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BackTable / ENT / Podcast / Transcript #71
Podcast Transcript: Nasal vs. Mouth Breathing: Does it Matter?
with Dr. Colleen Plein
In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Colleen Plein about functional nasal breathing in the treatment of facial pain, sleep apnea, postural defects, and improving general quality of life. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Why is Breathing Through Your Nose so Important?
(2) The Evolution of Nasal Obstruction
(3) When & How to Address Mouth Breathing in a Child
(4) Chronic Breathing Issues
(5) Initial Evaluation
(6) Teeth Grinding in Children
(7) Role of Sleep Studies
(8) Physical Examination
(9) How Mouth Breathing Can Cause Sleep Apnea
(10) Procedures, Mouth Taping, Breathe Right Strips & More
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[Dr. Gopi Shah]
My name is Gopi Shah, and I'm a pediatric ENT.
[Dr. Ashley Agan]
My name's Ashley Agan. I'm a general ENT in Dallas, Texas. Good morning, Gopi.
[Dr. Gopi Shah]
Good morning, Ash. How are you today?
[Dr. Ashley Agan]
I'm good. I'm trying not to melt in this 105-degree weather we're having in Dallas here in July.
[Dr. Gopi Shah]
It's brutal.
[Dr. Ashley Agan]
It's tough, but podcasting with you in the AC this morning, so that's nice. Keeps it cool.
[Dr. Gopi Shah]
Podcasting with the AC on. We've got a great show today. I'll go ahead and introduce our guest. We've got Dr. Colleen Klein. She is a general otolaryngologist practicing in the Chicago area since 2015. Her practice is focused on minimally invasive in-office rhinologic procedures and management of snoring and sleep apnea. She has a particular interest in functional nasal breathing and its relation to chronic craniofacial pain. Good morning, Colleen.
[Dr. Colleen Plein]
Good morning. Thanks so much for having me.
[Dr. Gopi Shah]
Welcome to the show. Let's start off just you tell us about you and your practice and how you got where you are today.
[Dr. Colleen Plein]
Sure. I finished my training about 2015. I've been out in practice for about seven years now and have had a couple of different jobs. I was a hospital-employed physician and then I was in one private practice and another private practice. I really spent time getting into the niche I want to be in for my practice. About a year ago, I was introduced to a dentist who actually sought me out because he was looking for people who perform nasal valve procedures. I went to meet him thinking that it was just a regular, "Hey, hi, nice to meet you. Can I refer you a patient?" sort of thing.
He launched into this entire world of how he treats people and nasal breathing and facial pain. I was like, "What are you talking about? I've never heard this before. What?" He was like, "No, no, no. Let me tell you about this. Let me teach you about this." What he actually ended up doing was bringing me to a conference that just happened to be in Chicago. I started learning about all this and the relationship between nasal breathing and sleep apnea and facial pain and temporomandibular disorders. It opened up this entirely new world that has really changed my practice for the better.
It's something that we don't learn in our training and nobody ever talks to us about, I think to our detriment, because I think we could help a lot more people than we do if we really understand this stuff.
(1) Why is Breathing Through Your Nose so Important?
[Dr. Gopi Shah]
When you say functional nasal breathing, can you define it? Is that just not mouth breathing?
[Dr. Colleen Plein]
Essentially, yes. It's unobstructed nasal breathing with your mouth closed. The way we are meant to breathe is with our mouth closed, with our tongue sitting fully on the roof of our mouth and unobstructed airflow through the nose. Doing that has a variety of benefits that we'll talk about. That's the goal is mouth closed, breathing through your nose.
[Dr. Gopi Shah]
Mouth breathing, and this probably sounds so ignorant, especially, but it's never just habit.
[Dr. Colleen Plein]
It can become habit. It starts out, and most of the problems often start in childhood, as I'm sure you have seen in your practice, that there's some obstruction in the nose. We start out as obligate nasal breathers, everybody knows that. Our larynx is high up in the pharynx, but it descends as we get older. That's an ontogeny recapitulates phylogeny sort of thing. If you look at the animal kingdom, in animals that don't have speech, their larynx is much higher, and their tongue sits much further forward. You don't see animals with obstructive sleep apnea.
There's actually this anthropologic theory called the Great Leap Forward, which is basically how humans develop speech. What happens is the larynx descended, and the tongue came further back. We basically prioritize the pharynx over the larynx to allow us resonant speech and all the speech sounds. In doing that, the tongue came further back. Now when we lay down, we have this big muscle sitting in our mouth and our throat that can now obstruct our airway. We have the benefits of speech, but there are evolutionary downsides to that.
[Dr. Gopi Shah]
Can we, just to set the stage, talk about the importance of nasal breathing and downsides of mouth breathing? I think at a very basic level, I tend to think that breathing is breathing. You breathe through either-- maybe you have a tracheostomy, you're breathing through a hole in your neck, you're breathing through your nose, you're breathing through your mouth. If you're moving air, you're breathing. Why does it matter?
[Dr. Colleen Plein]
That's what we're taught. Oxygen is oxygen. That may be true in terms of sustaining life, but it's not necessarily true in terms of optimal function. The nose does a bunch of different things. We know that it warms and humidifies air. We know when someone has a tracheostomy, if someone has a laryngectomy, what's their biggest problem? Humidification. They don't have humidification. It filters the air that we breathe. That's very important for our immune system. The turbinates grab particulate matter. Nasal breathing is important for ciliary function inside the nose.
