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Restricted nasal respiration, influence on facial growth
RESTRICTED GROWTH
NASAL
RESPIRATION,
INFLUENCE
ON FACIAL
ATLE FRENG Department (Norway)
of Oto-Rhino-Laryngology,
The National Hospital, University of Oslo, Oslo
(Received July 2nd, 1979) (Accepted August 13th, 1979)
SUMMARY
Used as models on restricted nasal respiration, 11 individuals with a unilateral inborn occlusion of the nose were examined with regard to growth of the mid-facial skeleton. The preference to oral breathing, also a fairly constant feature in patients with chronic or allergic rhinitis with hyperplasia of the pharynx tonsil, appeared to result in a significant underdevelopment of the maxilla in the saggittal plane.
INTRODUCTION
In the complex pattern of facial growth, the concept of functional cranial components is claimed by several authors to be of major importance. This concept stresses the mutual dependence of crania-facial morphology and functions like digestion, speech and respiration [13,14,17]. Others, however, incline to the opinion that this hypothesis is of secondary consideration and that inheritance and genetic factors are in priority [6,11,X3]. According to the first of these two opposite views a change from the normal nasal to the oral mode of respiration should consequently be reflected in a changed facial physiognomy. As early as 1868, the Danish otologist Meyer [12] claimed that this mode of breathing, due to the enlargement of the pharynx tonsil leads to the so-called “adenoid face”. Similar conclusions were also drawn by Linder-Aronson and Backstrom [lo] several years later. In allergic and infectious afflictions of the nose, both the adenoid and the swollen, oedematous nasal mucosa may give symptoms of nasal stenosis. However, irrespective of the provoking factors and the starting mechanisms, i.e. being the rhinitis, the adenoid or narrow dimensions of the epipharynx, an oral mode of respiration is easily induced. In such individuals the middle
250
third of the face has been shown to be relatively underdeveloped [9]. In any case, the magnitude and duration of this type of nasal stenosis will vary the intensity of the basal pathological condition [ 151. Therefore, a more constant nasal occlusion as presented by patients with congenital choanal atresia may consequently appear to be more favourable in estimating the interrelationship of postnatal facial development and mode of respiration. Based on this idea, the aim of the present study was to examine if restricted nasal respiration has an influence on facial sagittal growth, i.e. by using the disorder referred as a model. MATERIAL
AND METHODS
Material The material comprised 11 unoperated patients with unilateral choanal atresia, which is an inborn occlusion of the choana appearing about once in 25,000 births [31. Each patient had a “normal” control of corresponding age, sex and ethnic background, and showed themselves no other anomaly besides the nasal stenosis (Table I). Methods To obtain data suitable for comparisons, the patients and controls were placed in a special roentgenological device ensuring constant relations with regard to focus-film and object-film distances, i.e. a cephalostat [2]. On each lateral radiograph, linear dimensions were measured between the landmarks shown in Fig. 1 and Fig. 2. The precision of the registration method was tested by double determinations of all dimensions providing the standard method error, S.E. In further evaluations of the parameters, a Wilcoxon-Mann-Whitney test was applied with the null-hypothesis stating no differences between medians of the compared groups. RESULTS
No statistical differences were demonstrated regarding the vertical facial dimensions. Concerning the horizontal dimensions, however, significant disparities appeared. In patients with congenital choanal atresia both the
TABLE I PRESENTATION
OF MATERIAL
General and facial growth ended at about 20 years of age (BjGrk, 1964)
Patients with choanal atresia Controls
No. (males)
Age (years)
11 (4) lI(4)
36.8 _+9.9 23.3 & 2.1
251
Fig. 1. Vertical, AR-SN.
linear
dimensions
(mm).
PM-SN;
Fig. 2. Horizontal, linear dimensions (mm) S-N;
PM-A’;
ANS-SN;
AR-GN;
GN-SN;
AR-A’;
MLTP-SN;
AR-PM.
252 TABLE II HORIZONTAL
FACIAL DIMENSIONS (mm)
D.L.S. = descriptive level of significance between medians as treated with Wilcoxon test. Rejection of Ho at (Y” = 0.01 Patients with choanal atresia
Controls
x
S.D.
x
S.D.
