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TheNoseKnowsImportanceoftheNasalAirway

DennisR.Bailey,DDSNovember18,2020

Introduc>onandPlan•  Func>onandphysiologyofthenasalairway•  Anatomyofthenasalairway•  Evalua>onofthenasalairway–fromtheden>st’sperspec>ve–adultsandchildren

•  Managementofnasalairwaycompromiseandwaystoimprovenasalbreathing: day>mevsnighIme

•  Importancerelatedtomanagementop>ons•  Interac>onwiththeENTphysician

DentalSleepMedicineintheFuture–2020andBeyond

•  NeedtoviewDentalSleepMedicine(DSM)inanewlightbasedonexpandingdefini>onsthatdefinetheroleoftheDen>st

•  DSMgoesbeyondSleepBreathingDisordersandOralApplianceTherapy

•  Theprac>ceofDSMinvolvesthecraniofacialstructures–includesthenasalcavityandairway

NewDefini;onofDSM

“DentalSleepMedicineisthedisciplineconcernedwiththestudyoftheoralandmaxillofacialcausesandconsequencesofsleep-relatedproblems”NewDefini>onofDSM:F.Lobbezoo,etalJOralRehab2016

DentalSleepMedicineTopics&ExpandedRole

•  DentalmanagementofOSA•  Assessandmanagesleepbruxism(SB)•  Associa>onofSBandsleep-relateddisorders•  Bidirec>onalrela>onshipbetweenorofacialpainandsleepdisorders

Ref:ThefaceofDentalSleepMedicineinthe21stcenturyLobbezooF,LavigneG,etalJOralRehab2020FromSymposium:“Wake-upcall:DentalSleepMedicineisheretostay”June20,2019

MedicineDuringSleep•  NotthesameasSleepMedicineasweviewit•  MedicalandHealthconcernsduringsleepmaybedifferentwhencomparedtotheawakestate

•  BPisanexample:Elevatedduringsleepismorecloselyassociatedwithfatal&nonfatalCVevents

•  Donon-specificdiseasesoccuronlyduringsleep? Ref:Lefertotheeditor:SLEEP2020;43(1):1-3

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MouthBreathingandtheNasalAirway

•  Mouthbreathingleadstochangesthatfurtherlimittheabilitytonosebreath

•  Mostispredicatedonenlargedadenoids•  Tonsilsalsoinvolved•  ThisisthestartofaSBD!thenOSA•  In-betweenissnoringandUARS

GrowthandDevelopmentConsidera>ons

•  Needtostartlookingatchildrenandadolescents

•  ObserveGrowth&Development•  ObesityandCraniofacialabnormali;esaccountfortwo-thirds(2/3)ofthevaria;oninOSAmeasuredbytheAHI

Ref:DempseyetalChest2002;122:840-851

ImpactofChronicMouthBreathing•  AdenoidalFaces–LongFace•  Basedonpreviousstudies

fromthe70’sintothe90’sHarvold,WoodsideandLinder-Aronson

EnlargedAdenoids

TonsillarHypertrophy

GradingofTonsils

01+2+3+4+NotVisibleBarely¼ofway½WaytoObstruc>ve

visibletomidlinemidline“Kissing”

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Waldeyer’sRingGroupofLymphoidTissue

•  Lymphoidal>ssueintheupperairway(nasopharynxmainly)

•  Body’sfirstlineofdefense

Rela>onshipofAdenoidtotheEar

•  MostlyassociatedwiththeEustachiantube•  Eustachiantubedysfunc>on•  Firstsigns:Sleepbruxism–ear“infec>ons”orcloggedears-hearingloss–learningissues

RouteofRespira>onMouthvsNasalBreathing

•  Lackofabilitytonosebreathandadequatenasalbreathing–firstrecognizedasamouthbreathinghabit

•  Nasalbreathingisthepreferredrouteofrespira>on•  Shouldonlymouthbreath≈4%ofthe>me•  Day>memouthbreathingistypicallylessthanatnight•  Manyarepoornasalbreathersatnightduringsleep•  Posturalcomponent•  Otherconsidera>ons:Allergy–GERD–Asthma-Weight

HabitualMouthBreathing

Day?Night?Both?Day;meBreathing≠ Night Breathing

Mouth Breathing 100% PPV for OSA

Chest 2006;130:1765-1771

CoatedTongueMidlineGroove Scalloping/Crena>ons

TheNoseandNasalAirwayThePortaltotheAirway

WarmsandHumidifiesAirHumidifiestheAirto~80%

Warmsairto~90ºParanasalSinusesreleaseNO

AlsoFilterstheAir

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NOSE(OtolaryngolHeadNeckSurg2004:130(2);157-63)

Noseyouseecomprisesonly30%ofthetotalvolume

TheNasalAirway PhysiologyoftheNasalAirway•  Weknowitasthecarburetorofthebodyforhumidifica>onandwarming(alsofilters)

•  NasalairwayalsocontainsNitricOxideasagasfromtheparanasalsinuses–deliveredcon>nuouslyintothenasalairway

•  Thenitricoxideisavasodilator–enhancesuptakeofO2bytheblood

•  Anotherreasontonosebreath–notmouthbreathing–bloodoxygenlevels10%higherwithnosebreathing ActaPhysiolScand158(1996)pg343-347

ParanasalSinuses NitricOxideinMedicine

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MoreonNO•  Stableinlowconcentra>ons-canberapidlydestroyed

•  Potentvasodilator–hasan>-inflammatoryproper>es

•  Producedbywhitebloodcells–killsbacteria,fungiandviruses(COVID19??)

