GAP Australasian Dentist Mar Apr 2020

Category 72 Austràlàsiàn Dentist Grade 1 tonsils Grade 4 tonsils Grade 2 tonsils Introduction àhe management of mouth breathing and snoring in children often involves a multidisciplinary approach. àn childhood the most common aetiologies are adenotonsillar hypertrophy and nasal obstruction. àhe palatine tonsils, adenoids, tubal and lingual tonsils make up Waldeyer’s ring, a lymphoid collection that is involved in the development of regional immunity. àhese lymphoid structures are advantageously positioned at the entry point of airborne and food particulates and function as a mucosal immune barrier 1 . However, in diseased states, this same lymphoid tissue may become hypertrophied leading to upper airway obstruction. From an oral health perspective, mouth breathers are at increased risk of tooth decay, gingivitis and halitosis 2 due to poor mechanical salivary clearance, and subsequent “aciduric and acidogenic oral microflora” changes that promotes dental caries. More recently, there is emerging evidence that upper airway obstruction may also be lead to, and be associated with, abnormal dentofacial development 3 . àherefore, not only does the dental practitioner deal with the consequences of paediatric adenotonsillar hypertrophy and nasal obstruction, but they are also uniquely placed to identify early anomalies and manage the disease process within a multidisciplinary environment. Adenotonsillar Hypertrophy Sleep Disordered Breathing àleep disordered breathing (àDB) is a spectrum of disease that ranges from primary snoring to obstructive sleep apnoea (OàA) and has been shown to have significant effects on quality of life and health outcomes. àhe most common aetiology in a paediatric population is adenotonsillar hypertrophy, followed by allergic disease, septal deformity, obesity and syndromes/craniofacial anomalies. During sleep, patients and parents may report snoring, apnoeas, restless sleep and frequent night terrors. Consequently daytime behavioural problems (anxiety, depression, aggression), sleepiness, hyperactivity and poor educational attainment may ensue. Furthermore, àDB has been associated with long-term cardiopulmonary as well as neurobehavioural problems such as hyper- somnolence, emotional lability, decreased attention and enuresis 4 . àncouragingly, recent reviews have reinforced the cor- relation between adenotonsillar hyper- trophy and àDB, demonstrating reversal of associated cardiovascular sequelae and improvements in behaviour, attention, quality of life, neurocognitive function as well as enuresis, after treatment with tonsillectomy +/- adenoidectomy 5,6 . àn themedical management of children with àDB, an initial trial of intranasal steroid may be beneficial. By addressing the factors that commonly contribute to àDB, intranasal corticosteroids have been demonstrated to significantly reduce adenoid size 7 as well as reduce nasal obstruction after at least a 2-4 week trial of therapy. àhese intranasal steroids are now available over the counter in Australia and are relatively well tolerated. àhe most common side effects include nasal irritation, discomfort, dryness and epistaxis. àare side effects including septal perforations, mucosal atrophy, glaucoma, cataracts and hypo-pituitary-adrenal axis suppression 8 . àeferral to an surgeon for further assessment is also warranted in the child with àDB. Tonsillar Asymmetry Another important aspect of tonsillar assessment is symmetry. Although generally rare in a paediatric population (0.021 per 100,000 patients per year within the ) 9 , the third most common malignancy in children is lymphoma, Paediatric Adenotonsillar Hypertrophy and Nasal Obstruction – A Primer for the Dentist àlàn al By Dr Timothy Do MD, BMed 1 Clinical Associate Professor àirmal Patel, MBBà Mà FàACà 1,2,3 1à Department of Otolaryngology Head and àeck àurgery, àoyal àorth àhore Hospital, àt àeonards, àydney, Australia 2à Discipline of àurgery, àydney Medical àchool, àniversity of àydney, Australia. 3à Department of Otolaryngology – Head & àeck àurgery, Faculty of Medicine and Health àciences, Macquarie àniversity, àydney, Australia