What are the next treatment options for an 11-year-old child with long-standing mouth breathing and mild snoring due to slight nasal septal deviation and possible turbinate hypertrophy, unresponsive to nasal steroid spray for two months?

From the Guidelines

For an 11-year-old child with persistent mouth breathing and mild snoring due to septal deviation and possible turbinate hypertrophy who hasn't responded to nasal steroid spray, the next appropriate step would be referral to an otolaryngologist (ENT specialist) for evaluation and possible surgical intervention, such as septoplasty or turbinate reduction surgery, as these procedures have been shown to improve nasal obstruction symptoms in patients with deviated septum and turbinate hypertrophy 1.

The child's symptoms of long-standing mouth breathing and mild snoring are likely caused by the nasal obstruction resulting from the septal deviation and possible turbinate hypertrophy. Given that the child has not responded to nasal steroid spray, surgical intervention may be necessary to alleviate the symptoms.

• The ENT specialist will assess the severity of the septal deviation and turbinate hypertrophy to determine the best course of treatment.
• Septoplasty, which involves reshaping, repositioning, or recontouring the cartilage, has been shown to improve nasal obstruction symptoms in patients with deviated septum, with as many as 77% of patients achieving subjective improvement 1.
• Turbinate reduction surgery, such as submucosal resection or turbinate reduction, may also be considered to reduce the size of the inferior turbinate and improve nasal airflow.
• While waiting for the specialist appointment, parents can try saline nasal irrigation (using pre-made pediatric saline sprays or rinses) twice daily to help reduce congestion, and ensuring the child sleeps with their head slightly elevated and maintaining good hydration may provide some symptomatic relief.
• Allergy testing might also be warranted if environmental allergies are suspected as contributing factors, as allergic rhinitis and nonallergic rhinitis can cause swelling of the nasal mucosa and contribute to nasal obstruction 1.

It is essential to address the child's nasal obstruction symptoms to prevent potential long-term complications, such as facial development issues, dental malocclusion, and sleep disturbances that can affect growth and cognitive development. The ENT specialist will assess whether the septal deviation is significant enough to warrant surgical correction, which is typically deferred until facial growth is more complete in the mid-teenage years. However, in some cases, earlier intervention may be necessary to alleviate symptoms and prevent complications.

From the Research

Treatment Options for Nasal Septal Deviation and Turbinate Hypertrophy

The next treatment options for an 11-year-old child with long-standing mouth breathing and mild snoring due to slight nasal septal deviation and possible turbinate hypertrophy, unresponsive to nasal steroid spray for two months, include:

• Surgical procedures such as septoplasty with inferior turbinate reduction 2
• Endoscopic inferior turbinate reduction, which has been shown to be effective in improving nasal airway obstruction 3, 4
• Alternative therapies such as oral Montelukast, which has been found to be effective in reducing adenoid size and improving symptoms in children with adenoid hypertrophy 5

Considerations for Treatment

When considering treatment options, it is essential to take into account the child's overall health, medical history, and the severity of their symptoms.

• Clinical assessment has been found to be an accurate predictor of which patients will need septoplasty 6
• The effectiveness of treatment options may vary depending on the presence of comorbid conditions such as allergic rhinitis 4
• Surgical procedures carry risks and complications, such as postoperative infection and epistaxis, although these are relatively rare 2

Potential Outcomes

The potential outcomes of treatment options include:

• Improvement in nasal airway obstruction and reduction in symptoms such as mouth breathing and snoring 3, 4
• Reduction in the size of adenoids and improvement in overall symptoms with oral Montelukast therapy 5
• Relief from nasal obstruction and improvement in quality of life with septoplasty and inferior turbinate reduction 2