Snoring – a noise generated as a result of partial upper airway obstruction during sleep Apnoea – a period of no airflow in the nose or mouth for at least 10 seconds Snoring and OSA

Pathophysiology Snoring - Partial obstruction of the upper airway leads to vibration of the soft palate and pharyngeal walls Nose Soft palate Tongue base Apnoea – complete obstruction of the airway due to complete collapse Both associated with obesity but up to 1/3 rd of OSA sufferers may have a BMI <25

History Try to see with the sleep partner – It is usually the partner who has a problem with the snoring and they can describe it Apnoea episodes described? Day time somnolence Alcohol Smoking Sedatives Shift work Weight gain Nasal obstruction

Examination and Investigation BMI Nose Oropharynx – crowded ? Retrognathia Neck mass FBC, TFT, FBS – other cause of fatigue Epworth score < 10 reasurring

Management: Patient presents with snoring or ?OSA GP does Epworth Epworth <10 - OSA unlikely. If anatomical cause for snoring - nasal polyps, large tonsils – Rx / consider referral to ENT Treat rhinitis or nasal polyps if found Nasal expanders from pharmacist Lifestyle advice – weight loss, reduce alcohol, sleep on side etc Epworth <10 - OSA unlikely. No anatomical cause found - lifestyle advice - stop smoking, lose weight etc

Epworth <10 - OSA unlikely. No anatomical cause. Lifestyle change not worked. Consider mandibular advancement splint. Patient needs to have a dentist. Dentists can make these but will charge. GPs can refer direct to Simon Littlewood an Orthodontist at St Lukes who will make them on a no charge NHS basis. (We should look at the tariffs for this and if a commissioning group could ask local dentists to make them cheaper than a referral to St lukes. Also a long waiting list at St Lukes.)

Epworth >/= 10 - possible OSA. If anatomical cause for snoring/OSA could refer direct to sleep studies or ENT. Will probably need both anyway as wouldn't usually operate without sleep study results. Epworth >/= 10 - possible OSA. No anatomical cause for snoring/OSA - refer direct to sleep studies