Dear Dr. Dankle:
I would appreciate your opinion on the following situation: An orthodontist has told me that my 14-yr-old son's underbite has been caused by years of "mouth-breathing" and referred us to an E.N.T. The E.N.T. informed me that my son does, indeed, have a deviated septum and very enlarged turbinates. A nasal spray used for three weeks did not make a significant difference in his ability to breathe through his nose, so the E.N.T. has recommended that my son undergo surgery to correct the deviation and "trim" the turbinates. I understand, from a previous response you made to someone else, about the deviated septum repair, but I am concerned about the turbinate surgery. What happens to the turbinates after the surgery? Are they still able to do their job of cooling the air? My son scars badly. Is there any chance either of these corrections would cause scar tissue to form in the nose? Will these surgeries, in your opinion, keep my son's top teeth from being sucked in, as the orthodontist claims? What are the risks and possible complications of these surgeries?
I sincerely appreciate your time and expertise in offering an opinion in this matter.
Sincerely, Concerned Mom
Reply ---------------------------
The most important issue to resolve in your son's case is whether the "mouth- breathing" is related to an actual nasal airway obstruction. So-called "mouth-breathing" may be habitual or related to the anatomy of the dentition itself rather than due to actual nasal airway obstruction, and therefore in some cases may not improve following adenoid or nasal surgery. If actual nasal airway obstruction exists, adenoid enlargement is responsible in the majority of younger children. Adenoid tissue often atrophies or shrinks in the teenage years and therefore is less likely a major factor in nasal obstruction in these ages. Allergy or anatomic nasal obstruction should then be considered.
Caution must be exercised in recommending nasal surgery in children since
there is some potential for disturbing the growth centers in the nose. Often
by the mid-to late teens the nose has reached essentially adult size and nasal
surgery, if indicated, is usually deferred until that time. Even in the
presence of an obvious deviation of the nasal septum seen on a physical
examination, I do not recommend surgery as the initial management of a
complaint of nasal airway obstruction. There are many individuals who have
significant deviations of the nasal airway who do not complain of nasal
airflow obstruction. However, if there is a complaint about nasal
obstruction, I will initially recommend a trial of nasal steroid, usually
for a minimum of one month. Nasal steroids take some time to work and must
be used daily. If they don't help, and if allergy has been ruled out as a
major contributor, then surgery is a reasonable consideration.
Septal surgery is often combined with turbinate reduction surgery since both
a deviated septum and chronic turbinate enlargement can cause the obstruction.
The turbinates' function is to warm and humidify the air inspired and if they
are over-resected significant disturbance in normal nasal function could
result.
Ordinarily the turbinates are reduced by no more than 1/3 to at most 1/2 of
their original size. This can be accomplished either with the use of a laser
or a special scissors. Bleeding is the most common complication and the risk
can be reduced with the use of a laser. Dryness and crusting are common post-
operative sequela usually lasting for a few weeks after surgery. Careful
attention towards avoidance of over-reduction and careful post-operative care
reduce any risk of scarring.
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
NOTICE: OFCN is not engaged in the rendering of professional medical services. The information contained on this system or any other OFCN system should not supplant individual professional consultation. It is offered exclusively as a community education service. Advice on individual problems must be obtained directly from a professional.
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