Effect of hypoglossal nerve stimulation on snoring: an evaluation using objective acoustic parameters.

STUDY OBJECTIVES: Hypoglossal nerve stimulation is an established therapy for sleep apnea syndrome. Whether or not this therapy on snoring and nighttime noise exposure is effective and how strong this effect may be has not been objectively investigated thus far and was the aim of this study. METHODS: In 15 participants (14 males; age: 30-72 years; mean: 51.7 years), polysomnography and acoustic measurements were performed before and after hypoglossal nerve stimulation. RESULTS: The therapy led to a significant improvement in sleep apnea (apnea-hypopnea index from 35.8 events/h to 11.2 events/h, P < .001). Acoustic parameters showed a highly significant reduction in the average sound pressure level (42.9 db[A] to 36.4 db[A], P < .001), averaged sound energy, A-weighted (LAeq; 33.1 db[A] to 28.7 db[A], P < .001), snoring index (1,068 to 506, P < .001), percentage snoring time (29.7-14.1%, P < .001), and psychoacoustic snore score, the latter being a measure of annoyance due to snoring (47.9 to 24.5, P < .001). CONCLUSIONS: This study was able to show for the first time by means of objective acoustic and psychoacoustic parameters that hypoglossal nerve stimulation can not only cause a significant improvement in sleep apnea but also has a positive effect on snoring and thus noise annoyance experienced by the bed partner. CLINICAL TRIAL REGISTRATION: Registry: German Clinical Trials Register; Name: Effect of Hypoglossal Nerve Stimulation on Snoring: An Evaluation Using Objective Acoustic Parameters; URL: https://drks.de/search/de/trial/DRKS00032354; Identifier: DRKS00032354. CITATION: Fischer R, Vielsmeier V, Kuehnel TS, et al. Effect of hypoglossal nerve stimulation on snoring: an evaluation using objective acoustic parameters. J Clin Sleep Med. 2024;20(3):363-370.

Snoring Patterns During Hypoglossal Nerve Stimulation Therapy Up-Titration.

Longitudinal snoring changes can be captured using a mobile phone application. During hypoglossal nerve stimulator (HNS) therapy up-titration, increasing stimulation voltage was associated with reduced snoring frequency and intensity in this case series of six patients. Laryngoscope, 134:987-992, 2024.

Fractional exhaled nitric oxide-a possible biomarker for risk of obstructive sleep apnea in snorers.

STUDY OBJECTIVES: Airway inflammation in patients with obstructive sleep apnea (OSA) has been described and can be assessed by measuring the biomarker fractional exhaled nitric oxide (FeNO). In this pilot study, we investigated FeNO measurements in identification of OSA among persons with snoring. METHODS: In this study we aimed to investigate (1) if FeNO could be used in screening for OSA, (2) if daytime sleepiness correlated to FeNO levels, and (3) whether asthma affected FeNO levels. Persons with snoring were prospectively included in three primary care ear, nose, and throat clinics. Patients underwent spirometry, FeNO tests, and partial polygraphy. They filled out questionnaires on sinonasal and asthma symptoms, daytime sleepiness, and quality of life. Current smokers, patients with upper airway inflammatory conditions, and patients treated with steroids were excluded. RESULTS: Forty-nine individuals were included. Median apnea-hypopnea index was 11.4, mean age was 50.9 years, and 29% were females. OSA was diagnosed in 73% of the patients of whom 53% had moderate-severe disease. Patients with moderate-severe OSA had significantly higher FeNO counts than patients with no or mild OSA (P = .024). Patients younger than 50 years with a FeNO below 15 had the lowest prevalence of moderate-severe OSA. No correlation was found between FeNO measurements and daytime sleepiness, and asthma did not affect FeNO levels. CONCLUSIONS: We found a low prevalence of moderate-severe OSA in persons with snoring when FeNO and age were low. This might be considered in a future screening model, though further studies testing the FeNO cutoff level and the diagnostic accuracy are warranted. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: NO Measurements in Screening for Asthma and OSA, in Patients With Severe Snoring; URL: https://clinicaltrials.gov/study/NCT03964324; Identifier: NCT03964324. CITATION: Kiaer E, Ravn A, Jennum P, et al. Fractional exhaled nitric oxide-a possible biomarker for risk of obstructive sleep apnea in snorers. J Clin Sleep Med. 2024;20(1):85-92.

