Sleep-Disordered Breathing, Mouth Breathing and Quality of Life
I'm british, so please overlook my frequent use of the word interesting. I have a strong interest in children with sleep-disordered breathing (SDB) so I've just looked through the abstract of an interesting paper on Factors affecting quality of life of pediatric outpatients with symptoms suggestive of sleep-disordered breathing.
The authors examined several factors in SDB and children's quality of life. They report the following:
The most common clinical findings was mouth breathing (41.2%). Tonsillar hypertrophy (>/=3+) was found in 62.7 and 52.9% had adenoid-nasopharyngeal ratio greater than 70%. Overweight/obesity were found in 35.3% of the patients. OSA-18 scores ranged from 22 to 85. Tonsillar hypertrophy was significantly related to QOL (p<0.05). Adenoid hypertrophy had trends towards impact on QOL (p=0.094). Mouth breathing correlated well with QOL (p<0.01).We know from previous research that habits such as habitual mouth-breathing during the day may be clinically relevant in conjunction with other symptoms for severe obstructive sleep apnoea. The prevalence of mouth-breathing strongly supports my own anecdata working with children with SDB so I was pleased to see this.
Swollen tonsils and adenoids are common in children with SDB so I was intrigued to that the authors found that tonsillar hypertrophy was significant but not adenoidal hypertrophy in the population that they looked at. It was a contentious review in places but Gross and Harrison gave a common description of the consequences of mouth breathing in their discussion of tonsils and adenoids:
Mouth breathing presumably causes changes in facial growth patterns as the tongue is placed in an abnormally low position to expand the oropharyngeal cavity. Over time, due to altered vectors of force on facial development, the child develops a long and narrow face, a narrow upper jaw, steep palate, and open bite deformities. This classically is referred to as "adenoid facies".Adenoid facies are further reviewed and discussed in Adenoid Facies and Nasal Airway Obstruction.
I'm going to be a little persnickety and say that although the authors declared that their objective is:
[t]o determine the relationship between causative factors of sleep-disordered breathing (SDB) and quality of life (QOL) of children who presented with SDBthey should not claim that they are looking at causative factors. Previous studies have reported strong correlations for some of the factors but I can not accept that they are established as causative. Kotagal and Pianosi published an excellent review of Sleep disorders in children and adolescents earlier this year and it is clear that there is much uncertainty about what may be considered as causative. As for the discussion on adenoid facies and nasal airway obstruction, the sequence of events is not clear.
Wherever possible, encourage children to breathe through the nose. Nose-breathing is a useful part of re-training the breathing of children. Maddeningly, I have colleagues in other countries who report that they have worked with children with adenotonsillar hypertrophy that has been documented in scans. They have worked with the children to re-train their breathing and when those children have returned for scans, their hypertrophy has been significantly reduced. Anecdotes are useless however; at the bare minimum, we need to see these examples published in a case series.
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