An evidence-based approach to the management of snoring in adults

SYSTEMATIC REVIEW
Al-Hussaini, A. & Berry, S.
Department of Otolaryngology, Head and Neck Surgery, Royal Glamorgan Hospital, Llantrisant, UK
Accepted for publication 19 October 2014
Clin. Otolaryngol. 2015, 40: 79–85

Background: Snoring is frequently encountered by the and review articles. Relevant references from selected articles
otolaryngologist. Given its significant impact on quality of were also reviewed.
life and that it is a symptom of sleep-related breathing Results: The majority of published literature for snoring is
disorders, diagnosis and treatment are of major importance. of level II/III evidence and that for obstructive sleep apnoea
In particular, the diagnosis should aim to distinguish being of level I/II, with 36 relevant randomised controlled
between simple snoring and obstructive sleep apnoea. This trials identified. The diagnosis of obstructive sleep apnoea
article aims to provide a systematic, concise and evidence- involves thorough clinical assessment and typically a sleep
based method of managing the adult patient with snoring. study. Snoring may be managed with lifestyle modification,
Method: This review was based on a literature search last intra-oral devices or by surgical intervention, with contin-
undertaken on 30 June 2014. The MEDLINE, EMBASE and uous positive airway pressure being the treatment of choice
Cochrane databases were searched using the subject headings for moderate-to-severe obstructive sleep apnoea.
snoring and obstructive sleep apnoea in adults in combina- Conclusions: A structured history of snoring and its
tion with classification, diagnosis, investigations, manage- associated symptoms, comprehensive examination includ-
ment, treatment and surgery. Results were limited to English ing flexible laryngoscopy and sleep studies where relevant, in
language articles including case series, clinical trials, rando- addition to targeted investigations, should lead to the correct
mised controlled trials, meta-analyses, systematic reviews diagnosis and appropriate management.

A 47-year-old man presents with a 2-year history of

What should you cover in the history?
snoring and daytime hypersomnolence. This is causing
social disharmony in his household and difficulties with Snoring occurs because of a partially obstructed airway
his job as a lorry driver. typically due to collapse and vibration of the pharyngeal
tissues. In contrast, obstructive sleep apnoea occurs when
Snoring and daytime hypersomnolence are common, affect-
there is no airflow despite respiratory effort. The history
ing 40% and 10% of the general population, respectively.1
establishes the significance of snoring for the patient,
Clinical assessment should delineate which end of the sleep-
potential causes for it and aids in differentiating simple
related breathing disorder spectrum a patient is at. At one
snoring from obstructive sleep apnoea. An apnoea is
end of this spectrum is simple snoring, which may not have
arbitrarily defined in adults as a 10-s breathing pause and
any medical consequences but may be a considerable
hypopnoea as a 10-s event where there is continued
nuisance for the bed partner. At the other extreme of this
breathing, but ventilation is reduced by at least 50% from
spectrum is obstructive sleep apnoea, a prevalent condition
the previous tidal volume baseline during sleep.4 The
itself, affecting an estimated 80 000 people in the UK.2
frequency of apnoeas and hypopnoeas hourly is used to
Obstructive sleep apnoea may have substantial adverse
assess the severity of obstructive sleep apnoea and is termed
effects on sleep quality and a multitude of negative effects on
the apnoea/hypopnoea index.
daily function including daytime sleepiness, impairment of
1 Ask about the onset, duration and progression of snoring.
cognitive function, mood and personality changes.3 At
This establishes a timeline of complaints as well as any
worst, it can cause physiological disturbance with significant
worsening of snoring that may be associated with an increase
cardiovascular and respiratory morbidity.
in body weight.
2 Ask if the bed partner is still sleeping in the same room. The
Correspondence: Mr Ali Al-Hussaini, Department of Otolaryngology, Head
degree of annoyance is essential in the evaluation of snoring
and Neck Surgery, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon
Taff, CF72 8XR, UK. Tel.: +44 (0) 1443443677; Fax: +44 (0) 1443443304; and is highly dependent on the bed partner. Thus, it is useful
e-mail: [email protected] to have the bed partner present, with the patient’s

© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85 79
80 A. Al-Hussaini & S. Berry

permission, during the consultation. Snoring and obstruc- height was more useful as a predictor of obstructive sleep
tive sleep apnoea can have adverse effects on others including apnoea than general obesity.
impaired relationships between spouses and partners.5 9 Ask the patient to undertake a subjective assessment of their
3 Ask about symptoms suggestive of obstructive sleep apnoea. sleepiness. This is important because many patients present
In addition to snoring, the cardinal symptoms include with non-specific symptoms rather than increased daytime
excessive daytime sleepiness, poor concentration and a sleepiness per se. Additionally, subjective assessment of
reduction in alertness. Other symptoms include un-refresh- sleepiness is important as it is unlikely that patients will
ing sleep, nocturia and decreased libido. It is often useful to accept treatment unless they can perceive benefit with a
seek information from the partner, if present, regarding reduction in subjective sleepiness or improvement in work
witnessed apnoeas, nocturnal restlessness and irritability or performance; this benefit is related to the severity of the pre-
personality change. existing impairment.9
4 Ask about associated nasal symptoms. These include nasal The Epworth Sleepiness Scale10 is a validated tool for
obstruction and nasal discharge. If present, it is important to assessing the likelihood of the patient falling asleep in a
ask about other clinical features of allergic rhinitis or chronic variety of situations. The maximum score is 24. Based on
rhinosinusitis, which may be causing nasal obstruction and their Epworth Sleepiness Scale score, patients can be
contributing to snoring. subdivided into the normal range (<11), mild subjective
5 Ask about risk factors for snoring and obstructive sleep daytime sleepiness (11–14), moderate subjective daytime
apnoea. In an epidemiological study of a random Danish sleepiness (15–18) or severe subjective daytime sleepiness
population of 1504 individuals aged 30–60 years, Jennum (>18).11 If available, the partner should also independently
and Sjol6 found that smoking and alcohol consumption were complete the Epworth questionnaire (and the higher score
associated with obstructive sleep apnoea, as well as increas- taken) as the patient may underestimate the severity of their
ing age, male gender and high body mass index. In this study, sleepiness due to its insidious onset.
snoring specifically correlated with increasing age, male
gender, body mass index and alcohol consumption. There
What should you cover in the examination?
may also be a familial component to obstructive sleep apnoea
related to facial or pharyngeal morphology or function; The aim of the examination is to delineate obvious structural
however, further research is needed to clarify the role played abnormalities that may be contributing to upper airway
by genetics.7 obstruction and consequent snoring. Although the exami-
6 Exclude other causes of daytime sleepiness (if relevant). nation itself does not allow an accurate diagnosis of
Although obstructive sleep apnoea is a common cause of obstructive sleep apnoea, it aids in excluding other causes
excessive daytime sleepiness, the clinician should be aware for the patient’s symptoms.
that other conditions can cause similar symptoms. These 1 General examination. Weight and height should be
include fragmented sleep, sleep deprivation, shift work, measured and the calculated body mass index documented.
depression, narcolepsy and hypothyroidism. Additionally, Obesity is an independent risk factor for snoring and
drugs such as beta-blockers, selective serotonin reuptake obstructive sleep apnoea,6 and the body mass index should
inhibitors, sedatives and stimulants can cause excessive be monitored and correlated with symptoms on subsequent
daytime sleepiness in adults. clinic visits.
7 Ask about co-morbidities. In particular, the co-existence of 2 Examine the nose. Anterior rhinoscopy in the non-
chronic obstructive pulmonary disease with obstructive decongested nose should be undertaken to visualise the
sleep apnoea predisposes to a high risk of decompensation septum observing for position, spurs, perforation or mucosal
with cor pulmonale or hypercapnic respiratory failure. In abnormality, in addition to the colour and size of the inferior
such cases where there is high suspicion of obstructive sleep turbinates. Hold a metal tongue depressor under the nose
apnoea, patients should be referred urgently for a sleep study. and assess degree of fogging for an impression of nasal
8 Ask about collar size. Patients with snoring and patency. This is supplemented with endoscopic examination
obstructive sleep apnoea often have a neck circumference of the nasal cavity and postnasal space (as part of flexible
greater than 17 inches (43 cm). The adipose tissue that is laryngoscopy described below). Assess the nasal cavity for
deposited within the neck surrounds the upper airway and inflammation, mucopurulent discharge, polyps, adhesions
mass loads this, tending to collapse it when the dilator and masses. Assess the postnasal space for adenoidal
muscle tone is reduced. An observational study by Davies hypertrophy and nasopharyngeal masses.
et al.8 in a retrospective cohort of 150 patients and a 3 Examine the oral cavity and oropharynx. Inspect for
prospective cohort of 85 patients presenting to a sleep disproportionately small mandibular size or retrognathia.
clinic demonstrated that neck circumference corrected for

© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85
 An evidence-based approach 81

Inspect the tongue for macroglossia and assess dentition. logram, oronasal flow and thoraco-abdominal movement
Assess the oropharynx for tonsillar size, the appearance of the monitors, oximetry tracing, electrocardiogram, body posi-
soft palate noting whether the soft palate appears thickened, tion monitoring and recording of snoring. However, the
the appearance of the uvula and in particular whether it is clinical value of performing polysomnography on all
elongated or oedematous, the size of the oropharyngeal inlet, patients with daytime hypersomnolence has been ques-
and relative crowding of the oropharynx leading to a narrow tioned. In a prospective cohort study of 200 patients with
airway at this level. clinical suspicion of obstructive sleep apnoea undertaken by
4 Flexible laryngoscopy. The upper aerodigestive tract is Douglas et al., overnight polysomnography records were
assessed for the site of potential narrowing. This includes analysed to determine which signals contributed to diagno-
assessing the tongue base and in particular for tongue base sis. Thoraco-abdominal movement, oximetry and leg
collapse, hypopharyngeal constriction, position of the epi- movement sensors were found to be helpful, but neuro-
glottis and excluding any laryngeal lesion. A widely used test physiological signals did not contribute significantly to the
is the Muller manoeuvre to identify the level of obstruction. diagnosis.12 Limited sleep studies use any reduced combi-
This involves positioning the fibre-optic endoscope at the nation of the full range of variables present with polysom-
level of the tongue base with the patient’s mouth closed. The nography. They can be performed at home by the patient, are
patient inhales vigorously while the nares and mouth are cost-effective and may expedite the investigation pathway.
occluded, and the degree of hypopharyngeal collapse noted. Evidence from two clinical studies involving a total of 177
The manoeuvre is then repeated with the endoscope at the patients with the diagnostic criterion for obstructive sleep
velopharyngeal level. apnoea being an apnoea–hypopnoea index >10 demon-
5 Examine the neck. The neck should be examined for any strated a sensitivity range from 82 to 93% and a specificity
masses, including goitre. ranging from 90 to 100% of in-hospital-limited sleep studies
compared to full channel polysomnography.13,14
3 Overnight pulse oximetry. This is often used as the first
What further investigations or management should
screening tool for obstructive sleep apnoea due to its
you offer?
universal availability. It allows the monitoring of oxygen
The management of patients presenting with snoring should saturation as well as pulse rate; a dip in oxygen saturation of
involve a multidisciplinary approach. For cases in which typically more than 4% from baseline and an increase in
clinical assessment suggests possible obstructive sleep pulse rate of 6–10 beats per min are usually taken to be
apnoea, sleep studies should be performed. Generally, surrogates of a hypopnoeic or apnoeic episode. However,
obstructive sleep apnoea is treated with behavioural inter- there is considerable variation in the analysis of oximetry
ventions and continuous positive airway pressure. Snoring tracings. Furthermore, in comparison with full polysom-
as an isolated symptom is not associated with medical nography, a systematic review has demonstrated that pulse
morbidity; there is no indication for treatment beyond oximetry alone has a mean sensitivity of 87% and a mean
conservative measures unless requested by the snorer. For specificity of 65%.15 Thus, pulse oximetry can positively
the patient with snoring, investigations such as sleep diagnose obstructive sleep apnoea but cannot be used to
nasendoscopy aim to delineate the site of upper airway exclude it.
obstruction; such patients may be managed surgically, but 4 Sleep nasendoscopy. This technique was introduced by
nevertheless invasive treatments need to be indicated with Croft and Pringle in 1991 for use in the assessment of snoring
care. Figure 1 illustrates a suggested management algorithm to aid proper case selection for surgical and non-surgical
for the patient presenting with snoring. Given the multitude interventions.16 It provides a dynamic, three-dimensional,
of clinical permutations, this is not intended to be compre- real-time visualisation of the anatomical areas responsible
hensive nor exhaustive. for the generation of snoring or relative obstruction under
1 General investigations. These may include full blood count conditions that mimic sleep. Although sleep nasendoscopy
to exclude anaemia as a cause of somnolence, thyroid remains controversial as the technique involves assessment
function tests to exclude hypothyroidism, and an electro- of the upper airway in drug-induced sleep, which is different
cardiogram. to physiological sleep, a standardised method of sedation
2 Sleep studies. The main purposes of a sleep study are to using target controlled infusion of Propofol has been
confirm the clinical suspicion of obstructive sleep apnoea validated by a prospective cohort study.17 Furthermore, a
and to assess its severity in order to guide the therapeutic prospective cohort study by Hewitt et al.18 assessing the
options to offer patients. Polysomnography records sleep correlation between outpatient department assessment and
and breathing patterns simultaneously. It typically consists sleep nasendoscopy in treatment planning for 94 patients
of an electroencephalogram, electromyogram, electro-ocu- with sleep-related breathing disorders concluded that sleep

© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85
82 A. Al-Hussaini & S. Berry

Snoring

History and examination including

flexible laryngoscopy

Suspicion of obstructive sleep apnoea Isolated snoring

- Daytime somnolence - No daytime somnolence
- Witnessed apnoeas - No witnessed apnoeas
- Reduced alertness - Epworth Sleepiness Scale score <11
- Poor concentration - (Treat sinonasal disease if relevant)
- Nocturnal restlessness
- Un-refreshing sleep
- Epworth Sleepiness Scale score ≥11 Behavioural modifications
- Weight loss
Advice re: driving - Smoking cessation
- Avoid alcohol at night
- Avoid sleeping pills/sedatives
Refer to/liaise with sleep clinic - Sleep hygiene

Investigations
- Full polysomnography Persistence of snoring
NO YES
- Limited sleep study on clinical review
- ApneaGraph - Is there significant
impact on quality of life?
YES NO

Evidence of moderate/severe
obstructive sleep apnoea?
Discharge back to
care of GP Consider sleep
nasendoscopy
Refer for CPAP

NO YES
Interventions
Poor compliance with CPAP?
- Intra-oral device
- Septoplasty
- Uvulopalatoplasty
Continue with CPAP and - Tonsillectomy
sleep clinic follow-up - Radiofrequency
thermotherapy of soft palate/
tongue base
- Pillar implants

Fig. 1. A suggested management algorithm for patients presenting with snoring.

nasendoscopy afforded the clinician a greater accuracy of on the percentage upper and lower pharyngeal contribution
diagnosis and the patient a more focussed management to overall upper airway obstruction.
strategy. Notably, sleep nasendoscopy allows simultaneous 6 Behavioural interventions. Overweight patients should
mandibular advancement manoeuvres, which have been be encouraged to lose weight as reduction in weight
demonstrated to be of prognostic value in determining reduces snoring and improves obstructive sleep apnoea
successful mandibular advancement splint therapy19 (see symptoms. In addition, weight loss reduces perioperative
intra-oral devices below). risk in obese snorers that want to be treated surgically.
5 ApneaGraph. This relies on measuring pressure and Patients who smoke should be advised to stop for general
airflow simultaneously at different levels in the pharynx health reasons. Alcohol should be avoided at night as well
identifying the segment of upper airway obstruction and as sedatives and sleeping tablets as all of these reduce
providing baseline respiratory parameters. In a prospective airway dilator function. Other lifestyle modifications
study by Singh et al.20 comparing ApneaGraph (n = 49) endeavour to improve ‘sleep hygiene’. These comprise
with full polysomnography and sleep nasendoscopy, no measures to improve the sleep environment so that the
significant differences were found between ApneaGraph bed is comfortable and the room dark and quiet and
compared to polysomnography based on the apnoea– maintaining a regular sleep–wake cycle. Although a
hypopnoea index, total number of apnoeic events and Cochrane review21 of lifestyle modifications for obstruc-
average oxygen saturations; however, there was poor corre- tive sleep apnoea concluded there was no randomised
lation between sleep nasendoscopy and ApneaGraph based controlled trial evidence for the efficacy of the above-

© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85
 An evidence-based approach 85

