Sleep and Breathing

https://doi.org/10.1007/s11325-018-1651-5

SLEEP BREATHING PHYSIOLOGY AND DISORDERS • REVIEW

The relationship of the uvula with snoring and obstructive sleep apnea:
a systematic review
Edward T. Chang 1 & Grace Baik 2 & Carlos Torre 3 & Scott E. Brietzke 2 & Macario Camacho 1

Received: 8 March 2017 / Revised: 19 December 2017 / Accepted: 28 February 2018

# Springer International Publishing AG, part of Springer Nature 2018

Abstract
Currently, the relationship between uvula size and sleep-disordered breathing (snoring and obstructive sleep apnea) lacks data for
objective interpretation. This study conducted a systematic review of the international literature for research describing the
measurable characteristics of the uvula (i.e., size, length, width) and any association with snoring and obstructive sleep apnea
(OSA). PubMED, Scopus, Google Scholar, Embase, and the Cochrane Library were each systematically searched from inception
through November 15, 2016. We screened 1037 titles and abstracts. We conducted a full review of 54 downloaded articles.
Sixteen articles met inclusion and exclusion criteria. The 16 studies included a total of 2604 patients. The selected articles
included data and information for (1) normative data for uvular size in the control groups, (2) snoring and uvula size, (3) OSA
and uvula size, and (4) overall uvula function. Our review noted variability in findings; however, in general, a uvular length >
15 mm was considered elongated and a uvular width > 10 mm was considered to be wide. The studies included in this systematic
review reveal a relationship between uvula size, snoring, and OSA. Further, larger uvulas appear associated with more severe
snoring and OSA. The direct correlation between uvula size and its relationship specifically to snoring and OSA remain as topics
for future prospective research.

Keywords Uvula . Obstructive sleep apnea . Snoring

Introduction

Studies evaluating different upper airway anatomic sub-sites

* Edward T. Chang such as the epiglottis and other structures of the larynx identify
etchan78@gmail.com a positive correlation between the respective structures and
sleep-disordered breathing (SDB) [1–3]. The uvula is a com-
Grace Baik
grbaik@gmail.com
ponent of the soft palate previously linked to snoring and
obstructive sleep apnea (OSA) [4]. Histologic analysis reveals
Carlos Torre that patients with OSA exhibit bulkier, more edematous uvu-
ctorreleon22@gmail.com
las with thicker epithelium and increased leukocytes when
Scott E. Brietzke compared to samples from controls with no history of snoring
sebrietzke@msn.com
or OSA [5].
Macario Camacho Previous studies revealed that the simple act of moving
drcamachoent@yahoo.com from an upright to a supine position narrows the airway, espe-
1
cially in OSA patients [6]. An enlarged uvula may contribute
Department of Surgery, Division of Otolaryngology, Tripler Army
Medical Center, 1 Jarrett White Road, Honolulu, HI 96859, USA
to pharyngeal narrowing. With a decrease in the retropalatal
2
space, a large uvula likely contributes to snoring and OSA [7].
Department of Otolaryngology–Head and Neck Surgery, Walter
Reed National Military Medical Center, 8901 Rockville Pike,
Treatment modalities include surgical resection of the uvula.
Bethesda, MD 20889, USA As far back as the sixth century, written instructions describe
3
Department of Otolaryngology–Head and Neck Surgery, University
techniques for uvulectomy [8].
of Miami, Miller School of Medicine, 1120 NW 14th Street, 5th Although the uvula is not a vital organ, on occasion, its
Floor, Miami, FL 33136, USA complete removal leaves patients with persistent globus,