D.L.S.
S-N
69.7
PTM-A’ AR-GN AR-PTM AR-A’
43.0 53.3 32.5 75.5
3.8 2.8 11.0 2.9 4.0
71.5 47.0 69.5 37.1 84.2
3.0 2.4 6.5 3.4 5.3
0.242 0.004 R 0.009 R 0.016 0.004 R
maxilla (PTM-A’ and Ar-A’) and the mandible (Ar-GN) were shorter than in the controls (Table II). SE. was in no instance larger than 0.6 mm. DISCUSSION
Previous general examinations, oto-rhino-laryngological examinations and X-ray examinations, with contrast in the nasal cavity and tomography, had failed to reveal any other anatomical divergence from the normal than the unilaterally occluded choana. This observation, the equal distribution of males and females in the compared groups and the small value of SE. should provide a reliable basis to the experimental proceedings [ 1,8]. In the present study nasal spirometry was not performed, a situation, though, made amends for when recalling the normal nasal physiology. As shown by Stoksted [16] and Hasegawa and Kern [ 51, the nasal respiration is characterized by the nasal cycle. During this cycle the nasal air flow alternates between the two nasal halves with a period of a few hours. When one side is physiologically occluded, i.e. by swelling of the nasal mucosa, the air passes through the open cauity of the other side. In patients with unilateral choanal atresia, the effect of the disorder results in alternating periods of total nasal occlusion and total nasal openness. During at least two cycles, therefore, the average air conductive capacity is about half the normal magnitude. When the nose is pathophysiologically totally occluded, oral respiration is used. The situation is experienced by all afflicted patients and also suggested by Stoksted [ 151. Nasal spirometry should, therefore, in these special circumstances, be superfluous. Watson et al. [19] found no special predominance of any facial characteristic related to type of respiration. This is in contrast to the results of the present study and to the findings of Linder-Aronson [9]. This author, and to
253
some extent, also Hockenjos et al. [7] demonstrate a retrognathic face m addition to a narrow upper jaw. This last condition, i.e. a narrow upper jaw, has been shown not be a morphological feature in patients with choanal atresia [3]. In addition, a strict hereditary trend was not demonstrable in any of these patients, and there appeared to be no obvious correlation between this disorder and other associated malformations [4]. The anticipation that choanal atresia should be a part of a syndrome, i.e. a genetic basis to the condition seems, therefore, not to be the origin to the retrognathism observed. With no other obvious relationships influencing the present model of investigation, the findings may be interpreted as being the results of the restricted nasal respiration, i.e. the oral mode of breathing. This is an invariable situation in patients with choanal atresia and also a fairly constant feature in cases with inflammatory conditions in the nose and epipharynx [lo]. The results of the present study may therefore render another point in the discussion on the treatment of chronic rhinitis and in taking decisions on adenotomy. REFERENCES 1 Baumrind, S. and Frantz, R.C., The reability of head film measurements, Amer. J. Orthod., 60 (1971) 111. 2 Brodie, A.G., On the growth pattern of the human head from the third month to the eighth year of life, Amer. J. Orthod., 68 (1941) 209. 3 Freng, A., Growth in width of the dental arches after partial extirpation of the midPalatal suture in man, Stand. J. plast. reconstr. Surg., 12 (1979) 267. 4 Freng, A., Congenital choanal atresia. Etiology, morphology and diagnosis in 82 cases, Stand. J. plast. reconstr. Surg., 12 (1979) 261. 5 Hasegawa, M. and Kern, E.B., Variation in nasal resistance in man, Rhinology, 16 (1978) 19. 6 Harris, J.E., Kowaski, C.J. and Watnick, S.S., Genetic factors in the shape of the craniofacial complex, Angle Orthod., 43 (1973) 107. 