The evaluation and treatment for snoring and sleep apnea oftentime overlap. Both require a complete history and physical examination of the head and neck. Both require assessment with fiberoptic nasopharyngolaryngoscopy and polysomnography. Both may be treated with continuous positive airway pressure (CPAP), uvulopalatopharyngoplasty (UPPP), or tracheotomy. However, there is a great distinction between these two conditions. Snoring is largely of social concern, whereas sleep apnea has comorbidities that may be life threatening and warrants medical, if not surgical, treatment. The reasons why a given treatment may initially fail in treating either condition relate to errors in diagnosis, error in selection of treatment, or inadequate or improper treatment. Oftentimes, treatment of one site, such as the oropharynx, will improve but not eliminate the snoring or sleep apnea. However, if a second source of upper airways obstruction, such as the nasopharynx occluded with adenoid tissue, is identified and addressed at revision surgery, the snoring or sleep apnea may be further reduced or eliminated. Each of these issues will be addressed in the ensuing discussion.

A Clinical Evaluation

A detailed history relating to the upper airways is crucial in determining the diagnosis. One must inquire as to the presence or absence of snoring, alteration or cessation of breathing (sleep apnea), daytime somnolence, morning headaches, difficulty concentrating at work, and feeling tired or unrested upon awakening. The presence of nocturnal myoclonus, insomnia, narcolepsy (cataplexy, sleep paralysis, hypnogogic hallucinations), or short latency of sleep onset must be excluded. Nasal obstruction, congestion, allergies, and chronic sinusitis must be similarly questioned. The use of sedatives, sedating antihistamines, tranquilizers, and alcohol, especially prior to bedtime, must be questioned and if employed, must be eliminated. Any prior surgery of the upper aerodigestive tract, including rhinoplasty, tonsillectomy, or adenoidectomy, should be noted. A history of hypertension or arrhythmias should be questioned.

The general examination must include an evaluation of the general habitus of the patient, specifically regarding obesity. The nose must be examined to assess the septum and turbinates, rhinorrhea, and/or the presence of sinusitis. The nasal valve area should be assessed for collapse, particularly if the patient has undergone reduction rhinoplasty. The nasopharynx must be examined to rule out any adenoid enlargement, congenital obstruction, or tumors. The oral cavity and oropharynx must be assessed with specific attention to the size of the tongue, tonsils, uvula, and palate, and any redundancy or hypertrophy or tumors should be noted. The hypopharynx and larynx must be similarly evaluated to exclude any obstruction, such as lingual tonsil hypertrophy, obstructing vallecular cyst, or laryngeal tumor.

Once a patient fails a given modality of treatment, the assessment should include a nasal, nasopharyngeal, and oropharyngeal examination with the fiberoptic endoscope. Polysomnography, rhinometry, and pharyngometry may be repeated to evaluate if the patient has had any response to the prior treatment. If necessary, speech evaluation by a speech therapist should be conducted if there is any velopharyngeal incompetence or nasopharyngeal stenosis.

Medical Treatment

Allergic rhinitis or vasomotor rhinitis may cause significant airway obstruction, resulting in a negative nasopharyngeal pressure. This in turn promotes snoring, as the patient is forced to breathe transorally, and the elongated uvula is forced to vibrate. These conditions may be treated with the appropriate medicine, such as nasal steroids, systemic or topical antihistamines, and/or decongestants. Allergen avoidance and immunotherapy are also invaluable for the allergic patient. If all these measures fail to control rhinitis, turbinate injection may be indicated.