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Tamiya H, Abe M, Nagase T, Mitani A. The Link between Periodontal Disease and Asthma: How Do These Two Diseases Affect Each Other? J Clin Med 2023; 12:6747. [PMID: 37959214 PMCID: PMC10650117 DOI: 10.3390/jcm12216747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/03/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023] Open
Abstract
A growing body of evidence suggests that the effects of poor oral hygiene extend beyond the oral cavity and are associated with a variety of systemic diseases, including asthma. Asthma, which results in symptoms of cough, wheezing, and dyspnoea, and is characterized by airflow limitation with variability and (partial or complete) reversibility, is amongst the most prevalent respiratory diseases with approximately 262 million patients worldwide, and its prevalence and disease burden is on the increase. While asthma can occur at a young age, it can also develop later in life and affects a variety of age groups. Both of these diseases have a chronic course, and various researchers have suggested a link between the two. In this article, we aim to provide a literature review focusing on the association between the two diseases. The results demonstrate that medications (primarily, inhaler medicine), hypoxia induced by asthma, and the breathing behaviour of patients potentially trigger periodontal disease. In contrast, oral periodontopathogenic microorganisms and the inflammatory mediators produced by them may be involved in the onset and/or exacerbation of asthma. Common contributing factors, such as smoking, gastro-oesophageal reflux, and type-2 inflammation, should also be considered when evaluating the relationship between the two diseases.
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Affiliation(s)
- Hiroyuki Tamiya
- Division for Health Service Promotion, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
- The Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masanobu Abe
- Department of Sensory and Motor System Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Takahide Nagase
- The Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akihisa Mitani
- The Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Araújo BCL, de Magalhães Simões S, de Gois-Santos VT, Martins-Filho PRS. Association Between Mouth Breathing and Asthma: a Systematic Review and Meta-analysis. Curr Allergy Asthma Rep 2020; 20:24. [PMID: 32430704 DOI: 10.1007/s11882-020-00921-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This systematic review and meta-analysis evaluated the association between asthma and mouth breathing. We performed a systematic search in the PubMed, SCOPUS, Lilacs, Web of Science, Google Scholar and OpenThesis databases. RECENT FINDINGS Asthma is defined as a heterogeneous disease characterized by variable symptoms of wheezing, shortness of breath, chest oppression and/or cough, and limitation of expiratory airflow. Although several studies have examined the association between asthma and mouth breathing, there are no systematic reviews or meta-analyses that synthesize the available bodies of evidence. We used the odds ratio as a measure of the association between asthma and mouth breathing. Summary estimates were calculated using random-effects models, and the risk of bias was estimated using the Newcastle-Ottawa Scale for case-control studies and the National Institutes of Health tool for cross-sectional studies. Nine studies were included in the present systematic review. Data from 12,147 subjects were analyzed, of which 2083 were children and adolescents and 10,064 were adults. We found an association between mouth breathing and asthma in children and adolescents (OR 2.46, 95% CI 1.78-3.39) and in adults (OR 4.60, 95% CI 1.49-14.20). However, limitations were found in the methodological description of the included studies, as well as high heterogeneity among studies evaluating adult populations. This meta-analysis showed an association between mouth breathing and asthma in children, adolescents and adults, but the results should be interpreted with caution. Further studies with standardized criteria for the investigation of mouth breathing are needed.
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Affiliation(s)
- Brenda Carla Lima Araújo
- Department of Speech Therapy, Federal University of Sergipe, Aracaju, Brazil. .,Postgraduate Program in Health Sciences, Federal University of Sergipe, Rua Cláudio Batista, s/n. Bairro Sanatório, Aracaju, SE, 49060-100, Brazil. .,Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Brazil.
| | - Silvia de Magalhães Simões
- Department of Medicine, Federal University of Sergipe, Aracaju, Brazil.,Postgraduate Program in Health Sciences, Federal University of Sergipe, Rua Cláudio Batista, s/n. Bairro Sanatório, Aracaju, SE, 49060-100, Brazil
| | - Vanessa Tavares de Gois-Santos
- Postgraduate Program in Health Sciences, Federal University of Sergipe, Rua Cláudio Batista, s/n. Bairro Sanatório, Aracaju, SE, 49060-100, Brazil.,Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Brazil
| | - Paulo Ricardo Saquete Martins-Filho
- Postgraduate Program in Health Sciences, Federal University of Sergipe, Rua Cláudio Batista, s/n. Bairro Sanatório, Aracaju, SE, 49060-100, Brazil.,Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Brazil
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Baghban M, Lesan S, Farrokhnia T, Kiani A. Salivary Flow Rate and pH in Asthmatic and Non-Asthmatic Patients. JOURNAL OF RESEARCH IN DENTAL AND MAXILLOFACIAL SCIENCES 2020. [DOI: 10.29252/jrdms.5.1.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Arif AA, Korgaonkar P. The association of childhood asthma with mental health and developmental comorbidities in low-income families. J Asthma 2015; 53:277-81. [PMID: 26365092 DOI: 10.3109/02770903.2015.1089277] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of the study was to determine the relationship of childhood asthma with mental health and developmental indicators in low-income families. METHODS Parents/guardians of approximately 400 children, aged 2-14 years, were recruited from a charity hospital serving low income neighborhoods in the outskirts of Karachi, Pakistan. Mothers of children were interviewed in their local language by a trained nurse. Eight self-reported comorbidities were grouped into two constructs based on factor analysis and conveniently labeled as mental health (anxiety, attention and behavioral problems) and developmental problems (learning, developmental delay, hearing impairment, sleep and speech problems). Data were analyzed using multiple logistic regression, adjusted for age, sex, presence of older siblings, number of people in the household, child birth weight, presence of mold, and family history of asthma or hay fever. RESULTS Children with asthma had 18 times greater odds of mental health problems (adjusted OR = 18.0, 95% CI: 9.2, 35.1) as compared to children without asthma. The odds of developmental problems were more than 14 times greater for children with asthma (adjusted OR = 14.3, 95% CI: 7.8, 26.1) as compared to children without asthma. CONCLUSIONS This study found mental and developmental adverse consequences of childhood asthma in low-income families. Identifying and treating asthma at an early age could reduce the burden of comorbidities in this population.
