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.