Part of the reason, one of the theories goes that, why do we see enlarged tonsils in kids? If they're breathing through their mouth, the tonsils, which are lymphoid organs, are getting exposed to all this air and all these particles that they shouldn't be. Now you have tonsillar hypertrophy as a secondary problem. It's not the primary problem causing the sleep apnea or those issues. It's secondary from not breathing through their nose. Our sinuses also make nitric oxide, which is produced in the mucosal lining of our sinuses. It's then put out into the nasal airway.
Nitric oxide is a vasodilator. It helps with our blood pressure. It decreases stress. It also increases the efficiency of oxygen transfer to the tissues. There's actually been studies done on elite athletes that when you change them from being nasal breathers to mouth breathers in an exercise test, their exercise capacity reduces significantly. We also know that people who breathe through their mouth actually breathe at a faster rate than people who breathe through their nose.
That actually ends up in, instead of actually having our carbon dioxide levels in our blood be slightly too low, and very subtle shifts in pH in our blood have effects on our body. There's more. I could go on, but those are, I'd say, some of the major things. The thing about it is if you look in the population, about 75% of people have some sort of issue like this. It's a problem of humanity.
[Dr. Gopi Shah]
Yes, absolutely. You'll have mouth breathers just at night when they sleep, but also mouth breathers 24 hours a day, or some would just exercise. Do those categories make a difference to you?
(2) The Evolution of Nasal Obstruction
[Dr. Colleen Plein]
Sure. Definitely. In my practice, the vast majority of people I see is for snoring and sleep apnea. They'll come in for the snoring and sleep apnea, but if you ask, they'll say, "Yes, you know what? I never really breathe through my nose. Yes, I'm primarily a mouth breather." It's very rare that someone comes in and says, "Oh, it's just when I exercise." It does happen. We can talk about the constellation of how the nose gets that way because it's almost-- The way the nose develops and develops obstructed, there's no little bit. It's usually either totally non-functional or really not functional much or works well.
[Dr. Gopi Shah]
Let's talk about that. Why do some people have issues? Why do people develop deviated septums or turbinate hypertrophy or nasal valve collapse and things that make their nose pinch up? If we're all supposed to be breathing through our noses, you would think that our craniofacial skeleton would grow to have a big hole in the middle of our head so that we breathe fine.
[Dr. Colleen Plein]
For sure. What's interesting is this is actually an evolutionary problem for human beings. We think of all evolution as good and helpful in having new things, but really what we're talking about is what's happened to humans, even as recent as the past 200 0r 300 years, there are a couple of orthodontists who are doing this research and they're actually measuring facial skeletons from the 1600s, 1700s, and compared to today. What we see is a narrowing of the face, so a shrinking and a hypoplasia of the maxilla and the mandible. We believe that the main reason for this is due to the introduction of the processed diet and processed food primarily during the Industrial Revolution.
You think of us as cavemen or native cultures, you're eating foods in their most raw form, or even if you cook them, cooking tenderizes stuff, but if you're eating vegetables and plants and roughage, you have to really chew those things. We know that chewing helps develop the muscles of mastication, but in turn, those forces actually generate bone growth in the mandible and in the maxilla. What we're seeing with processed diets is we don't have to chew our food as much, especially kids, we give them more processed things, soft things, and you get that hypoplasia, particularly of the maxilla, but the mandible as well.
It's not growing wide enough and that in turn is narrowing the nasal aperture. The other thing that happens is as that nasal aperture isn't wide enough and we have a more inflammatory diet that's irritating our nasal mucosa, we start to mouth breathe. When we start to mouth breathe, our tongue no longer sits on the roof of our mouth. The tongue on the roof of the mouth is really important for that maxillary horizontal growth. That's why you start to see that very high-arched palate that we see in kids who have what we think of as adenoid facies. It didn't get like that out of nowhere.
Now you have a maxilla that's starting to arch and the maxillary spine is the floor of the nasal septum. As the maxillary spine starts to ascend, there's nowhere for the cartilage to go. Now it buckles and now you have a deviated septum. You have a deviated septum, the piriform aperture is not as wide as it should be. Now the nasal sidewalls are at a more acute angle than they should be and you have nasal valve collapse. The turbinates is mostly from allergies and inflammatory diets, but basically you've just got the width of the nasal aperture is not as good as it should be.
Now you're mouth breathing even more. This is why we don't have enough room in our faces for our teeth. Why do we all need our wisdom teeth out? That's a big thing and we'll talk about that later. If you look at native cultures and they've studied this, so people who don't have these diets, you go and find them and there are accounts from the 19th century about this. You go and see them and they all have perfect teeth. Their teeth are perfectly straight. They have room for all their teeth and that's because their faces have developed the way they should. Our rash of needing orthodontia, we're fixing the cosmetics, but we're not addressing the functional problems that are underlying all of this.
(3) When & How to Address Mouth Breathing in a Child
[Dr. Gopi Shah]
I apologize if this is jumping ahead, but for the child then who comes in from the age of two to six, you take out the tonsils and adenoids, or let's say it's just an adenoid problem, but they still are mouth breathing because, like you said, there might be mid-face hypoplasia. There may be retrognathia. There may be the high-arched palate. We're not always jumping to turbinates at that age. What do you do? What else should we be addressing? Because I'm like, "Oh, you're not snoring. You're not pausing. That's great. A little mouth breathing, that might just be habit." Do you grow out of that? I don't know.