Exploring acupuncture treatment strategies for snoring based on meridian theory. / 基于经络学说探析鼾症的针刺治疗思路.

Starting from the perspective of meridian theory, this article briefly analyzes the meridian pathophysiology of snoring and the relationship between snoring and meridian theory. It proposes that acupuncture treatment for snoring should focus on regulating qi from the shaoyang meridians, harmonizing the spirit by the governor vessel, resolving phlegm through the three yang meridians, and harmonizing qi and blood from the yangming meridians. Additionally, attention is placed on both the root cause and the symptoms, the theory of "four seas". The ultimate goal is to promote the flow of meridian and qi-blood, improve symptoms such as nighttime snoring, poor sleep quality, and daytime sleepiness, and achieve the desired outcome of stopping snoring and ensuring restful sleep.

[Clinical thinking of acupuncture for snoring based on "disharmony qi leads to restlessness"].

This study summarizes the clinical thinking of acupuncture for snoring based on "disharmony qi leads to restlessness". According to the pathological characteristics of qi stagnation and blood stasis, phlegm dampness and internal obstruction in snoring patients, combined with the etiology, pathogenesis and location of the disease, the innovative viewpoint of "disharmony qi leads to restlessness" is proposed. It is believed that the key to snoring treatment lies in "regulating qi ". In clinical practice, acupuncture can directly regulate the qi of the disease's location, regulate the qi of the organs and viscera, and regulate the qi of the meridians to achieve overall regulation of the body's internal and external qi, smooth circulation of qi and blood, and ultimately achieve the therapeutic goal of harmonizing qi, stopping snoring, and improving sleep quality.

Dental Appliance Therapy in the Treatment of Snoring and Obstructive Sleep Apnea.

People who snore have an increased risk of obstructive sleep apnea (OSA). Both of these conditions have a strong association with the potential development of cardiovascular disease. The use of oral appliances for OSA has been found to be equivalent to continuous positive airway pressure (CPAP) at reducing blood pressure in adults, and oral appliance therapy (OAT) has higher compliance than CPAP. Oral appliances give tonus to the muscles of the throat, specifically the velopharynx and oropharynx, via mandibular positioning. Used to treat both snoring and OSA, oral appliances are designed to maintain and/or advance the mandible while the user is in the supine position. An effective oral appliance is titratable, durable, retentive, adjustable, comfortable, and minimally invasive, providing marginal tooth movement and reducing the risk of temporomandibular disorder or joint pain. This article discusses the function and design of and materials used for optimal OAT to treat snoring and OSA.

[A PhD completed. Developments in diagnosis and treatment of obstructive sleep apnea]. / Serie: Hora est. Ontwikkelingen in de diagnostiek en behandeling van obstructieve slaapapneu.

Identification of phenotypes and endotypes contributes to a better understanding of the complex pathophysiology and heterogeneous clinical presentation of obstructive sleep apnea. The general goal of this dissertation was to determine the added value of the identification and use of potential predictors; risk factors associated with obstructive sleep apnea and factors influencing treatment outcome. By identifying predictors, the specificity and sensitivity of diagnostic tools can be increased. In addition, these predictors can provide guidance in choosing from the treatment options, which could subsequently lead to an increase in treatment success. The phenotypes studied in this dissertation are: snoring sound, dental parameters and positional dependency. The predictive value of specific manoeuvres and tools during sleep endoscopy for treatment success with a mandibular repositioning device was also studied. Finally, the innovative treatment for obstructive sleep apnea, hypoglossal nerve stimulation was investigated.

