ArticlePDF Available

Assessment of Nasal Breathing Using Lip Taping: A Simple and Effective Screening Tool. Author List: International Journal of Otorhinolaryngology 2020; X(X): XX-XX Levels of Evidence: 2b -Cross sectional cohort study

Authors:
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Assessment of Nasal Breathing Using Lip Taping: A Simple and Effective Screening Tool.
Author List:
Soroush Zaghi1*; Cynthia Peterson1; Shayan Shamtoob1; Brigitte Fung2; Daniel Kwok-keung Ng3; Triin
Jagomagi4; Nicole Archambault5; Bridget O’Connor6; Kathy Winslow7; Zahra Peeran8; Miche’ Lano9;
Janine Murdock9; Sanda Valcu-Pinkerton1; Lenore Morrissey10.
Affiliations/ Institution:
1The Breathe Institute, Los Angeles, CA, USA
2Kwong Wah Hospital, Hong Kong SAR
3Hong Kong Sanatorium & Hospital, Hong Kong SAR
4University of Tartu, Unimed United Clinics, Estonia
5Minds in Motion, Santa Monica, CA, USA
6O’Connor Dental Health, Ireland
7Independent Researcher, Halfmoon Bay, USA
8Happy Kids Dental Planet, Agoura Hills, CA, USA
9South County Pediatric Speech, Mission Viejo, USA
10Be Well Collaborative Care, Huntington Beach, CA
*corresponding author and author to whom correspondence, reprint requests, and proofs will
be sent:
Soroush Zaghi, MD ENT-
Sleep Surgeon The
Breathe Institute
10921 Wilshire Blvd Suite 912 Los
Angeles, CA 90024
Email: soroush.zaghi@gmail.com Phone: 310-
579-9710
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Abstract
Objectives: Subjective assessment of nasal obstruction with patient-reported outcome measures such
as visual analogue scale and NOSE score may be limited in chronic mouth breathing subjects who are
not consciously aware of nasal breathing difficulties. This study investigates a simple objective
screening tool to assess the capacity for comfortable nasal breathing that is based on sealing the lips
and mouth with tape and assessing whether the subject can breathe comfortably through the nose for
up to three minutes. Method: Cross-sectional, multi-center cohort study with 663 participants (ages: 3-
83 years, 50.5% female). Lips were gently sealed using MicroPore paper tape; timer was used to
assess how long the participants were able to breathe comfortably through the nose for up to 180
seconds. Other measures included subjective rating of perceived difficulty with nasal breathing (VAS,
0-100) as well as self-assessed reports of mouth breathing. Results: There were 9.3% of patients with
subjective reports of moderate to severe nasal obstruction (VAS> 50) and 17.2% of patients with
predominance of self-reported mouth breathing in this series. Overall, 93.4% of participants
successfully passed the nasal breathing test. Among patients with habitual mouth breathing, 83.5%
(91/109) were able to breathe comfortably through the nose when instructed to do so for the entire 3-
minute duration tested. Similarly, there were 67% (40/59) patients with VAS score >50 who could
breathe comfortably through the nose for >180 seconds despite subjective reports of moderate to
severe nasal obstruction. Participants unable to breathe exclusively through the nose for 180 seconds
had increased likelihood of mouth breathing while awake (O4 4.12, 95% confidence interval 2.14-7.89,
p<.0001) as well as increased odds of mouth breathing while asleep (OR 3.05, 95% confidence
interval 1.61-5.72, p=0.0003). Conclusion: Objectively testing whether a subject can breathe through
the nose with the lips and mouth taped for three minutes can identify patients at risk of mouth
breathing and is a simple and effecting screening tool to distinguish organic nasal obstruction from
functional mouth breathing habit and or nasal resistance.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Levels of Evidence: 2b Cross sectional cohort study
Keywords: nasal breathing, assessment tool, nasal obstruction, mouth breathing, lip taping, lip seal
test.
1. Introduction:
Establishment of exclusive nasal breathing is now appreciated as the single most important
objective in securing adequate craniofacial and airway development in children [1]. Indeed, chronic
mouth breathing in growing children is associated with palatal growth restriction, alterations of
craniofacial development, altered head posture, sleep-disordered breathing, and increased risk for
obstructive-sleep apnea later in life [2] [3] [4]. Nasal breathing in adulthood has many advantages:
nasal ventilation filters, warms, and humidifies the air [5]; protects against exercise-induced
bronchospasm [8]; reduces snoring, improves daytime energy, and self-reported sleep quality [7] [8];
decreases vocal effort and laryngeal dryness [9]; and facilitates anxiety reduction and deep meditation
techniques [10].
