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The Influence of Snoring, Mouth Breathing and Apnoea

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The Influence of Snoring, Mouth Breathing and Apnoea Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-009027 on 8 September 2015. Downloaded from The influence of snoring, mouth breathing and apnoea on facial morphology in late childhood: a three-dimensional study Ala Al Ali,1 Stephen Richmond,1 Hashmat Popat,1 Rebecca Playle,1 Timothy Pickles,1 Alexei I Zhurov,1 David Marshall,2 Paul L Rosin,2 John Henderson,3 Karen Bonuck4 To cite: Al Ali A, ABSTRACT et al Strengths and limitations of this study Richmond S, Popat H, . Objective: To explore the relationship between the The influence of snoring, prevalence of sleep disordered breathing (SDB) and ▪ mouth breathing and apnoea The strengths of this study are its large sample face shape morphology in a large cohort of 15-year-old on facial morphology in late size based on a population cohort of UK children childhood: children. that is broadly representative of the general a three-dimensional study. Design: Observational longitudinal cohort study population. In addition, the children were of the BMJ Open 2015;5:e009027. Setting: Avon Longitudinal Study of Parents and same age (15 years) making comparisons stron- doi:10.1136/bmjopen-2015- Children (ALSPAC), South West of England. ger. Furthermore, the possible confounding 009027 Participants: Three-dimensional surface laser scans effect of obesity was ascertained. Finally, the were taken for 4784 white British children from the imaging method used in the study is valid and ▸ Prepublication history for ALSPAC during a follow-up clinic. A total of 1724 therefore the methods are transferrable to other this paper is available online. children with sleep disordered breathing (SDB) and population groups. To view these files please 1862 healthy children were identified via parents’ ▪ A limitation of this study is that sleep disordered visit the journal online report of sleep disordered symptoms for their children. breathing (SDB) data are based on parent-report (http://dx.doi.org/10.1136/ We excluded from the original cohort all children of SDB symptoms rather than a polysomnogram bmjopen-2015-009027). identified as having congenital abnormalities, (PSG), which is considered the ‘gold standard’ Received 10 June 2015 diagnoses associated with poor growth and children for assessing SDB. However, the time, expense, http://bmjopen.bmj.com/ Accepted 17 June 2015 with adenoidectomy and/or tonsillectomy. possible selection bias of those undergoing PSG Main outcome measures: Parents in the ALSPAC and possible methodological changes over time reported sleep disordered symptoms (snoring, mouth rendered it unfeasible for epidemiological pur- breathing and apnoea) for their children at 6, 18, 30, poses in a large longitudinal cohort study. 42, 57, 69 and 81 months. Average facial shells were However, the five patterns of symptoms of SDB created for children with and without SDB in order to defined in this study are correlated with the out- explore surface differences. comes of polysomnogram examinations and Results: Differences in facial measurements were were found to be reliable. found between the children with and without SDB on September 30, 2021 by guest. Protected copyright. 1 throughout early childhood. The mean differences Applied Clinical Research & included an increase in face height in SDB children of Public Health, Dental School, 0.3 mm (95% CI −0.52 to −0.05); a decrease in Wales, UK − INTRODUCTION 2School of Computer Science mandibular prominence of 0.9° (95% CI 1.30 to − & Informatics, Cardiff 0.42) in SDB children; and a decrease in nose Sleep-disordered breathing (SDB), including University, Wales, UK prominence and width of 0.12 mm (95% CI 0.00 to obstructive sleep apnoea (OSA), is highly 3Avon Longitudinal Study of 0.24) and 0.72 mm (95% CI −0.10 to −0.25), prevalent in the general population. The Parents and Children, respectively, in SDB children. The odds of children most common symptoms are primary University of Bristol, Bristol, exhibiting symptoms of SDB increased significantly snoring, mouth breathing and repetitive UK with respect to increased face height and mandible 4 periods of cessation in breathing during Department of Family and angle, but reduced with increased nose width and Social Medicine, Albert sleep, termed apnoeas or reductions in the prominence. 