Preliminary short-term outcomes of rapid maxillary expansion on periodic limb movements during sleep in pediatric sleep-disordered breathing.

OBJECTIVE: To assess the short-term outcome of rapid maxillary expansion (RME) on periodic limb movement disorder (PLMD) in children with residual snoring after late adenotonsillectomy (AT). METHODS: This prospective clinical trial included 24 patients treated with rapid maxillary expansion (RME). Participants' inclusion criteria were children with maxillary constriction aged 5-12 years who had AT for more than two years and those whose parents/guardians reported that they still snored ≥4 nights per week. Of which 13 had primary snoring, and 11 had OSA. All patients underwent laryngeal nasofibroscopy evaluation and complete polysomnography. The Quality of life (QOL) Questionnaire (OSA-18), the Pediatric Sleep Questionnaire (PSQ), the Conners Abbreviated Scale (CAE), and the Epworth Sleep Scale (ESS) were applied before and after palatal expansion. RESULTS: The OSA 18 domain, PSQ total, CAE, and ESS scores were significantly reduced in both groups (p < 0.001). There was a decrease in PLMS indices. In the total sample, the mean decreased significantly from 4.15 to 1.08. In the Primary Snoring group, the mean decreased from 2.64 to 0.99; in the OSA group, the average decreased significantly from 5.95 to 1.19. CONCLUSION: This preliminary study suggests that the improvement of PLMS in the OSA group with maxillary constriction is correlated with a favorable neurological impact of the treatment. We suggest a multi-professional approach to the treatment of sleep disorders in children.

Mandibular Distalisation for Tooth Wear in Patients Requiring Mandibular Protrusion for Sleep Apnoea.

BACKGROUND: Pathological tooth wear is an increasing concern and may require intervention and occlusal rehabilitation. Often the treatment includes distalisaton of the mandible to restore the dentition in centric relation. Obstructive sleep apnoea (OSA) is another condition treated my mandibular repositioning but in this case by an advancement appliance. The authors have a concern that there could be a group of patients with both conditions where distalisation for their tooth wear management would be contrary to their OSA treatment. This paper aims to look at this potential risk. METHODS: A literature search was carried out using the following keywords (OSA or sleep apnoea or apnea or snoring or AHI or Epworth score) and for tooth surface loss (TSL or distalisation or centric relation or tooth wear or full mouth rehabilitation). RESULTS: No studies were identified which considered the effect of mandibular distalisation on OSA. CONCLUSION: There is a theoretical risk that dental treatment involving distalisation may adversely affect patients at risk of OSA or worsening their condition due to the modification of airway patency. Further study is recommended.

Australasian Sleep Association position statement on consensus and evidence based treatment for primary snoring.

Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence-based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are: Weight loss, and reduced alcohol consumption should be recommended, where appropriate If clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advised Positional therapy should be considered in supine dominant snorers In dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physician Continuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to try Surgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non-surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association.

New non-invasive electrical stimulation devices for treatment of snoring and obstructive sleep apnoea: a systematic review.

INTRODUCTION: Recently, new non-invasive electrical stimulation devices have been developed with the aim to increase the tongue muscle tone for patients with obstructive sleep apnoea (OSA) and snorers. The aim of this study was to provide a review of the first results found in the literature regarding the efficacy of non-invasive electric stimulation devices for the treatment of primary snoring and OSA. MATERIAL AND METHODS: An electronic search was performed on PubMed/MEDLINE, Google Scholar, and Ovid databases. The PRISMA statement was followed. Databases were searched from inception through September, 2021. RESULTS: Four studies met the criteria for inclusion in this review, for a total of 265 patients. Two devices were included in this review, Apone-Stim 400 Muscle Stimulator and eXciteOSA. All studies suggested that these new devices are effective in improving snoring by approximately 50% after device training, without major complications. However data regarding OSA improvement are conflicting. CONCLUSIONS: Intraoral non-invasive electrical stimulation devices can be considered a valid option to current therapies for snoring. Further studies are needed to support these interesting new devices for treatment of OSA.

