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Diagnosis and treatment of snoring in adults–S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery

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Abstract

Objectives

This guideline aims to promote high-quality care by medical specialists for subjects who snore and is designed for everyone involved in the diagnosis and treatment of snoring in an in- or outpatient setting.

Discussion

To date, a satisfactory definition of snoring is lacking. Snoring is caused by a vibration of soft tissue in the upper airway induced by respiration during sleep. It is triggered by relaxation of the upper airway dilator muscles that occurs during sleep. Multiple risk factors for snoring have been described and snoring is of multifactorial origin. The true incidence of snoring is not clear to date, as the incidence differs throughout literature. Snoring is more likely to appear in middle age, predominantly in males. Diagnostic measures should include a sleep medical history, preferably involving an interview with the bed partner, and may be completed with questionnaires. Clinical examination should include examination of the nose to evaluate the relevant structures for nasal breathing and may be completed with nasal endoscopy. Evaluation of the oropharynx, larynx, and hypopharynx should also be performed. Clinical assessment of the oral cavity should include the size of the tongue, the mucosa of the oral cavity, and the dental status. Furthermore, facial skeletal morphology should be evaluated. In select cases, technical diagnostic measures may be added. Further objective measures should be performed if the medical history and/or clinical examination suggest sleep-disordered breathing, if relevant comorbidities are present, and if the subject requests treatment for snoring. According to current knowledge, snoring is not associated with medical hazard, and generally, there is no medical indication for treatment. Weight reduction should be achieved in every overweight subject who snores. In snorers who snore only in the supine position, positional treatment can be considered. In suitable cases, snoring can be treated successfully with intraoral devices. Minimally invasive surgery of the soft palate can be considered as long as the individual anatomy appears suitable. Treatment selection should be based on individual anatomic findings. After a therapeutic intervention, follow-up visits should take place after an appropriate time frame to assess treatment success and to potentially indicate further intervention.

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Acknowledgments

We want to thank Mrs. Angela Wenzel, MD, for her support in the translation of the guideline.

Conflicts of interest

Boris A. Stuck has received study support, consultancy fees, or reimbursement of travel expenses from Aspire Medical, Celon AG Medical Instrument, Olympus, Sutter Medizintechnik, Neuwirth Medical Products, Philips Healthcare, Fachlabor Dr. W. Klee, Heinen & Löwenstein, Fisher & Paykel Healthcare, and Inspire Medical.

Armin Steffen has received study support, consultancy fees, or reimbursement of travel expenses from Creative Centical, Südbadische Apothekenkammer, Pharmazeutische Zeitung, ResMed, and Inspire Medical.

Hans Pistner holds stocks from Fresenius and Rhön-Klinikum AG.

Thomas Kühnel has received study support, consultancy fees, or reimbursement of travel expenses from Merz Pharmaceuticals, Sutter Medizintechnik, Neuwirth Medical Products, and Storz Endoskope and holds a European (1833436) and a German (10 2005 000 702) patent.

Thomas Verse has received study support from Revent and Sileomed.

Joachim T. Maurer has received study support, consultancy fees, or reimbursement of travel expenses from Inspire Medical, GlaxoSmithKline, Olympus, Heinen & Löwenstein, Novartis, Fisher & Paykel, Revent, and Medtronic.

Susanne Schwarting has received consultancy or speaking fees from Scheu-Dental, Somnomed, ResMed, and various dental labs.

Clemens Heiser has received support for the realization of a scientific meeting from Happersberger otopront, NMP Neuwirth Medical Products, Heinen & Löwenstein, Inspire Medical, Fisher & Paykel Healthcare, VIVISOL, Institut Schilling, ResMed, NightBalance B.V., and Weinmann Geräte für Medizin.

Reinhard Müller, Gerald Gronke, Alfred Dreher, and Michael Herzog have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany

    Boris A. Stuck & Joachim T. Maurer

  2. Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig-Maximilians-Universität, Munich, Germany

    Alfred Dreher

  3. Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

    Clemens Heiser

  4. Department of Otorhinolaryngology, Head and Neck Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany

    Michael Herzog

  5. Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Regensburg, Germany

    Thomas Kühnel

  6. German Association for Cranio-Maxillo-Facial Surgery, Erfurt, Germany

    Hans Pistner

  7. Institute for Surgical Research, Marburg, Germany

    Helmut Sitter

  8. Department of Otorhinolaryngology, Head and Neck Surgery, University of Lübeck, Lübeck, Germany

    Armin Steffen

  9. Department of Otorhinolaryngology, Head and Neck Surgery, Asklepios-Klinik Harburg, Hamburg, Germany

    Thomas Verse

Authors
  1. Boris A. Stuck
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  2. Alfred Dreher
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  3. Clemens Heiser
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  4. Michael Herzog
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  6. Joachim T. Maurer
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  7. Hans Pistner
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  8. Helmut Sitter
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  9. Armin Steffen
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  10. Thomas Verse
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Corresponding author

Correspondence to Boris A. Stuck.