[Dr. Colleen Plein]
What's so fascinating about that is I know that as a pediatric ENT, you know when you look at the studies, "Well, why do the studies show that there's a big benefit for removing the tonsils and adenoids in the short term, but in the long term, these kids still have problems?" What you're talking about is exactly the issue. We're addressing essentially the symptom, but not the problem. There's a few different things. Number one, early orthodontic intervention, super important. There are people, Kevin Boyd in Chicago and others, who really advocate for early maxillary expansion, because when you're a kid, those sutures haven't fused yet. You have a lot more wiggle room. Yes, expansion for these kids.
[Dr. Gopi Shah]
How early are we talking?
[Dr. Colleen Plein]
Basically, they'll tell you as early as they can tolerate. They really say four or five is the first time they should be having at least an evaluation if you're concerned about them having these problems because you can make such a big difference. That's number one. Usually, these people will work with people who are called myofunctional therapists. Myofunctional therapy is about promoting these behaviors of keeping the tongue on the roof of your mouth, keeping your lips sealed, strengthening the tongue, changing the diet. There are these therapists who are really trained to help in these problems.
Unfortunately, there's not a ton of them, and finding a good one is difficult, but they are out there and these interventions can make a humongous difference because we can impact the facial growth when they're younger, but the older they get, it's harder and harder to do. Once a kid is at 11 or 12, you're already behind the eight ball. The biggest thing that I advocate is actually you just got to look for these things. If you look for them, you will see them everywhere. My practice isn't-- I don't do pediatrics, but I see this in my own kids, and being able to do that is going to save so much pain and heartache and intervention later on, not to mention their quality of life overall.
[Dr. Gopi Shah]
Changing the diet in kids, does that-- basically having them chew more and eat less soft stuff?
[Dr. Colleen Plein]
Yes, within reason. At ENT, I'm still an airway doctor. I know people are super into baby-led weaning and those sorts of things. No, I don't want your child to choke on food, but age-appropriate, keeping things in their least processed form. It's difficult because the question is, you have to balance safety with functionality, but also again, minimizing processed food, which we know is good dietary advice overall.
[Dr. Gopi Shah]
Just regardless. Yes, for sure.
[Dr. Colleen Plein]
Exactly.
[Dr. Gopi Shah]
In terms of orthodontics and myofunctional therapy, we said the younger, the better, but of course, in terms of access and insurance and knowledge. It's not like this is part of our normal repertoire of workup and treatment options. My question though is, is there an age at which these things don't help, or is this something that you do for any-- whether the patient is 20, 40, 60 years old, who comes in that you say, "Okay, we're going to try myofunctional therapy." Is there a certain ages or things like that?
[Dr. Colleen Plein]
No, they work with all ages, and they have age-appropriate things. There are even age-appropriate-- just this morning I was giving my daughter this little thing. It's cool. It's called a myomunchie. Basically, it looks like a tiny little-- almost like a football mouth guard, but it's got little prongs inside of it and little things for them to do with their tongue. Basically, it's something to give them in their mouth that they're like, "Oh, I can chew on this. Oh, I can play with my tongue with this." It basically stimulates their using those muscles.
No, there's no age in which it doesn't help, but of course, and this comes back to what we were originally talking about, none of this will help you if you can't breathe through your nose. Learning to close your mouth and do all those things, well, if your nose is obstructed, you're going to naturally do that because you need to breathe. You have to look at this stuff in conjunction with getting the kids to breathe through their nose.
That's where I go back to what you were talking about about turbinates. With those kids and the sleep-distorted breathing and those sorts of things, I do start to pay attention to the nose a little bit earlier because my threshold-- and again, I don't do a ton of this, but I will get patients sent to me. I work with a dentist who does a lot of this stuff on kids and they'll say, "We've been doing everything and everything, this kid still can't breathe through their nose." I'm like, "Okay, well, we can do a turbinate reduction on them." Is it super common? No. Is there any real super downside to doing it? Not really.
(4) Chronic Breathing Issues
[Dr. Gopi Shah]
Can we talk about pathologies that we might be able to specifically link to mouth breathing, OSA, poor sleep quality, and specifically for patients who come in and they're not saying, "I can't breathe through--" maybe they're just so used to it that they're coming in and they have ear pain or they have headaches and you have to maybe do a little bit more digging to see if there is actual problems breathing through their nose.
[Dr. Colleen Plein]
This is the part that has made my practice so much better because when I came out of training, I was like everybody else when you're like, you get the patient with unilateral ear pain or sinus and you look in their ear, ear's normal. "Okay. Well, it's TMJ. Okay. Go see this other dentist. I can't help you." Then you have an unhappy patient and it's frustrating for you and it's no fun or the "I have sinus patient." "I have sinus headaches. I have pain in my forehead, pain in my cheeks." You work them up, you put them on Flonase, you scan them, their sinuses are totally clear, and you're like, "Well, go see a neurologist."
We can help these people. The thing to understand is when someone is a chronic mouth breather, they usually alternate between two activities. Their mouth is open. Now, again, your muscles of mastication are engaged. Alternately, they clench too. These are people who clench their teeth during the day. You get the inflammation from the chronic clenching. The other thing that happens that we don't recognize as much is when we're mouth breathers, when our mouth is open to optimize our breathing, so it's both gravity and to optimize our breathing, what happens is our jaw comes down and our head comes forward.
You get what's called this forward head posture. If you look at someone from the side, ideally, the middle of their ear should line up with the line that goes straight through their shoulder. Forward head posture is when the head comes forward. You see all these people and I'm one of them, I have this problem, where people are always like, "Stand up straight. Why are you leaning over? Why is your posture so bad?" It's because your head is forward. For every inch your head comes forward, it adds about 10 pounds of weight to your cervical spine.