Subjective assessment of nasal breathing ability with validated tools such as the Visual
Analogue Scale [11] and NOSE [12] [13] score may sometimes be inadequate in chronic mouth
breathing subjects who are not consciously aware of problems with nasal breathing.
Furthermore, these tools may prove ineffective in children who cannot accurately articulate difficulties
with nasal breathing. Objective tools available for assessment of nasal breathing include peak nasal
airflow, acoustic rhinomanometry, rhinomanometry, Odiosof Rhino [14], and computation flow dynamics
using CT- generated three-dimensional nasal models [15]. However, these techniques are often
cumbersome and time-consuming and may not serve well as a quick screening tool.
As such, there is a need for more easily accessible methods to objectively screen and assess
nasal breathing ability. Here we investigate the efficacy of a simple screening tool to assess the
individuals’ capacity for comfortable nasal breathing that is based on sealing the lips and mouth with
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
tape while simultaneously assessing whether the subjects can breathe comfortably through
the nose for a duration of up to three minutes.
2. Methods:
2.1 Study Design: Cross-sectional multi-center cohort study of subjects age three and up from the
general population surveyed in a standardized fashion by interdisciplinary professionals trained in the
evaluation of orofacial myofunctional disorders at 10 sites including researchers in the United States,
Hong Kong, Estonia, and Ireland as part of the Functional Airway Evaluation Screening Tool
(FAIREST) study. The study was approved by Solutions IRB on 3-16-18; IRB Protocol # 2018/03/4.
Data was collected between 3-22-18 and 8-5-18. Subjects recruited include friends, family, colleagues,
and private clients of the researchers who volunteered without financial compensation and provided
written-informed consent to participate. Exclusion criteria: syndromic craniofacial disorder (e.g. Downs,
Treacher Collins, Crouzon, Apert); history of tracheostomy dependence; prior history of laryngeal,
subglottic, or pulmonary airway stenosis or surgery; pregnant women; and
mentally/emotionally/developmentally disabled; impaired decision-making capacity; and prisoners.
There were 21 objective screening-tool items and an 8-item subjective screening tool questionnaire
completed by both subject and a FAIREST researcher (See Appendix A for FAIREST Questionnaire).
2.2 Lip Taping Nasal Breathing Assessment: Lips and mouth of the subject were sealed completely
with gentle MicroPore paper tape. A timer was used to assess how long the subject could comfortably
breathe through the nose for up to 180 seconds with the lips and mouth taped. Subjects were deemed
to pass the test if they could successfully breathe through the nose for three minutes. This test is also
known as “lip seal test” [16]. See Figure 1 (Photo of individual with lips taped as described).
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Figure 1. Lip Taping Nasal Breathing Assessment: Lips are sealed with MicroPore tape. A timer is used to
assess how long the subject can comfortably breathe through the nose for up to 180 seconds with the lips taped.
2.3 Other Assessments: Other assessments included in the analysis for this manuscript from the
FAIREST dataset included: age, gender; subjective visual analogue scale rating of perceived difficulty
with nasal breathing (“Rate how difficult it is to breathe through the nose from 0-100, 0= no obstruction,
100= complete obstruction”) [11]; self-assessed reports of mouth breathing when awake and mouth
breathing when asleep were graded on 4 point Likert Scale: (Rarely to never, sometimes, often, almost
always). For the statistical analysis, reports of “often” and “almost always” were considered positive as
an assessment of chronic mouth breathing habit.
2.4 Statistical Analysis: Statistical analyses were performed using JMP Pro 14 (SAS Institute Inc.,
Cary, NC). Continuous variables are summarized as mean (M) ± standard deviation (SD), standard error
(SE) where applicable. Categorical variables are summarized as frequencies and percentages.
Univariate analysis with Pearson’s Chi Square or independent t-test (continuous variables) was
performed to assess for nominal or continuous covariates of lip taping test: pass vs. unable including
VAS nasal breathing difficulty score, mouth breathing while awake, mouth breathing while asleep,
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
age-cohort, and gender. Due to the testing of multiple variables for each outcome, a two-tailed p-value
<0.01 was selected as the cut-off for statistical significance.
