Likely Diagnosis: Allergic Rhinitis with Obstructive Sleep-Disordered Breathing
This 5-year-old girl with eczema (indicating atopy) who has started snoring with her mouth closed most likely has developed allergic rhinitis causing nasal obstruction and sleep-disordered breathing. The closed-mouth snoring specifically indicates nasal airway obstruction rather than oropharyngeal obstruction 1.
Why This Is Happening
The Atopic Connection
- Children with eczema have a high likelihood of developing other atopic conditions, particularly allergic rhinitis 1.
- The presence of rhinitis is a strong predictor of habitual snoring in children 1.
- Atopy has been directly associated with habitual snoring in infants and children 1.
The Mechanism of Closed-Mouth Snoring
- Closed-mouth snoring specifically indicates nasal airway obstruction 2.
- Increased nasal airway resistance from allergic inflammation forces turbulent airflow through narrowed nasal passages, creating the snoring sound even with the mouth closed 1.
- This differs from mouth-breathing snoring, which typically indicates oropharyngeal or adenotonsillar obstruction 2.
The Steroid Connection
- Frequent topical corticosteroid use for eczema does NOT cause the snoring - this is a common misconception 3.
- When used appropriately for eczema, topical corticosteroids do not cause systemic effects that would lead to upper airway obstruction 3.
- The association here is that both conditions (eczema and rhinitis) are part of the "atopic march" - the natural progression of atopic diseases in childhood 1.
What Needs to Happen Next
Immediate Evaluation Required
- Formal evaluation for obstructive sleep apnea syndrome (OSAS) should be considered in this child 1.
- Children with rhinitis and upper respiratory disease are at enhanced risk for sleep-disordered breathing 1.
- Polysomnography is the diagnostic method of choice to quantify sleep and ventilatory abnormalities 1.
Clinical Assessment Priorities
- Examine the upper respiratory tract for increased nasal secretion, mucosal swelling, and/or nasal polyps 1.
- Assess for adenotonsillar hypertrophy, which commonly coexists with allergic rhinitis in children 1.
- History and physical examination alone are poor at differentiating between primary snoring and obstructive sleep apnea 1.
Treatment Approach
- Intranasal corticosteroids are recommended for childhood OSAS in the presence of co-existing rhinitis and/or upper airway obstruction 1.
- These medications reduce nasal airway resistance and can improve sleep-disordered breathing 1.
- Environmental control measures to reduce allergen exposure should be implemented 1.
Critical Pitfalls to Avoid
Don't Dismiss This as "Just Snoring"
- Untreated obstructive sleep apnea syndrome can result in serious complications including neurocognitive impairment, behavior problems, failure to thrive, cor pulmonale, and death 1.
- Early diagnosis and treatment have reduced the incidence of severe complications 1.
Don't Blame the Eczema Steroids
- Parents may be concerned that topical corticosteroids for eczema caused this problem 3.
- Reassure them that appropriate topical corticosteroid use for eczema does not cause systemic effects leading to upper airway problems 3.
- The connection is that both conditions share an atopic/allergic basis 1.
Don't Wait for Mouth Breathing to Develop
- Closed-mouth snoring is a red flag for nasal obstruction and warrants evaluation 2.
- Mouth breathing signals progression of sleep-disordered breathing and orofacial growth changes in children 2.
The "One Airway, One Disease" Concept
- Patients with persistent allergic rhinitis should be evaluated for asthma, and vice versa 1.
- Pulmonary function tests should be considered in this child with rhinitis to assess for possible asthma 1.
- The upper and lower airways are linked by common epidemiologic, physiologic, and pathologic mechanisms 1.