Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

adult: without UARS or OSA

1st line – lifestyle measures

Back
ONGOING
|
adult: without UARS or OSA
1st line – 

lifestyle measures

Patients without upper airway resistance syndrome (UARS) or obstructive sleep apnoea (OSA) should aim to lose weight if overweight, avoid smoking, avoid alcohol (especially before bed), avoid sedating medications, and try to refrain from sleeping on their backs. Wearing a t-shirt with a breast pocket the wrong way round, and putting a ball such as a squash ball in the pocket, may help keep patients off their backs while asleep. Oropharyngeal exercises may have some limited benefit.[46] Earplugs for bed partners may be of benefit.

Plus – intranasal corticosteroids

Back
ONGOING
|
adult: without UARS or OSA
|
with allergic rhinitis or chronic nasal inflammation
Plus – 

intranasal corticosteroids

Treatment recommended for ALL patients in selected patient group

Topical corticosteroids usually improve the nasal airway in patients and may improve snoring.

Primary options

beclometasone nasal: (50 micrograms/spray) adults: 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

budesonide nasal: (32 micrograms/spray) adults: 32-64 micrograms (1-2 sprays) in each nostril once daily

OR

flunisolide nasal: (25 micrograms/spray) adults: 50 micrograms (2 sprays) in each nostril twice daily

OR

fluticasone propionate nasal: (50 micrograms/spray) adults: 50-100 micrograms (1-2 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/spray) adults: 100 micrograms (2 sprays) in each nostril once daily

Consider – nasal dilator

Back
ONGOING
|
adult: without UARS or OSA
|
with allergic rhinitis or chronic nasal inflammation
Consider – 

nasal dilator

Additional treatment recommended for SOME patients in selected patient group

Simple external nasal dilators may improve snoring.

These are available over the counter at most pharmacies.

Studies suggest reduction of snoring and improvement of sleep quality,​ but objective evaluations are lacking or are less convincing, and no particular dilator would seem superior.[51][52][53][54][55][56]

Plus – nasal decongestants

Back
ONGOING
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adult: without UARS or OSA
|
with upper respiratory tract infection
Plus – 

nasal decongestants

Treatment recommended for ALL patients in selected patient group

In transient snoring associated with an upper respiratory tract infection (URTI), nasal decongestants, such as topical oxymetazoline, may be considered for a short period.

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays in each nostril every 10-12 hours, maximum 6 sprays per nostril every 24 hours

More

Plus – nasal surgery

Back
ONGOING
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adult: without UARS or OSA
|
with anatomical nasal obstruction
Plus – 

nasal surgery

Treatment recommended for ALL patients in selected patient group

For patients with nasal polyps and no or minimal improvement with intranasal corticosteroids, an endoscopic nasal polypectomy with or without functional endoscopic sinus surgery should improve the symptom of nasal obstruction and may improve snoring.

Patients with a deviated nasal septum may experience an improvement in their snoring with a septoplasty to correct the deviated nasal septum.

If a patient has turbinate hypertrophy, options include cautery, laser, radiofrequency, reduction, and outfracturing.[58]

Plus – mandibular advancement splint (MAS) or radiofrequency to tongue base

Back
ONGOING
|
adult: without UARS or OSA
|
with tongue base level snoring
Plus – 

mandibular advancement splint (MAS) or radiofrequency to tongue base

Treatment recommended for ALL patients in selected patient group

MAS is a relatively simple non-surgical option in which a patient wears a dental splint during sleep to bring the mandible forwards to increase the pharyngeal airway and improve the pharyngeal muscular tension.

In selected cases, radiofrequency can be applied to the tongue base under local anaesthesia. This has been shown to reduce snoring scores on a visual analogue scale (VAS), but not to the point of patient satisfaction.[73] However, repeat procedures may be necessary before a clinically significant improvement is seen. Complications are reported at a rate of 2% and include ulcers of the tongue base or soft palate, dysphagia, temporary hypoglossal nerve palsy, and an abscess of the tongue base.[74]

Plus – upper airway surgery

Back
ONGOING
|
adult: without UARS or OSA
|
with uvulopalatal level snoring
Plus – 

upper airway surgery

Treatment recommended for ALL patients in selected patient group

There are a large number of possible uvulopalatal and uvulopalatopharyngeal interventions used to treat snoring at this anatomical level. Which is used depends on many factors including clinical findings, training and preferences of the surgeon, size of the tonsils, and the views of the patient with regard to minimising pain and/or avoiding a general anaesthetic.

