Description

Snoring affects hundreds of millions of people worldwide and describes vibration of airway tissues including the palate, tongue, tonsils, and epiglottis. In a random sample of middle-aged adults, habitual snoring was reported by 45%. Snoring decreases the sleep quality of the snoring individual and the snorer's bed partner, causes social stigma, and may lead bed partners to sleep in separate rooms. Snoring may also be a manifestation of obstructive sleep apnea (OSA), in which the upper airway collapses partially or fully, leading to episodic pauses in breathing (apneas) or shallow breathing (hypopneas). While many physicians and patients recognize health risks of OSA, snoring is often dismissed as "benign" or "simple", but this is a misnomer. Heavy snoring per se can contribute to unrefreshing sleep and daytime fatigue. In study of 400 adult women who underwent polysomnography, snoring was associated with daytime sleepiness, even after adjustment for the presence of OSA. Data from a home sleep apnea testing device equipped with a snoring microphone found that loud sustained snoring predicted daytime sleepiness better than intermittent bursts of sound characteristic of OSA. Other studies suggest that snoring may increase risks of carotid atherosclerosis which could increase the chances of a stroke. A study of surgery for simple snoring reported improvements in marital life after surgery illustrating the impact of snoring and its resolution on sleep quality and relational health. Hence, snoring is a highly prevalent problem that impairs the sleep quality of snorers and the snorer's bed partner.

Current approaches to snoring include weight loss, avoidance of tobacco and alcohol, lateral sleep, nasal decongestants or steroids, nasal dilator adhesive devices, surgeries, or devices (such as CPAP or mandibular advancement devices). Most of these therapies are recommended on the basis of anecdotes and small studies. Insurance generally does not cover CPAP or oral appliances for simple snoring. Despite the nearly ubiquitous nature of snoring, there is no well-researched standard of care.

A large proportion of air enters and exits the nose during typical awake breathing. During sleep some people breathe more orally, which predisposes to snoring and OSA by increasing upper airway resistance and decreasing retro-glossal and retro-palatal area. Under sedation, mouth opening caused a significant increase in the upper airway critical pressure indicating a greater likelihood of airway obstruction compared to mouth closure. Using an oronasal ("full face") mask with a partition installed between the nose and mouth, closure of the nasal port caused severe OSA, which resolved after closing only the mouth port to force nasal breathing, or opening both ports to allow spontaneous breathing. CPAP applied via an oronasal mask is less effective than CPAP applied via a nasal mask. In recent studies, mouth occlusion with a plastic barrier device or silicone tape dramatically reduced snoring volume, and lowered the apnea hypopnea index (AHI) in patients with mild OSA or simple snoring. Mouth closure with a barrier device also improved the performance of an oral appliance for treatment of OSA. These studies demonstrate that mouth breathing predisposes to snoring and OSA, and that diverting breathing through the nose can reduce snoring. However, these studies are limited by small sample size, a homogenous population (Asian men with normal BMI), short study duration, and lack of input from the bed partner.

This project investigates the efficacy of mouth tape in two common clinical scenarios. First, the scenario of a patient with simple snoring after OSA has been ruled out. These patients are typically prescribed lifestyle modification (weight loss, avoidance of supine sleep, tobacco and alcohol) or non-prescription remedies such as nasal dilator strips or decongestant sprays. The second scenario is a patient presenting with snoring and few other symptoms who is found to have mild OSA (apnea hypopnea index, AHI 15). While the treatment for mildly symptomatic mild OSA is debated, the first line therapy is typically CPAP or lifestyle modification. Adherence to CPAP is notoriously challenging. Even among patients who use CPAP chronically, there are frequent side effects such as skin abrasions. Mouth tape might be another treatment option for these patients.

The investigators justify the combined inclusion of snoring patients and those with mild OSA in this study for several reasons. First, overlap in physiology: the same individual may be diagnosed with simple snoring on one night and mild OSA on another, as snoring and OSA are caused by inspiratory flow limitation, which may manifest as night-to-night variability of AHI on sleep studies. Second, overlap in evidence-based management: patients with mild OSA are often managed similarly to simple snorers, since the necessity of CPAP (or other therapies) for mild OSA is controversial. Third, overlap in clinical need: there is significant demand for alternative effective and well-tolerated treatments for both conditions.

In the clinical setting of simple snoring or mild OSA, the investigators will offer patients the option of mouth tape during sleep. A small piece of silicone mouth tape is placed vertically over the lips without fully occluding the mouth, which the investigators hypothesize will lower snoring volume and improve sleep quality for the snorer and bed partner. Patients will be carefully screened who tolerate nasal breathing and have no other complicating cardiopulmonary disease. In consented patients the investigators will measure the safety and tolerability of mouth tape, and the impact of mouth tape on sleep and snoring as perceived by the patient and bed partner after 3 months.

Interestingly, mouth taping has become a viral social media trend with the hashtag mouth taping (#mouthtaping) on Tiktok reaching 160 million views as of 1/5/2024. Many of these posts make bold claims about improved sleep quality, improved sinuses, and even lower blood pressure with mouth taping. The medical community has been slow and uncertain in its response to this phenomenon, illustrating the need for more rigorous research.