Additional information

Guideline report

The current guideline was initiated by the German Society of Otolaryngology Head and Neck Surgery (Deutsche Gesellschaft für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie e.V., DGHNO), and the first author of the guideline (Stuck) was assigned its development. In order to provide an interdisciplinary approach, all involved societies and interest groups were contacted and asked for participation in May 2012. The following societies and institutions were contacted: German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemein- und Familienmedizin, DEGAM) German Sleep Society (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, DGSM), German Respiratory Society (Deutsche Gesellschaft für Pneumologie, DGP), German Society of Oral and Maxillofacial Surgery (Deutsche Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie, DGMKG), German Occupational Union of Otorhinolaryngologists (Deutscher Berufsverband der Hals-Nasen-Ohrenärzte), German Society of Dental Sleep Medicine (Deutsche Gesellschaft zahnärztliche Schlafmedizin, DGZS), and the Union of Chronic Sleep Disorders (Allgemeiner Verband chronische Schlafstörungen Deutschland e.V., AVSD) as representatives of self-help organizations. These institutions were asked to delegate representatives for the nominal group process and to delegate authors for the guideline in order to achieve an interdisciplinary approach at an early stage of the guideline.

Consecutively, the DGMKG delegated one representative to be an author and a member of the nominal group process. The DEGAM decided not to take part in the process. Initially, the DGSM and the DGP were willing to be part of the process and delegated authors, but both withdrew from the process at a later stage. The DGSZ, the Occupational Union of Otorhinolaryngologists, and AVSD did not delegate authors for the guideline but took part in the nominal group process.

Setting and date of the nominal group process and Delphi process

The nominal group process to revise the existing guideline took place in Mannheim, Germany on February 21, 2013 under the direction of Helmut Sitter (Marburg). The members of this meeting were given a draft of the guideline prior to the meeting. Based on this draft and according to the formal rules of a nominal group process, the content of this draft was discussed and controversial aspects were voted on in order to reach a consensus. A simple majority was enough during voting. The following delegates were part of the group process: Alfred Dreher (DGHNO), Clemens Heiser (DGHNO), Gerald Gronke (German Occupational Union of Otorhinolaryngologists), Michael Herzog (DGHNO), Joachim T. Maurer (DGHNO), Reinhard Müller (AVSD), Hans Pistner (DGMKG), Susanne Schwarting (DGZS), Helmut Sitter (AWMF), Boris A. Stuck (DGHNO), and Thomas Verse (DGHNO).

The revised guideline resulting from the nominal group process was further discussed in a nonanonymized Delphi process. The members of the Delphi process were the authors of the guideline as well as the members of the nominal group process.

In order to provide the recommendations of this guideline, two formal consensus processes were combined: the nominal group process and the Delphi process. In a nominal group process, all members meet in strictly structured conditions under direction of a neutral mediator. The process is subdivided into the following steps:

1. Presentation of the statement to be evaluated.

2. Every member revises the statements and makes comments on the statements and presented algorithms.

3. A neutral mediator collects these revisions and comments. Similar comments are summarized.

4. For every suggestion, there is a vote to determine if there should be a discussion about the topic.

5. Suggestions are ranked for discussion.

6. Discussion takes place according to this ranking.

7. The vote of the majority is recorded and the guideline is revised according to this vote before the next meeting.

8. At the next meeting, all steps (1–6) are repeated.

This process is repeated until consensus is reached. For all questions and suggestions that were ranked as less important, the nonanonymized Delphi process (or Delphi technique) was used. The Delphi process has a similar formal structure, but in contrast to the nominal group process described above, the members do not meet in person to reach consensus but communicate in written form.

Funding and conflict of interests

The guideline was developed with funding from the German Society of Otolaryngology, Head and Neck Surgery (DGHNO) without external funding. All authors revealed potential conflicts of interests (e.g., relationships with the pharmaceutical industry and manufacturers of medical devices). Those potential conflicts of interests were evaluated by a team of coordinators, and it was determined that none should prevent any of the authors’ participation in the process. The authors’ conflict of interest statements were collected and are presented as a supplement to this guideline.

Validity and update of the guideline

This guideline will be valid until August 2016. At that time, a revision of the content and a potential update to the guideline will take place. If the coordinator of the guideline becomes aware of any new and important findings that require an update to the guideline in the meantime, an update will be made earlier.

Passage of the guideline

After finalization of the Delphi process, the guideline was presented for revision and comment to the headquarters of the involved societies as well as to the German Society of Dental, Oral and Craniomandibular Sciences (Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde, DGZMK). The Occupational Union, the AVSD, the DGMKG, and DGZMK had no further comments. The DGZS required inclusion of a diverging statement concerning treatment with intraoral devices, which can now be found in the corresponding section of the guideline. In July 2013, this version of the guideline was presented to and approved by the initiator of the guideline, the German Society of Otolaryngology Head and Neck Surgery.

This guideline was initially published in German: Stuck BA, Dreher A, Heiser C, Herzog M, Kühnel T, Maurer JT, Pistner H, Sitter H, Steffen A, Verse T für die Arbeitsgemeinschaft Schlafmedizin der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e.V. S2k-Leitlinie “Diagnostik und Therapie des Schnarchens des Erwachsenen”. HNO 2013; 61:944–957

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Stuck, B.A., Dreher, A., Heiser, C. et al. Diagnosis and treatment of snoring in adults–S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery. Sleep Breath 19, 135–148 (2015). https://doi.org/10.1007/s11325-014-0979-8

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