1 Einstein College of Medicine, amplitude of a breath, known as hypopneas. Conclusions: The combination of a long face, Bronx, New York, USA American Academy of Otolaryngology-Head reduced nose prominence and width, and a and Neck Surgery (AAO-HNS) defines SDB Correspondence to retrognathic mandible may be diagnostic facial features “ Dr Ala Al Ali; of SBD that may warrant a referral to specialists for the as an abnormal respiratory pattern during [email protected], evaluation of other clinical symptoms of SDB. sleep and includes snoring, mouth breath- [email protected] ing, and pauses in breathing”.2 Al Ali A, et al. BMJ Open 2015;5:e009027. doi:10.1136/bmjopen-2015-009027 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-009027 on 8 September 2015. Downloaded from SDB is a subtle disorder of early childhood, and may mandibular retrognathia, enlarged tongue, soft palate, have serious consequences for long-term health, espe- adenotonsillar hypertrophy and an inferiorly positioned cially among children with macroglossia and retro- hyoid bone, may be associated with decreased posterior gnathia.34There have been few investigations airway space and restriction of the upper airway, promot- concerning the prevalence of SDB in children. Snoring ing apnoeas and hypopnoeas during sleep.25 Cessation – has been reported in 10% of preschool children.5 7 The of airflow may develop during OSA because of anatomic prevalence of parent-reported snoring is estimated to be obstruction of the upper airway related to obesity, and 7.5% for 2–18-year-olds,8 while the prevalence of mouth excessive tissue bulk in the pharynx.1 breathing in young children ranges from 3% to more Our previous studies on ALSPAC children with breath- – than 50%,9 11 and the prevalence of OSA is reported to ing disorders (atopy, allergic rhinitis and asthma) show range from 0.7% to 4% among 2–18-year-olds.12 13 that the previously mentioned breathing disorders may The prevalence of SDB symptoms is reported by have influenced face shape to varying degrees.26 27 Bonuck et al,14 who conducted the first study on the Atopic and allergic children had an increased total face natural history of snoring, mouth breathing and apnoea height on an average of 0.6 mm when compared to con- in a population-based cohort across a key 6-year period, trols, whereas asthmatic children had a shorter mid-face in the development of SDB symptoms. The prevalence height (0.4 mm) compared to a control group drawn of ‘Always’ snoring range=3.6%–7.7%, ‘habitually’ from the same population. snoring range=9.6%–-21.2%, the prevalence of apnoea Linder-Aronson28 evaluated children who had (‘Always’) was 1–2% and ‘Always’ mouth breathing adenoid hyperplasia and concluded that nasal obstruc- ranged from 2.1% to 7.6%.14 tion may alter facial growth, for which the term ‘long or The current view is that adenotonsillar hypertrophy is adenoidal face’ was coined. He found that children with – the major cause of SDB in otherwise healthy children.15 17 large adenoids usually have longer and narrow faces, Adenotonsillar hypertrophy is associated with nasal lower tongue position, anterior open bite, narrow upper obstruction, resulting in breathing problems and leading jaw and steep mandibles with a more backward position. to disturbed patterns of sleeping, eating, swallowing and Linder-Aronson et al29 hypothesised that adenotonsillar speaking.18 Consequently, the primary therapy for chil- hypertrophy in children induces mouth breathing, dis- dren with SDB is adenotonsillectomy.19 rupting the balance of labial, lingual and cheek muscles, It is possible that obesity is a risk factor of SDB. resulting in facial anomalies. Tomer and Harvold,30 and Rudnick et al20 reported that children with SDB who Vickers,31 suggest that nasal obstruction causes changes undergo adenotonsillectomy are more likely to be obese in muscular function, conditioning dentofacial anomal- than children seen in a general paediatric clinic, and ies. Children with enlarged tonsils may have a larger that African-American children who are obese are more anterior total and lower facial height, a more retro- 21 likely to have SDB. Verhulst et al reviewed the literature gnathic mandible, proclined upper incisors, retroclined http://bmjopen.bmj.com/ on the prevalence, anatomical correlates and treatment lower incisors and a large overjet.32 Other facial anomal- of SDB in obese children. They concluded that obese ies that may potentially be associated with SDB include children are at a higher risk of developing SDB, and increased anterior face height, incompetent lip posture, suggest that in such children, adiposity and upper airway increased mandibular plane angle and V-shaped maxil- factors, such as adenotonsillar hypertrophy, both moder- lary arch.33 Nasal obstruction associated with mouth ated the severity of SDB. In a direct response to this breathing may lead to a downward and backward rota- review, Kohler and van den Heuvel22 argue “We believe, tion of the mandible associated with increased anterior 24 however, that the available studies do not support a face height. A recent systematic review and on September 30, 2021 by guest. Protected copyright. straightforward association of overweight or obesity with meta-analysis comparing healthy controls versus children increased prevalence of SDB. Rather, the available data with OSA and primary snoring, matched for gender,34 are clearly equivocal mainly due to methodological dif- provides limited statistical support for an association ferences between the previous studies”. Kohler and van between OSA and cephalometric measurements in chil- den Heuvel examined other factors that may moderate dren aged 0–18 years.
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