What are the treatment options for snoring in non-obese individuals?

Treatment Options for Snoring in Non-Obese Individuals

For non-obese adults with snoring, the first priority is to determine whether this represents simple (primary) snoring or is a symptom of obstructive sleep apnea, as this distinction fundamentally changes management.

Initial Evaluation and Risk Stratification

The critical first step is distinguishing simple snoring from sleep-disordered breathing, as treatment pathways differ substantially 1, 2:

• Assess for OSA symptoms: witnessed apneic episodes, excessive daytime sleepiness, morning headaches, and cardiovascular comorbidities 3, 2
• Perform polysomnography if any concerning features are present, as snoring may signal underlying sleep-disordered breathing even in non-obese patients 3, 1
• Evaluate upper airway anatomy including flexible laryngoscopy to identify specific sites of obstruction 2
• Consider mouth breathing patterns, which indicate nasal obstruction and predict progression of sleep-disordered breathing 1

Treatment Algorithm Based on Diagnosis

For Simple Snoring (Without OSA)

Lifestyle modifications should be the foundation of treatment 4, 5:

• Weight optimization remains beneficial even in non-obese individuals, as any weight reduction improves upper airway patency 4
• Positional therapy can yield moderate reductions in snoring severity, particularly in younger patients with lower severity, though long-term compliance is poor (Grade C recommendation) 4
• Avoid sedatives and alcohol before sleep, as these worsen upper airway muscle tone 5, 6
• Sleep positioning to avoid supine position may help mild cases 5

Surgical and device-based options for simple snoring:

• Nasal dilators are NOT recommended for reducing snoring (Grade D recommendation) 4
• Nasal surgery alone cannot be recommended as a single intervention (negative Grade C recommendation) 4
• Pillar implants may be considered in carefully selected patients with mild symptoms who have suitable anatomy (not obese, small tonsils, no retrolingual obstruction), but cannot be broadly recommended (Grade B) 4

For Snoring with Mild-to-Moderate OSA

Mandibular advancement devices (MADs) are recommended as first-line therapy for non-obese patients with mild-to-moderate OSA who cannot tolerate or refuse CPAP (Grade A recommendation) 4, 7:

• MADs reduce apneas, improve subjective daytime sleepiness, and enhance quality of life compared to control treatments 4
• Emerging evidence supports beneficial cardiovascular effects 4
• Tongue-retaining devices (TRDs) cannot be recommended (Grade C) 4

Surgical options for anatomically appropriate candidates:

• Tonsillectomy can be recommended as single therapy in the presence of tonsillar hypertrophy (Grade C) 4
• Maxillomandibular advancement (MMA) is as efficient as CPAP in young OSA patients without excessive BMI or comorbidities, and is recommended in this circumstance (Grade B) 4, 7
• UPPP cannot be recommended except in carefully selected patients with obstruction limited to the oropharyngeal area, given frequent long-term side effects including velopharyngeal insufficiency, dry throat, and abnormal swallowing (Grade C) 4
• Laser-assisted uvulopalatoplasty is NOT recommended, as it has not demonstrated significant effects on OSA severity, symptoms, or quality of life (negative Grade B recommendation) 4

For Moderate-to-Severe OSA

CPAP remains the treatment of choice for moderate-to-severe OSA, even in non-obese patients 2:

• If CPAP fails or is not tolerated (usage <4 hours/night for at least 5 nights/week over one month), hypoglossal nerve stimulation (HNS) may be considered in patients meeting specific criteria 7:
  • AHI 15-65 events/hour
  • BMI <32-40 kg/m² (depending on guideline)
  • Central/mixed apneas <25% of total AHI
  • Age ≥18 years
  • Drug-induced sleep endoscopy (DISE) required when multiple levels of obstruction suspected 7

Critical Pitfalls to Avoid

• Do not assume non-obese patients have simple snoring—they can have significant OSA requiring polysomnography 4, 1
• Drug therapy is NOT recommended for OSA treatment (Grade C for most drugs, Grade B negative recommendation for mirtazapine and protriptyline) 4
• Tongue muscle training improves snoring but is not efficacious for sleep apnea (negative Grade B recommendation) 4
• Do not expect spontaneous improvement—there is a trend toward worsening of sleep-disordered breathing over time, not cure (Grade C) 4
• Intranasal corticosteroids are only beneficial in children with rhinitis/adenotonsillar hypertrophy or as concomitant therapy in adults with these conditions (Grade B) 4

Key Principle

The anatomic phenotype drives surgical success in non-obese patients, making careful patient selection with upper airway examination and potentially DISE essential before recommending invasive interventions 1, 2.