What is the appropriate evaluation and management for a 4‑year‑old girl with chronic mouth breathing that worsens when her nose is blocked?

Evaluation and Management of Chronic Mouth Breathing in a 4-Year-Old with Nasal Obstruction

This 4-year-old requires immediate evaluation for adenoidal hypertrophy as the most likely cause, with assessment for sleep-disordered breathing and consideration of allergic rhinitis as contributing factors.

Initial Clinical Assessment

Evaluate specifically for adenoidal hypertrophy, which is the most common acquired anatomic cause of nasal obstruction in children and commonly results in mouth breathing, nasal speech, and snoring 1. Look for:

• Signs of sleep-disordered breathing: snoring, witnessed apneas, restless sleep, daytime somnolence 1
• Adenoid facies: long, narrow face with open mouth posture 2
• Nasal quality of speech and chronic nasal congestion 1
• Feeding difficulties or failure to thrive (particularly concerning in younger children) 3
• Recurrent rhinosinusitis or chronic otitis media 1

Examine for allergic rhinitis as a contributing factor, including turbinate hypertrophy on examination, clear rhinorrhea, and nasal mucosal edema 1. Children with allergic rhinitis have increased risk of habitual snoring and sleep-disordered breathing 1.

Diagnostic Workup

Obtain flexible nasopharyngoscopy to directly visualize adenoid size, turbinate hypertrophy, and assess for other anatomic abnormalities 1. This is the gold standard for evaluating upper airway obstruction in children and allows examination in the most physiological conditions 1.

Screen for obstructive sleep apnea (OSA) given the strong association between chronic rhinitis, mouth breathing, and sleep-disordered breathing in children 1. Formal polysomnography should be considered if the child has:

• Habitual snoring (≥3 nights per week)
• Witnessed apneas or gasping
• Behavioral problems or hyperactivity
• African American ethnicity or family history of sleep apnea 1

Consider allergy testing if allergic rhinitis is suspected based on history of seasonal variation, family history of atopy, or physical findings of allergic shiners and turbinate hypertrophy 1.

Medical Management (First-Line)

Initiate intranasal corticosteroids as first-line therapy for nasal obstruction related to adenoidal hypertrophy or allergic rhinitis 1, 4. For a 4-year-old:

• Fluticasone propionate 1 spray per nostril once daily (children 4-11 years) 4
• Continue for up to 2 months before reassessing 4
• Intranasal steroids significantly improve symptom scores and reduce adenoid/polyp size 1

Implement saline nasal irrigation as adjunctive therapy, which is safe and effective for nasal congestion in children and helps prevent progression to acute rhinosinusitis 3. This is particularly important given the child's inability to blow her nose effectively at this age 3.

Avoid montelukast in this age group unless absolutely necessary, as the FDA issued a black box warning regarding serious behavioral and mood-related changes, and benefits may not outweigh risks when symptoms can be treated with other medications 1.

Indications for Surgical Referral

Refer to pediatric otolaryngology if:

• Failure to improve after 4-8 weeks of optimal medical therapy (intranasal corticosteroids plus saline irrigation) 5
• Moderate to severe OSA documented on polysomnography (obstructive apnea-hypopnea index >5/hour) 1
• Recurrent acute rhinosinusitis or chronic adenoiditis despite medical management 1
• Significant feeding difficulties or failure to thrive 3

The main indication for adenoidectomy is sleep apnea caused by adenotonsillar hypertrophy, chronic adenoiditis, or chronic sinusitis 1. However, adenoidectomy should only be considered after maximizing medical therapy 1.

Critical Considerations for Long-Term Management

Monitor for craniofacial development abnormalities, as chronic nasal obstruction and mouth breathing are associated with longer, narrower faces and dental malocclusions, particularly in dolichocephalic (narrow-faced) children 6, 7. While the causal relationship remains debated, relief of nasal obstruction should be attempted to establish a patent airway and decrease the possibility of abnormal craniofacial development 6.

Reassess after 2 months of intranasal steroid use in this 4-year-old, as prolonged use beyond 2 months per year requires physician consultation due to potential effects on growth rate 4. When used long-term, intranasal glucocorticoids may cause slower growth rates in some children 1.

Do not assume all nasal obstruction is adenoidal—also consider choanal stenosis, nasal septal deviation, or inferior turbinate hypertrophy, particularly if unilateral symptoms are present 1, 8.

Common Pitfalls to Avoid

• Do not delay evaluation in young children with chronic mouth breathing, as neonates and young infants are obligate nasal breathers and even minor congestion can create near-total obstruction 1, 3
• Do not use topical decongestant sprays beyond 3-5 days to prevent rhinitis medicamentosa 5
• Do not proceed directly to surgery without a trial of medical management, as intranasal steroids can significantly reduce adenoid size and symptoms 1
• Do not overlook gastroesophageal reflux as a contributing factor, particularly if the child has recurrent pneumonia or feeding difficulties 1