Snoring

Who to refer

RED FLAG SYMPTOMS
Any patient with new onset symptoms of severe snoring plus any of the following:
Otalgia
Globus
Odynophagia
Dysphagia
Voice change
Sore throat
Hot Potato speech

These patients must be assessed urgently  to rule out a mass in the oropharynx / larynx / hypopharynx

If patient also has nasal obstruction, before referral consider:

• What is the patient’s motivation for requesting help?

• Exclusion of underlying disease – reassure
• Social disharmony – coping strategies
• Advice regarding treatment options – see below
• Cure (rarely possible) – counsel accordingly
• Is the patient prepared to consider surgery on the nose?  If not, consider whether the referral is necessary

Prior to Referral

Does the patient have disruptive snoring? If so, try the following prior to referral:

Reassurance – simple snoring is rarely a symptom of significant disease (see red flag symtoms above)

Treatment – treat underlying nasal disease (try also if patient wakes with a dry mouth):

• 10 day trial of Oxymetazoline (Otrivine) AND 2 MONTH trial of intranasal corticosteroids
• saline douches to reduce mucus viscosity
• trial of  nasal dilator strips from chemist

General advice-

• reduce weight to normal BMI
• stop smoking
• reduce alcohol intake especially at night
• stop sedative medications.

Coping strategies–

• bed partner wearing ear plugs
• trial of mandibular advancement splint from dentist  (will need to pay)
• change sleeping position (lie on side not back)
• increase hydration especially in the evening.

Please check thyroid function

Provide patients with patient advice leaflet

Surgery for Snoring

Surgery for snoring is rarely required.

In carefully selected patients surgery may help.  This can only be decided after careful assessment and appropriate counselling.  Surgery must be tailored to individual patient’s anatomy (see Friedman Tongue Position)

Surgery on appropriate patients is successful in 80-90% provided weight remains stable and normal. Any palatal / tongue base surgery can only be done if the patient has a clear nasal airway.  This is not provided by NHS Lothian.

 Surgically correctable contributors to snoring:

Nasal pathology

• Significant septal deviation
• Turbinate hypertrophy
• Adenoidal hypertrophy
• Nasal valve collapse

Oral / oropharyngeal pathology

• Oral mass
• Gross tonsillar hypertrophy
• Lingual tonsillar hypertrophy
• Palatal laxity
• Tongue base hypotonicity / bulk

Laryngeal / hypopharyngeal pathology

• Laryngomalacia (rare)
• Pharyngeal masses

Who not to refer

• Epworth Sleepiness Score >11
• Witnessed frequent apnoeas with loud “rescue” breaths
• Day time sleepiness
• Poor concentration
• Morning headaches
• Restless / sweaty during sleep.
• Patients without  nasal obstruction
• Morbid obesity (bmi>40) – consider weight management referral

How to refer

SCI Gateway to ENT at Lauriston Building

Include on referral:

• OSAS excluded
• Therapy trialled
• BMI (>40 consider weight management referral)
• Collar size (women >15″,  men >17″ associated with OSAS)
• BP
• Nose – external deviation? septum deviation?  turbinates enlarged?
• Mouth / oropharynx  – tonsil size
• Oral pathology
• Dentition
• The patient’s expectations of the consultation

See Referral to the Sleep Disorder Service

The following is a guide and will allow you to safely reassure most patients, but we recognise that some are bothered by their symptoms to such a degree that they need secondary care management.

Snoring: 

This is a normal part of ageing and is associated with obesity. 

Provided the Epworth Sleepiness score is less than 12, there is no nasal obstruction or “hot potato speech, it is rarely indicative of pathology. Consider checking thyroid function.

Patients should be advised to lose weight if appropriate, and to avoid sleeping with others after drinking alcohol. 

There are a variety of devices available for purchase online/in chemists but the evidence for all is scanty. The best evidence is for mandibular splint devices which can be supplied by most General Dental Practitioners.  They are no longer supplied free by NHS Lothian.

• ENT – Snoring Advice for Patients v2.0 NHSL Approved
• ENT -Friedman Tongue Position