Snoring

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ENT: Snoring & Obstructive Sleep Apnea (OSA)

High-Yield Revision Notes for Board Review & PG Entrance Examinations

Snoring is the vibration of respiratory structures due to the obstruction of air movement during respiration while sleeping. While simple snoring is a social nuisance, Obstructive Sleep Apnea (OSA) is a serious medical condition characterized by recurrent episodes of upper airway collapse during sleep.

1. Pathophysiology: The “Collapse” Mechanism

The airway collapses at one or more levels. Key anatomical narrowing sites include:

  • Nasal level: Deviated nasal septum, hypertrophic turbinates.
  • Oropharyngeal level: Tonsillar hypertrophy, redundant soft palate, uvula elongation.
  • Hypopharyngeal level: Tongue base hypertrophy, retrognathia (mandibular hypoplasia).

2. Clinical Evaluation (The STOP-BANG Questionnaire)

Used to screen for high risk of OSA. STOP-BANG stands for:

  • Snoring: Do you snore loudly?
  • Tired: Do you often feel tired/sleepy during the day?
  • Observed: Has anyone observed you stop breathing or choking during sleep?
  • Pressure: Do you have/are you being treated for hypertension?
  • BMI: BMI > 35 kg/m²?
  • Age: Age > 50 years?
  • Neck size: Neck circumference > 40 cm (16 in)?
  • Gender: Male?

3. Diagnosis & Management

Gold Standard: Polysomnography (PSG). It measures the Apnea-Hypopnea Index (AHI).

  • Mild OSA: AHI 5–15/hour.
  • Moderate OSA: AHI 15–30/hour.
  • Severe OSA: AHI > 30/hour.

Treatment:

  • Conservative: Weight loss, positional therapy (avoiding supine position), and avoiding alcohol/sedatives.
  • Gold Standard Medical: Continuous Positive Airway Pressure (CPAP), which acts as a “pneumatic splint” to keep the airway open.
  • Surgical: Reserved for failures of CPAP. Examples include Uvulopalatopharyngoplasty (UPPP), septoplasty, or mandibular advancement devices.

4. High-Yield Board Points

Point High-Yield Detail
Friedman Staging Used to predict the success of UPPP, based on tongue position (Mallampati score) and tonsil size.
Cardiovascular Risk OSA is a major independent risk factor for systemic hypertension, pulmonary hypertension, and myocardial infarction.
Pickwickian Syndrome Obesity-hypoventilation syndrome (Obesity + daytime hypoventilation + sleep-disordered breathing).
Snoring Surgery Surgery for snoring alone has lower success rates than surgery for documented OSA; patient counseling is vital.