neurologic disorders
Snoring
Evaluation of Snoring
The primary goal is to identify snorers who are at high risk of having obstructive sleep apnea. Many snorers do not have OSA, but most patients with OSA snore (the precise proportion is not known). Because several important manifestations of OSA are noticed mainly by others, bed partners or roommates should also be interviewed when possible. History of present illnessshould cover severity of snoring, including its frequency, duration, and loudness. Also, the degree that snoring affects the bed partner should be noted. Review of systemsshould seek symptoms suggesting obstructive sleep apnea, such as the presence of sleep disturbance as indicated by Number of awakenings Witnessed apneic or gasping/choking episodes Presence of unrefreshing sleep or morning headaches Excessive daytime sleepiness The Epworth Sleepiness Scale can be used to quantify daytime sleepiness. The STOP-BANG score (see table STOP-BANG Risk Score for Obstructive Sleep Apnea ) is a useful tool to predict risk of OSA for patients who snore. should note presence of disorders that may be associated with OSA, particularly Hypertension , coronary ischemia, Examination should begin by measuring height and weight, with calculation of body mass index (BMI). The rest of the examination should focus on inspecting the nose and mouth for evidence of obstruction. Signs include Nasal polyps and engorged turbinates A high, narrow arched palate Enlargement of the tongue, tonsils, soft palate, lateral pharyngeal walls, or uvula A small or posteriorly displaced mandible (retrognathia) A modified Mallampati score of 3 or 4 (only the base or none of the uvula is visible during oral inspection—see figure Modified Mallampati scoring ) suggests increased risk of OSA. Modified Mallampati scoring is as follows: Class 1: Tonsils, uvula, and soft palate are fully visible. Class 2: Hard and soft palate, upper portion of tonsils, and uvula are visible. Class 3: Soft and hard palate and base of the uvula are visible. Class 4: Only the hard palate is visible. The following findings are of particular concern: Witnessed apnea or choking during sleep Morning headaches Epworth sleepiness score ≥ 10 BMI ≥ 35 kg/m2 Very loud, constant snoring Hypertension None The clinical evaluation is not completely reliable for diagnosis of obstructive sleep apnea but can be suggestive. Red flag findings clearly correlate with OSA. However, all of these findings occur along a continuum, and there is no widespread agreement on cut-off points and relative weighting. Nonetheless, the more red flag findings a patient has and the more severe they are, the greater the likelihood of OSA. Testing is done when a diagnosis of obstructive sleep apnea is suspected; it consists of Testing (in a laboratory or at home). Polysomnography should be done when clinical suspicion for OSA is significant. Patients who should be tested include those who have red flag findings (particularly witnessed apnea), including those whose test scores (eg, STOP-BANG risk score for OSA) are not quite high enough for a diagnosis of OSA. However, because snoring is so common, polysomnography, particularly home testing, which is not as expensive, can be used more liberally and should be considered when clinical suspicion for OSA is lower. People with no symptoms or signs of sleep disturbance other than snoring may not need to be tested but should be clinically monitored for development of such manifestations. 