Where in a physical examination do you document mouth breathing in a 2-year-old?

Documentation of Mouth Breathing in Physical Examination

Mouth breathing in a 2-year-old should be documented in the HEENT (Head, Eyes, Ears, Nose, Throat) section of the physical examination, specifically under the respiratory/airway assessment portion, noting both the presence of an open mouth posture and any associated findings such as incompetent lip seal, nasal obstruction, or oropharyngeal abnormalities.

Primary Documentation Location

• Document mouth breathing under the HEENT examination, as this represents an upper airway and orofacial finding that requires assessment of nasal patency, oral cavity, pharyngeal structures, and facial characteristics 1
• The respiratory section may also include notation of mouth breathing as it relates to the child's breathing pattern and potential airway obstruction 2

Key Physical Examination Findings to Document

Orofacial Assessment

• Incompetent lip seal (inability to maintain closed lips at rest) is the most representative physical finding of mouth breathing and should be specifically noted 3
• Document whether the child maintains an open mouth posture during quiet breathing while awake 1
• Note any associated facial muscle imbalance or craniofacial changes that may result from chronic mouth breathing 1

Nasal and Pharyngeal Examination

• Assess and document nasal patency to differentiate between habitual mouth breathing versus obstructive causes 2, 1
• Document presence of nasal obstruction, enlarged adenoids, or tonsillar hypertrophy that may contribute to mouth breathing 2
• Note whether the soft palate and tongue positioning suggest oropharyngeal obstruction 4

Respiratory Pattern Documentation

• Record the breathing route (nasal, oral, or mixed) during the examination 3
• Document whether mouth breathing is present during sleep (if history available) or only during waking hours 2
• Note the child's posture during examination, as this can affect breathing patterns 5

Clinical Context and Pitfalls

Age-Specific Considerations

• At 2 years of age, children are not obligatory nasal breathers and can switch between nasal and oral breathing, so the finding must be interpreted in context 4
• Mouth breathing lasting more than 6 months is considered clinically significant and warrants documentation and further evaluation 2

Differentiation Between Habit and Obstruction

• It is critical to distinguish between habitual mouth breathing and obstructive mouth breathing, as management differs significantly 2, 1
• Document findings from nasal examination and consider endoscopic evaluation if obstruction is suspected 2
• Habitual mouth breathing may persist even after mechanical causes are resolved, which has implications for treatment planning 2

Associated Findings to Document

• Dry lips and their condition should be noted as part of the mouth breathing assessment 3
• Document any speech alterations, as mouth breathing can affect speech development in this age group 6
• Note eating and drinking habits, swallowing difficulties, or problems with chewing if present 3
• Record presence of bad breath, which may be associated with mouth breathing 3

Documentation Format

The examination note should clearly state:

• Presence or absence of mouth breathing
• Whether lips are competent or incompetent at rest
• Nasal patency assessment findings
• Any visible oropharyngeal abnormalities
• Duration of symptoms if known from history
• Whether the pattern appears habitual or obstructive in nature

This systematic documentation allows for appropriate follow-up, referral decisions, and tracking of the condition over time 1.