HNY Policy and Pathway Repository - York

Loud respiratory noises created by the upper airways during sleep. This is common both in men and women and can occur in children. Although not necessarily a medical condition it can cause significant distress for patients (e.g. impact on relationships). Factors contributing or leading to it include:

• Partial inflammatory air way obstruction (e.g. due to infection, adeno-tonsillar hypertrophy, chronic rhinitis etc.).
• Enlarged uvula.
• BMI > 25.
• Side effects of medications (e.g. hypnotics, muscle relaxants etc.) or alcohol.
• Other factors affecting circadian rhythm and quality / depth of sleep (e.g. night shift work, jet-lag etc.).

Exclude Red Flag Symptoms

• Symptoms or signs suggesting possible obstructive sleep apnoea (Epworth scale); in this case refer to respiratory medicine for sleep studies.
• Any possibly abnormal growths, swellings etc. in the head and neck area.
• Stridor or voice changes.
• Swallowing problems.

General Points

Snoring is very common and it can be difficult to draw the line, where it becomes a “medical condition”
 

Management

• Check BMI and advise patient, that reducing it to healthy levels is likely to be an important.
• Inspect nose and oral cavity for possible physiological obstruction (uvula, tonsils, tongue).
• Check cervical glands and palpate thyroid gland.
• For children: consider general health and growth of child, daytime sleepiness and behavioural problems when trying to assess significance of possible nocturnal obstruction.
• Advice smoking, alcohol intake, normal weight.
• Some patients benefit from “postural training” to avoid supine sleeping position (e.g. by sewing a tennis ball or marble into the mid-back of their pyjama top).
• Consider seeking advice from their dentist, e.g. on mandibular advancement devices.
• Consider a trial of steroid nasal sprays for at least one month at a time.
• Give advice on “sleep hygiene” (aim for several hours sleep before midnight, avoid frequent day time snoozing etc.)
• There is little or no evidence for the efficacy of nose clips, magnets, accu-pressure devices etc. which are often advertised in mass media.
• In most cases surgical options are limited to improve outcomes.
• Adeno-tonsillar hypertrophy in children usually resolves with time.
   
• Do an Epworth score if indicated. If sleep apnoea is suspected refer to respiratory medicine for further assessment (sleep studies) and potential treatment (CPAP).
   

Outcome

A lot of snoring problems can be managed with life-style advice, BMI and alcohol control, positional improvement and “sleep hygiene”. Specialist options are generally limited.

Indications for referral

• Suspected sleep apnoea (clinically, high Epworth score): please refer to respiratory medicine for sleep studies, not to ENT
• Persistent severe snoring symptoms, which are unresponsive to normalised BMI or nonmedical lifestyle interventions (sleeping position training, alcohol reduction etc.), as outlined above
   

Information to include in referral letter

• Timeline, severity, impact on daily living.
• Known variation of intensity, triggers. 
• BMI, smoking, alcohol intake. Note: these should have been worked on, if needed, before a referral; otherwise the referral may well be returned with the advice to allow more time for normalisation.
• Current medications and significant co-morbidities.
• Actions attempted so far (medical and non-medical).
• Patient’s understanding and expectation regarding options in a specialist service setting.
   

Investigations prior to referral

• Consider TFT if suspected thyroid problem Referral Criteria
• Please aim to avoid referring obese patients, because weight loss may be the main intervention needed to improve or resolve snoring.
• See above under indications for referral

Patient Information Leaflet

http://www.britishsnoring.co.uk/
 

References

http://guidance.nice.org.uk/IPG240