Snoring and sleep-related breathing | Prof. Dr. Alper Tunga Derin

General education only; not a substitute for examination or diagnosis.

What this area covers

Snoring is the sound made when relaxed tissues such as the soft palate, uvula, tonsils and tongue base vibrate in a narrowed airway during sleep. Snoring on its own may be harmless, but it is the most common symptom of obstructive sleep apnoea (OSA).

In obstructive sleep apnoea, the upper airway repeatedly narrows partly (hypopnoea) or closes completely (apnoea) during sleep. These pauses lower blood oxygen and fragment sleep. Untreated moderate-to-severe sleep apnoea is associated with high blood pressure and cardiovascular disease, and daytime sleepiness increases the risk of accidents.

Excess weight and a large neck circumference are among the main risk factors.
Male sex, older age and the post-menopausal period increase risk.
Nasal blockage, large tonsils, a set-back lower jaw and a large tongue can narrow the airway.
Alcohol, sedative medicines and smoking can make symptoms worse.

In children, snoring and apnoea are usually linked to enlarged tonsils and adenoids and need a different approach; this page focuses on adults.

Symptoms

Loud, habitual snoring.
Breathing pauses noticed by a partner, or choking or gasping awake during sleep.
Waking unrefreshed despite enough time in bed, with excessive daytime sleepiness and fatigue.
Morning headaches and a dry mouth.
Getting up at night to pass urine (nocturia).
Problems with concentration and memory, irritability, and sleep broken by frequent awakenings.

Not everyone with sleep apnoea notices daytime sleepiness, so the absence of sleepiness does not rule apnoea out.

When to see a doctor

Situations that need emergency care

Call 112 (the emergency number in Türkiye) for chest pain, sudden breathlessness, marked palpitations or fainting.
Call 112 without delay for signs of stroke such as facial drooping, weakness of an arm or leg, or difficulty speaking.
If you nod off while driving, or have had an accident or near miss due to sleepiness, stop driving until you have been assessed and treatment is effective, and see a doctor as soon as possible.

Situations that need a planned appointment

Loud snoring together with breathing pauses noticed by others.
Excessive daytime sleepiness, unrefreshing sleep or morning headaches.
Snoring together with blood pressure that is hard to control, heart rhythm problems or heart disease.
Persistent nasal blockage that forces mouth breathing.
Difficulty using a CPAP device, or symptoms that continue despite it.

This information is for general education. A definite diagnosis and treatment decision is made after examination and a sleep study.

How it is diagnosed

History and questionnaires: sleep pattern, a partner's observations, alcohol and medicines are reviewed. Screening questionnaires such as the Epworth Sleepiness Scale and STOP-Bang help estimate risk, but the American Academy of Sleep Medicine (AASM) advises that questionnaires should not be used to diagnose OSA without a sleep study.
Examination: body mass index, neck circumference, blood pressure, nose, mouth and throat, tonsils, tongue base and jaw structure are assessed; the upper airway may be examined with a flexible endoscope.
Polysomnography (PSG): the standard diagnostic test, recording brain waves, breathing, oxygen level, heart rhythm and movements overnight in a sleep laboratory.
Home sleep apnoea testing: can be used in uncomplicated adults with a high likelihood of moderate-to-severe apnoea. According to the AASM, PSG should follow if the test is negative or inadequate, and PSG is preferred in significant heart or lung disease, neuromuscular disease, previous stroke, regular opioid use or severe insomnia.
Severity is graded by the apnoea–hypopnoea index (AHI), the number of apnoeas and hypopnoeas per hour: 5 to under 15 is mild, 15 to under 30 moderate, and 30 or more severe sleep apnoea.
Drug-induced sleep endoscopy (DISE): performed in selected patients being considered for surgery or hypoglossal nerve stimulation, to see where the airway collapses; it is not a diagnostic test for OSA.

Treatment options

Lifestyle and conservative measures

Weight loss, cutting down alcohol (especially before bed), stopping smoking and regular sleep habits are advised for everyone.
Positional therapy: devices that encourage side-sleeping may be considered in mild-to-moderate apnoea that is clearly worse on the back; they are unlikely to work in severe apnoea.
According to the UK National Institute for Health and Care Excellence (NICE), mild sleep apnoea without troublesome symptoms usually needs no treatment beyond lifestyle changes.