22 Driver and Vehicle Licensing Authority. URL https://www.gov.uk/ 29 Mason M., Welsh E.J. & Smith I. (2013) Drug therapy for
driving-medical-conditions [accessed 15 June 2014] obstructive sleep apnoea in adults. Cochrane Database Syst. Rev.
23 Patel S.R., White D.P., Malhotra A. et al. (2003) Continuous (5), CD003002
positive airway pressure therapy for treating sleepiness in a diverse 30 National Health Service. URL http://www.nhs.uk/ [accessed on 1
population with obstructive sleep apnea: results of a meta-analysis. June 2014]
Arch. Intern. Med. 163, 565–571 31 Walker R.P., Garrity T. & Gopalsami C. (1999) Early polysomno-
24 Antonopoulos C.N., Sergentanis T.N., Daskalopoulou S.S. et al. graphic findings and long-term subjective results in sleep apnea
(2011) Nasal continuous positive airway pressure (nCPAP) patients treated with laser-assisted uvulopalatoplasty. Laryngoscope
treatment for obstructive sleep apnea, road traffic accidents 109, 1438–1441
and driving simulator performance: a meta-analysis. Sleep Med. 32 Gupta S., Nicoli T. & Kotecha B. (2014) Latest trends in the
Rev. 15, 301–310 assessment and surgical management of snoring in England: a
25 Montesi S.B., Edwards B.A., Malhotra A. et al. (2012) The effect of prospective questionnaire study. Clin. Otolaryngol. 39, 177–182
continuous positive airway pressure treatment on blood pressure: a 33 Friedman M., Tanyeri H., Lim J.W. et al. (2000) Effect of improved
systematic review and meta-analysis of randomized controlled nasal breathing on obstructive sleep apnea. Otolaryngol. Head Neck
trials. J. Clin. Sleep Med. 8, 587–596 Surg. 122, 71–74
26 Cooke M.E. & Battagel J.M. (2006) A thermoplastic mandibular 34 Choi J.H., Kim S.N. & Cho J.H. (2013) Efficacy of the Pillar implant
advancement device for the management of non-apnoeic snoring: a in the treatment of snoring and mild-to-moderate obstructive sleep
randomized controlled trial. Eur. J. Orthod. 28, 327–338 apnea: a meta-analysis. Laryngoscope 123, 269–276
27 Balk E.M., Moorthy D., Obadan N.O. et al. (2011) Diagnosis and 35 Main C., Liu Z., Welch K. et al. (2009) Surgical procedures and non-
Treatment of Obstructive Sleep Apnea in Adults. Comparative surgical devices for the management of non-apnoeic snoring: a
Effectiveness Review No. 32. Agency for Healthcare Research and systematic review of clinical effects and associated treatment costs.
Quality. Publication No. 11-EHC052-EF, Rockville, MD Health Technol. Assess. 13, 1–208
28 Ferguson K.A., Cartwright R., Rogers R. et al. (2006) Oral 36 Lin H.C., Friedman M., Chang H.W. et al. (2008) The efficacy of
appliances for snoring and obstructive sleep apnea: a review. Sleep multilevel surgery of the upper airway in adults with obstructive
29, 244–262 sleep apnea/hypopnea syndrome. Laryngoscope 118, 902–908

© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85
84 A. Al-Hussaini & S. Berry

ablation of the soft palate and Pillar implants were all 2 Sleep Apnoea Trust Association. URL http://www.sleep-apnoea-
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continuous positive airway pressure treatment on daytime function
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in sleep apnoea/hypopnoea syndrome. Lancet 343, 572–575
tions, defined as involving at least two of the frequently 4 Scottish Intercollegiate Guidelines Network (SIGN). (2003) Man-
involved anatomical sites (nose, oropharynx and/or hypo- agement of Obstructive Sleep Apnoea/Hypopnoea Syndrome in Adults.
pharynx) in adults with obstructive sleep apnoea, demon- SIGN. Publication No. 73, Edinburgh
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hypopnoea index, but this benefit was predominantly from sleep apneic patients. Sleep 10, 244–248
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and obstructive sleep apnoea in adults in combination with apnoea syndrome. Thorax 47, 101–105
9 McArdle N., Devereux G., Heidarnejad H. et al. (1999) Long-term
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to subjectively assess the degree of daytime sleepiness. Respiratory polygraphy in the diagnosis of obstructive sleep apnea
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15 Ross S.D., Allen I.E., Harrison K.J. et al. (1999) Systematic Review of
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• Treatment options for snoring and mild obstructive assessment in snoring and obstructive sleep apnoea. Clin. Otolar-
sleep apnoea include behavioural modifications, intra- yngol. Allied Sci. 16, 504–509
oral devices and surgery. 17 Berry S., Roblin G., Williams A. et al. (2005) Validity of sleep
• A multidisciplinary approach is essential to managing nasendoscopy in the investigation of sleep related breathing
disorders. Laryngoscope 115, 538–540
patients with snoring.
18 Hewitt R.J., Dasgupta A., Singh A. et al. (2009) Is sleep nasendos-
copy a valuable adjunct to clinical examination in the evaluation
of upper airway obstruction? Eur. Arch. Otorhinolaryngol. 266,
691–697
Conflicts of interest 19 Johal A., Hector M.P., Battagel J.M. et al. (2007) Impact of sleep
None declared. nasendoscopy on the outcome of mandibular advancement splint
therapy in subjects with sleep-related breathing disorders. J.
Laryngol. Otol. 121, 668–675
20 Singh A., Al-Reefy H., Hewitt R. et al. (2008) Evaluation of
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© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85
 An evidence-based approach 85

