1. 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

2. 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

3. 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

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

5. 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

6. 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.)

7. 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