3. Results: There were 633 subjects who participated in the lip taping nasal breathing test including
335 females and 298 males with average age: 21.4 +/- 18.7 years including
315 children (ages 3-11), 71 adolescents (age 12-17), 102 young adults (age 18-35), 126 adults (age
36-64), and 19 seniors (age >65). A total of 591 subjects (93.4%) passed the test as they were able to
breathe through the nose with lips taped for at least 180 seconds. There were 42 subjects (6.6%) who
were unable to complete the nasal breathing test. Among n=42 subjects unable to complete nasal
breathing for 180 seconds, average time to failure was 58.9 +/- 40 seconds (mean +/- SD), median 60
seconds, range 0-150 seconds (Figure 2). There was an increased rate of inability to pass the test
among the adolescent age-cohort (15.5%, 11/71) as compared to children (23/315, 7.3%), young
adults (4/102, 3.9%), adults (4/126, 3.2%), and seniors (0/19, 0%), Pearson Chi Square, p= 0.0066.
There were no significant gender differences.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Figure 2. Distribution of time to failure in seconds among subjects unable to pass the lip taping nasal breathing
test. “Pass” was defined as being able to breathe comfortably through the nose with lips taped for the entire 180
seconds tested.
Among subjects who passed the nasal breathing test, mean +/- SD report of nasal breathing difficulty
on the visual analogue scale (0-100) was 8.28 +/- 18.8. Among subjects who were unable to complete
the lip taping nasal breathing test, mean report of nasal breathing difficulty was 41.6 +/- 26.3
(p<0.0001) (Figure 3). Subjects who could not complete the nasal breathing tape test had increased
odds of mouth breathing while awake (OR 4.12, 95% confidence interval 2.14-7.89, p<0.0001) as well
as increased odds of mouth breathing while asleep (OR 3.04, 95% Confidence Interval 1.61- 5.72,
p=0.0003).
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Figure 3. Box and whisker plot of perceived nasal obstruction (Visual Analogue Scale, 0-100) among patients able
and unable to pass the lip taping nasal breathing test.
There were 17.2% (109/633) patients with reports of a predominance of mouth breathing (“often” or
“almost always” mouth breathes) while awake in this series. Among these patients with habitual
mouth breathing, 83.5% (91/109) were able to successfully pass the lip taping nasal breathing test.
There were only 16.5% (18/109) of mouth breathers who physically could not tolerate breathing
through their nose for 3 minutes duration. Similarly, there were 67% (40/59) patients with moderate to
severe difficulty breathing through the nose (VAS score >50) who could still tolerate lip taping for
>180 seconds despite subjective reports of moderate to severe nasal obstruction.
4. Discussion: This study supports the use of the lip taping nasal breathing test as an effective
screening tool in the assessment of mouth breathing and nasal breathing difficulty. Subjects who
could not complete the nasal breathing tape test had a four-fold increased likelihood of mouth
breathing while awake and three-fold increased likelihood of mouth breathing during sleep. The lip
tape test for nasal breathing was found to be a safe, simple, inexpensive, and rationale tool that offers
excellent utility in bringing nasal obstruction and/or mouth breathing habit to the forefront of a
subject’s awareness.
Although physical examination of the nasal cavity can provide accurate information as to the cause of
nasal obstruction and potential treatment options, previous studies have shown that physical exam
findings (including septal deviation, turbinate hypertrophy, and internal nasal valve collapse) do not
accurately correlate with patients’ subjective awareness and report of nasal obstruction [17] [18]. This
highlights the controversy seen regarding the correlation between changes in objective and subjective
outcome measures of nasal obstruction [19]. Given the lack of correlation found between objective and
subjective nasal obstruction outcome measures, clinical consensus [20] has focused on assessing the
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
efficacy of nasal breathing interventions on patient-reported outcome measures such as the Visual
Analogue Scale [11], Nasal Surgical Questionnaire [21], Nasal Obstruction Septoplasty Effectiveness
[22], and Nasal Obstruction Symptom Evaluation [12], among others [19].
Whereas these tools are effective in helping those patients who proactively report problems with and
seek intervention for nasal obstruction, they do not address the needs of mouth breathing patients who
do not acknowledge, or may be unaware of a problem with nasal breathing. Other tools investigated for
the assessment of nasal patency in the clinical recognition of mouth breathing among this population of
patients include the Glatzel mirror test and water-retention test. [23] [16]. In the Glatzel mirror test, also
called nasographic mirror, a cold mirror is placed under the nostrils and the subject is asked to inhale
and exhale through the nose. If moisture condenses on the mirror, this demonstrates that the patient has
successfully exhaled through the nares. However, prior studies have shown that the Glatzel mirror test
lacks inter-trial reproducibility and does not correlate with other objective and subjective measures of
nasal patency [24]; moreover, it was deemed a poor assessment tool in detecting patient-reported
improvements in breathing following rhinoplasty [25]. The water retention test, on the other hand, is an
effective alternative to the lip taping test in which approximately 15 ml of water is placed in the mouth
and the subject is asked to hold it for three minutes. A prior study shows similar distribution of results
and efficacy between the water retention test and the lip taping test for assessment of nasal versus
mouth breathing [23].
