Snoring (Primary snoring / habitual snoring)

Snoring (Primary snoring / habitual snoring)

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🔑 Definition & Epidemiology

• เสียงจาก vibration ของ upper airway soft tissue ระหว่าง sleep
• พบได้บ่อยมาก
• ชาย ~44%
• หญิง ~28% (อายุ 30–60 ปี)
• Occasional snoring พบได้แทบทุกคน

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🧠 Pathophysiology (Key clinical concept)

• กลไกหลัก:
• ↑ upper airway resistance
• ↑ pharyngeal collapsibility
• จุดสำคัญ:
• Anterior nasal valve = narrowest segment → highest resistance
• Progression:

1.                   mild → snoring only

2.                   moderate → RERA (respiratory effort related arousal)

3.                   severe → OSA (apnea/hypopnea + desaturation)

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⚠️ Associated conditions (ต้องคิดเสมอ)

1. Obstructive Sleep Apnea (OSA)

• Snoring = marker ของ OSA
• Habitual snorer:
• ชาย ~34%
• หญิง ~19% → มี OSA

2. Upper airway narrowing causes

• Obesity
• Nasal obstruction (allergic rhinitis, septal deviation)
• Craniofacial abnormality
• Adenotonsillar hypertrophy
• Hypothyroidism / acromegaly

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📈 Natural history

• Weight gain → progression to OSA (strongest factor)
• BMI ↑ 1 unit → AHI ↑ ~5 events/hr

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❤️ Clinical consequences

Strong evidence

• 🧠 Carotid atherosclerosis (dose-response relationship)

Weak / unclear

• Hypertension → likely confounded by OSA
• Ischemic heart disease → no clear independent association

Practical consequence

• Bed partner sleep disturbance → significant QoL impact

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🔍 Evaluation (focus = rule out OSA)

1. History (include bed partner)

• Loud habitual snoring
• Witnessed apnea
• Gasping/choking
• Daytime sleepiness
• Morning headache, poor concentration
• Risk factors:
• obesity
• alcohol
• smoking
• sedatives (benzodiazepine)

2. Physical exam

• Large neck circumference
• Crowded oropharynx
• Nasal obstruction / turbinate hypertrophy
• Craniofacial abnormality
• Signs endocrine disease (hypothyroid, acromegaly)

3. Screening tools

• STOP-Bang
• Berlin questionnaire

4. Indication for sleep study

• Loud snoring + ≥1:
• witnessed apnea
• daytime sleepiness
• obesity
• CV disease

→ ส่ง polysomnography / home sleep apnea test

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🧾 Management

🟢 1. Conservative (first-line)

• Weight loss (strongest evidence)
• Avoid:
• alcohol (especiallyก่อนนอน)
• smoking
• Sleep position:
• lateral position (positional therapy)
• Optimize nasal patency:
• saline irrigation
• short-term decongestant
• intranasal steroid (chronic rhinitis)

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🟡 2. Devices

Oral appliance (mandibular advancement device)

• First choice if conservative fail
• Effect:
• ↓ snoring intensity & frequency (good evidence)
• Side effects:
• jaw discomfort, salivation, occlusal change

Nasal dilator

• Low risk → trial ได้

CPAP

• Effective แต่:
• compliance ต่ำถ้าไม่มี OSA

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🔴 3. Surgery (last option)

• Indication: refractory cases
• Options:
• UPPP (uvulopalatopharyngoplasty)
• LAUP (laser-assisted UPPP)
• Radiofrequency ablation
• Palatal implants

⚠️ Limitations:

• Effect ลดลงระยะยาว
• อาจ mask OSA
• complication: pain, dysphonia, reflux, bleeding

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🧠 4. Myofunctional therapy

• Oropharyngeal exercises
• Evidence: moderate benefit (selected patients)

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❌ Not recommended

• Lubricating nasal sprays → ineffective

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📌 Practical clinical approach (ใช้จริง)

1.       Snoring → screen OSA first

2.       ถ้า OSA → treat OSA

3.       ถ้า primary snoring:

o   lifestyle + positional

o   nasal optimization

o   → oral appliance

o   → surgery (last)

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💡 Key take-home for ER / OPD

• Snoring ≠ benign เสมอ → ต้องคิดถึง OSA
• Weight gain = strongest modifiable risk
• ถ้ามี daytime sleepiness + snoring → ส่ง sleep study
• Treatment snoring alone → mainly QoL indication (partner)

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