•  HasanimpactontheHypoglossalmotornucleus–helpskeepthetongueforward

•  Importantinangiogenesisforwouldhealing•  ReducedinDiabetes

AFewNOReferences•  Lundberg,JO.NOandtheParanasalSinusesinTheAnatomicalRecord2008;291:1479-1484

•  LundbergJOandWeitzbergE.Nasalnitricoxideinman.Thorax1999;54:947-952

•  BainAR,etal.Insufficientsleepisassociatedwithimpairednitricoxide-mediatededothelium-dependentvasodial>on.AtherosclerosisOct2017;265:41-46

•  WeitzbergE&LundbergJO.HummingGreatlyIncreasesNasalNitricOxide.AJRRCM2002;166:144-145

Dreaming:ColororBlack&White

Beforetheintroduc>onofthecolortelevision,only15percentofpeopledreamedincolor.Today,themajoritydo,butastudyfromtheUniversityofDundeefoundthat12percentofusdreamexclusivelyinblackandwhite,mostlyolderpeople,wholikelyrecallthedaysofblackandwhiteTV.Ref:JConsciousnessandCogni>onVol17,issue4Dec2008pg1228-1237

Anatomy of the Nose External •  Nasal Vestibule •  Alar Rim (External

nasal valve) •  Columella

Internal

•  Turbinates •  Nasal Septum •  Choanae •  Nasal Valve •  Retropalatal Area

(Nasopharynx)

TheNasalValve NasalValve

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AdenoidalFaces AdenoidalFaces•  LongHistoryofMouthbreathing•  OpenMouthPosture•  NosethatAppearsFlafened•  NostrilsareSmall&PoorlyDeveloped•  ShortUpperLip•  Pou>ngLowerLip•  VacantFacialExpressionFrom:Naso-RespiratoryFunc2onandCraniofacialGrowth1979UnivofMichJAMcNamara,

Nasal Turbinates

and Allergic Shiners

Function of the Nasal Turbinates

•  Inferior:largestone–airflowdirec>on-filterstheairhumidifyandheatair

•  Middle:protecttheopeningofthemaxillaryandethmoidalsinuses–bufferstoprotectthesinusesfrompressurizedairflow

•  Superior:protectolfactorybulbs

Visualiza>onofNasalTurbinates UseofNasalSpeculumGover>cal–NOThorizontal

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Alterna>veMethodtoVisualizetheNasalAirway

•  Livthe>pofnosegently–openingthenasalves>bule-Shineabrightlightintothenasalairway

NasalFunc>onalTes>ng•  AlarRimCollapse•  AlarRimStabiliza>on(stabiliza>onusingaQ->p)

•  CofleTest(impactofnasaldila>on)•  Nasalliv(liv>pofnose)

Poiseulle’s Law (pwah-zwez)

Law of Flow Dynamics

Flow = Radius4

For every amount a tube is opened or closed flow is impacted to the

fourth power

Mechanism:HowNasalAirway

Obstruc>onleadstoSleepDisorderedBreathing

NasalAirwayResistance↓

IncreasedInspiratoryPressure↓

IncreasedIntra-thoracicPressure↓

AirwayCollapse(Snoring&SleepApnea)

TheNoseandSleepDisorderedBreathing(SDB)

•  SDBcanresultfromorbemadeworsebynasalobstruc>on

•  Nasalbreathingincreasesven>latorydrive•  NasalOcclusion(anycause)decreasesnasalpatencyinnormalsubjects

•  Nasalconges>on(anycause)predisposesSDB•  Oralbreathinginchildrenleadstofacialstructureabnormali>es CHESTDec2003 Vol124(6):2309-2323

ChronicRhini>s

MostFrequentlyCausedbyAllergyto:

Pollen(Seasonal)HouseDustMites

AndGERDassociatedAsthma

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It’stoughtomakepredic>onsespeciallyaboutthefuture

YogiBera

ClintonWagner,MDPublishedin1884

“HabitualMouthBreathing

ItsCauses,Effects,andTreatment”

“Shutyourmouth...Andstretchthenostrilswide.”