The most interesting finding of this study is that the majority of patients with self-reported mouth
breathing and/or subjective reports of moderate to severe nasal breathing difficulty were still physically
able to breathe comfortably through the nose for at least three minutes duration when instructed to do so
in this study. This is consistent with prior studies on mouth breathing and nasal disuse which show that
oral breathing route may persist even after structural obstructions for nasal breathing have been removed
and that nasal breathing re-education plays an important role in the treatment of mouth breathing [26]
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
[27] [28]. According to the Proceedings of the Royal Academy of Medicine in 1957, it had been widely
appreciated that: “Nasal breathing depends on the patency of the nasal passages and on the orofacial
muscles closing and sealing off the oral cavity from the nasopharyngeal airway. Mouth breathing due
solely to gross nasal obstruction is comparatively rare [whereas,] mouth breathing due to failure of
the orofacial muscles is relatively common” [29]. Since that time, models of oro-nasal rehabilitation
have been developed and incorporated into myofunctional therapy programs to address the functional
aspects of mouth breathing with a high degree of success [28] [30]. Therapeutic mouth and lip-taping
during the day as well as overnight while asleep has been shown to be helpful in re-educating nasal
breathing [31] as well as in improving symptoms of mouth breathing, snoring, and obstructive sleep
apnea [32]. Assessment of nasal breathing ability with the lip tape test can help identify patients with
organic structural obstructions who would benefit from interventions for nasal obstructions, as well as to
distinguish patients with functional deficits who may benefit from re-education of nasal breathing with
myofunctional therapy, oro-nasal rehabilitation programs, or simple lip taping to encourage and
reinforce nasal breathing as a long-term habit.
5. Conclusion: Proper breathing, specifically exclusive nasal breathing, is essential to the health
and development of children. Children who are unable to breathe well through the nose compensate by
breathing more through the mouth. This not only negatively impacts their current health but may also
lead to detrimental issues in adulthood. Early detection of improper breathing is therefore vital. Current
methods for assessing nasal breathing capacity such as visual analogue scale and NOSE score are
subjective and may be limited in chronic mouth breathing subjects who are not consciously aware of
nasal breathing difficulties. This paper advances the field of research by introducing a novel method for
assessing nasal breathing. Specifically, objectively testing whether a subject can breathe through the
nose with the lips and mouth taped for three minutes is a safe and effective screening tool for the
assessment of nasal obstruction and mouth breathing habit.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
Compliance with Ethical Standards
Conflict of Interest: Soroush Zaghi declares that he has no conflict of interest. Cynthia Peterson
declares that she has no conflict of interest. Shayan Shamtoob declares that he has no conflict of
interest. Brigitte Fung declares that she has no conflict of interest. Daniel K. Ng declares that he has
no conflict of interest. Triin Jagomagi declares that she has no conflict of interest. Nicole Archambault
declares that she has no conflict of interest. Bridget O’Connor declares that she has no conflict of
interest. Kathy Winslow declares that she has no conflict of interest. Zahra Peeran declares that she
has no conflict of interest. Miche’ Lano declares that she has no conflict of interest. Janine Murdock
declares that she has no conflict of interest. Sanda Valcu-Pinkerton declares that she has no conflict
of interest. Lenore Morrissey declares that she has no conflict of interest.
Ethical approval: All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional 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. The subjects who are portrayed in the photos provided consent to have these photos submitted
and published by the journal.
Acknowledgement: This study was sponsored by the Academy of Applied Myofunctional Sciences
with financial support for funding of the IRB application. We acknowledge The Breathe Institute for
financial support for the open access publication fees and research assistant support. We also
acknowledge Hoang Anh Dao, Judith Dember-Paige, Jennifer Hobson, and Barry Raphael for their
data collection contributions, Marc Moeller for help in the IRB application, as well as Bruce Peterson
for his efforts with tool creation, design, photography and technical support. The data that support the
findings of this study are available from the corresponding author, Soroush Zaghi, upon reasonable
request.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
References
[1] Torre C, Guilleminault C. Establishment of nasal breathing should be the ultimate goal to
secure adequate craniofacial and airway development in children. Jornal de pediatria 2018;
94:101-103.
