Diagnosis and treatment of snoring in adults-S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery.

OBJECTIVES: This guideline aims to promote high-quality care by medical specialists for subjects who snore and is designed for everyone involved in the diagnosis and treatment of snoring in an in- or outpatient setting. DISCUSSION: To date, a satisfactory definition of snoring is lacking. Snoring is caused by a vibration of soft tissue in the upper airway induced by respiration during sleep. It is triggered by relaxation of the upper airway dilator muscles that occurs during sleep. Multiple risk factors for snoring have been described and snoring is of multifactorial origin. The true incidence of snoring is not clear to date, as the incidence differs throughout literature. Snoring is more likely to appear in middle age, predominantly in males. Diagnostic measures should include a sleep medical history, preferably involving an interview with the bed partner, and may be completed with questionnaires. Clinical examination should include examination of the nose to evaluate the relevant structures for nasal breathing and may be completed with nasal endoscopy. Evaluation of the oropharynx, larynx, and hypopharynx should also be performed. Clinical assessment of the oral cavity should include the size of the tongue, the mucosa of the oral cavity, and the dental status. Furthermore, facial skeletal morphology should be evaluated. In select cases, technical diagnostic measures may be added. Further objective measures should be performed if the medical history and/or clinical examination suggest sleep-disordered breathing, if relevant comorbidities are present, and if the subject requests treatment for snoring. According to current knowledge, snoring is not associated with medical hazard, and generally, there is no medical indication for treatment. Weight reduction should be achieved in every overweight subject who snores. In snorers who snore only in the supine position, positional treatment can be considered. In suitable cases, snoring can be treated successfully with intraoral devices. Minimally invasive surgery of the soft palate can be considered as long as the individual anatomy appears suitable. Treatment selection should be based on individual anatomic findings. After a therapeutic intervention, follow-up visits should take place after an appropriate time frame to assess treatment success and to potentially indicate further intervention.

Diagnosis and treatment of snoring in adults--S1 guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery.

INTRODUCTION: Snoring has received increased attention over the last years. Given its high prevalence and its impact on quality of life, diagnosis and treatment of snoring are of major importance. AIM OF THE GUIDELINE: This guideline aims to promote high-quality care by medical specialists for adults who snore. DIAGNOSTIC MEASURES: Before every intervention, a medical history, clinical examination and sleep test need to be performed. INTERVENTIONS: There is no need to treat snoring unless requested by the snorer. Invasive treatments should be selected with care; for surgical treatment, minimally invasive procedures are preferred. Weight reduction; the avoidance of sleeping pills, alcohol and nicotine; and a regular sleep-wake cycle can be recommended, although convincing evidence is lacking. Since currently, there is not enough evidence to confirm the effectiveness of muscle stimulation or other forms of muscle training, these treatments cannot be recommended. Snoring can be treated successfully with intraoral devices, but it is essential to select suitable subjects. Devices preventing sleep in the supine position can also be helpful in selected cases. The data on the success rates of surgical intervention are often limited to short-term follow-up studies, and not all interventions have been sufficiently evaluated. The techniques used to treat nasal obstruction in snorers are identical to those used for general nasal obstruction. Nasal surgery is only indicated when subjects complain about nasal obstruction. A significant amount of data is available for laser-assisted resection of excessive mucosa; however, resections can be performed with other tools. The efficacy of radiofrequency surgery at the soft palate has been documented in placebo-controlled trials. Soft palate implants can reduce snoring. Tonsillectomy or uvulopalatopharyngoplasty should be selected with care, especially as less invasive alternatives are available.

The annoyance of snoring.

Is the annoyance of snoring a reliable tool for the measurement of snoring or does it depend more on the sensitivity of the listener? During an automatized hearing experiment, 550 representative snoring sequences, recorded during polysomnography, were randomly presented to ten examiners for the evaluation of their annoyance (0-100). The mean annoyance score for each snoring sound and the covariance parameters for rater and snoring sounds (restricted maximum likelihood method) were calculated. The average annoyance rating of all snoring sequences was 63.9+/-23.0, the most acceptable snoring sequence rating was 49.2+/-28.0, the most annoying rating was 77.7+/-16.4. The covariance parameters were estimated as 28.7% for the rater and 22.3% for the snoring sound. Our results show that the listeners' noise sensitivity is at least equally relevant for the snoring annoyance as the snoring sound itself.

