Current Management of Primary Snoring

While snoring has primarily been considered a social problem for the approximately 40% of adults who snore—and their bed partners—snoring is no laughing matter. Sleep is disrupted, relationships strained. And, while it has primarily been considered a social problem, some recent evidence suggests that snoring may carry cardiovascular health risks, even in the absence of sleep apnea.

“There’s some evidence that the vibrations of snoring can affect the surrounding blood vessels of the head and neck and may even accelerate atherosclerosis,” said M. Boyd Gillespie, MD, MSc, professor and chairman of otolaryngology–head and neck surgery at the University of Tennessee in Memphis and member of the ENTtoday Editorial Advisory Board. A 2014 study comparing snorers to non-snorers found that snorers have a significantly greater carotid intima-media thickness (Laryngoscope. 2014;124:1486–1491). This finding suggests a possible physiological link between snoring and cerebrovascular events.

“It may not be the apneas that are contributing to an increased risk of cerebrovascular events in patients with sleep apnea, but the vibrations of snoring,” said Kathleen Yaremchuk, MD, an author of the 2014 study and chair of the department of otolaryngology–head and neck surgery at Henry Ford Hospital in Detroit. “The vibrations may disrupt the endothelial lining, and then cholesterol is more likely to be laid down because it’s an injured spot.”

While there’s no consensus on the belief that primary snoring is an independent cardiovascular risk factor, plenty of evidence does show that snoring interferes with the health and well-being of the snorer. A 2015 study of more than eight million Americans found that snorers get less sleep per night (approximately 11 minutes, or more than an hour less per week) than non-snorers and experience 11.5 days of insufficient sleep per month, compared with 7.6 days for non-snorers. The study also found “significant associations between the presence of snoring and coronary artery disease” that persisted after adjusting for age, sex, smoking status, marital status, and body mass index (Laryngoscope. 2015;125:2413–2416).

Still, most individuals who turn to otolaryngologists for snoring treatment are seeking help because their snoring annoys a bed partner. It’s incumbent on otolaryngologists to educate snorers about the possible health implications of snoring even as they work with the patient to find possible solutions.

“There’s still no cure for snoring, but if we attack snoring from multiple angles, it can be managed to the point that most people find it satisfactory,” Dr. Gillespie said.

Otolaryngologists should educate snorers about possible health implications as they work to find solutions

Careful Assessment Is Key to Appropriate Treatment

Because at least 50% of snorers have obstructive sleep apnea (OSA), most otolaryngologists recommend an overnight sleep study for all patients who complain of snoring. If the study confirms the presence of sleep apnea, the patient is treated for sleep apnea. If OSA is ruled out, a careful history and physical exam are conducted to identify the anatomical sites that may be contributing to snoring.

“In the past, we used to think that all snoring came from the uvula and soft palate, so that’s where a lot of treatments were focused,” Dr. Gillespie said. “Now, through the use of drug-induced sleep endoscopy and observation of the airway in real time, we realize that there are multiple areas of vibration in the upper airway that can create the snoring sound, including the soft palate, the uvula, the lateral walls of the throat, tongue tissues, and epiglottis. Certainly, nasal congestion and a tight nasal cavity can also contribute. Our goal is to find which sites are contributing and try to treat those.”

An overall assessment of the patient’s health and lifestyle is also essential, because obesity, alcohol use, allergies, acid reflux, and sleep position can also contribute to snoring. If any of these lifestyle factors are evident, it’s prudent to suggest lifestyle modifications before turning to invasive treatment.

“The reality is that intervening surgically on somebody who needs to lose 10 pounds isn’t the best way to proceed,” said David Volpi, MD, a sleep specialist based in New York City. And, because primary snoring treatment is typically not covered by health insurance, many patients are willing to try low-cost lifestyle changes first.

Nasal-Based Snoring Treatments

For patients who report nasal congestion, allergies, or mouth-breathing during sleep, the nose may be the most appropriate site of intervention. Nasal steroid sprays, oral anti-inflammatory medication, and antihistamines are often used as first-line treatments.

