What is the best course of treatment for a patient presenting with snoring, potentially indicative of obstructive sleep apnea (OSA)?

Management of Snoring in Adults

All patients presenting with snoring require comprehensive sleep evaluation to distinguish between primary (simple) snoring and obstructive sleep apnea (OSA), as snoring is a cardinal symptom of sleep-disordered breathing that demands objective testing to guide appropriate treatment. 1

Initial Evaluation and Risk Stratification

Comprehensive Sleep Assessment

• Evaluate all OSA-associated symptoms systematically: witnessed apneas, gasping/choking at night, excessive daytime sleepiness, nonrefreshing sleep, sleep fragmentation, nocturia, morning headaches, decreased concentration, memory loss, decreased libido, and irritability 1
• Assess high-risk comorbidities that mandate sleep testing: obesity, systolic or diastolic heart failure, coronary artery disease, history of stroke or TIA, significant arrhythmias, and hypertension with nocturnal symptoms 1
• Perform upper airway examination including flexible nasopharyngolaryngoscopy to identify anatomic abnormalities such as micrognathia, retrognathia, maxillary arch constriction, enlarged soft palate/uvula, and base of tongue hypertrophy 2, 3, 4

Objective Testing Requirements

• Polysomnography (PSG) is the gold standard and routinely indicated for diagnosis of sleep-related breathing disorders—no clinical model alone can predict OSA severity 1
• Home portable monitoring (PM) may be used only in patients with high pretest probability of moderate-to-severe OSA as part of comprehensive sleep evaluation, but is contraindicated in those with moderate-to-severe pulmonary disease, neuromuscular disease, congestive heart failure, or suspected comorbid sleep disorders 1
• Diagnosis of OSA is confirmed when apnea-hypopnea index (AHI) >15 events/hour, or AHI >5/hour with symptoms (daytime sleepiness, unrefreshing sleep, fatigue, insomnia, breath-holding/gasping, or bed partner-reported snoring/breathing interruptions) 1

Treatment Algorithm Based on Severity

Primary (Simple) Snoring Without OSA

• Lifestyle modifications are first-line: weight loss (as weight gain is the primary risk factor for progression to OSA), smoking cessation (required at least 1 month before any surgical intervention), alcohol avoidance, and positional therapy 1, 5, 6
• Conservative surgical options for socially disruptive snoring include laser-assisted uvulopalatoplasty (LAUP), radiofrequency volumetric tissue reduction (RVTR), or electrocautery of soft palate 4
• Oral appliances may be considered for symptomatic simple snoring after ruling out OSA 5

Mild OSA (AHI 5-14 events/hour)

• Mandibular advancement devices (MADs) are appropriate first-line therapy, particularly custom-made devices, with follow-up PSG or type 3 PM study required after final adjustments to ensure therapeutic benefit 1, 5, 6
• Lifestyle modifications remain essential: weight loss shows trend toward improvement and should be combined with primary treatment 1, 7

Moderate-to-Severe OSA (AHI ≥15 events/hour)

• Continuous positive airway pressure (CPAP) is the gold standard first-line treatment, with documented efficacy in controlling symptoms, improving quality of life, normalizing accident risk, reducing sympathetic activity, and decreasing cardiovascular morbidities 1, 7, 6
• CPAP titration protocol: start at minimum 4 cm H₂O, increase until all obstructive events (apneas, hypopneas, RERAs, snoring) are eliminated or maximum pressure reached 1
• Bilevel positive airway pressure (BPAP) should be offered if patient is intolerant of high CPAP pressures or continued obstructive events occur at 15 cm H₂O CPAP (starting IPAP 8 cm H₂O, EPAP 4 cm H₂O) 1

CPAP-Intolerant Patients

Comprehensive CPAP optimization must be documented before proceeding to alternative therapies, including mask refitting, pressure adjustments, heated humidification, and behavioral interventions 7

For CPAP-intolerant patients with moderate-to-severe OSA:

• Hypoglossal nerve stimulation (HNS) is appropriate second-line therapy when: AHI 15-65 events/hour, BMI <32 kg/m² (some guidelines allow <40 kg/m²), documented CPAP failure/intolerance, and absence of complete concentric collapse at soft palate level confirmed by drug-induced sleep endoscopy (DISE) 7
• Mandibular advancement devices are less effective than CPAP for moderate-to-severe OSA but represent a viable alternative for mild-to-moderate disease 7, 6
• Multilevel surgery is reserved as salvage procedure after HNS failure, with unpredictable results and higher morbidity (velopharyngeal insufficiency, dysphagia, mandibular fracture, nerve injury) 7

Follow-Up and Monitoring

• Follow-up PSG is routinely indicated after surgical treatment for moderate-to-severe OSA, after substantial weight loss (≥10% body weight) or weight gain with symptom return in CPAP-treated patients, and when symptoms return despite good initial treatment response 1
• Oral appliance efficacy must be verified with PSG or attended type 3 PM study with appliance in place after final adjustments 1
• Unattended PM may monitor response to non-CPAP treatments including oral appliances, upper airway surgery, and weight loss 1

Critical Pitfalls to Avoid

• Never assume snoring is benign—80% of OSA cases remain undiagnosed, and untreated OSA is associated with hypertension, coronary disease, stroke, arrhythmias, diabetes, and increased accident risk 2, 6
• Never diagnose OSA based solely on clinical assessment—objective testing with PSG or PM is mandatory as no clinical model reliably predicts severity 1
• Never delay definitive treatment with prolonged weight loss attempts in symptomatic moderate-to-severe OSA—weight loss should be combined with primary treatment, not used as monotherapy 7
• Never provide oral appliance therapy without confirmed OSA diagnosis from polysomnography or home sleep testing interpreted by a sleep physician 2
• Avoid surgical intervention before ruling out pathologic entities (neoplasia, cysts) and documenting disproportionate anatomy with appropriate imaging 4