Tonsillotomy in the treatment of obstructive sleep apnea syndrome in children: polysomnographic results.

INTRODUCTION: The therapy of choice in the treatment of pediatric obstructive sleep apnea syndrome (OSAS) consists of tonsillectomy or tonsillotomy combined with adenoidectomy. While tonsillectomy unfortunately has a notable risk of secondary hemorrhage and postoperative pain, tonsillotomy is safer and less painful for children. The effect of both surgical methods on symptoms of OSAS seems to be equal, but up to now postoperative polysomnographic data for children treated by tonsillotomy are missing. MATERIALS AND METHODS: Twenty children aged 2-9 years (mean age: 4.1+/-2.0 years) with OSAS diagnosed by full-night polysomnography were included in the study. OSAS was defined as an apnea-hypopnea index (AHI) of 5 or more with minimum oxygen saturation (SaO(2) min) of less than 90%. Exclusion criteria were obesity, craniofacial abnormalities or other pulmonary, cardiac or metabolic diseases as well as a history of recurrent tonsillitis. All children were treated by CO(2) laser tonsillotomy and adenoidectomy. Three to 12 months (mean: 7.7 months) after the procedure a control-polysomnography was performed in all children. RESULTS: No statistically significant changes were seen in the pre- and postoperative distribution of sleep stages, sleep efficacy and total sleep time. The AHI decreased from 14.9+/-8.7 to 1.1+/-1.6 (p<0.001), SaO(2) min increased from 71.1+/-11.1% to 91.2+/-3.5% (p<0.001). Thus, all children were cured by the operation. DISCUSSION: These polysomnographic data show that CO(2) laser tonsillotomy in combination with adenoidectomy is highly effective in the treatment of pediatric OSAS and should be preferred over tonsillectomy because of less postoperative pain and a lower risk of postoperative bleeding.

Correlation between otorhinolaryngologic evaluation and severity of obstructive sleep apnea syndrome in snorers.

OBJECTIVES: To examine whether medical history and nasopharyngeal examination are useful for predicting obstructive sleep apnea syndrome (OSAS) and to compare these findings with those of the gold standard, polysomnography. DESIGN: Patients underwent polysomnography recordings for 2 nights and an otorhinolaryngologic examination, including flexible endoscopy and the Muller maneuver. Nasal and pharyngeal findings were scored in a semiquantitative way. The medical history of each patient was taken using a standardized questionnaire. Anatomic and functional findings and patient history were correlated with the mean apnea-hypopnea index (AHI). SETTING: An otorhinolaryngologic clinic. PATIENTS: A total of 101 patients presenting with a primary complaint of snoring. MAIN OUTCOME MEASURES: Differences between patients with OSAS and primary snorers were assessed using the Mann-Whitney test (anatomic findings), t test (Muller maneuver), and chi(2) test after Pearson correlation (questionnaire). P values less than .05 were considered statistically significant. RESULTS: The mean +/- SD AHI of the patients was 19.7 +/- 21.5); 52 patients had an AHI higher than 10, which confirmed the diagnosis of OSAS. These patients tended to report the occurrence of apneas more frequently than patients with an AHI of 10 or lower. The average ranks (Mann-Whitney findings) of patients with AHIs higher than 10 vs those with AHIs of 10 or lower were 52 vs 50 for septal deviation; 50 vs 52 for tonsil size; 53 vs 49 for low velum level; and 56 vs 46 for hyperplasia of the tongue base. None of these differences reached statistical significance. Mean +/- SD narrowing of the airway during the Müller maneuver was significantly (P<.05) more pronounced in patients with an AHI higher than 10 than in patients with an AHI of 10 or lower at the levels of the velum (80% +/- 20% vs 68% +/- 30%) and the tongue base (57% +/- 24% vs 44% +/- 27%). CONCLUSIONS: None of the reported medical history and/or anatomic parameters alone or in combination could be used to distinguish patients with OSAS from snoring patients. Snoring patients, therefore, should be examined at least by a nocturnal screening test for OSAS before any therapeutic decision is made.