This article summarises the work done by the German Society of Otorhinolaryngology, who have developed guidelines for the management of snoring. ‘S2k’ is German nomenclature for a consensus based guideline, which (for those of you interested in such things), is one step above an informal consensus (S1), and two steps below a full evidence validated review (S3).
For a ‘S2k’ review, this is a remarkably comprehensive account of the present evidence related to snoring surgery. Evidence for each step in the patient journey is provided from presentation to aftercare. A reasonable algorithm protocol is outlined for ‘Diagnostic measures’ and a separate one for ‘Therapeutic principles’. A good section on history taking and minimal standards for examination of snoring patients is provided. In addition the evidence for the more peripheral, esoteric aspects of snoring management is presented, such as acoustic analysis, rhinoresistometry, nasal dilators etc.
Predictably the level of evidence for much of this protocol is rather lower than what one would like when judged against modern levels of scrutiny, but as a current state of the evidence, it is an impressive work. My impression however of the level of enthusiasm for some of the measures in the protocol was slightly too high. It felt too positive in the description of some of these measures, when really little evidence was presented. This may be due to a heightened cultural acceptance of snoring management in Germany, or perhaps secondary to the translation process from German to English. I would have liked a little more information about questionnaires used in snoring patients, but the brevity of this section may again be due to the lack of evidence for a more detailed account. The algorithms do seem to make a good attempt at avoiding sending everyone off for full polysomnography, but some of steps aren’t clearly defined. For example the step before PSG is ‘objective diagnostic measures’, but the evidence presented suggests that there aren’t any. The article seems to leave this to the discretion of the reader.
Developing a protocol for snoring management was never going to be easy, particularly as we still don’t even have the basics such as a working definition! But I would recommend this article to anyone considering setting up a snoring practice / clinic, as it does provide a reasonable protocol and an overview of the state of our understanding (or lack of it) with regards snoring management.