Transoral awake state neuromuscular electrical stimulation therapy for mild obstructive sleep apnea.

INTRODUCTION: Obstructive sleep apnea (OSA) is a common disorder with major neurocognitive and cardiovascular sequelae. The treatment of symptomatic patients with mild OSA remains controversial given that adherence to positive airway pressure (PAP) has historically been suboptimal. With this notion in mind, we assessed a daily transoral neuromuscular electrical stimulation (NMES) device for individuals with mild OSA. METHODS: The sample represents a subset of participants with a baseline AHI 5-14.9 events/hour, drawn from a parent study which also included participants with primary snoring. Outcome measures for the current study included changes in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and snoring levels before and after use of the NMES.  RESULTS: Among 65 participants (68% men) with median age of 49 years (range 24 to 79) and median BMI of 27.7 kg/m2 (range 20 to 34), the NMES device was used daily for 6 weeks. We observed a significant improvement in the AHI from 10.2 to 6.8 events/hour among all participants and from 10.4 to 5.0 events/h among responders. Statistically significant improvements in the ESS, PSQI, objectively measured snoring, and bed partner-reported snoring were observed. Adherence among all participants was 85%. DISCUSSION: This NMES device has the benefit of being a treatment modality of daytime therapy which confers a high level of tolerability and patient acceptance. It alleviates the need for an in situ device during sleep and leads to improvements in OSA severity, snoring, and subjective sleep metrics, potentially crucial in mild OSA. Further studies are needed to define which individuals may benefit most from the device across the wider spectrum of OSA severity and assess long-term therapeutic outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03829956.

Adherence and efficacy of mandibular advancement splint treatment of sleep-disordered breathing during pregnancy: a pilot study.

PURPOSE: Sleep-disordered breathing (SDB) is common in pregnancy and is associated with adverse health consequences for both mother and child. Mandibular advancement splints (MAS) have been shown to improve sleep quality, daytime sleepiness and snoring in non-pregnant women. The effectiveness of MAS for treating SDB in pregnancy is unknown. This pilot study aimed to evaluate the efficacy and adherence to MAS in pregnant women with SDB. METHODS: Women with mild-moderate SDB (apnea-hypopnea index (AHI) 10-29/h) on level 2 polysomnography (PSG) performed at 22.0 ± 5.5 weeks' gestation were treated with a MAS during pregnancy to 6 months postpartum. An embedded micro-recorder measured adherence. PSG was repeated while on titrated treatment, and off treatment in the postpartum period. RESULTS: Among 17 women completing the study, MAS was worn ≥ 4 h/night for 57.5 ± 36.7% of nights during the antepartum period. While using MAS, nightly snoring time decreased from 25.9 ± 24.5% at baseline to 6.4 ± 7.8% when treated during pregnancy (p = .003). AHI decreased from 17.6 ± 5.1 to 12.9 ± 6.3 (p = .02) and fell by ≥ 30% and below 15/h in 60% of participants. During the postpartum period, MAS was used for ≥ 4 h/night on 24.8 ± 27.9% of nights. Moreover, the mean AHI off MAS was 17.9 ± 13.1; 88% of women had persistent SDB (AHI ≥ 10). CONCLUSIONS: In this cohort, treatment efficacy and objective adherence were variable. Device use was less frequent in the postpartum period even though a substantial number of women had persistent SDB after delivery. Clinical trial registered with  www. CLINICALTRIALS: gov number: NCT03138291.

Obstructive sleep apnea hypopnea syndrome in ancient traditional Chinese medicine.

