Often dismissed as a habit, mouth breathing is a health problem due to the presence of nasal obstruction. An experienced ear nose and throat surgeon can help solve this problem for you or your child.

1. M
OUTH
BREATHING
W
HY
YOUR
LUNGS
AND
HEART DON’T LIKE
IT
Associate Professor
Dr David McIntosh
Ear Nose Throat Specialist
www.entspecialists.com.au

2. ASSOCIATE PROFESSOR DR DAVID MCINTOSH
Ear, nose, and throat specialist
Specialising in paediatric ENT, nose and sinus disease, and upper
airway obstruction
Contact details:
Phone 07 5451 0333
Web entspecialists.com.au
Facebook ENT Specialists Australia

3. DISCLAIMER
The advice presented here is general in nature and for the purposes of
education and information only
All health matters should be directly discussed with your qualified
health professional

4. THE AIR WE BREATHE
The most important thing we do is breathe
The second most important thing we do is pump blood around our
bodies
If either of these stop happening, we stop living
In the air, the most important thing is oxygen
Oxygen makes up about 20% of the gas in the air
Our lungs are designed to allow oxygen to enter our bloodstream, so it
can be transported around our bodies
Our bodies need a constant steady stream of oxygen- if the levels drop
this is called hypoxia (pronounced high-pox-ee-ah)

5. HOW THE LUNGS WORK
Our lungs need to be inflated to fill up with a fresh lot of air
This happens by the action of muscles around the chest wall and most
importantly a muscle called the diaphragm, that all work to stretch
the lungs open, sucking air in to our bodies
Once the air is drawn in, it comes into very close contact with blood
that has been pumped into the lungs by the heart
The right side of the heart pumps blood in to the lungs, and the left
side of the heart pumps blood to the rest of our body
So the system is designed such that blood low in oxygen is pumped by
the right side of the heart, to the lungs to be recharged with oxygen,
and from here it goes to the left side of the heart, and is then
pumped to the rest of the body
The brain controls all of this to keep everything organised

6. IT’S ALL ABOUT THE OXYGEN
As mentioned, the body needs a steady flow of oxygen to function
properly
If it starts to miss out on even just a little bit here and there it causes
problems
There are different types of low oxygen and the one most important to
this presentation is the type where there are very brief drops in the
oxygen level below normal, with these dips being very regular all be
it short lived
A drop in oxygen levels is known as hypoxia, and brief dips are known
as intermittent hypoxia
When intermittent hypoxia has been going on for a while, it is called
chronic intermittent hypoxia
A dip in the oxygen levels results in a body reaction called inflammation
and this can cause damage to the tissues of the body

7. WHY YOUR NOSE IS IMPORTANT
Although there is no difference in the amount of oxygen in the air we
breathe through the nose or mouth, there is a big difference as to
how much of that oxygen finds its way in to the blood
When we breathe through the nose, we use our diaphragm more than
our chest wall muscles, and likewise when we breath though our
mouth, we use the chest wall muscles more than our diaphragm
So called diaphragmatic breathing results in a better distribution of the
oxygen through the lungs, which means the blood can recharge itself
better
Furthermore, there is a chemical made by the nose and sinuses called
nitric oxide. This chemical travels from the nose, with air breathed
in through the same, down in to the lungs, Nitric oxide opens up the
blood vessels, which helps more blood flow to then pick up the
oxygen along its journey through the lungs

8. WHAT LOW OXYGEN DOES TO YOUR BODY
Chronic intermittent hypoxia affects every body organ you can think of
For example, it makes the heart have to work harder to make up for the
reduced oxygen levels in the blood
And the brain gets triggered in to a panic mode to be on the alert- and
this affects your sleep quality, concentration, behaviour, and
emotions, all for the worse
And it makes your skin age prematurely, and your blood pressure go
high, your eyesight deteriorate, your bones become weaker, your
immune system changes, your body hormones become erratic, your
appetite increases, you are more likely to end up with diabetes…..
And the list goes on

9. MORE ABOUT INFLAMMATION
Inflammation is not a disease but a description of a bodily reaction
It can be triggered by infection, trauma, and stress
Stress can be physical, emotional, and psychological
Inflammation is a process that is mediated by the body’s immune
system
In people with chronic intermittent hypoxia, we can measure this over-
activity
It is this inflammatory response at a local tisue level that causes all the
problems for the body systems

10. WHAT CAUSES A BLOCKED NOSE
The nose starts at the nostrils, goes through the nasal passages, and
into the open space at the back of the nose, and this then leads
down the back of the throat to the voice box, wind pipe, and lungs
So the nose can be blocked because there is a problem with the
nostrils, a problem inside the nasal passages, or a blockage in the
space behind the nose
Whilst there are lots of things that can cause this, the 3 most common
things are:
1. The adenoids in the space behind the nose are too big
2. The middle part of the nose known as the septum is crooked
(deviated septum)
3. The swellings inside the nose known as turbinates are too big