Devices and medical treatment

CPAP (continuous positive airway pressure): a device that keeps the airway open through a mask and is first-line treatment for moderate-to-severe sleep apnoea. In mild apnoea it may be recommended if symptoms affect daily life. Benefit depends on regular use.
Oral appliances (mandibular advancement devices): hold the lower jaw forward to widen the airway and are custom-made by a dentist. They are an option in mild apnoea or for moderate-to-severe patients who cannot use CPAP, and require healthy teeth and gums.
Treating nasal blockage: allergic or other rhinitis is treated; a clearer nose can make CPAP more comfortable but does not always correct apnoea on its own.
In selected patients with obesity, weight-loss medicines may also be considered.

Surgical options

Surgery is considered for selected patients with suitable anatomy, particularly those who cannot use or do not accept CPAP. The AASM recommends discussing referral for sleep surgery with patients who cannot tolerate CPAP and have a body mass index below 40.

Tonsillectomy: NICE states it can be considered in adults with large obstructive tonsils and a body mass index below 35.
Septoplasty and turbinate reduction: opening the nasal airway can make CPAP easier to use, but usually does not treat apnoea on its own.
Palatal surgery and other throat procedures: may be considered in selected patients with suitable anatomy.
Hypoglossal nerve stimulation: an implanted system that stimulates the tongue muscle during sleep to keep the airway open; an option for selected patients who cannot use CPAP and meet specific criteria.
Jaw advancement surgery and bariatric surgery may also be evaluated with the relevant specialists in selected patients.

Before any procedure aimed only at snoring, a sleep study should check whether sleep apnoea is present.

Before and after surgery

Sleep apnoea matters for anaesthesia and should be reported to the anaesthetic team before surgery. If you use CPAP, you may be asked to bring your device to hospital.
Blood thinners and other regular medicines are changed only on the advice of the doctor who manages them.
Painkillers and sedatives can depress breathing, so close monitoring may be needed after surgery.
After tonsil and palate surgery, throat pain usually lasts one to two weeks; plenty of fluids and the recommended painkillers are important. Bleeding from the mouth during this time needs emergency care.
A hypoglossal nerve stimulator is usually switched on and adjusted a few weeks after healing.
Return to work and daily activities varies with the type of operation and will be discussed with you.

Follow-up

NICE recommends a first review within one month of starting CPAP, with annual follow-up considered once treatment is optimised. Reviews cover symptoms, device data, mask fit and hours of use.
People using an oral appliance usually have a first review at around three months, when the device is adjusted.
After surgery a follow-up sleep study is recommended to assess the result; NICE advises this within three months of the operation.
After significant weight change the need for treatment is reassessed and the sleep study repeated if needed. Sleepiness is checked at every visit in people who drive.

Frequently asked questions

No. Snoring is very common and not everyone who snores has apnoea. But if snoring comes with breathing pauses, daytime sleepiness or high blood pressure, a sleep study is recommended.

In uncomplicated adults with a high likelihood of moderate-to-severe apnoea, a home test can be enough for diagnosis. If it is negative or inadequate, or if there is significant heart or lung disease, laboratory polysomnography is preferred.

CPAP controls apnoea while it is used; it does not cure the condition. After changes such as significant weight loss, apnoea may lessen, and the need for treatment can then be reassessed with your doctor.

The result depends on your anatomy, the severity of apnoea and body weight. Some people improve markedly, while in others apnoea may partly persist. That is why a follow-up sleep study is done after surgery.

Daytime sleepiness reduces attention and reaction time and increases the risk of accidents. If you nod off at the wheel, do not drive until treatment is effective. Professional drivers may need additional assessment under national regulations.

Relieving nasal blockage can reduce snoring and make CPAP easier to use. But nose surgery on its own usually does not treat sleep apnoea; in most patients it is planned alongside other treatments.

Sources

The general information on this page is based on the guideline and institutional sources below. Individual diagnosis and treatment decisions require an examination.

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