These people have chronic neck pain, chronic shoulder pain. You're like, "What do I do? No matter how many massages I get, this won't go away." The other thing that happens now is you have these like C1, C2 nerve roots that are all irritated from this. Actually, if you x-ray these people, you see they get a loss of the curvature of their cervical spine. It should have this nice soft lordosis to it, and it's actually straight when you x-ray them. The area of the spinal cord that those run through is they all run through the trigeminal nucleus. It's all the same.
I know I hate neuroanatomy. I don't like to talk about it at all. The end result is that basically, our brain starts to register this as facial pain and migraine-type symptoms. When you have these people who have chronic headaches, chronic facial pain, pressure, tension-type headaches, it's all from their head not sitting right on their shoulders. Why is their head not sitting right on their shoulders? Because they're not breathing properly. If you help these people breathe better, it's amazing how many of these headache symptoms and jaw symptoms get better.
They may need some other things. They may need some decompression therapy. There are other things you can do in the short term to get their pain better, but sending them off to the neurologist doesn't fix anything. They get put on a bunch of drugs or not recognizing their sleep problem. That's the other thing is these patients often have sleep issues and they may not have the frank obvious sleep apnea that we're used to seeing, but they're not sleeping properly. That's also contributing to their symptoms.
The one thing I would say to just bring this all together is we see these problems way more often in women than we do in men. In men, we're used to a larger guy, big neck, large tongues, sleep apnea. In women, these sleep problems and these breathing problems manifest more as pain than they do as snoring insomnolence. We think about it, it's described as the young fit female syndrome. How many of these people do we see that come in with facial pain and headaches? Often we're like, "Well, we can't help you," but we can. We definitely can. Sorry, that was a little rumbling and all over the place. I don't know if it made sense.
[Dr. Gopi Shah]
Noo.
[Dr. Ashley Agan]
No. This is great.
(5) Initial Evaluation
[Dr. Gopi Shah]
Actually, my question for you is in terms of imaging and posture, is that something, Colleen, that you're looking at on your physical exam or as soon as the patient walks in the room, you're looking at those things? Are there certain things on x-ray or MRIs that you're looking for to help you determine that, "Hey, this is maybe a posture thing that's related to mouth breathing," that helps you put it all together?
[Dr. Colleen Plein]
What I do generally is you can usually tell just from their symptoms. The way that things happen is-- Again, you have to be looking for it. Say someone comes in, middle-aged woman or even younger woman comes in and says, "I'm having headaches, or facial headaches." Then you start to ask them, "Okay, well, do you snore?" "Oh yes, I do." "Do you clench your teeth?" "Oh yes, I definitely grind my teeth." "Do you get headaches? Is your neck and shoulder sore?" "Oh yes, it's sore all the time." It's fun because they're like, "How did you know that? I didn't come in for this." You see it all the time.
I don't have to necessarily look for those things. My dental colleagues who do this, they actually take photos of people's postures and things like that. You can actually see the changes before and after treatment. I obviously don't really have time in my office to do that, but I'll ask them. I'll say, "Are people always telling you to stand up straight? That you have bad posture?" They're like, "Yes." I'm like, "Yes, it's not your fault because you're not just lazy. It's not that you just need some training. It's that your body is functionally doing this to help you breathe." It's one of those things that if you start to look for it, you see it everywhere.
I tell all my patients this is a problem of humanity that is completely under-recognized and undertreated.
[Dr. Gopi Shah]
That's a good launching-off point to talk about what your evaluation looks like. Patients come in and you're asking the right questions. I think that's probably an important thing. Do you use questionnaires? Do you use the nose score and OSC questionnaire, or do you just have your spiel of questions you go through that help guide you?
[Dr. Colleen Plein]
I don't use any questionnaires. Obviously we're sleep apnea practice, so use Epworth and StopBang, things like that. The really interesting thing too, is a lot of times you have to convince these patients that they have a nasal problem.
A lot of times they'll come in for snoring and I'm like, "Well, can you breathe through your nose?" "Yes, I breathe through my nose fine." You stick a scope in their nose, and there's just no room. You have to plant this idea in their head a little bit because, usually I'll see these patients, I'll give them some medications, they'll come back for followup, and so many of them come back and they're like, "Now that you said that, I was paying attention and you're right. I breathe through my mouth all the time."
You'll ask them, "Does your bed partner notice that when you're snoring, you sleep with your mouth open," in terms of people who come in complaining of sinusitis, or "Oh, I get a sinus infection every month." We know as ENTs that that's really unlikely that you're getting a sinus infection every single month. It happens, but it's rare. You say, "Well, when you get your-- tell me about your typical sinus infection." "Oh, I get pain here and I get pain here." I'm like, "Okay, well, does your nose feel more congested? Are you coughing? Is there green stuff coming out of your nose?" "No, no, no."
They go to their doctor and they get put on antibiotics. Starting to look for these-- I think most ENTs are pretty good at distinguishing headache from true sinusitis. What we don't want to do is when it's not true sinusitis, just push them off and say, "Well, that's not for me." Asking about their sleep quality because even if they don't snore, or don't complain of snoring, it's like, "Well, how's your sleep? Do you feel like you're resting?" They're like, "No, I wake up a couple of times a night," or in men, this is a huge thing. How many men do we see who they're like-- I say, "Do you have to get up in the middle of the night to pee?"
They're like, "Yes." They're 50 and they all say that it's their prostate. It's not their prostate. What happens, the hypoxia actually causes the heart to make more BNP which makes you actually-- it thinks that you're fluid-overloaded. Your body makes more urine and now you got to get up and go pee. There are so many people that when you treat their sleep, they don't have to get up to go to the bathroom anymore. You really shouldn't have to get up in the middle of the night to go to the bathroom, even in women. That's a big marker for me. Teeth grinding is a big thing.