22 Driver and Vehicle Licensing Authority. URL https://www.gov.uk/ 29 Mason M., Welsh E.J. & Smith I. (2013) Drug therapy for
driving-medical-conditions [accessed 15 June 2014] obstructive sleep apnoea in adults. Cochrane Database Syst. Rev.
23 Patel S.R., White D.P., Malhotra A. et al. (2003) Continuous (5), CD003002
positive airway pressure therapy for treating sleepiness in a diverse 30 National Health Service. URL http://www.nhs.uk/ [accessed on 1
population with obstructive sleep apnea: results of a meta-analysis. June 2014]
Arch. Intern. Med. 163, 565–571 31 Walker R.P., Garrity T. & Gopalsami C. (1999) Early polysomno-
24 Antonopoulos C.N., Sergentanis T.N., Daskalopoulou S.S. et al. graphic findings and long-term subjective results in sleep apnea
(2011) Nasal continuous positive airway pressure (nCPAP) patients treated with laser-assisted uvulopalatoplasty. Laryngoscope
treatment for obstructive sleep apnea, road traffic accidents 109, 1438–1441
and driving simulator performance: a meta-analysis. Sleep Med. 32 Gupta S., Nicoli T. & Kotecha B. (2014) Latest trends in the
Rev. 15, 301–310 assessment and surgical management of snoring in England: a
25 Montesi S.B., Edwards B.A., Malhotra A. et al. (2012) The effect of prospective questionnaire study. Clin. Otolaryngol. 39, 177–182
continuous positive airway pressure treatment on blood pressure: a 33 Friedman M., Tanyeri H., Lim J.W. et al. (2000) Effect of improved
systematic review and meta-analysis of randomized controlled nasal breathing on obstructive sleep apnea. Otolaryngol. Head Neck
trials. J. Clin. Sleep Med. 8, 587–596 Surg. 122, 71–74
26 Cooke M.E. & Battagel J.M. (2006) A thermoplastic mandibular 34 Choi J.H., Kim S.N. & Cho J.H. (2013) Efficacy of the Pillar implant
advancement device for the management of non-apnoeic snoring: a in the treatment of snoring and mild-to-moderate obstructive sleep
randomized controlled trial. Eur. J. Orthod. 28, 327–338 apnea: a meta-analysis. Laryngoscope 123, 269–276
27 Balk E.M., Moorthy D., Obadan N.O. et al. (2011) Diagnosis and 35 Main C., Liu Z., Welch K. et al. (2009) Surgical procedures and non-
Treatment of Obstructive Sleep Apnea in Adults. Comparative surgical devices for the management of non-apnoeic snoring: a
Effectiveness Review No. 32. Agency for Healthcare Research and systematic review of clinical effects and associated treatment costs.
Quality. Publication No. 11-EHC052-EF, Rockville, MD Health Technol. Assess. 13, 1–208
28 Ferguson K.A., Cartwright R., Rogers R. et al. (2006) Oral 36 Lin H.C., Friedman M., Chang H.W. et al. (2008) The efficacy of
appliances for snoring and obstructive sleep apnea: a review. Sleep multilevel surgery of the upper airway in adults with obstructive
29, 244–262 sleep apnea/hypopnea syndrome. Laryngoscope 118, 902–908

© 2014 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 79–85