7 Hockenjos, von C., Komposch, G. and Schumann, C., Fernrontgenologischer und klinischer Befund bei erschwerter Nasenatmung, Fortschr. Kieferorthod., 35 (1974) 391. 8 Koski, K., Growth changes in the relationships between some basicranial planes and the palatal plane, Suom. Hammaliiak Toivo, 57 (1961) 15. 9 Linder-Aronson, S., Adenoids, their effect on mode of breathing and the nasal airflow and their relationship to characteristics of the facial skeleton and the dentition, Acta oto-laryng. (Stockh.), Suppl 265 (1970). 10 Linder-Aronson, S. and Biickstrijm, A., A comparison between mouth breathers and nose breathers with respect to occlusion and facial dimensions, Odontol. Rev., 11 (1960) 343. 11 Lundstrom, A., The importance of genetic and non genetic factors in the facial skeleton studied in 100 pairs of twins, Trans. Europ. Orthod. Sot., (1954) 92. 12 Meyer, W., Cited in Jepsen, 0. and Thomsen, R.A., Ore-Nzese-Mund- & Halssygdomme, 3rd ed., Scandinavian University Books, 1970, p. 279. 13 Moss, M.L. and Young, R.W., A functional approach to craniology, Amer. J. phys. Anthrop., 18 (1960) 281. 14 Moss, M.L. and Salentijn, L., The capsular matrix, Amer. J. Orthod., 56 (1969) 474.
254 15 Stoksted, P., The physiologic cycle of the nose under normal and pathological conditions, Acta oto-laryng. (Stockh.), 42 (1952) 143. 16 Stoksted, P., Rhinometric measurements for determination of the nasal cycle, Acta oto-laryng. (Stockh.), Suppl. 109 (1953). 17 van der Klaauw, G.J., Size and position of the functional components of the skull, Arch. neerl. Zoo]., 9 (1952) 1. 18 van der Linden, F.P.M., Genetic and evironmental factors in dentofacisl morphology, Amer. J. Orthod., 52 (1966) 576. 19 Watson, R.M., Jr., Warren, D.W. and Fischer, N.D., Nasal resistance, skeletal classification, and mouth breathing in orthodontic patients, Amer. J. Orthod., 53 (1968) 367.
NASAL
RESPIRATION,
INFLUENCE
ON FACIAL
ATLE FRENG Department (Norway)
of Oto-Rhino-Laryngology,
The National Hospital, University of Oslo, Oslo
(Received July 2nd, 1979) (Accepted August 13th, 1979)
SUMMARY
Used as models on restricted nasal respiration, 11 individuals with a unilateral inborn occlusion of the nose were examined with regard to growth of the mid-facial skeleton. The preference to oral breathing, also a fairly constant feature in patients with chronic or allergic rhinitis with hyperplasia of the pharynx tonsil, appeared to result in a significant underdevelopment of the maxilla in the saggittal plane.
INTRODUCTION
In the complex pattern of facial growth, the concept of functional cranial components is claimed by several authors to be of major importance. This concept stresses the mutual dependence of crania-facial morphology and functions like digestion, speech and respiration [13,14,17]. Others, however, incline to the opinion that this hypothesis is of secondary consideration and that inheritance and genetic factors are in priority [6,11,X3]. According to the first of these two opposite views a change from the normal nasal to the oral mode of respiration should consequently be reflected in a changed facial physiognomy. As early as 1868, the Danish otologist Meyer [12] claimed that this mode of breathing, due to the enlargement of the pharynx tonsil leads to the so-called “adenoid face”. Similar conclusions were also drawn by Linder-Aronson and Backstrom [lo] several years later. In allergic and infectious afflictions of the nose, both the adenoid and the swollen, oedematous nasal mucosa may give symptoms of nasal stenosis. However, irrespective of the provoking factors and the starting mechanisms, i.e. being the rhinitis, the adenoid or narrow dimensions of the epipharynx, an oral mode of respiration is easily induced. In such individuals the middle
250