xerostomia, and dysphagia [9, 10]. Some studies also suggest
that the uvula plays an immunological role against inhaled and
ingested antigens [8, 11]. Consequently, a clearer under-
standing of the potential role the uvula plays in the patho-
genesis of SDB and how its surgical modification helps
improve the outcomes of surgery for specific aspects of
SDB such as OSA appears warranted. Formal research
dedicated to the measurable characteristics of the uvula
remains scarce in the current literature. Given the paucity
of the studies, we conducted a systematic review of the
existing literature specifically evaluating measurable and
objective characteristics of the uvula such as length, width,
volume and their correlation to SDB, if any. The aspects of
SDB in our review included, but were not limited to, snor-
ing, upper airway resistance syndrome and/or obstructive
sleep apnea, hypopneas, and respiratory effort-related
arousals. After identifying the pertinent data, this study
subsequently evaluated and synthesized the information
for comprehensive comparison and interpretation.
Methods
A protocol was submitted to the Tripler Army Medical
Center Institutional Review Board, and the exempt proto-
col (TAMC 16N14) was approved for this review. The
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) statement was adhered to
throughout the review [12].
Literature search
Two authors (G.B. and E.T.C) independently searched the
international literature for search terms relating uvula size
and function with sleep-disordered breathing. Keywords,
phrases, and MeSH terms were searched as related to: uvula,
size of uvula, sleep and uvula, snoring and uvula, obstructive
sleep apnea and uvula, sleep disturbances and uvula, and uvu-
la function. A search strategy example for PubMed is ((uvula)
AND (Bsnore*^ OR Bsnoring^ OR BSleep Apnea Syndromes^
[Mesh] OR Bobstructive sleep apnea^ OR Bobstructive sleep
apnoea^)). Searches were performed in PubMed, Scopus,
Google Scholar, Embase, and the Cochrane Library. The
search included published literature from the inception of
each journal to November 15, 2016. Inclusion criteria were
(1) evaluation of adult populations (age > 18 years), (2)
patients diagnosed with snoring, SDB, or OSA using sleep
studies/PSG, and (3) explicit measurement/categorization
of the uvula’s size. Exclusion criteria included (1) inclu-
sion of the soft palate when reporting uvula size (i.e., not
truly isolating uvula size).
Sleep Breath
Data collection and pooling
The collected data outcomes included (1) number of subjects
with sleep-disordered breathing (i.e., primary snoring, ob-
structive sleep apnea), (2) patient demographics (age, BMI),
(3) method of examination of the uvula, and (4) statistically
significant findings regarding uvula size. The articles identi-
fied included data and information for (1) normative data for
uvular size in the control groups, (2) snoring and uvula size,
(3) obstructive sleep apnea and uvula size, and (4) and uvula
size and other aspects of sleep disturbances and/or SDB
(Table 1).
Statistics
Upon review of the identified literature meeting inclusion
criteria, the authors found that studies reported a statistically
significant relationship between uvula size and SDB (e.g.,
snoring and OSA when reported) using either a contingency
table analysis (e.g., chi-squared, odds ratios) or measured lin-
ear correlation data (e.g., Spearman coefficient). Pooled con-
tingency tables were created, for a pooled odds ratio, with
sensitivity, specificity, PPV, and NPV calculations.
Correlation data was also collected and evaluated in tabular
format. Due to paucity and inconsistency of data within the
respective studies, these calculations and results failed to pro-
vide any significant information for some of the data.
Consequently, we included only pertinent calculations
(Table 1).
Results
Overall, 1037 titles and abstracts were screened, 54 articles
were downloaded for full review, and 16 articles met inclusion
and exclusion criteria. A total of 2604 patients were included.
The majority of studies were observational, with BC^ level of
evidence. There was variability in findings, however, in gen-
eral, a uvular length > 15 mm was considered elongated and a
uvular width > 10 mm was considered to be wide. There was
insufficient consistency in measured and recorded data
amongst the studies to perform a comprehensive meta-
analysis.
Selection criteria
Results and inclusion criteria are outlined in Fig. 1.
Methods of uvula measurement
Uvula size was described as a grade in a rubric, a measured
value [13–16], or a binary enlarged vs. regular. Multiple au-
thors utilized their own uvula grading scales [4, 17–19], all of
Sleep Breath