11. HOW TO FIX A BLOCKED NOSE
Unblocking the nose is a glorified plumbing job
The easiest way to look at it is based on the 3 main causes:
1. Large adenoids- quite simply, the only thing that works is surgical
removal; we used to thing nasal sprays would help, but the more
recent research on this has cast doubt on that notion
2. Deviated septum- this is a structural problem, and the only thing
that fixes it is surgery
3. Large turbinates- these may shrink with nasal steroid sprays or
otherwise require surgery to trim them down to size
So lets go through the basic details of surgery

12. REMOVING THE ADENOIDS- ADENOIDECTOMY
The adenoids sit at the back of the nose, so the only 2 ways of seeing
them are wither with a telescope through the nose or using a
telescope or mirror placed inside the mouth at the time of surgery
The historical approach of removing adenoids though, is to not even
look at them- this is called blind scraping or “curettage”
The research on blind scraping shows a high rate of adenoids being left
behind, and sometimes so much can be left behind, there is still a
blockage present
Newer techniques mean that the old style blind curette approach has a
limited role in modern surgeon’s hands
An adenoidectomy can be performed in isolation or in conjunction with
other ENT surgery and can be done for reasons other than airway
obstruction
The post-op recovery is usually pretty straight forward

13. STRAIGHTENING A CROOKED SEPTUM-
SEPTOPLASTY
The middle part of the nose may be crooked in as many as 20% of
people
When it comes to fixing it, if it is a simple deviation, then this can be
done entirely on the inside of the nose, with no cuts on the outside
If the septum is severely deformed, or the outside of the nose is also
deformed, then an approach that requires an incision to be made on
the outside of the nose may be necessary – this is called an open,
or external, septorhinoplasty
In modern surgeons hands this is a day surgery procedure more often
than not, and may be performed in conjunction with other surgery
such as on the turbinates or sinuses
The post-op recovery is variable, depending on the degree of surgery
required and other procedures performed at the same time

14. SURGERY FOR LARGE TURBINATES
In the mainstay, there are 3 types of operations to reduce the size of
the nasal turbinates:
1. Cautery- this is simply the application of an electrical burn to the
tissue which results in the formation of scar tissue, which shrinks
the turbinate down; it tends to only last 6-12 months, so it is useful
for little kids where other procedures are harder to perform due to
the small size of their nose
2. Coblation turbinate reduction- this is the use of a special instrument
that generates a plasma field; this results in tissue melting away
and tends to last about 2-5 years, and is well suited again for
children where the access is possible
3. Micro-debrider assisted turbinate reduction- this is the gold standard
for surgery as it physically removes both soft tissue and the
supporting bone, to truly open up the space within the nose; it is the
go to operation for adults and kids that are appropriately selected

15. WHAT NOT TO DO IF THE NOSE IS BLOCKED
Sometimes the best of intentions are misplaced
As a starting point, it is important to realise that 80% of the time, a
person is breathing through their mouth because there is a physical
obstruction of some sort to nasal breathing
As a result of this, it is important that the cause be identified-
remember, mouth breathing is merely an observation, not a
diagnosis
When it comes to management strategies, there are 2 things to
absolutely avoid until an ENT has checked out the breathing:
1. Breathing exercises to force someone to breathe through their
nose
2. Taping the lips closed at night (and this should probably never be
done ever)
If nasal breathing is forced against obstruction, it may result in ever
worse inflammation, which is not a good thing for the body

16. WHEN TO FIX A BLOCKED NOSE
People often wonder when they should get their kids or themselves
sorted
The short answer is as soon as a problem is identified
Kids are not supposed to snore, mouth breathe, or for that matter grind
their teeth at night; these are all potential symptoms of airway
obstruction and this needs to sorted out immediately
When it comes to adults, some notice a problem and some have such
long standing basal obstruction they have become used to it and do
not realise just how bad they truly are; so if you snore, mouth
breathe, notice you are not getting good quality sleep, waking up
tired, or have limited exercise capability, then you may have an
underlying issue with nasal obstruction
So in short- if it’s broke, fix it!

17. WHAT TO DO WHEN MOUTH BREATHING
CONTINUES
Sometimes once the nose is unblocked, the patient does not transition
to using their newly created breathing option
Now often with time things will sort themselves out, but where this is
not the case, then it may be necessary to engage the services of
either a speech therapist or a myofunctional rehabilitation specialist
The best analogy is if you break your leg- being stuck in a cast leads to
muscle disuse, and then requires a physiotherapist to get things
sorted once the cast comes off- well the same applies to breathing
Having said that, it is a bit different to breaking your leg as more often
than not, nasal breathing will evolve within about 3 months from
surgery- nobody is really sure at what time point breathing therapy
should be started due to this being the case, so that is something to
discuss with your surgeon as to their own experience

18. ASSOCIATE PROFESSOR DR DAVID MCINTOSH
Ear, nose, and throat specialist
Specialising in paediatric ENT, nose and sinus disease, and upper
airway obstruction
Contact details:
Phone 07 5451 0333
Web entspecialists.com.au
Facebook ENT Specialists Australia