65
Snoring
David L. Steward
History
A 35-year-old man is sent in by his bed partner with complaints of snoring. He reports recent weight gain of 10 lb with worsening of his snoring. The patient denies a history of witnessed apnea or excessive daytime sleepiness. He denies insomnia and routinely sleeps 7 hours nightly. He underwent adenotonsillectomy as a child because of concerns for obstructive breathing. He has a family history of snoring. He drinks alcohol on occasion, which exacerbates his snoring. He is taking no medications and has no known medical problems.
Physical examination reveals an overweight man (body mass index 30 kg/m2) with a neck circumference of 16.5 inches. Oropharyngeal examination demonstrates elongated and thickened soft palate and uvula, with the free edge of the soft palate visible without use of a tongue depressor or requiring phonation (modified Mallampati/Friedman tongue position I). Nasal examination is unremarkable.
Differential Diagnosis—Key Points
The primary diagnostic dilemma in a patient complaining of snoring is to exclude obstructive sleep apnea; factors increasing the likelihood of sleep apnea include obesity, neck circumference greater than 17 inches, witnessed apnea, excessive daytime sleepiness, male gender, and family history of sleep apnea. Because of the insensitivity of history and physical examination alone to exclude sleep apnea, sleep testing or polysomnography is often needed to exclude it.
The location of the source of the snoring is usually but not always the soft palate. Mouth breathing increases turbulent airflow, which worsens snoring.
Test Interpretation
Flexible fiberoptic nasopharyngoscopy is performed in the sitting and supine position to assess degree of retropalatal and possibly retroglossal pharyngeal obstruction. Volitional snoring during fiberoptic examination can reveal the site of vibration and source of the snoring.
The degree of daytime sleepiness can be assessed with the Epworth Sleepiness Scale, an eight-item questionnaire that queries the patient about the likelihood of falling asleep during the day in eight scenarios scored from 0 (none) to 3 (often). An Epworth score of 10 or more is consistent with excessive daytime sleepiness.
