RAG rating
Document type
Clinical policy
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions

Referral and Surgery for Snoring, Sleep Disordered Breathing and Obstructive Sleep Apnoea

July 2022 v1.0

Related policies:

  • EBI 1 for tonsillectomy for recurrent tonsillitis (quinsy, emergency presentations and suspected cancer)
  • Local policy on tonsillectomy for tonsilloliths
  • EBI 2 for adenoidectomy as adjuvant when inserting grommets

Simple snoring

Snoring is a noise that occurs during sleep that can be caused by vibration of tissues of the throat and palate. It is very common and as many as one in four adults snore, as long as it is not complicated by periods of apnoea (temporarily stopping breathing) it is not usually harmful to health, but can be disruptive, especially to a person’s partner.

Surgical interventions to the palate for simple snoring (in the absence of OSA) are outside of the scope of this policy. Please refer instead to the national EBI programme (list 1)

Other surgical interventions for simple snoring (in the absence of OSA), including but not limited to tonsillectomy and adenoidectomy, are considered a low priority and will therefore not be routinely funded. 

Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS) in Adults

Referral for investigation of suspected obstructive sleep apnoea/hypopnoea syndrome should only be made inline with NICE guidance NG202.

Criteria for referral for assessment for oropharyngeal surgery (including tonsillectomy): 

  • Diagnosed with OSAHS (confirmed during a multi-channel sleep study) 


  • Have attempted all relevant lifestyle changes, including 

- Weight loss

- Stopping smoking

- Reducing alcohol intake

- Improving sleep hygiene


  • Diagnosed with severe OSAHS (defined as AHI 30 or more))


  • Unable to tolerate CPAP and a customised mandibular advancement splint despite medically supervised attempts over a sufficient period of time


  • Have symptoms affecting usual day-time activities


  • Have large obstructive tonsils


  • Body mass index (BMI) of less than 35 kg/m2 

Nasal or skeletal framework surgery will not be funded due to a lack of sufficient evidence.

Obstructive Sleep Apnoea Syndrome/Sleep disordered breathing in Children

Children should be referred to a child paediatric ENT specialist if:

  • Suspected OSAS*


  • Clinical features of nasopharyngeal obstruction (such as adenotonsillar hypertrophy AND regular snoring at night)

Children with the following should be referred to a paediatrician rather than ENT:

  • Obesity
  • Behavioural problems, irritability, reduced concentration, or reduced school performance
  • Faltering growth
  • Congenital or developmental disorder that may be contributing to symptoms.

Adenotonsillectomy will be funded for children with adenotonsillar hypertrophy and corresponding symptoms impacting quality of life, behaviour or development, in order to correct the anatomic obstruction causing symptoms. This procedure is usually curative in children

* Suspect a diagnosis of OSAS in a child with:

  • Witnessed snoring and breathing pauses while sleeping (apnoeas), which may be followed by a gasp or snort.
  • Restlessness and sudden arousals from sleep, laboured breathing, unusual sleep posture (for example with neck hyperextended).
  • Nocturnal enuresis (due to decreased appropriate arousals during sleep).
  • Daytime symptoms such as behavioural problems, irritability, hyperactivity, reduced concentration, reduced school performance, mouth breathing.
  • Daytime tiredness and sleepiness, faltering growth (rare).


1.NICE (2021) NG202 Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s. Available online at https://www.nice.org.uk/guidance/ng202 [Accessed 9th June 2022)

2.NICE (2021) Clinical Knowledge Summary: Obstructive sleep apnoea syndrome. Available online at: https://cks.nice.org.uk/topics/obstructive-sleep-apnoea-syndrome/ [Accessed 9th June 2022)