I have no idea how to actually look at teeth and know if you're grinding. I'm not a dentist, but you'll ask them, "Did you grind your teeth or has your dentist ever told you that you grind your teeth?" "Oh yes." Then sometimes they'll have a mouthguard. The really important thing to know about mouthguards, about bite plates, is what they actually do is by putting something in your mouth, you now have pushed the person's tongue further back and you've actually made their sleep apnea worse. Most bite splints actually worsen sleep apnea.
People don't like to hear that when they've paid money for it, but that's why you tell them you can address both things at the same time. You can have an appliance that addresses clenching and breathing all at the same time. Again, it's this thing of, the dentist sees the teeth grinding, "Oh, we just got to protect your teeth. Let's make this thing up, but yes, your teeth will be nice, but you'll feel like crap."
(6) Teeth Grinding in Children
[Dr. Gopi Shah]
In terms of teeth grinding in kids, I find, especially between the ages of three to six, is that some kids just do that and then it gets better, or is that something that we think of as related to sleep-disordered breathing in the young pediatric patient? I don't know how to place teeth grinding in the kid that comes in that-- Again, maybe it's just my narrow, "Are you snoring? Are you mouth breathing? Do you have pauses, poor concentration, bedwetting, attention?" Yet it may not be much of any of those things, but there may be teeth grinding and maybe an attention concern.
I might see two plus tonsils, but I'm like, "Do I watch you? Do I get a sleep study? Does this mean anything?" I don't know where to put that.
[Dr. Colleen Plein]
Yes. Again, caveat, I'm not an expert in peds. I would say that it's at least worth investigating. I feel like this is where we get in-- especially in kids. In kids, an AHI over one is sleep apnea. It's at least worth investigating. In that case, I would, "Do they have allergies?" A trial of Flonase is not going to hurt. The sleep studies I understand, in kids are a little more difficult. Also, we got to think about this thing is, we're not just dealing with sleep apnea.
It's just this upper airway resistance syndrome-type thing. Again, do you see those other signs. Do do you see the high arched palate? It's the parents. Are they breathing-- That might someone, if they can tolerate it, might be a good candidate for something like myofunctional therapy. Maybe it's just more of a habitual thing. Maybe it's a little bit of a dietary change. Maybe they just need some nasal sprays or their allergies addressed. Whatever you can do to get them breathing better.
Again, I don't think there's necessarily hard data to support this, but the thought is that the bruxism is your body automatically trying to give you a jaw thrust to help you breathe better. That's where it's coming from. it's what they call parafunctional activity that's stemming from improper breathing. I'm sure you tell parents, a kid that snores, it's never normal to have a young kid that snores. It's probably not that normal to have a kid-- they're in your office for a reason. Someone sent them there for some sort of problem. There's something going on.
[Dr. Gopi Shah]
You're right. It's usually the dentist, to be honest with you, which is great because there is some communication and collaboration, but sometimes because, like you said, I think from the beginning in our ENT, our traditional literature, whatever, or what we learn, and maybe the education is changing now, but teeth grinding and sleep apnea in kids, it's not one of your classic or even in the constellation. I see a lot of teeth grinding, but as well as tongue thrust. I don't always know where to place that and what that means.
[Dr. Colleen Plein]
The tongue thrust is like the tongue is looking for somewhere to go and there's no room. A tongue thrust in an adult, what you get is, I didn't mention this when you were talking about the physical exam, tongue scalloping. Scalloped edges on the tongue. That finding in an adult in and of itself is about 70% predictive for obstructive sleep apnea, because what that means is while they're sleeping, their tongue is pushing against their teeth and that's what's making those little indents on the tongue. What a tongue thrust says to me, and again, I think the myofunctional therapist would say this too, is that there's not enough room for their tongue to either sit down on the floor of their mouth or on the roof of their mouth. The bony structures are too narrow and now the tongue is trying to find somewhere to go to open up the airway. You'll see these teeth that get angled outwards. Instead of being straight up and down, they get pushed out because your body's trying to breathe. Then again, that's why you're saying when these orthodontic problems, it's like, "Well, why is it like that? Why did it get that way?" You can turn the teeth in and make it look pretty, but you haven't fixed the problem.
(7) Role of Sleep Studies
[Dr. Gopi Shah]
Are a large percentage of your patients getting sleep studies? Are you doing home sleep studies or lab sleep studies?
[Dr. Colleen Plein]
I have a pretty low threshold for sleep studies. We do mostly home sleep tests. What I'm really looking for is the designation between the people who have really severe sleep apnea who definitely need a CPAP or something like that in the meantime. It's helpful too sometimes in the younger patients, the women. You'll see these low AHIs, seven, eight, but I think we're accustomed to thinking of, again, sleep apnea in the traditional context of like, "Well, yes, an AHI of seven, eight is not going to kill you and give you a heart attack at age 55," but it's still going to give you all these other sequelae. Being tired, concentration.
There isn't a good correlation between the severity of sleep apnea and the symptoms. I would never use a normal home sleep test as a reason to say, "Don't address this." I also like to look at the pattern because sometimes you'll see the pattern. We get this little printout of the position and the oxygen saturation. You'll see, it'll be fine, fine, fine, then about an hour, hour and a half in, all the events will start and then the person will roll over and they'll stop. Then 20 minutes later, they'll go on their back and it'll all start again. You can show them that, "As you go into your deepest, most restorative sleep, your sleep is getting interrupted. This is why you feel like crap all day long."