third of the face has been shown to be relatively underdeveloped [9]. In any case, the magnitude and duration of this type of nasal stenosis will vary the intensity of the basal pathological condition [ 151. Therefore, a more constant nasal occlusion as presented by patients with congenital choanal atresia may consequently appear to be more favourable in estimating the interrelationship of postnatal facial development and mode of respiration. Based on this idea, the aim of the present study was to examine if restricted nasal respiration has an influence on facial sagittal growth, i.e. by using the disorder referred as a model. MATERIAL
AND METHODS
Material The material comprised 11 unoperated patients with unilateral choanal atresia, which is an inborn occlusion of the choana appearing about once in 25,000 births [31. Each patient had a “normal” control of corresponding age, sex and ethnic background, and showed themselves no other anomaly besides the nasal stenosis (Table I). Methods To obtain data suitable for comparisons, the patients and controls were placed in a special roentgenological device ensuring constant relations with regard to focus-film and object-film distances, i.e. a cephalostat [2]. On each lateral radiograph, linear dimensions were measured between the landmarks shown in Fig. 1 and Fig. 2. The precision of the registration method was tested by double determinations of all dimensions providing the standard method error, S.E. In further evaluations of the parameters, a Wilcoxon-Mann-Whitney test was applied with the null-hypothesis stating no differences between medians of the compared groups. RESULTS
No statistical differences were demonstrated regarding the vertical facial dimensions. Concerning the horizontal dimensions, however, significant disparities appeared. In patients with congenital choanal atresia both the
TABLE I PRESENTATION
OF MATERIAL
General and facial growth ended at about 20 years of age (BjGrk, 1964)
Patients with choanal atresia Controls
No. (males)
Age (years)
11 (4) lI(4)
36.8 _+9.9 23.3 & 2.1
251
Fig. 1. Vertical, AR-SN.
linear
dimensions
(mm).
PM-SN;
Fig. 2. Horizontal, linear dimensions (mm) S-N;
PM-A’;
ANS-SN;
AR-GN;
GN-SN;
AR-A’;
MLTP-SN;
AR-PM.
252 TABLE II HORIZONTAL
FACIAL DIMENSIONS (mm)
D.L.S. = descriptive level of significance between medians as treated with Wilcoxon test. Rejection of Ho at (Y” = 0.01 Patients with choanal atresia
Controls
x
S.D.
x
S.D.
D.L.S.
S-N
69.7
PTM-A’ AR-GN AR-PTM AR-A’
43.0 53.3 32.5 75.5
3.8 2.8 11.0 2.9 4.0
71.5 47.0 69.5 37.1 84.2
3.0 2.4 6.5 3.4 5.3
0.242 0.004 R 0.009 R 0.016 0.004 R
maxilla (PTM-A’ and Ar-A’) and the mandible (Ar-GN) were shorter than in the controls (Table II). SE. was in no instance larger than 0.6 mm. DISCUSSION
Previous general examinations, oto-rhino-laryngological examinations and X-ray examinations, with contrast in the nasal cavity and tomography, had failed to reveal any other anatomical divergence from the normal than the unilaterally occluded choana. This observation, the equal distribution of males and females in the compared groups and the small value of SE. should provide a reliable basis to the experimental proceedings [ 1,8]. In the present study nasal spirometry was not performed, a situation, though, made amends for when recalling the normal nasal physiology. As shown by Stoksted [16] and Hasegawa and Kern [ 51, the nasal respiration is characterized by the nasal cycle. During this cycle the nasal air flow alternates between the two nasal halves with a period of a few hours. When one side is physiologically occluded, i.e. by swelling of the nasal mucosa, the air passes through the open cauity of the other side. In patients with unilateral choanal atresia, the effect of the disorder results in alternating periods of total nasal occlusion and total nasal openness. During at least two cycles, therefore, the average air conductive capacity is about half the normal magnitude. When the nose is pathophysiologically totally occluded, oral respiration is used. The situation is experienced by all afflicted patients and also suggested by Stoksted [ 151. Nasal spirometry should, therefore, in these special circumstances, be superfluous. Watson et al. [19] found no special predominance of any facial characteristic related to type of respiration. This is in contrast to the results of the present study and to the findings of Linder-Aronson [9]. This author, and to