Table 1 General characteristics of included studies

Authors Sleep pathology Uvula exam N Age BMI Outcome measure

Akpinar et al., 2011 [20] Snoring s/p palatal Physical exam 36 39.66 ± 9.32 26.06 ± 2.44 Uvula grade (≤ 15 vs > 15 mm)
implant vs. palatal implant efficacy
via pre/post-op VAS and ESS
Back et al., 2012 [17] Snoring s/p RFSP Physical exam 74 42 (median) 25.6 (median) Uvula grade (1–4) vs. RF efficacy
surgery via pre/post-op VASpt
VASpartner
Barcelo et al., 2011 [4] OSA Physical exam 301 51 ± 12 29.8 ± 4.6 Uvula score (1–4) vs. AHI
Dahlqvist et al., 2007 [18] OSA Physical exam 801 Uvula grade (1–4) vs. AHI (> 15)
Herzog et al., 2009 [19] SDB Simulate snoring 622 56 ± 12 31.7 ± 6.1 Uvula grade (1–4) vs. AHI
(awake)
Lee et al., 2013 [21] OSA, snoring Physical exam 90 Large uvula in snoring vs. OSA
vs. control
Martinho et al., 2008 [26] OSA Physical exam 45 46.5 ± 10.8 49 ± 7 Uvula size in OSA vs. control
Miller and Gerhardt, Snoring Physical exam 1 57 28 Case report
2006 [7]
Min et al., 1997 [13] OSA, snoring Physical exam 22 46.5 Uvula size vs. PSG
Reda et al., 1999 [14] Snoring s/p LAUP Physical exam 121 45 ± 10 Uvula size in controls vs.
habitual snorers
Schellenberg et al., OSA Physical exam 158 50.5 ± 13.9 35.9 ± 9.3 Uvula enlargement vs. AHI > 15
2000 [22]
Svensson et al., 2006 [25] OSA Physical exam 132 51.3 ± 10.1 26.9 ± 4.8 Large uvula in AHI < 10 vs. > 10
Thulesius et al., 2004 [24] OSA Pharyngometry 96 49 28.2 Uvula breadth vs. AHI (> 10)
(photo)

which were variants of a four-category scale classifying the of the 16 studies utilized radiographic imaging (lateral cepha-
uvula as normal vs. long vs. wide vs. long and wide (see lometry, craniofacial CT) [15, 16, 23].
Table 2). A uvula was often considered enlarged (i.e., longer,
wider) if its length exceeded 15 mm or width exceeded 10 mm Uvula enlargement in sleep-disordered breathing
[18, 20–22]. The majority of included studies measured the
uvula via physical exam (e.g., flexible laryngoscopy, direct All included studies demonstrated a significant, direct re-
visualization, pharyngometry with recorded images). Three lationship between uvula size and sleep-disordered breath-
ing. All studies found a positive correlation between uvula
size and snoring [17, 20] and uvula size and OSA, demon-
Arcles from the database searches strating a positive relationship between larger uvulas and
(aer removal of duplicates)
N=1037 sleep-disordered breathing; see Table 2. Svaza et al. found
that increased uvula sizes directly correlated with increas-
Arcles excluded ing severity of OSA categories [16]. Uvula size correlated
aer screening: with the presence of OSA, determined by an apnea-
N=983 hypopnea index (AHI) cut-off, or directly correlated to
Potenally relevant arcles retrieved the AHI values themselves. Uvula width directly correlated
for detailed evaluaon
with the AHI and inversely with lowest oxygen saturation
N=54
on a direct linear scale [15, 24].
Addional studies
idenfied from Arcles excluded Gender differences
reference lists aer detailed
N=0 evaluaon
Herzog et al. [19] noted a statistically significant difference in
N=38
uvula size between men and women referred for suspected
SDB; see Table 2. While examining patients referred for pos-
Included Studies sible OSA, Dahlqvist et al. found that an enlarged uvula was
N=16
more common in men than in women (60 vs 29%) [18]. This
Fig. 1 Literature selection process overview finding of enlarged uvulas being more common in men was