[2] Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal
breathing on dentofacial and craniofacial development in orthodontic patients. The
Laryngoscope 2010; 120:2089-2093.
[3] Chambi-Rocha A, Cabrera-Domínguez ME, Domínguez-Reyes A. Breathing mode influence
on craniofacial development and head posture. Jornal de Pediatria (Versão em Português)
2018; 94:123-130.
[4] Juliano ML, Machado MAC, Carvalho LBCd, Prado LBFd, Prado GFd. Mouth breathing
children have cephalometric patterns similar to those of adult patients with obstructive sleep
apnea syndrome. Arquivos de neuro-psiquiatria 2009; 67:860-865.
[5] Elad D, Wolf M, Keck T. Air-conditioning in the human nasal cavity. Respiratory
physiology & neurobiology 2008; 163:121-127.
[6] Griffin MP, McFadden E, Ingram RH. Airway cooling in asthmatic and nonasthmatic
subjects during nasal and oral breathing. Journal of Allergy and Clinical Immunology 1982;
69:354-359.
[7] Friedman M, Tanyeri H, Lim JW, Landsberg R, Vaidyanathan K, Caldarelli D. Effect of
improved nasal breathing on obstructive sleep apnea. Otolaryngology—Head and Neck
Surgery 2000; 122:71-74.
[8] Michels DdS, Rodrigues AdMS, Nakanishi M, Sampaio ALL, Venosa AR. Nasal involvement
in obstructive sleep apnea syndrome. International journal of otolaryngology 2014; 2014.
[9] Sivasankar M, Fisher KV. Oral breathing increases Pth and vocal effort by superficial
drying of vocal fold mucosa. Journal of Voice 2002; 16:172-181.
[10] Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the treatment of stress,
anxiety, and depression: part II—clinical applications and guidelines. Journal of
Alternative & Complementary Medicine 2005; 11:711-717.
[11] Ciprandi G, Mora F, Cassano M, Gallina AM, Mora R. Visual analog scale (VAS) and nasal
obstruction in persistent allergic rhinitis. Otolaryngology—Head and Neck Surgery 2009;
141:527-529.
[12] Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and
validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngology—
Head and Neck Surgery 2004; 130:157-163.
[13] Lipan MJ, Most SP. Development of a severity classification system for subjective nasal
obstruction. JAMA facial plastic surgery 2013; 15:358-361.
[14] Chaaban M, Corey JP. Assessing nasal air flow: options and utility. Proceedings of the
American Thoracic Society 2011; 8:70-78.
[15] Quadrio M, Pipolo C, Corti Set al. Review of computational fluid dynamics in the
assessment of nasal air flow and analysis of its limitations. European Archives of Oto-
Rhino-Laryngology 2014; 271:2349-2354.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
[16] Pacheco MCT, Casagrande CF, Teixeira LP, Finck NS, Araújo MTMd. Guidelines
proposal for clinical recognition of mouth breathing children. Dental press journal of
orthodontics 2015; 20:39-44.
[17] Camacho M, Zaghi S, Certal Vet al. Predictors of nasal obstruction: quantification and
assessment using multiple grading scales. Plastic surgery international 2016; 2016.
[18] Villwock JA, Kuppersmith RB. Diagnostic Algorithm for Evaluating Nasal Airway
Obstruction. Otolaryngologic Clinics of North America 2018.
[19] Spataro E, Most SP. Measuring Nasal Obstruction Outcomes. Otolaryngologic Clinics of North
America 2018.
[20] Rhee JS, Weaver EM, Park SSet al. Clinical consensus statement: Diagnosis and management
of nasal valve compromise. Otolaryngology-Head and Neck Surgery 2010; 143:48-59.
[21] Haye R, Tarangen M, Shiryaeva O, Døsen LK. Evaluation of the nasal surgical
questionnaire for monitoring results of septoplasty. International journal of
otolaryngology 2015; 2015.
[22] Stewart MG, Smith TL, Weaver EMet al. Outcomes after nasal septoplasty: results from the
Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngology–Head and Neck
Surgery 2004; 130:283-290.
[23] Pacheco MCT, Fiorott BS, Finck NS, Araújo MTMd. Craniofacial changes and
symptoms of sleep-disordered breathing in healthy children. Dental press journal of
orthodontics 2015; 20:80-87.