Shakespeare

Publishedin1889

“OnSomecausesofBackwardnessAndStupidityinChildren:

And the Relief of These Symptoms in Some Instances by Naso-Pharyngeal Sacrification”

Author:Wm.Hill,BSc

AnnualMee>ngoftheBri>shMedicalAssoc. BMJSept28,1889p711-712

In1892•  WilliamOslerdocumentedsleepandday>meperformanceofchildrenwithsleep-relatedupperairwayobstruc>on

•  “childisverystupidlooking” •  “at night the child’s sleep is greatly disturbed, the

respirations are loud and snorting, and there are prolonged pauses, followed by deep noisy inspirations”

•  “influenceonmentaldevelopmentisstriking”•  “impossibletofixtheafen>onforlongata>me”

PersistentMouthBreathingFollowingAdenoidectomy

•  Indicateshowmouthbreathingisnotthenorm–examiningthenoseshouldberou>ne

•  Examinethenoseforenlargedinferiorturbinates(truehypertrophy)andforseptaldevia>on

•  Dothisbeforethereisahighpalate–ifthereisa“higharch”needexpansion From:BostonMedicalandSurgicalJournal Feb13,1913

OslerW.ThePrinciplesandPrac>ceofMedicine.8thed.NewYork:Appleton,

1919;468-471.

SirWilliamOslerwasthegreatestphysicianofthe20thcentury.In1919henoted:Chronicenlargementofthe2ssuesofthetonsillarringisanaffec2onofgreatimportance,andmayinfluenceinanextraordinarywaythementalandbodilydevelopmentofchildren.Oslerwasreallywri>ngaboutsleepbreathingproblemsinchildren.Mostoftheseproblemsarecausedbyenlargedtonsilsand/oradenoids.

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BlueLakeinNelsonLakesNa>onalPark–SouthIslandNewZealand

Visibilityis230to262feet

ManagementofNasalAirwayObstruc>on

NasalDila>onand/orNasalCleansingOliveOil(Oleocanthal)

PalatalExpansion(mostlyinchildren)AllergyManagement-NasalSprays

MandibularReposi>oningSurgery(nasalvalve/alarrimsuspension)

ExtraVirginOliveOil

NasalCleansing

•  UseofSalineSpraysandGels•  CombinedSalineandSodiumBicarbonateSolu>ons

•  UseoftheNe>Pot

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OtherMethodstoConsider•  MouthTaping(ifnasalairwayisopen)usingmicroporetapeordevice

•  Myofunc>onalTherapy/Exercises•  Maxillaryexpansion(RPE)•  Inchildren:FocusonG&D•  Weightmaybeafactor•  ManageAllergy•  Surgeryifthereisastructural/anatomiccondi>onthatneedstobeaddressed

MouthTaping

Myofunc>onalTherapyOropharyngealExercises

•  Getsthetongueupintothepalate•  Actsas“Dam”formouthbreathing•  Bringsthetonguebaseoutoftheoropharynx•  Remember:thetongueisamuscularhydrostat

The Tongue as a Muscular Hydrostat

Tongue functions like the elephants trunk

The Human Tongue Comprised of Muscles with

Little Skeletal Support •  4 Extrinsic muscles – have some bony

support •  4 Intrinsic muscles – no bony support •  Extrinsic muscles originate from external

bony attachment •  Intrinsic muscles originate and terminate

within the tongue mass

Expansion

•  RapidPalatal/MaxillaryExpansion(RPEorRME)

•  Schwarzappliance(removable)forbothmaxillaandmandible

•  Sagifalappliances-ForA-Pchangesinmaxillaandmandible

•  ClarkTwin-Block–forlateralexpansionandforA-Pchanges

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RPEandSchwarzExpanderClarkTwinBlock

(Ortho-tain/Occlus-OGuard)

Ortho-TainHealthyStartSystem•  Habit Corrector •  Nite Guide for ages 5-7 •  Occlus-O-Guide for ages 8-12 •  Ortho-T ages 12 to adult

WeightandInac>vity

•  IncreasingBMIamongadolescentpa>ents•  Leadstopoorandfragmentedsleep•  Thisalonemayimpactweightgain•  Biggestimpact–visceralorcentralobesity•  Mayincreasetendencytomouthbreathduetoairhunger

•  Commonsymptoms:ADD/ADHDandsleepbruxism

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AbdominalGirtheffectontheDiaphragm ManageAllergy

•  Considerthe“AllergicMarch”•  Maybeseasonal–petrelated•  Nasalspraysmaybehelpfulshortterm•  ManageGERD–trialorPrilosecOTCx2wks•  Refertoallergist•  MayimproveifT&Adone•  Consider“OverlapSyndrome”

SurgicalOp>ons

•  T&AorsimplyAdenoidectomy•  Turbinatereduc>on•  Septoplasty•  AlarRimstabiliza>on•  ReducetheColumella•  Miniscrew-assistedRME(MARME)•  MMAasanadult

MARME

Expansionmayalsoimprovethenasalairway

26+mm 30+mm

DevelopRela>onshipwithENTPhysicians

•  DatesbacktoCosten’sSyndrome•  Referpa>entsforevalua>onofthenasalairwayandupperairwayifproblemsexist

•  Considerearrelatedissues•  CanbeBi-direc>onalrela>onship–especiallyifthereareorofacialpaincomplaints

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ThisisTheRealMcCoy

William“Bill”

McCoy

212DegreesisKey•  At211degreeswaterishot•  At212degreeswaterboilssteamiscreated•  Steamwillpoweralocomo>ve•  Thatextradegreecandefinesuccess

Toachievesuccess–turnitupadegreeThanksforAZending!!