(8) Physical Examination
[Dr. Gopi Shah]
As far as your evaluation, when you're evaluating the nose, anything particular or special or different because you are more focused on not just being able to breathe, but truly good functional nasal breathing, meaning when you look with a scope, are you looking before Afrin, after Afrin? Are you doing modified caudal? When you use a speculum, that's spreading the nose open. That changes how it looks. What are ways that you've modified your exam as you've started to hone in on nasal breathing?
[Dr. Colleen Plein]
I never decongest anybody before I examine them because who walks around decongested? No, seriously.
[Dr. Gopi Shah]
No, that's a good point.
[Dr. Colleen Plein]
If you decongest anybody, their nose is going to look perfect. For me, decongestion is like if you're going to do a flexible scope on somebody and just want to make it less uncomfortable, but even then-- I don't decongest anybody. Everybody gets a nasal endoscopy. I pretty much never even pull out the speculum because you want to see the nose in its most normal state. Looking at, again, their facial anatomy. Is their maxilla narrow? Is their face long? Looking at their nasal valve is super important, both externally and internally.
A caudal maneuver is going to help almost anybody breathe better, but looking for a static and dynamic collapse. That's why the scope is helpful too, because you'll stick a scope in and they'll have this horrible valve and then everything behind it is fine. The other thing that's really important for me that I have found, which I think is contrary to our thinking, is I really want to have a scope exam and a CT scan of the sinuses because I cannot tell you how many times the CT is just so revealing, especially-- We don't really do a great job of examining the posterior septum.
You'll see these people who you think, "Oh, their septum is not so bad," and then they get a scan and they have these horrible posterior spurs, just like ridiculous noses. Conversely, you'll get a scan and you'll look at the scan and you'll be like, "You know what? Their airway doesn't look so bad. It looks pretty open." You'll stick a scope in there and there's no room, none whatsoever. They're very complementary to each other. Again, also you're looking for things like concha bullosa, obviously sinus disease if there is any. You can actually appreciate the nasal valve pretty well on a CT scan on the most anterior coronal cuts.
You can actually see the concavity that happens there and really appreciate how much it obstructs the anterior nose. I do like to get a CT on almost everybody before deciding what I'm going to do with them.
[Dr. Gopi Shah]
That's going to help you more with nasal obstruction as opposed to-- Do you ever use it for sleep apnea evaluation, for tongue base or adenoids?
[Dr. Colleen Plein]
No, not generally. This is a different discussion. If someone has huge tonsils, I do intracapsular tonsillectomy on adults. I do not do any uvulectomies, I do not do any tongue-based procedures because they don't work.
[Dr. Gopi Shah]
They hurt.
[Dr. Colleen Plein]
No, seriously.
[Dr. Gopi Shah]
They hurt really bad.
[Dr. Ashley Agan]
They hurt.
[Dr. Colleen Plein]
They do not work.
[Dr. Gopi Shah]
Sure.
[Dr. Colleen Plein]
They don't work. What you need to do is you need to close your mouth. No, seriously, because when you close your mouth, that in and of itself is almost like a jaw thrust, or an oral appliance, those sorts of things. Again, to me, you're demonstrating the symptom, not the problem. This other thing that we didn't talk about is there's this thing called the Starling resistor model. Do you guys know about this?
[Dr. Gopi Shah]
No. Tell me more.
(9) How Mouth Breathing Can Cause Sleep Apnea
[Dr. Colleen Plein]
It's much easier to understand with a picture, but essentially it's the Bernoulli principle applied to the human airway. You've got two fixed segments, so in this case, your nose and your trachea with a collapsible segment in between them, which is the pharynx. There's a pressure differential between the nose and the throat or between-- we'll call it the upper airway and the trachea. At a certain point, there's a pressure, they call it the Pcrit or critical pressure where there's enough of a differential where you cause collapse of the middle segment.
The more pressure upstream, the more likely that segment is to collapse. The pressure, and the force of breathing through your nose is much less than the pressure and the force that you can breathe in through your mouth. This is why mouth breathing and sleep apnea, it's not just the tongue, but it makes the pharynx actually more collapsible because you're bringing air in at a higher speed and a higher pressure, which actually causes that collapse of the pharynx. This is why the switch from mouth breathing to nose breathing actually helps keep the airway more open.
Nasal breathing gets you better pharyngeal patency than mouth breathing, which sounds really weird, but it's true because you're not creating that vacuum effect exactly.
(10) Procedures, Mouth Taping, Breathe Right Strips & More
[Dr. Gopi Shah]
It all goes back to physics. Do you do DISEs? Do you do drug-induced sleep endoscopy?
[Dr. Colleen Plein]
I don't. I was never trained to do them. As what I just said, it doesn't really matter how the pharynx is collapsing. The reason it's collapsing is because there's too much pressure going through it. I was never really trained to do it and I don't do Inspire or any of those things. I have varying thoughts about it, but I think it's probably good for some patients. I don't really have a reason to do the DISEs.
[Dr. Gopi Shah]
Yes, because it's not going to change your management probably.
[Dr. Colleen Plein]
Exactly.
[Dr. Gopi Shah]
That makes sense. Every once in a while, a child may come in with a CT or whatnot. I can always look at the sagittal and sometimes look at the adenoids that way just because they may not let me scope them. Sometimes that can be helpful, at least I think in that three to eight year old, that may not sit for you.