[24] Brescovici S, Roithmann R. Modified glatzel mirror test reproducibility in the evaluation of
nasal patency. Revista Brasileira de Otorrinolaringologia 2008; 74:215-222.
[25] Pochat VDd, Alonso N, Mendes RRdS, Gravina PR, Cronenberg EV, Meneses JVL.
Assessment of nasal patency after rhinoplasty through the Glatzel mirror. International
archives of otorhinolaryngology 2012; 16:341-345.
[26] Lee S-Y, Guilleminault C, Chiu H-Y, Sullivan SS. Mouth breathing,“nasal disuse,” and
pediatric sleep-disordered breathing. Sleep and Breathing 2015; 19:1257-1264.
[27] Guilleminault C, Huang Y, Monteyrol P, Sato R, Quo S, Lin C. Critical role of myofascial
reeducation in pediatric sleep-disordered breathing. Sleep medicine 2013; 14:518-525.
[28] Levrini L, Lorusso P, Caprioglio Aet al. Model of oronasal rehabilitation in children with
obstructive sleep apnea syndrome undergoing rapid maxillary expansion: Research review.
Sleep Science 2014; 7:225-233.
[29] Gwynne-Evans EDB, A. . Discussion on the Mouth-Breather. Proceedings of the Royal
Society of Medicine 1958; 51:279-285.
[30] Gallo J, Campiotto AR. Myofunctional therapy in children with oral breathing. Revista
CEFAC 2009; 11:305-310.
[31] Govardhan C, Jabara M, Sendek Get al. Lip-Taping to Improve Nasal Breathing: Practice
Patterns and Preferences in Orofacial Myofunctional Therapy. International Archives of
Otorhinolaryngology 2019.
[32] Huang T-W, Young T-H. Novel porous oral patches for patients with mild obstructive sleep
apnea and mouth breathing: a pilot study. Otolaryngology–Head and Neck Surgery 2015;
152:369-373.
International Journal of Otorhinolaryngology
2020; X(X): XX-XX
doi: 10.11648/j.XXXX.2020XXXX.XX
ISSN: 2472-2405 (Print); ISSN: 2472-2413 (Online)
List of Titles/Captions For Each Figure:
1. Figure 1. Lip Taping Nasal Breathing Assessment: Lips are sealed with MicroPore tape. A
timer is used to assess how long the subject can comfortably breathe through the nose for up
to 180 seconds with the lips taped.
2. Figure 2. Distribution of time to failure in seconds among subjects unable to pass the lip
taping nasal breathing test. “Pass” was defined as being able to breathe comfortably through
the nose with lips taped for the entire 180 seconds tested.
3. Figure 3. Box and whisker plot of perceived nasal obstruction (Visual Analogue Scale, 0-
100) among patients able and unable to pass the lip taping nasal breathing test.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Objective: The incidence of abnormal breathing and its consequences on craniofacial development is increasing, and is not limited to children with adenoid faces. The objective of this study was to evaluate the cephalometric differences in craniofacial structures and head posture between nasal breathing (NB) and oral breathing (OB) children and teenagers with a normal facial growth pattern. Method: Ninety-eight 7-16 year-old patients with a normal facial growth pattern were clinically and radiographically evaluated. They were classified as either nasal breathing (NB) or oral breathing (OB) patients according to the predominant mode of breathing through clinical and historical evaluation, and breathing respiratory rate predomination as quantified by an airflow sensor. They were divided in two age groups (G1: 7-9) (G2: 10-16) to account for normal age-related facial growth. Results: OB children (8.0±0.7 years) showed less nasopharyngeal cross-sectional dimension (MPP) (p=0.030), whereas other structures were similar to their NB counterparts (7.6±0.9 years). However, OB teenagers (12.3±2.0 years) exhibited a greater palate length (ANS-PNS) (p=0.049), a higher vertical dimension in the lower anterior face (Xi-ANS-Pm) (p=0.015), and a lower position of the hyoid bone with respect to the mandibular plane (H-MP) (p=0.017) than their NB counterparts (12.5±1.9 years). No statistically significant differences were found in head posture. Conclusion: Even in individuals with a normal facial growth pattern, when compared with NB individuals, OB children present differences in airway dimensions. Among adolescents, these dissimilarities include structures in the facial development and hyoid bone position.