Table 2 Main results of included studies regarding uvula size
Author, year
Akpinar et al., 2011 [20]
Back et al., 2012 [17]
Barcelo et al., 2011 [4]
Dahlqvist et al., 2007 [18]
Herzog et al., 2009 [19]
Lee et al., 2013 [21]
Martinho et al., 2008 [26]
Miller and Gerhardt, 2006 [7]
Min et al., 1997 [13]
Olszewska et al., 2009 [23]
Reda et al., 1999 [14]
Ryu et al., 2015 [15]
Schellenberg et al., 2000 [22]
Svaza et al., 2011 [16]
Svensson et al., 2006 [25]
Thulesius et al., 2004 [24]
Sleep Breath
N Results regarding uvula
36 In patients receiving palatal implant for primary snoring (AHI < 5), those with uvula ≤ 15 mm
had significantly higher rates of subjective satisfaction (50% VAS reduction). Uvula length was
the determinant factor of subjective satisfaction (OR = 0.75, p = 0.005), 50% ESS reduction
(OR = 0.84, p = 0.038), and partner reported improvement (OR = 0.83, p = 0.039)
74 In patients receiving interstitial soft palate radiofrequency surgery for snoring only (no OSA, SDB),
uvula grade correlated with post-op changes in VAS scores for patients (− 0.686, p < 0.001) and bed
partners (− 0.483, p < 0.001). Uvula grade explained 23.3 and 47.0% of achieved changes in snoring
301 Positive correlation between author-created uvula score (grades 1–4; 1—uvula without hypertrophy,
2—uvula slightly hypertrophied without touching tongue, 3—hypertrophic uvula contacting tongue
base, and 4—markedly hypertrophic uvula lying on tongue base) and AHI (Spearman r = 0.17,
p = 0.003). However, uvula score did not enter predictive model determined by multivariate regression
801 A wide uvula (> 10 mm) was independently associated with AHI > 15 in men (adjusted OR = 1.87,
CI 1.17–2.97), but not women
622 In patients with suspected SDB, uvula size classification correlated with AHI (r = 0.175, p < 0.001).
For males, AHI correlated with uvula size (r = 0.098, p = 0.042), as did for females (r = 0.315,
p < 0.001). However, there was no significant correlation in the generalized linear model
90 Long uvula was defined as ≥ 15 mm. 46.7% of habitual snorers had a long uvula or low lying soft palate,
whereas 17% of non-snorers did (p < 0.001). Similarly, 42.2% of those at high-risk for OSA
(as determined by the Berlin Questionnaire) had a long uvula or low lying soft palate, whereas 18.9%
of those not high-risk (p < 0.001). The presence of a long uvula or low lying soft palate predicted the
presence of OSA (OR = 2.579, p = 0.022)
45 Specific to patients with class III obesity (BMI > 40). In patients without OSA, 10% had a long uvula
and 20% a thick uvula. In patients with OSA, 45.7% had a long uvula and 71.4% a thick uvula
(χ2, p < 0.005). The presence of OSA was associated with both a long uvula (P = 0.04) and a thick
uvula (p = 0.0052)
1 Case report of patient who had deep snoring under anesthesia and returned on POD2 with elongated,
erythematous uvula which self-resolved by POD7. Uvular edema attributed from negative pressure
from deep snoring
22 Patients suspected to have OSA were evaluated, including PSG and uvula measurement. Mid-point
uvula width (9.3 ± 2.5 mm) correlated with RDI (Spearman r = 0.56, p = 0.02) and lowest SaO2
(r = − 0.66, p = 0.01). Uvula length (12.8 ± 3.2 mm) correlated with lowest SaO2 (r = − 0.62, p = 0.02)
28 Patients with OSA had significantly longer uvulae as measured on lateral cephalometry and
craniofacial CT compared to controls
121 Patients examined prior to undergoing laser-assisted uvulopalatoplasty for snoring. Habitual snorers
have significantly longer (p < 0.0002, 95% CI 0.96–2.94) and wider (p < 0.00001,
95% CI 0.53–1.29) uvulae when compared to age- and sex-matched non-snorers. Non-snorer uvulae
were 10.2 ± 3 mm long and 6.4 ± 1 mm wide. Habitual snorer uvulae were 12.2 ± 3 mm long and
7.3 ± 1 mm wide
140 In patients with OSA, uvula thickness correlated with AHI (Pearson’s r = 0.19, p < 0.05) and
lowest oxygen saturation (r = − 0.22, p < 0.01). There was no correlation for uvula length. Uvula
width was included in the ultimate discriminant function formula
