What are the treatment options for snoring?

Treatment Options for Snoring

For primary snoring without obstructive sleep apnea, mandibular advancement devices (oral appliances) are the most effective evidence-based treatment, with high-quality evidence showing significant reductions in snoring frequency and loudness. 1

Initial Assessment and Risk Stratification

Before initiating treatment, you must distinguish between primary (simple) snoring and snoring associated with obstructive sleep apnea (OSA), as this fundamentally changes management:

• All patients with snoring should be screened for OSA symptoms including witnessed apneas, excessive daytime sleepiness, morning headaches, and cardiovascular comorbidities 1
• Polysomnography or alternative sleep testing is indicated when snoring is accompanied by symptoms suggesting OSA 1
• Primary snoring can be treated without objective sleep testing, though annual re-evaluation is recommended 1

First-Line Treatment Approaches

Weight Reduction (If Overweight/Obese)

Weight loss should be the initial intervention for any snoring patient with elevated BMI, as it addresses the fundamental pathophysiology of upper airway narrowing:

• Dietary weight reduction decreases snoring severity and improves breathing patterns, sleep quality, and daytime sleepiness 1, 2
• Weight loss through diet can reduce apnea-hypopnea index by 44% in those with concurrent OSA 2
• This recommendation applies regardless of whether OSA is present 1

Mandibular Advancement Devices (Oral Appliances)

For primary snoring, custom-fitted oral appliances provide the strongest evidence for efficacy:

• High-quality evidence demonstrates significant reductions in snoring frequency (278 fewer snores per hour), nights per week with snoring (1.9 fewer nights), and loudness (3.31 points lower on 1-10 scale) 1
• Custom, titratable devices are superior to non-titratable versions and should be the standard 1
• Oral appliances also improve quality of life with moderate-quality evidence 1

For mild-to-moderate OSA with snoring, mandibular advancement devices are recommended with Grade A evidence (highest level), showing reductions in AHI, improvements in oxygen saturation, and decreased arousal index 1, 2

Practical Implementation of Oral Appliances

• Fitting and titration must be performed by a qualified dentist trained in sleep medicine 1
• Follow-up schedule: every 6 months for the first year, then annually thereafter 1
• Common side effects are mild and temporary: hypersalivation, dry mouth, dental discomfort, jaw pain—most resolve within weeks 1
• Long-term monitoring is essential for dental changes including decreased overbite/overjet and tooth movement 1

Behavioral and Conservative Measures

Lifestyle Modifications

• Avoid alcohol and sedatives before sleep, as they increase upper airway collapsibility 3, 4
• Positional therapy (avoiding supine sleep position) may provide moderate benefit in younger, less obese patients with positional snoring, but compliance is poor long-term and it is clearly inferior to other treatments 1, 2
• Sleep hygiene optimization should be implemented universally 5

Nasal Interventions

• Intranasal corticosteroids are recommended only for children with mild OSA and concurrent rhinitis/adenotonsillar hypertrophy (Grade B evidence) 1, 2
• Nasal dilators (internal or external) are NOT recommended for snoring treatment, as they show no significant effect on snoring severity, sleep architecture, or breathing disorders (Grade D evidence) 1
• Nasal surgery alone is NOT recommended for snoring or OSA treatment (negative recommendation, Grade C) 1, 2

Surgical Options

When to Consider Surgery

Surgery should be reserved for carefully selected patients with specific anatomical findings:

• Tonsillectomy is recommended in adults with tonsillar hypertrophy causing obstruction (Grade C) 1, 2
• Adenotonsillectomy is first-line treatment for pediatric OSA with adenotonsillar hypertrophy (Grade C) 1, 2

Procedures NOT Recommended

• Uvulopalatopharyngoplasty (UPPP) can only be considered in highly selected patients with isolated oropharyngeal obstruction, weighing benefits against frequent long-term complications including velopharyngeal insufficiency and swallowing abnormalities (Grade C) 1, 2
• Laser-assisted uvulopalatoplasty has NO demonstrated benefit and is not recommended (negative recommendation, Grade B) 1, 2
• Injection snoreplasty is NOT recommended due to insufficient evidence 6
• Radiofrequency soft palate surgery has insufficient evidence and cannot be recommended except in very select mild cases 1

Interventions to Avoid

• Pharmacological therapy is NOT recommended for snoring or OSA treatment (Grade C for most medications, Grade B negative recommendation for mirtazapine and protriptyline) 1, 2
• Tongue muscle training improves snoring but is not efficacious for sleep apnea (negative recommendation, Grade B) 1, 2

Treatment Algorithm for Primary Snoring

1. Assess BMI: If >25 kg/m², initiate weight reduction program 2
2. Screen for OSA: If symptoms present, obtain sleep study before proceeding 1
3. For confirmed primary snoring: Fit custom, titratable mandibular advancement device 1
4. Implement lifestyle modifications: Alcohol avoidance, sleep position optimization 5, 3
5. Schedule follow-up: 6-month intervals first year, then annually 1
6. Re-evaluate annually: Assess for development of OSA symptoms 1

Critical Pitfalls to Avoid

• Do not treat snoring without screening for OSA—missing OSA diagnosis can lead to serious cardiovascular and metabolic consequences 1, 5
• Do not recommend nasal dilators or strips—they have no evidence of efficacy despite widespread marketing 1
• Do not perform palatal surgery without careful patient selection—complications are common and benefits uncertain 1, 2
• Do not use non-custom or non-titratable oral appliances—they are significantly less effective 1
• Do not assume snoring will improve spontaneously—natural history shows progression over time, especially with weight gain 1