[Dr. Colleen Plein]
The other thing you can see in whether adults or kids on a coronal, and I'll show people this, you will actually see in the mouth that there's the tongue and then there's air. There's an air pocket above the tongue, which shows me where I can show them, "See your tongue is not sitting on the roof of your mouth. This tells me that this is another sign that you're a chronic mouth breather. When you're at rest, your tongue is not up on the roof of your mouth." That's something you can probably see in the kids too.
[Dr. Gopi Shah]
Do people ever ask you about the role of tongue tie and sleep apnea? What are your thoughts on that? Because on one hand, I'm like, "Why are we doing a frenulectomy if we're worried about sleep apnea? Doesn't that make the tongue go back?" Then sometimes patients will come in and ask, "I was told by whoever that if we do a lingual frenulectomy, it will help him or her breathe better." I don't know–
[Dr. Colleen Plein]
Isn't that always the best when someone is like, "Someone else said I need X, Y, Z procedure." I love that.
[Dr. Gopi Shah]
Then again, maybe it's like my limited view of teeth grinding in the three-year-old. Maybe I need to be looking for something more because I don't understand.
[Dr. Colleen Plein]
What I would say about that is you can be tethered by a tongue tie in terms of not being able to get the tongue to sit on the roof of the mouth because again, the proper rest position is mouth closed, tongue fully on the roof of the mouth. If it's tethered in the vertical dimension, which is the same thing that we look at when we look at tongue ties for speech and those sorts of things, I think that is worth thinking about.
All this stuff about posterior tongue ties and all these, I do not get very excited about. For me it has to be a very obvious restriction, a very clear, obvious problem. I really don't look at it too much. Again, if you look at that kid and you're like, "Yes, this kid is going to have speech issues," if they try to stick out their tongue and it's one millimeter out of their mouth, okay, fine. The other thing I would say is if you're working with someone like a myofunctional therapist and it's somebody that you trust and they say, "Look, I'm working with this kid. They cannot get their tongue up on the roof of their mouth and it's really impairing things," I would consider that if it matched up with what I saw in my exam.
[Dr. Gopi Shah]
Your myofunctional therapists, are those usually speech pathologists?
[Dr. Colleen Plein]
Yes. It's actually its own classification, its own certification. It's annoying because sometimes it's hard to get insurances to pay for it or it's a cash-pay thing. Myofunctional therapy is its own field and they're hard to find. Good ones are hard to find. We need more of them for sure. I'm sure with Googling or asking people, especially if you talk to people who are a little more tuned into this world, they will know who to send people to.
[Dr. Gopi Shah]
Segwaying from that, you refer patients to myofunctional therapists. Are there any other providers that you're working with? Let's say you've already optimized the nose as much as you can and they're still mouth breathing, or let's say they are really resistant to any sort of procedural or surgical intervention, or maybe they're not a good candidate or for whatever reason, hHow are you utilizing other services and colleagues to help? I know we talked about sharing patients with some of the dentists.
[Dr. Colleen Plein]
Sure. A good dentist and a good sleep dentist is invaluable. This might be a little too into the weeds, but when you talk about making oral appliances, there's different ways to take the bite position that you want them in. The classical thing that most sleep dentists do is they use this instrument called a George Gauge, which is basically, "How far can I pull your jaw forward? Just pull it as far forward as I can." That doesn't work and it gives people pain.
You want someone who's going to take the bite in a proper way. It's called the synetic bites, but it's in a proper position that is a more functional position that actually still opens up the throat significantly, but it's not necessarily just the chin all the way forward. There are physical therapists who work a lot with TMJ and TMJ-type problems and they can be very helpful. The dentists that I work with are-- there's two competing schools. There's the American Academy of Oral Facial Pain and the American Academy of Craniofacial Pain, but they treat patients very differently.
The people I work with are all associated with the American Academy of Craniofacial Pain. If you look for providers who have that sort of background, that sort of training. Luckily from what I found, it's becoming more and more of a thing in the dental community. They're doing a lot of good advocacy to try and raise people's awareness of this because a lot of times dentists will be the frontline people who are recognizing these problems. They'll see the tongue scalloping, they'll see the grinding, they'll see the high-arched palate, they'll see the giant tonsils and they can be the first ones to direct these people to, "There's a problem here, let's get it addressed."
Then there are people who actually manage the temporomandibular pain. The person I work with the most is a dentist, but he does decompression therapy and other things to help relieve pain. Nasal stuff, obviously Breathe Right Strips are great. If you have a problem getting Breathe Right Strips to stay on, there are a variety of intranasal silicone appliances. One is called a mute, like the mute button on the remote control. It's a little intranasal dilator. I recently saw something called Hale, which is supposedly designed by an ENT. It also sits in that nasal valve area, opens everything up, obviously maximizing topical treatment inside the nose.
Intranasal steroids, combining that with intranasal antihistamine if needed. Allergy management, if that's part of this, immunotherapy, nasal irrigations. Then also there's actually, believe it or not, I was very surprised to learn about this, how much the diet can actually influence nasal congestion. I've seen before and after scans of people who actually managed to go gluten-free and there's a humongous improvement in their nasal mucosal inflammation. My dental colleagues will tell people, "Avoid gluten and dairy." I tell people, "Look, that all sounds nice in theory, but it's very difficult to do."
I know lots of people, probably including myself, who would choose nasal surgery over having to live the rest of their lives without gluten and dairy. There's limiting benefit to all of these things, but there's always non-invasive options.
[Dr. Gopi Shah]
The other thing, I can't let you go without asking you about the mouth taping. What do you think about that? Putting tape across the mouth at night to make you breathe through your nose.