Patients may initially undergo sub-mucosal radiofrequency ablation to the soft palate, under either a local or general anaesthetic. This technique involves inserting a probe into the soft palate and delivering radiofrequency energy to shrink and stiffen the soft palate.

With radiofrequency or laser uvulopalatoplasty, the uvula is removed and soft palate incisions are made to create a neo-uvula. There are a number of variations to the technique. It can be performed under local anaesthetic in a clinic setting.

If the tonsils are large (size 3 or 4) and the patient is not overweight, then surgical uvulopalatoplasty (in which the tonsils and uvula are removed using conventional surgical techniques), can be curative. It is performed under a general anaesthetic.

Palatal implant procedures usually involve 3 braided polyester implants being introduced via a special needle device into the soft palate in order to make it stiffer and less likely to vibrate. It can be performed under local anaesthetic in a clinic setting.

adult: with UARS or OSA

1st line – continuous positive airway pressure (CPAP)

Back
ONGOING
|
adult: with UARS or OSA
1st line – 

continuous positive airway pressure (CPAP)

For patients with upper airway resistance syndrome (UARS) or obstructive sleep apnoea (OSA), sleeping with a sealed mask over the face, with applied positive airway pressure, prevents the upper airway from collapsing, stopping airway obstruction and snoring.

Plus – lifestyle measures

Back
ONGOING
|
adult: with UARS or OSA
Plus – 

lifestyle measures

Treatment recommended for ALL patients in selected patient group

Patients should aim to lose weight if overweight, avoid smoking, avoid alcohol (especially before bed), avoid sedating medications, and try to refrain from sleeping on their backs. Wearing a t-shirt with a breast pocket the wrong way round, and putting a ball such as a squash ball in the pocket, may help keep patients off their backs while asleep. Oropharyngeal exercises may have some limited benefit.[46] Earplugs for bed partners may be of benefit.

Consider – intranasal corticosteroids

Back
ONGOING
|
adult: with UARS or OSA
Consider – 

intranasal corticosteroids

Additional treatment recommended for SOME patients in selected patient group

If the patient suffers from allergic rhinitis or chronic nasal inflammation, topical corticosteroids usually improve the nasal airway and may help improve snoring.

Primary options

beclometasone nasal: (50 micrograms/spray) adults: 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

budesonide nasal: (32 micrograms/spray) adults: 32-64 micrograms (1-2 sprays) in each nostril once daily

OR

flunisolide nasal: (25 micrograms/spray) adults: 50 micrograms (2 sprays) in each nostril twice daily

OR

fluticasone propionate nasal: (50 micrograms/spray) adults: 50-100 micrograms (1-2 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/spray) adults: 100 micrograms (2 sprays) in each nostril once daily

Consider – nasal dilator

Back
ONGOING
|
adult: with UARS or OSA
Consider – 

nasal dilator

Additional treatment recommended for SOME patients in selected patient group

Simple external nasal dilators may provide some benefit.

These are available over the counter at most pharmacies.

Studies suggest reduction of snoring and improvement of sleep quality, but objective evaluations are lacking or are less convincing, and no particular dilator would seem superior.[51][52][53][54][55][56]

Consider – nasal surgery

Back
ONGOING
|
adult: with UARS or OSA
Consider – 

nasal surgery

Additional treatment recommended for SOME patients in selected patient group

For patients with nasal polyps, an endoscopic nasal polypectomy with or without functional endoscopic sinus surgery should improve the symptom of nasal obstruction and may improve snoring.

Patients with a deviated nasal septum may experience an improvement in their snoring with a septoplasty to correct the deviated nasal septum.

If a patient has turbinate hypertrophy, options include cautery, laser, radiofrequency, reduction, and outfracturing.[58]

Consider – mandibular advancement splint (MAS)

Back
ONGOING
|
adult: with UARS or OSA
Consider – 

mandibular advancement splint (MAS)

Additional treatment recommended for SOME patients in selected patient group

MAS is a relatively simple non-surgical option in which a patient wears a dental splint during sleep to bring the mandible forwards to increase the pharyngeal airway and improve the pharyngeal muscular tension.