158 Enlarged uvula (wider than 10 mm or longer than 15 mm) was a significant independent risk factor
for having an AHI > 15 (OR = 1.9, 95% CI 1.2–2.9). This finding remained significant when
analyzing males only (OR = 2.0, 95% CI 1.2–3.3), but not females
58 Patients with snoring had a uvula width 9.5 ± 1.47 mm and length of 39.5 ± 9.55 mm; those with
mild OSA (AHI < 5) 10.3 ± 1.82 and 42.0 ± 4.98 mm; those with moderate OSA (AHI ≥ 5–15)
10.2 ± 2.13 and 41.6 ± 5.97 mm; severe OSA (> 15) measurements not reported. One-way ANOVA
showed significant differences in uvula thickness between snorers and OSA III (p = 0.001), OSA
I and OSA III (p = 0.032), OSA II and OSA III (p = 0.075)
132 Having the uvula touch the posterior pharyngeal wall while supine was a risk factor for sleep apnea
(defined by authors as AHI ≥ 10) in women with BMI < 25 (OR 8.62, 95%CI 1.96–37.95), but not
for those BMI ≥ 25
96 Uvula breadth correlated with AHI (Pearson’s r = 0.31, p = 0.002). However, uvula breadth did
not enter predictive RDIA model determined by linear regression models
Sleep Breath
confirmed in the study by Schellenberg et al. (89 of men vs
27% of women) [22]. Both authors also report that a larger
uvula was independently associated with an AHI > 15 in men,
but not in women. Another study found that a long uvula or
low lying soft palate predicted the presence of OSA in young,
male soldiers (OR 2.579, p = 0.022) [21].
However, uvula size was associated with OSA in females
as well, as demonstrated in the study by Svensson et al. [25].
This group studied females exclusively and found that a uvula
touching the posterior pharyngeal wall while supine was pre-
dictive of sleep apnea (defined as AHI ≥ 10) for women with a
BMI < 25 kg/m2 (OR 8.62, 95% CI 1.96–37.95).
Uvula size for predicting surgical outcomes
A smaller uvula correlated with better surgical outcomes for
two separate procedures for patients with primary snoring [17,
20]. Akpinar et al. found that patients with a uvula ≤ 15 mm
had significantly higher rates of post-palatal implant success,
measured by reduction in visual analog scale (VAS), Epworth
sleepiness scale (ESS), and by bed partner reported improve-
ment. Back et al. found similar results in patients receiving
interstitial soft palate radiofrequency surgery. This study noted
that having a larger uvula correlated negatively with reduction
in VAS scores and portended worse outcomes.
Discussion
There are four main findings from this review. First, every
study identified for inclusion in this review consistently dem-
onstrated a direct relationship between an enlarged uvula and
the presence of SDB. However, this review cannot draw con-
clusions on whether an enlarged uvula is causative or the
result of SDB. Prior studies documented histological changes
in the tissue composition of patients with OSA [10], such as
increased intercellular space (indicating edema), plasma cell
infiltration, and epithelial hyperplasia. These factors appear
indicative of an inflammatory process possibly as a conse-
quence of trauma induced by snoring and a reasonable cause
of changes that lead to SDB.
Second, despite the variability in uvula grading scales
throughout the studies identified in the literature, a consistent
relationship generally reported is that a uvula length > 15 mm
was considered elongated and a uvula width > 10 mm was
considered to be wide. The simple presence of an enlarged
uvula could serve as a sign that a patient has sleep-
disordered breathing. Two studies (Back et al. and Akpinar
et al.) [17, 20] demonstrated that uvula size correlated with
surgical outcomes for procedures performed for primary snor-
ing. If indeed uvula size can predict surgical results, a stan-
dardized method of reporting uvula size could be a useful
clinical tool to aid in the overall decision making process for
snoring procedure selection.
Third, in order to make more generalizable statements with
regard to the specific relationship between elongated uvulas
and SDB, a method for objectively evaluating SDB appears
necessary. Several tools exist to assess OSA, but other aspects