[Dr. Colleen Plein]
It's a thing and it works, to an extent. I hear stories about people who have done mouth taping and they had horrible congestion, and the more and more they did it, their congestion improved and great. That's awesome. It probably helps. It is something that I tell my patients to do post-operatively once they've healed. Anytime I'm treating a snoring patient, I always tell them, "Step one is I have to get you breathing through your nose. Step two is I have to get you to close your mouth. Sometimes you automatically close your mouth and sometimes you don't."
This goes back to that, "Is it habit?" My first thing after they're about four to six weeks out of nasal surgery, they're pretty much healed, I will have them start mouth taping and there's a variety of different products you can use for this. I just tell them to use regular medical tape. You don't need a very large piece. Put it on about 15 minutes before you go to bed at night so you get used to the feeling. Then usually over a couple of weeks, you can train yourself to go the whole night with your mouth closed.
It works great for some people. I would say it's going to work better for people who have mild or sleep apnea and some people can't do it so I say, "Okay, well, if that doesn't work for you, then that's when it's time for an oral appliance, because an oral appliance is going to do essentially the same thing." It still allows you to breathe through your mouth, but it's going to stop the mouth hanging open, tongue falling back thing from happening.
[Dr. Gopi Shah]
I'm glad you went over the list of all the non-surgical options you can do because I feel like the hard part is the oral appliances and myofunctional therapy is cost. Most of it's not covered. Like you said, there are resources that are difficult to find. You have to find a myofunctional therapist that's in the area as well as a dental colleague that you can work with. Again, mostly it can be cost-limiting. In terms of age, granted, we do topical nasal steroids phase, topical antihistamines, nasal rinses in kids, what's the youngest that you would do Breathe Right Strips for, and what's the youngest you would consider something like mouth -taping for?
[Dr. Colleen Plein]
That's a great question.
[Dr. Gopi Shah]
Are we thinking adolescents or are you thinking closer to 10?
[Dr. Colleen Plein]
Yes, I'm thinking more-- well, because again, you're not going to see the nasal valve issues as much I think in younger kids because they haven't had the skeletal growth to end up with that collapse if that makes sense. The mouth taping, I don't know. Obviously, that's something I would be very careful of in younger children for sure. I think they definitely need to be old enough that they could take it off themselves if they felt like they couldn't breathe. I would think maybe early adolescence for that. I don't know. That's a good question. I've never really thought about it in great detail.
[Dr. Gopi Shah]
I would agree. I think probably teens, 13 and up.
[Dr. Colleen Plein]
Not a 3-year-old.
[Dr. Gopi Shah]
Not a 3-year-old.
[Dr. Colleen Plein]
We don't want any mouth-taping-associated asphyxia events.
[Dr. Gopi Shah]
No. God, no.
[Dr. Colleen Plein]
No, thank you.
[Dr. Gopi Shah]
Then about the Breathe Right Strips. Do you ever have patients that are maybe history of cleft lip, craniofacial patients where the nasal obstruction, they've had the cleft rhinoplasty or they have an inherent reason? Do Breathe Right Strips help for those patients?
[Dr. Colleen Plein]
Breathe Right Strips have never hurt anybody. That's the nice thing about it. These are all non-invasive things that you can try. Also there's a variety of nasal dilator things because I mentioned a couple, there's nose cones, there's all sorts of stuff. It's more about realizing that that's the area of obstruction and you need something to hold it open, basically. I don't see a lot of those patients, obviously. The great thing about it is it's all non-invasive.
[Dr. Gopi Shah]
Well, Colleen, we are coming up on an hour. It'd probably be a good place to put a pin in it or land this plane, as we like to say. Thank you so much for coming and talking to us. Where can listeners learn more? You and I, when we talked before, we talked about James Nestor's book called Breath: The New Arts of an Old Science or The New Science of an Old Art. I'm butchering that title, but that's enough. People will be able to find it based on that description.
[Dr. Ashley Agan]
We'll Google it and make sure it's correctly written in the show notes.
[Dr. Gopi Shah]
What other references would you recommend for people who are interested to learn more?
[Dr. Colleen Plein]
There's a lot of stuff out there if you just start looking into benefits of mouth breathing and things like that. Even, believe it or not, Google is a good resource. Again, that American Academy of Craniofacial Pain if you're looking for someone who has these interests. One of the organizations that I have done a lot of this with, I've talked at some of their conferences, it's called TMJ and Sleep Therapy Center International. They have a lot of good resources, they have books, they put on courses. Like I mentioned earlier, I actually went to one of their courses. They were so excited. They were like, "We've never had an ENT take one of these courses."
It's all out there if you want to find it. It's just I think people don't even know that this is a thing. They don't know that it exists. I think we could take a lot better care of patients if we knew more about it.
[Dr. Gopi Shah]
Absolutely. If people want to find you or connect with you, do you have a website or social media handles?
[Dr. Colleen Plein]
Yes I'm on Twitter. My handle is @IHaveSinus.
[Dr. Gopi Shah]
Very appropriate.
[Dr. Colleen Plein]
People can always email me. I'm just cplein@gmail.com. I'm always happy to talk to anybody about anything at any time.
[Dr. Gopi Shah]
Awesome. Thank you so much for being here.
[Dr. Ashley Agan]
Thank you, Colleen. I learned a ton.
[Dr. Colleen Plein]
Thank you, guys.
Podcast Contributors
Dr. Colleen Plein
Dr. Colleen Plein is a practicing otolaryngologist in Milwaukee and Chicago.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2022, September 27). Ep. 71 – Nasal vs. Mouth Breathing: Does it Matter? [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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