If physical exam shows narrowed nasal passages or anatomic obstruction, such as a deviated septum or enlarged adenoids, nasal surgery may be the best approach; however, otolaryngologists should be careful about offering nasal surgery as the primary intervention for snoring, said Brian Rotenberg, MD, associate professor and division chief of rhinology at Western University in London, Ontario.

“In and of itself, it’s unlikely to be effective,” Dr. Rotenberg said. Additional procedures may be needed to address other contributing factors. “Coupling nasal surgery with the appropriate throat and palate procedures can really help people have a much better night’s sleep and improve their snoring.”

Oral Interventions

If the tongue appears to contribute to snoring, patients can try an oral appliance to bring the mandible forward during sleep. Although some otolaryngologists will prescribe and fit oral appliances, many send patients to a dentist who specializes in sleep disorders.

Radiofrequency ablation of the tongue is another option for patients with excess tissue.

The most common and popular interventions for primary snoring are those that target the soft palate, including injection snoreplasty, radiofrequency ablation, and surgical implants. The decision about which procedure to use often comes down to patient and provider preference. Dr. Volpi, for instance, offers patients a choice. “I describe both radiofrequency ablation and the Pillar procedure to the patient. The success rate is about the same for both procedures,” he said. “A lot of patients just don’t want something permanently implanted in them if they can avoid it, and the radiofrequency procedure avoids that.”

It’s important to note that scar tissue created by radiofrequency “may start to soften over two or three years and may require repeat applications in the future,” Dr. Gillespie said.

Pillar implants, on the other hand, remain in the tissue and help maintain stiffness over time; however, “palatal implants are a really great example of a small intervention that means a small result,” Dr. Rotenberg said. “You’re not going get a huge bang for your buck, but you will get some noticeable improvements. If people are okay with that, then that’s perfectly fine.”

Patients who continue to have bothersome snoring after palatal implants may require additional surgery. “At that point in time, I’d do either a uvulopalatal flap or an expansion sphincterectomy, depending on the patient’s anatomy,” Dr. Rotenberg said.

Combination Treatments

One option used by some otolaryngologists, sometimes in conjunction with a dentist, is combination treatments. “I partner with a sleep dentist, and when we have a patient who wants maximum snoring reduction, we do a brief sedation and examine their airway to see where the snoring is coming from. Often, while they’re sedated, we’ll go ahead and do a nasal turbinate reduction to open the nasal passage, place Pillar implants to stiffen the soft palate, and fit them with an oral appliance,” Dr. Gillespie said. “We treat all three levels of the airway. It’s really the only way, I think, to get maximum snoring reduction.”

Such an approach can be convenient for both the patient and practitioner, in terms of scheduling, but can involve more discomfort than would be experienced after a single procedure, because more sites are involved. Physicians should carefully discuss the risks, benefits, and expected recovery process with patients.

“Some patients are not willing to consider combination approaches, but if they are, these multilevel approaches can be helpful,” said Eric Kezirian, MD, MPH, professor of clinical otolaryngology-head and neck surgery at the University of Southern California Keck School of Medicine in Los Angeles and president of the International Surgical Sleep Society.

Outcomes

It can be difficult to assess the effectiveness of snoring treatments, in both the short- and long-term, in large part because there is no good way to objectively assess snoring. Often, the standard for success is whether or not the bed partner remains annoyed. That said, “the studies we have basically suggest the results are improved noticeably with these treatments in the right patients,” Dr. Kezirian said. “However, results tend to get worse over time.” Whether that’s because scar tissues soften over time, because patients tend to gain weight over time, or because patients and partners perhaps overemphasize the benefits of snoring interventions immediately post-procedure is hard to say.

“Based on data, most snoring interventions are going to be temporary,” Dr. Kezirian said. “I never tell a patient they’re going to be cured forever.”

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Jennifer LW Fink is a freelance medical writer based in Wisconsin.