In western medicine, obstructive sleep apnea hypopnea syndrome (OSAHS) is an increasingly serious public health hazard, which is exacerbated by the obesity epidemic and an aging population. Ancient medical literature of traditional Chinese medicine (TCM) also recorded OSAHS-like symptoms but described the disease from a completely distinct theoretical perspective. The earliest records of snoring in ancient China can be traced back 2500 years. In TCM, the pathogenesis of OSAHS can be attributed mainly to turbid phlegm and blood stasis. Various TCM prescriptions, herbal medicines, and external therapy have also been proposed for the prevention and therapy of OSAHS. Some of these strategies are still used in current clinical practice. This review highlights historical characterizations of OSAHS and the theory of TCM and also explores its therapy in TCM, which may shed light on future OSAHS research. This is the first systematic English review of the role of TCM in the treatment of OSAHS.

Evaluation of nasal airway resistance in a cohort of children with primary snoring and maxillary deficiency.

BACKGROUND: The aim of this study was to test whether rapid palatal expansion is effective to improve nasal airway patency in a sample of pediatric patients with primary snoring. METHODS: A group of 21 subjects, 11 girls (52%) and 10 boys (48%), with a mean age of 7.1 years (SD=1.3; range 4-9 years) were treated with a rapid maxillary expansion (RME) device. Nasal airway resistance was assessed via rhinomanometric exam before (pre-) and 6 months after (post-) the rapid palatal expansion treatment. RESULTS: Data analysis showed a statistically significant increase in the mean scores of the results of the rhinomanometric exam between the pre- and post-measurements with a significant reduction in total inspiratory and expiratory air resistance values after rapid palatal expansion. CONCLUSIONS: Our results show that RME treatment is associated with an improvement in nasal airway resistance due to a substantial reduction in nasal resistance associated with the orthopedic action of the orthodontic device.

Orofacial Pain and Snoring/Obstructive Sleep Apnea in Individuals with Head and Neck Cancer: A Critical Review.

AIMS: (1) To summarize current knowledge on the prevalence, intensity, and descriptors of orofacial pain and snoring/obstructive sleep apnea (OSA) before and after head and neck cancer (HNC) treatment; and (2) to propose future directions for research. METHODS: The median prevalence for each condition was estimated from the most recent systematic reviews (SRs) and updated with new findings retrieved from the PubMed, Web of Science, Embase, and Cochrane databases up to December 2021. RESULTS: The prevalence of HNC pain seems relatively stable over time, with a median of 31% before treatment in three studies to a median of 39% at 1 month to 16 years after treatment in six studies. HNC pain intensity remains mild to moderate. There was a threefold increase in temporomandibular pain prevalence after surgery (median 7.25% before to 21.3% after). The data for snoring prevalence are unreliable. The OSA/HNC prevalence seems relatively stable over time, with a median of 72% before treatment in three studies to 77% after treatment in 14 studies. CONCLUSION: With the exception of temporomandibular pain, the prevalence of HNC pain and OSA seems to be stable over time. Future studies should: (1) compare the trajectory of change over time according to each treatment; (2) compare individuals with HNC to healthy subjects; (3) use a standardized and comparable method of data collection; and (4) assess tolerance to oral or breathing devices, since HNC individuals may have mucosal sensitivity or pain.

Evaluation and Management of Snoring.

Snoring can be harmless (primary) or a symptom of sleep-disordered breathing (secondary) and should alert the physician to evaluate the patient for risks thereof. Phenotypes of snoring and sleep-disordered breathing (SDB) are anatomic and nonanatomic and identifying these phenotypes and their interrelationships are critical to effective therapy. Mouth breathing alerts the physician to nasal airway obstruction, signals orofacial growth changes in children, and heralds the progression of SDB. Systematic evaluation to establish phenotypes includes assessing sleep habits, comorbidities, upper airway examination, polysomnography, and drug-induced sleep endoscopy. Strategies for treatment should be personalized and precise to the phenotype(s) to achieve the most benefit.

IoT snoring sound detector prototype as a model of future participatory healthcare.

