What specialist should a patient with normal sleep study results, loud snoring, and considering their age, sex, body mass index (BMI), medical history, including any allergies or previous surgeries, be referred to?

Referral for Loud Snoring with Normal Sleep Study

Refer patients with loud snoring but normal polysomnography to an otolaryngologist (ENT specialist) for evaluation of upper airway anatomy and potential surgical or non-surgical interventions targeting the specific site of obstruction. 1, 2

Primary Specialist Recommendation

An otolaryngologist (ENT) is the appropriate specialist for this clinical scenario because:

• Loud snoring without obstructive sleep apnea (normal AHI) represents primary snoring, which requires anatomic evaluation of the upper airway to identify the site and mechanism of obstruction 2, 3
• ENT specialists can perform fiberoptic rhinolaryngoscopy to assess nasal passages, soft palate, tonsils, tongue base, and epiglottis while the patient is awake 3
• For more precise localization, ENT specialists can conduct drug-induced sleep endoscopy (DISE) using midazolam or propofol to visualize the exact location and pattern of airway collapse during sleep-like conditions 4, 3

Diagnostic Evaluation by ENT

The otolaryngologist should systematically evaluate:

• Nasal airway patency: Septal deviation, turbinate hypertrophy, or allergic rhinitis can contribute to mouth breathing and snoring 5
• Oropharyngeal structures: Soft palate redundancy, tonsillar hypertrophy, uvula elongation, and lateral pharyngeal wall collapse 2, 3
• Tongue base and hypopharynx: Macroglossia, tongue base collapse, or epiglottic obstruction 4, 3
• Anatomic phenotyping: Identifying whether obstruction is primarily anatomic (structural) or nonanatomic (functional) guides treatment selection 2

Treatment Options Available Through ENT

Based on the anatomic findings, the ENT specialist can offer:

• Nasal surgery: Septoplasty or turbinate reduction for nasal obstruction contributing to mouth breathing and snoring 5, 3
• Palatal procedures: Uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP), or uvulopalatal flap for soft palate-related snoring 3
• Tongue base interventions: Tongue suspension, genioglossus advancement, or hyoid suspension if tongue base collapse is identified 3
• Medical management: Nasal steroids for rhinitis-associated snoring 5
• Oral appliance referral: Coordination with dental specialists for mandibular advancement devices if appropriate 4

Critical Clinical Considerations

Important caveats to avoid:

• Do not assume the normal sleep study excludes all sleep-disordered breathing—ensure the study was technically adequate and included supine REM sleep, as positional and REM-related events may be missed 6, 7
• Verify that the polysomnography measured all appropriate parameters (EEG, EOG, EMG, airflow, oxygen saturation, respiratory effort, ECG) to exclude other sleep disorders 6
• Consider that 78% of patients with confirmed OSA deny common symptoms of snoring and sleepiness, so absence of daytime symptoms does not validate the normal study 6
• If the patient has significant cardiovascular comorbidities (hypertension requiring ≥2 medications, type 2 diabetes) or BMI ≥33 kg/m², consider repeat testing or home sleep apnea testing, as initial studies can miss positional or REM-related OSA 1, 6

When to Consider Alternative Specialists

Refer to a sleep medicine specialist instead if:

• The patient reports excessive daytime sleepiness despite normal polysomnography, suggesting possible central hypersomnolence disorders (narcolepsy, idiopathic hypersomnia) 1, 7
• There are concerns about sleep study quality or technical adequacy requiring repeat comprehensive polysomnography 6, 7
• The patient has significant cardiopulmonary disease, neuromuscular conditions, or chronic opioid use that may indicate central sleep apnea or hypoventilation syndromes 1, 7

Follow-Up Considerations

After ENT evaluation and any interventions:

• Reassess symptoms at 4-6 months post-intervention 3
• Consider repeat polysomnography if substantial weight change occurs (≥10% body weight gain or loss) or if symptoms persist or worsen 6
• Monitor for development of obstructive sleep apnea over time, particularly if risk factors increase (weight gain, aging, development of hypertension) 1, 6