Article
Full-text available
Unlabelled: Objective. To evaluate the association between nasal obstruction and (1) demographic factors, (2) medical history, (3) physical tests, and (4) nasal exam findings. Study Design. Case series: Methods. Chart review at a tertiary medical center. Results. Two hundred-forty consecutive patients (52.1 ± 17.5 years old, with a Nasal Obstruction Symptom Evaluation (NOSE) score of 32.0 ± 24.1) were included. Demographic factors and inferior turbinate sizes were not associated with NOSE score or Nasal Obstruction Visual Analog Scale (NO-VAS). A significant association was found between higher NOSE score on univariate analysis and positive history of nasal trauma (p = 0.0136), allergic rhinitis (p < 0.0001), use of nasal steroids (p = 0.0108), higher grade of external nasal deformity (p = 0.0149), higher internal nasal septal deviation grade (p = 0.0024), and narrow internal nasal valve angle (p < 0.0001). Multivariate analysis identified the following as independent predictors of high NOSE score: NO-VAS: ≥50 (Odds Ratio (OR) = 17.6 (95% CI 5.83-61.6), p < 0.0001), external nasal deformity: grades 2-4 (OR = 4.63 (95% CI 1.14-19.9), p = 0.0339), and allergic rhinitis: yes (OR = 5.5 (95% CI 1.77-18.7), p = 0.0041). Conclusion. Allergic rhinitis, NO-VAS score ≥ 50, and external nasal deformity (grades 2-4) were statistically significant independent predictors of high NOSE scores on multivariate analysis. Inferior turbinate size was not associated with NOSE scores or NO-VAS.
Article
Full-text available
Monitoring the results of surgery is important. The otorhinolaryngology department of our hospital currently uses preoperative and postoperative versions of the Nasal Surgical Questionnaire (NSQ) for continuous evaluation of nasal septoplasty. In this study, 55 patients undergoing septoplasty answered the preoperative version twice to assess the NSQ's test-retest precision, and 75 patients answered the preoperative questionnaire before and the postoperative one 6 months after surgery to evaluate the NSQ's ability to detect change in symptoms following surgery. Both the pre- and postoperative versions of the NSQ use separate visual analogue scales (VAS) to assess nasal obstruction during the day, at night, and during exercise. Other nasal symptoms are graded as secondary outcomes using 4-point Likert scales. The mean VAS scores for the two preoperative obstruction ratings were not significantly different. The scores were significantly higher than in a normal population. There were also significant differences between preoperative and postoperative ratings. The mean pre- and postoperative scores at night for those who reported complete improvement were 66.1 and 8.4, substantial improvement 74.5 and 24.2, and no improvement 83.3 and 76.4. The NSQ reliably assesses nasal symptoms in patients and may be useful for both short and long term prospective studies of septoplasty.
Article
Full-text available
Introduction: Mouth breathing (MB) is an etiological factor for sleep-disordered breathing (SDB) during childhood. The habit of breathing through the mouth may be perpetuated even after airway clearance. Both habit and obstruction may cause facial muscle imbalance and craniofacial changes. Objective: The aim of this paper is to propose and test guidelines for clinical recognition of MB and some predisposing factors for SDB in children. Methods: Semi-structured interviews were conducted with 110 orthodontists regarding their procedures for clinical evaluation of MB and their knowledge about SDB during childhood. Thereafter, based on their answers, guidelines were developed and tested in 687 children aged between 6 and 12 years old and attending elementary schools. Results: There was no standardization for clinical recognition of MB among orthodontists. The most common procedures performed were inefficient to recognize differences between MB by habit or obstruction. Conclusions: The guidelines proposed herein facilitate clinical recognition of MB, help clinicians to differentiate between habit and obstruction, suggest the most appropriate treatment for each case, and avoid maintenance of mouth breathing patterns during adulthood.
Article
Full-text available
The main cause of mouth breathing and sleep-disordered breathing (SDB) in childhood is associated with upper airway narrowing to varying degrees. The aim of this study was to assess the prevalence of morphological and functional craniofacial changes and the main clinical symptoms of SDB in healthy children. A cross-sectional observational study was conducted. A sample comprising 687 healthy schoolchildren, aged 7-12 years old and attending public schools, was assessed by medical history, clinical medical and dental examination, and respiratory tests. The self-perceived quality of life of mouth breathing children was obtained by a validated questionnaire. Out of the total sample, 520 children were nose breathers (NB) while 167 (24.3%) were mouth breathers (MB); 32.5% had severe hypertrophy of the palatine tonsils, 18% had a Mallampati score of III or IV, 26.1% had excessive overjet and 17.7% had anterior open bite malocclusion. Among the MB, 53.9% had atresic palate, 35.9% had lip incompetence, 33.5% reported sleepiness during the day, 32.2% often sneezed, 32.2% had a stuffy nose, 19.6% snored, and 9.4% reported having the feeling to stop breathing while asleep. However, the self-perception of their quality of life was considered good. High prevalence of facial changes as well as signs and symptoms of mouth breathing were found among health children, requiring early diagnosis and treatment to reduce the risk of SDB.
