Dr. Smith: There are a few, but this one is specific to your question. Not a validated study, but interesting.

Dental malocclusion and upper airway obstruction, an otolaryngologist’s perspective

Dudley J. Weider, , a, Greg L. Bakerb and Fred W. Salvatorielloc

Available online 20 January 2003.

Abstract
Introduction: This paper, through the presentation of eight case reports and a limited literature review, attempts to illustrate the negative effect that upper airway obstruction can have on developing dental occlusion and the positive effect that upper airway relief can have on the ‘normalization’ of various malocclusion patterns believed to be related to chronic obligate mouth breathing. Objective: To study the effect of airway relief (usually through tonsillectomy and/or adenoidectomy) on various patterns of dental malocclusion. Methods: Children coming to the office of the lead author (D.J.W.) found to be obligate mouth breathers and who also had dental malocclusion had Polaroid ‘bite’ pictures taken at the time of their initial visit. One year or more after their surgery for upper airway relief (tonsillectomy and adenoidectomy in these cases) a second ‘bite’ photograph was taken and compared to the first. Results: In all cases selected in this study there was observed improvement in their dental occlusion within a year following surgery to improve their breathing. Conclusion: It is the opinion of the authors of this paper that upper airway obstruction may have a negative effect on the developing transitional dental occlusion and that eliminating the cause of upper airway obstruction can lead to ‘normalization’ of occlusion in such children. Further orthodontic corrective modalities may be required for optimal occlusal results.

Snoring and crossbite. Seems like an airway problem to me. Should I just recommend the patients mother find another ENT to go to? Can crossbite/snoring be caused by something else?

Dr. Smith: In Jankleson’s publication on posture and airway, he quotes a study saying only 1% of upper airway obstruction is due to tonsilar hypertrophy.

39% adenoid hypertrophy
34% allergic rhinitis
21% turbinate hypertrophy
21% habitual mouth breathing
19% deviated septum
8 % vasomotor rhinitis.

So don’t forget asking the ENT to check some of these if the tonsils look normal We really need to be careful and only remove the offending obstructors, and then only if nutritional therapy to remove inflammation has been considered. With tonsillar tissue specifically (which includes the adenoids), we should be careful not to remove these unless we know they are obstructing, as they play a big part in our immune system.

That being said, the newest research is showing obesity and neck size larger than the norm are playing a bigger role in adolescent snoring and OSA, so I do not want to lessen the importance of these two.

Dr. Smith: Excellent questions! I’ll address each numerically.
1. Most sleep centers are well equipped to handle children’s sleep studies, so if you suspect sleep apnea in your child, a study would be a good idea.

pediatric sleep room at Comprehensive Sleep Medicine

If they prefer no sleep study, I would suggest an allergist first, to rule out any allergens that could be disrupting the immune system, creating an inflammatory process that swells the pharyngeal tissues. It’s also a good idea to find an ENT with good knowledge of the child’s airway and the negative developmental changes that can occur when the airway is restricted during growth.

2. Tonsils (palatine – the ones you can see, out of 4 sets) should only be removed if the cost-benefits are weighed appropriately. Studies show that tonsillar tissue helps in creation of T-Cells, which are important for cancer prevention. However, if they are impeding the airway, and if inflammatory processes have been addressed, I would have them removed. Remember, the child does have 3 other sets. Oh, and one more thing. The adenoids are FAR more likely to be obstructing the child’s airway, so THIS set of tonsils should be studied by the ENT, if anything! The ENT’s organization has a set of guidelines for when they will remove tonsils. They can be found here. Finally, yes, most will “outgrow” large palatine tonsils and adenoids. Actually, the tonsillar tissues usually shrink, unless there are inflammatory processes present. The usual suspect is a mouth breather, who has to use the tonsils to trap pathogens as they enter the oral cavity. Without the valuable nose filters, which are set up to do this job with regularity and expertise, the tonsils take on this arduous responsibility, and become enlarged to house the many bad guys. This can be seen in the “pocked” tonsils with “crypts”. Does that conger up a lovely thought?

3. Can snoring in children cause ADHD? You bet. Email me or comment here if you would like to read some studies. Additionally, a Johns Hopkins study showed that children with OSA average a 16 point drop in I.Q. What parent wants this?

Dr. Smith: OK, Susan. First, does he happen to be left-handed? Just curious.

Here are some references:
http://www.springerlink.com/content/vp5glr1chmjydadm/ (I can get you the whole article if you want)
http://www.ncbi.nlm.nih.gov/pubmed/16600788?dopt=AbstractPlus
http://www.aafp.org/afp/20040301/1147.pdf
http://www.ijporlonline.com/article/S0165-5876(01)00463-3/abstract
http://www.med.umich.edu/pediatrics/ebm/cats/enuresis.htm

Plenty more, but that should be a good start. Get that stepson’s airway open!