance syndrome. Respiration. 201283(6):559-66. doi: 10.1159/000335839. Epub 2012 Mar 1.
Epworth Sleepiness Scale; British Snoring and Sleep Apnoea Association
Suzuki M, Saigusa H, Chiba S, et al; Prevalence of upper airway tumors and cysts among patients who snore. Ann Otol Rhinol Laryngol. 2007 Nov116(11):842-6.
Robertson S, Loughran S, MacKenzie K; Ear protection as a treatment for disruptive snoring: do ear plugs really work? J Laryngol Otol. 2006 May120(5):381-4.
Almeida FR, Lowe AA; Principles of oral appliance therapy for the management of snoring and sleep disordered breathing. Oral Maxillofac Surg Clin North Am. 2009 Nov21(4):413-20. doi: 10.1016/j.coms.2009.07.002.
Church SK, Littlewood SJ, Blance A, et al; Are general dental practitioners effective in the management of non-apnoeic Br Dent J. 2009 Apr 25206(8):E15
Saylam G, Korkmaz H, Firat H, et al; Do palatal implants really reduce snoring in long-term follow-up? Laryngoscope. 2009 May119(5):1000-4.
Radiofrequency ablation of the soft palate for snoring; NICE Interventional Procedures Guidance, January 2014
Iyngkaran T, Kanagalingam J, Rajeswaran R, et al; Long-term outcomes of laser-assisted uvulopalatoplasty in 168 patients with snoring. J Laryngol Otol. 2006 Nov120(11):932-8. Epub 2006 Jul 3.
Hultcrantz E, Harder L, Loord H, et al; Long-term effects of radiofrequency ablation of the soft palate on snoring. Eur Arch Otorhinolaryngol. 2009 Apr 17.
Soft-palate implants for simple snoring; NICE Interventional Procedures Guidance, November 2007
Douglas N, Young A, Roebuck T, et al; Prevalence of depression in patients referred with snoring and obstructive sleep apnoea. Intern Med J. 2013 Jun43(6):630-4. doi: 10.1111/imj.12108.
Balsevicius T, Uloza V, Sakalauskas R, et al; Peculiarities of clinical profile of snoring and mild to moderate obstructive sleep apnea-hypopnea syndrome patients. Sleep Breath. 2012 Sep16(3):835-43. doi: 10.1007/s11325-011-0584-z. Epub 2011 Sep 3.
Li D, Liu D, Wang X, et al; Self-reported habitual snoring and risk of cardiovascular disease and all-cause mortality. Atherosclerosis. 2014 Jul235(1):189-95. doi: 10.1016/j.atherosclerosis.2014.04.031. Epub 2014 May 6.
Kim J, Pack A, Maislin G, et al; Prospective observation on the association of snoring with subclinical changes in carotid atherosclerosis over four years. Sleep Med. 2014 Jul15(7):769-75. doi: 10.1016/j.sleep.2014.03.009. Epub 2014 Apr 18.
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