What are the treatment options for snoring?

Treatment of Snoring in Adults

For primary snoring without obstructive sleep apnea (OSA), mandibular advancement devices (MADs) are the most effective evidence-based treatment option, while for snoring associated with mild-to-moderate OSA, MADs are recommended as first-line therapy (Grade A recommendation). 1, 2

Critical First Step: Distinguish Primary Snoring from OSA

Before treating snoring, you must determine whether the patient has simple snoring or underlying OSA, as this fundamentally changes management 2, 3:

• Assess for OSA symptoms: witnessed apneic episodes, excessive daytime sleepiness, morning headaches, cardiovascular comorbidities 2
• Obtain sleep study if medical history or clinical examination suggests sleep-disordered breathing, if relevant comorbidities are present, or if the patient requests treatment 3
• Do not assume non-obese patients have simple snoring—they can have significant OSA requiring polysomnography 2

Treatment Algorithm Based on Diagnosis

For Primary Snoring (Without OSA)

Behavioral Modifications (should be implemented first):

• Weight reduction to BMI ≤25 kg/m² in overweight patients—associated with improvement in breathing pattern, quality of sleep, and daytime sleepiness (Grade C) 1, 2
• Avoid alcohol and sedatives before bedtime 1, 3
• Smoking cessation 4
• Positional therapy (tennis balls, vests, positional alarms) for supine-dependent snorers—yields moderate reductions but has poor long-term compliance (only 29% still using devices after 2 years), and is clearly inferior to CPAP; therefore not recommended except in carefully selected younger patients with lower severity (Grade C) 1, 2

Mandibular Advancement Devices (MADs):

• Recommended for primary snoring in suitable candidates 1
• Must be custom-made and titratable, advancing the mandible at least 50% of maximum protrusion 1
• Titration procedure is essential for optimal results 1
• Success factors: younger age, lower BMI, smaller neck circumference, female gender 1
• Side effects: jaw discomfort, tooth tenderness, excessive salivation, temporary occlusal changes in >50% initially 1
• Long-term compliance: 76% continue after 1 year, 65% after 4 years 1

Surgical Options (for selected cases):

• Minimally invasive soft palate surgery can be considered only when individual anatomy appears suitable 1, 3
• Tonsillectomy as single therapy in presence of tonsillar hypertrophy (Grade C) 1, 2
• Uvulopalatopharyngoplasty (UPPP) cannot be recommended except in carefully selected patients with obstruction limited to oropharyngeal area—frequent long-term side effects include velopharyngeal insufficiency, dry throat, abnormal swallowing (Grade C) 1
• Laser-assisted uvulopalatoplasty is NOT recommended—no significant effect on symptoms or quality of life (negative Grade B recommendation) 1

For Snoring with Mild-to-Moderate OSA

Mandibular Advancement Devices (MADs) are the primary recommendation:

• Grade A recommendation for mild-to-moderate OSA patients who cannot tolerate or refuse CPAP 1, 2
• Reduce sleep apneas, subjective daytime sleepiness, and improve quality of life compared to placebo 1
• Treatment success (AHI <5): 19-75% of patients; AHI <10: 30-94% of patients 1
• Comparable effects to CPAP on daytime sleepiness, general physical and mental health, driving simulation, and nocturia 1
• Better patient preference and compliance compared to CPAP 1
• Emerging evidence on beneficial cardiovascular effects, blood pressure reduction, improved endothelial function 1
• CPAP is superior in normalizing respiratory parameters (AHI, oxygen desaturation), but MADs show similar symptom improvement 1

Additional Options:

• Hypoglossal nerve stimulation can be considered in selected adult patients seeking alternative treatments (conditional recommendation) 1
• Maxillomandibular advancement (MMA) is efficient in young OSA patients without excessive BMI or comorbidities (Grade B) 2

For Moderate-to-Severe OSA

• CPAP therapy is the gold-standard treatment 1
• MADs are an accepted alternative for severe symptomatic OSA patients who are intolerant to CPAP or request alternative therapy 1

What NOT to Do (Common Pitfalls)

• Do NOT use nasal dilators—not recommended for reducing snoring or improving sleep-disordered breathing (Grade D) 1, 2
• Do NOT prescribe drug therapy for OSA treatment (Grade C for most drugs, Grade B negative recommendation for mirtazapine and protriptyline) 1, 2
• Do NOT recommend tongue muscle training for sleep apnea—improves snoring but not efficacious for apnea (negative Grade B) 1, 2
• Do NOT use tongue-retaining devices (TRDs)—cannot be recommended (Grade C) 1
• Do NOT expect spontaneous improvement—sleep-disordered breathing trends toward worsening, not cure (Grade C) 1, 2
• Do NOT use nasal surgery as single intervention for OSA treatment (negative Grade C) 1

Essential Follow-Up

• Re-evaluation with sleep study is necessary after MAD treatment, particularly in patients with more severe disease and concomitant health problems, as symptom improvement is an imprecise indicator of treatment success 1
• Follow-up visits should occur after appropriate time frame to assess treatment success and indicate further intervention 3