of SDB such as snoring also require methods/techniques for
measurement [26, 27]. Use of universally available tools such
as smartphones appears to be a viable method of assessing the
other facets of SDB. For example, several apps available for
use on smartphones exist to assess snoring. A recent analysis
of all the smartphone snoring apps on iTunes found the app
BQuit Snoring^ to be the most useful, and when compared to
sleep studies, the app had sensitivities that ranged from 64 to
96% and a positive predictive value that ranged from 93 to
96% [28]. The gold standard is sleep study reported snoring
index values; however, it is the authors’ experience that the
value is only rarely reported in the sleep studies.
Lastly, more research is needed with regard to the signifi-
cance of the effect of the uvula size on sleep-disordered
breathing. Though the studies reviewed found an association
between the size of the uvula and SDB, other potential factors
contributing to SDB such as BMI, palate dimensions, and
position and neck size were not addressed. A first step in
researching the uvula is to standardize the reporting of the size
of the uvula. A simple, consistent way to document the size
would be to measure the uvula length and width in millimeters
when patients are in the operating room and are under anes-
thesia, followed by reporting of individual patient data in the
published manuscript.
In lab sleep studies or validated home sleep tests, labs
should start reporting the snoring index in their results, as this
will allow for analysis of the snores per hour and will facilitate
researchers evaluating outcomes. This provides a use of
existing methods to standardize a more comprehensive report
of the measurable aspects of SDB. In addition, more studies
are needed to improve the level of evidence and consistency.
To make the findings more generalizable, the studies should
evaluate consecutive patients and use prospective study de-
signs such as observational case series, case-control studies,
cohort, or randomized trials. Incorporation of existing tools
such as the visual analog scale, snoring index based on sleep
studies, and/or smartphone applications facilitates obtaining
the breadth of data necessary for meta-analyses. Given the
relatively few studies and subsequent paucity of data reporting
outcomes for the uvula as related to sleep-disordered breath-
ing, we were unable to perform a meta-analysis in this study.
Limitations
There are limitations to this study. As with any systematic
review, it is possible that we missed including studies meeting

our criteria, despite our best effort. Further, there was not
sufficient quantitative data to perform a meta-analysis. An
additional reason we could not perform a meta-analysis is that
there is heterogeneity in grading the uvula size, and thus far,
there is no validated grading scale. Lastly, there are very few
prospective studies in the literature at this time; therefore, to
improve the ability to generalize findings, more prospective
studies are needed.
Conclusion
The studies included in this systematic review reveal a rela-
tionship between uvula size and snoring and OSA. Further,
larger uvulas appear associated with more severe snoring and
OSA. Uvula size and its relationship specifically to snoring
and OSA remain as topics for future prospective research.
Compliance with ethical standards
Conflict of interest All authors certify that they have no affiliations with
or involvement in any organization or entity with any financial interest
(such as honoraria; educational grants; participation in speakers’ bureaus;
membership, employment, consultancies, stock ownership, or other eq-
uity interest; and expert testimony or patent-licensing arrangements), or
non-financial interest (such as personal or professional relationships, af-
filiations, knowledge, or beliefs) in the subject matter or materials
discussed in this manuscript.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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