Article
Full-text available
Adenotonsillectomy (T&A) may not completely eliminate sleep-disordered breathing (SDB), and residual SDB can result in progressive worsening of abnormal breathing during sleep. Persistence of mouth breathing post-T&As plays a role in progressive worsening through an increase of upper airway resistance during sleep with secondary impact on orofacial growth. Retrospective study on non-overweight and non-syndromic prepubertal children with SDB treated by T&A with pre- and post-surgery clinical and polysomnographic (PSG) evaluations including systematic monitoring of mouth breathing (initial cohort). All children with mouth breathing were then referred for myofunctional treatment (MFT), with clinical follow-up 6 months later and PSG 1 year post-surgery. Only a limited subgroup followed the recommendations to undergo MFT with subsequent PSG (follow-up subgroup). Sixty-four prepubertal children meeting inclusion criteria for the initial cohort were investigated. There was significant symptomatic improvement in all children post-T&A, but 26 children had residual SDB with an AHI > 1.5 events/hour and 35 children (including the previous 26) had evidence of "mouth breathing" during sleep as defined [minimum of 44 % and a maximum of 100 % of total sleep time, mean 69 ± 11 % "mouth breather" subgroup and mean 4 ± 3.9 %, range 0 and 10.3 % "non-mouth breathers"]. Eighteen children (follow-up cohort), all in the "mouth breathing" group, were investigated at 1 year follow-up with only nine having undergone 6 months of MFT. The non- MFT subjects were significantly worse than the MFT-treated cohort. MFT led to normalization of clinical and PSG findings. Assessment of mouth breathing during sleep should be systematically performed post-T&A and the persistence of mouth breathing should be treated with MFT.
Article
Full-text available
Rapid maxillary expansion (RME) is a widely used practice in orthodontics. Scientific evidence shows that RME can be helpful in modifying the breathing pattern in mouth-breathing patients. In order to promote the restoration of physiological breathing we have developed a rehabilitation program associated with RME in children. The aim of the study was a literature review and a model of orofacial rehabilitation in children with obstructive sleep apnea undergoing treatment with rapid maxillary expansion. Muscular training (local exercises and general ones) is the key factor of the program. It also includes hygienic and behavior instructions as well as other therapeutic procedures such as rhinosinusal washes, a postural re-education (Alexander technique) and, if necessary, a pharmacological treatment aimed to improve nasal obstruction. The program should be customized for each patient. If RME is supported by an adequate functional rehabilitation, the possibility to change the breathing pattern is considerably amplified. Awareness, motivation and collaboration of the child and their parents, as well as the cooperation among specialists, such as orthodontist, speech therapist, pediatrician and otolaryngologist, are necessary conditions to achieve the goal.
Article
Nasal obstruction is a common symptom and can have a large impact on patient quality of life. There are numerous causes, including anatomic, congenital, inflammatory, infectious, neoplastic, toxic, and systemic. An algorithmic approach can aid in ensuring all pertinent patient information is incorporated into the final diagnosis and treatment plan. Key components include a thorough history, physical examination including modified Cottle and Cottle maneuver, patient-reported outcome measures and/or quality of life questionnaires, examination with and without decongestion, and nasal endoscopy. The resultant information can then be effectively used to narrow the differential and guide the next steps in management.
Article
Methods of measuring nasal obstruction outcomes include both objective anatomic and physiologic measurements, as well as subjective patient-reported measures. Anatomic measurements include acoustic rhinometry, imaging studies, and clinician-derived examination findings. Physiologic measures include rhinomanometry, nasal peak inspiratory flow, and computational fluid dynamics. Patient-reported outcome measures (PROMs) are self-reported assessments of disease-specific quality-of-life outcomes. Several studies attempted correlation of these outcome measures; however, few show strong correlation. Expert opinion favors determining successful surgical outcomes using PROMs. This review provides a summary of current nasal obstruction outcome measures.