Snoring

A 35-year-old man is brought in by his wife who complains of his loud snoring, which forces the couple to sleep in separate bedrooms. You suspect that he might suffer from obstructive sleep apnea (OSA). Which of the following clinical factors should you scrutinize that represent an increased risk for OSA?

A. Body mass index
B. Neck circumference
C. Age
D. Blood pressure
E. All of the above

 

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Answer: E-All of the above.

Discussion
Snoring is a common complaint, voiced by 57% of men and 40% of women. It can be an embarrassing and annoying phenomenon, and can result in breaches in relationships. Although the medical risks of snoring alone are not well known, if it occurs in isolation, it is generally thought to be a benign phenomenon. Typically, conservative measures are employed to address primary snoring, including weight loss, avoidance of CNS depressants, body positioning devices that ensure that individuals avoid the supine position when asleep, nasal dilator devices, and nasal decongestants and intranasal corticosteroids. A variety of surgical techniques are also available.

Snoring is, however, one of the hallmark symptoms of OSA, which, in turn, is associated with significant morbidity and mortality. Therefore, its identification and treatment, when present, is important. According to one study, symptoms that increase the risk of OSA in snorers include:

• Complaints of excessive daytime sleepiness, tiredness, or fatigue
• Observation by bedpartners/family members that the patient has breathing pauses during sleep
• A history of hypertension
• Male gender
• Age >50 years
• Body mass index >35
• Neck circumference >40 cm (thick neck)

An additional finding is crowding and narrowing of the upper airway. To assess the level of upper airway narrowing, it is useful to obtain a Mallampati score  while the patient protrudes the tongue without phonation. Optimally, the entire palate and the tonsillar fossa are visible (class I). Higher levels of obstruction include class II, where the structures above the upper half of the tonsils are visible; class III, where tonsils are not visible, but soft and hard palate are visible; and class IV, where only hard palate is visible. On average, the odds of having OSA increase more than 2-fold for every 1-point increase in Mallampati Scale. Patients in whom OSA is suspected should always be referred for polysomnography for confirmation of the diagnosis.

Take-home points:
1. Conduct a systematic clinical evaluation in snorers to assess for the risk of OSA
2. Patients in whom OSA is suspected should always undergo polysomnography for confirmation of the diagnosis


References

1. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-1053. (Abstract)
2. Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 5th ed. Philadelphia: Elsevier; 2011.
3. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-821.  (Free PDF available)
4. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep. 2006;29:903-908. (Abstract)