253
some extent, also Hockenjos et al. [7] demonstrate a retrognathic face m addition to a narrow upper jaw. This last condition, i.e. a narrow upper jaw, has been shown not be a morphological feature in patients with choanal atresia [3]. In addition, a strict hereditary trend was not demonstrable in any of these patients, and there appeared to be no obvious correlation between this disorder and other associated malformations [4]. The anticipation that choanal atresia should be a part of a syndrome, i.e. a genetic basis to the condition seems, therefore, not to be the origin to the retrognathism observed. With no other obvious relationships influencing the present model of investigation, the findings may be interpreted as being the results of the restricted nasal respiration, i.e. the oral mode of breathing. This is an invariable situation in patients with choanal atresia and also a fairly constant feature in cases with inflammatory conditions in the nose and epipharynx [lo]. The results of the present study may therefore render another point in the discussion on the treatment of chronic rhinitis and in taking decisions on adenotomy. REFERENCES 1 Baumrind, S. and Frantz, R.C., The reability of head film measurements, Amer. J. Orthod., 60 (1971) 111. 2 Brodie, A.G., On the growth pattern of the human head from the third month to the eighth year of life, Amer. J. Orthod., 68 (1941) 209. 3 Freng, A., Growth in width of the dental arches after partial extirpation of the midPalatal suture in man, Stand. J. plast. reconstr. Surg., 12 (1979) 267. 4 Freng, A., Congenital choanal atresia. Etiology, morphology and diagnosis in 82 cases, Stand. J. plast. reconstr. Surg., 12 (1979) 261. 5 Hasegawa, M. and Kern, E.B., Variation in nasal resistance in man, Rhinology, 16 (1978) 19. 6 Harris, J.E., Kowaski, C.J. and Watnick, S.S., Genetic factors in the shape of the craniofacial complex, Angle Orthod., 43 (1973) 107. 7 Hockenjos, von C., Komposch, G. and Schumann, C., Fernrontgenologischer und klinischer Befund bei erschwerter Nasenatmung, Fortschr. Kieferorthod., 35 (1974) 391. 8 Koski, K., Growth changes in the relationships between some basicranial planes and the palatal plane, Suom. Hammaliiak Toivo, 57 (1961) 15. 9 Linder-Aronson, S., Adenoids, their effect on mode of breathing and the nasal airflow and their relationship to characteristics of the facial skeleton and the dentition, Acta oto-laryng. (Stockh.), Suppl 265 (1970). 10 Linder-Aronson, S. and Biickstrijm, A., A comparison between mouth breathers and nose breathers with respect to occlusion and facial dimensions, Odontol. Rev., 11 (1960) 343. 11 Lundstrom, A., The importance of genetic and non genetic factors in the facial skeleton studied in 100 pairs of twins, Trans. Europ. Orthod. Sot., (1954) 92. 12 Meyer, W., Cited in Jepsen, 0. and Thomsen, R.A., Ore-Nzese-Mund- & Halssygdomme, 3rd ed., Scandinavian University Books, 1970, p. 279. 13 Moss, M.L. and Young, R.W., A functional approach to craniology, Amer. J. phys. Anthrop., 18 (1960) 281. 14 Moss, M.L. and Salentijn, L., The capsular matrix, Amer. J. Orthod., 56 (1969) 474.
254 15 Stoksted, P., The physiologic cycle of the nose under normal and pathological conditions, Acta oto-laryng. (Stockh.), 42 (1952) 143. 16 Stoksted, P., Rhinometric measurements for determination of the nasal cycle, Acta oto-laryng. (Stockh.), Suppl. 109 (1953). 17 van der Klaauw, G.J., Size and position of the functional components of the skull, Arch. neerl. Zoo]., 9 (1952) 1. 18 van der Linden, F.P.M., Genetic and evironmental factors in dentofacisl morphology, Amer. J. Orthod., 52 (1966) 576. 19 Watson, R.M., Jr., Warren, D.W. and Fischer, N.D., Nasal resistance, skeletal classification, and mouth breathing in orthodontic patients, Amer. J. Orthod., 53 (1968) 367.