BACKGROUND: Traditional healthcare is centred around providing in-hospital services using hospital owned medical instruments. The COVID-19 pandemic has shown that this approach lacks flexibility to insure follow-up and treatment of common medical problems. In an alternative setting adapted to this problem, participatory healthcare can be considered centred around data provided by patients owning and operating medical data collection equipment in their homes. OBJECTIVE: In order to trigger such a shift reliable and price attractive devices need to become available. Snoring, as a human sound production during sleep, can reflect sleeping behaviour and indicate sleep problems as an element of the overall health condition of a person. METHODS: The use of off-the-shelf hardware from Internet of Things platforms and standard audio components allows the development of such devices. A prototype of a snoring sound detector with this purpose is developed. RESULTS: The device, controlled by the patient and with specific snoring recording and analysing functions is demonstrated as a model for future participatory healthcare. CONCLUSIONS: Design of monitoring devices following this model could allow market introduction of new equipment for participatory healthcare, bringing a care complementary to traditional healthcare to the reach of patients, and could result in benefits from enhanced patient participation.

El paciente roncador: evaluación y alternativas terapéuticas / The snoring patient: evaluation and therapeutic alternatives

El ronquido es un problema altamente prevalente, que afecta a millones de personas a nivel mundial. Impacta negativamente en la calidad de vida al afectar la relación de pareja y la calidad de sueño, además de constituir un factor de riesgo cardiovascular. El objetivo de esta revisión es analizar y discutir los aspectos más relevantes de esta condición, desde su etiopatogenia hasta las diferentes alternativas terapéuticas disponibles. En la evaluación del paciente roncador se debe realizar un minucioso examen de nariz, boca, faringe, cuello y esqueleto facial, además de estimar el riesgo de que exista una apnea obstructiva del sueño asociada. Son de utilidad una serie de cuestionarios que permiten asignar puntaje a la sintomatología del paciente y evaluar su impacto en la vida diaria. En general, el estudio deberá incluir exámenes radiológicos, endoscopías de la vía aérea superior (con el paciente despierto y bajo sueño inducido por medicamentos) y estudios del sueño, que se pueden realizar tanto en forma ambulatoria como hospitalizado. Existe una amplia gama de tratamientos disponibles para el ronquido, los que han demostrado una alta efectividad en diferentes subgrupos de pacientes: bajar de peso, dejar de fumar, medicamentos antialérgicos, terapia postural, ejercicios faríngeos, dispositivos de avance mandibular y procedimientos quirúrgicos que van desde intervenciones mínimamente invasivas hasta procedimientos avanzados como cirugía robótica, avances máxilo-mandibulares y la estimulación del nervio hipogloso. Es clave para manejar exitosamente el ronquido el realizar una evaluación detallada del paciente y establecer un plan terapéutico personalizado.

Snoring is a highly prevalent problem, affecting millions of people worldwide. It negatively impacts quality of life by affecting couple relationships and sleep quality, as well as being a cardiovascular risk factor. The aim of this review article is to analyze and discuss the most relevant aspects of this condition, ranging from its etiology and pathogenesis to the different available therapeutic options. When evaluating a snoring patient, a thorough examination of the nose, mouth, pharynx, neck and facial skeleton should be performed, and the risk of having an associated obstructive sleep apnea must be estimated. A series of questionnaires are useful to assign scores to the patient's symptoms and assess their impact on daily life. In general terms, patient evaluation should include radiological examinations, upper airway endoscopies (awake and under drug-induced sleep) and sleep studies, which can be performed both on an outpatient or inpatient basis. There is a wide range of treatments available for snoring, which have shown high effectiveness in different patient subgroups: weight loss, quitting smoking, anti-allergic medications, postural therapy, pharyngeal exercises, mandibular-advancement devices and surgical procedures ranging from minimally invasive interventions to advanced procedures such as robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. The cornerstone for a successful snoring management is to perform a detailed patient evaluation and to establish a personalized therapeutic plan.