Consider – upper airway surgery

Back
ONGOING
|
adult: with UARS or OSA
Consider – 

upper airway surgery

Additional treatment recommended for SOME patients in selected patient group

Upper airway surgery may be of benefit in improving the symptoms of OSA in carefully selected patients.

There are a large number of possible uvulopalatal and uvulopalatopharyngeal interventions used to treat snoring at this anatomical level. Which is used depends on many factors including clinical findings, training and preferences of the surgeon, size of the tonsils, and the views of the patient with regard to minimising pain and/or avoiding a general anaesthetic.

Patients may initially undergo sub-mucosal radiofrequency ablation to the soft palate, under either a local or general anaesthetic. This technique involves inserting a probe into the soft palate and delivering radiofrequency energy to shrink and stiffen the soft palate.

With radiofrequency or laser uvulopalatoplasty, the uvula is removed and soft palate incisions are made to create a neo-uvula. There are a number of variations to the technique. It can be performed under local anaesthetic in a clinic setting.

If the tonsils are large (size 3 or 4) and the patient is not overweight, then surgical uvulopalatoplasty (in which the tonsils and uvula are removed using conventional surgical techniques), can be curative. It is performed under a general anaesthetic.

Palatal implant procedures usually involve 3 braided polyester implants being introduced via a special needle device into the soft palate in order to make it stiffer and less likely to vibrate. It can be performed under local anaesthetic in a clinic setting.

child: without concurrent indication for tonsillectomy or adenoidectomy

1st line – reassurance and monitoring

Back
ONGOING
|
child: without concurrent indication for tonsillectomy or adenoidectomy
1st line – 

reassurance and monitoring

Simple snoring from adenotonsillar hypertrophy usually settles with age.

Plus – intranasal corticosteroids

Back
ONGOING
|
child: without concurrent indication for tonsillectomy or adenoidectomy
|
with allergic rhinitis
Plus – 

intranasal corticosteroids

Treatment recommended for ALL patients in selected patient group

This improves the nasal airway and may also reduce adenoidal hypertrophy, which in turn may improve snoring.[10][41][61]

Primary options

beclometasone nasal: (50 micrograms/spray) children >6 years of age: 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

budesonide nasal: (32 micrograms/spray) children >6 years of age: 32-64 micrograms (1-2 sprays) in each nostril once daily

OR

flunisolide nasal: (25 micrograms/spray) children >6 years of age: 50 micrograms (2 sprays) in each nostril twice daily

OR

fluticasone propionate nasal: (50 micrograms/spray) children >4 years of age: 50-100 micrograms (1-2 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/spray) children >2 years of age: 50 micrograms (1 spray) in each nostril once daily

child: with concurrent indication for tonsillectomy or adenoidectomy

1st line – tonsillectomy and/or adenoidectomy

Back
ONGOING
|
child: with concurrent indication for tonsillectomy or adenoidectomy
1st line – 

tonsillectomy and/or adenoidectomy

If there are other indications for surgery (e.g., recurrent tonsillitis, or nasal obstruction from adenoidal hypertrophy), then an adenoidectomy, a tonsillectomy, or a combined procedure may be curative.

child: with UARS or OSA

1st line – referral to a specialist to consider adenotonsillectomy

Back
ONGOING
|
child: with UARS or OSA
1st line – 

referral to a specialist to consider adenotonsillectomy

For the majority of children with with upper airway resistance syndrome (UARS) or obstructive sleep apnoea (OSA), adenotonsillectomy results in improvement in respiratory parameters measured by polysomnography and quality-of-life measures, although the correlation between the two is poor.[85]

Severe OSA preoperatively is associated with persistence of OSA after adenotonsillectomy. Postoperative reports of symptoms such as snoring and witnessed apnoeas correlate well with persistence of OSA after adenotonsillectomy.[85]

2nd line – CPAP

Back
ONGOING
|
child: with UARS or OSA
2nd line – 

CPAP

Sleeping with a sealed mask over the face, with applied positive airway pressure, prevents the upper airway from collapsing, stopping airway obstruction and snoring.

CPAP is effective in children with OSA and is indicated when adenotonsillectomy is contraindicated or has failed.[86]

CPAP is difficult for approximately 20% of children to tolerate. Since children grow rapidly, frequent follow-up visits are necessary and the mask must be adjusted at least every 6 months.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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