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Affiliation(s)
- Ahmed A Arif
- a Department of Public Health Sciences , University of North Carolina at Charlotte , Charlotte , NC , USA
| | - Purva Korgaonkar
- a Department of Public Health Sciences , University of North Carolina at Charlotte , Charlotte , NC , USA
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Yamaguchi H, Tada S, Nakanishi Y, Kawaminami S, Shin T, Tabata R, Yuasa S, Shimizu N, Kohno M, Tsuchiya A, Tani K. Association between Mouth Breathing and Atopic Dermatitis in Japanese Children 2-6 years Old: A Population-Based Cross-Sectional Study. PLoS One 2015; 10:e0125916. [PMID: 25915864 PMCID: PMC4411141 DOI: 10.1371/journal.pone.0125916] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/26/2015] [Indexed: 02/06/2023] Open
Abstract
As mouth breathing is associated with asthma and otitis media, it may be associated with other diseases. Therefore, this population-based cross-sectional study evaluated the association of mouth breathing with the prevalences of various diseases in children. Preschool children older than 2 years were included. A questionnaire was given to parents/guardians at 13 nurseries in Tokushima City. There were 468 valid responses (45.2%). We defined a subject as a mouth breather in daytime (MBD) if they had 2 or more positive items among the 3 following items: “breathes with mouth ordinarily,” “mouth is open ordinarily,” and “mouth is open when chewing.” We defined subjects as mouth breathers during sleep (MBS) if they had 2 or more positive items among the following 3 items: “snoring,” “mouth is open during sleeping,” and “mouth is dry when your child gets up.” The prevalences of MBD and MBS were 35.5% and 45.9%, respectively. There were significant associations between MBD and atopic dermatitis (odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.4–4.2), MBS and atopic dermatitis (OR: 2.4, 95% CI: 1.3–4.2), and MBD and asthma (OR: 2.2, 95% CI: 1.2–4.0). After adjusting for history of asthma and allergic rhinitis; family history of atopic dermatitis, asthma, and allergic rhinitis; and nasal congestion; both MBD (OR: 2.6, 95% CI: 1.3–5.4) and MBS (OR: 4.1, 95% CI: 1.8–9.2) were significantly associated with atopic dermatitis. In preschool children older than 2 years, both MBD and MBS may be associated with the onset or development of atopic dermatitis.
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Affiliation(s)
- Harutaka Yamaguchi
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | - Saaya Tada
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | | | | | - Teruki Shin
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | - Ryo Tabata
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | - Shino Yuasa
- Tokushima Prefecture Naruto Hospital, Naruto City, Japan
| | - Nobuhiko Shimizu
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | - Mitsuhiro Kohno
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | - Atsushi Tsuchiya
- Department of Civil and Environmental Studies, Faculty of Integrated Arts and Sciences, The University of Tokushima Graduate School, Tokushima City, Japan
| | - Kenji Tani
- Department of General Medicine, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima City, Japan
- * E-mail:
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Haavisto LE, Lukkarinen M, Lukkarinen H, Jartti T, Papadopoulos NG, Sipilä JI. Physical exercise increases nasal patency in asthmatic and atopic preschool children. Am J Rhinol Allergy 2014; 27:451-6. [PMID: 24274218 DOI: 10.2500/ajra.2013.27.3956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Physical exercise causes a decrease in nasal mucosal congestion and hence an increase in nasal patency. This nasal response has been studied only in adults. A correlation between nasal obstruction and asthma or allergic rhinitis has been previously found. This study evaluates the influences of atopy and asthma on nasal patency and the changes in nasal patency induced by physical exercise in preschool children. METHODS An 8-minute exercise challenge test was conducted in 31 children aged between 4.1 and 6.4 years: 13 children had asthma, 17 were atopic, and 13 had neither asthma nor atopy. Nasal patency was measured with acoustic rhinometry at baseline and 10 minutes after the exercise. RESULTS At baseline, the total acoustic values were 17-25% larger in nonasthmatic children than in asthmatic children. Accordingly, the acoustic values in nonatopic children were 16-35% larger than in atopic children. After physical exercise, there was an overall increase in mean total nasal volume from 2.973 (SD = 0.647) to 3.405 cm(3) (SD = 0.705), indicating an improvement of 15% in nasal volume (p = 0.025). The increase in nasal patency was similar in asthmatic and nonasthmatic children, as well as in atopic and nonatopic children. CONCLUSION A significant increase in total nasal volume after physical exercise was found in all preschool children. The minimal cross-sectional areas remained smaller in asthmatic and atopic children after exercise, indicating partly irreversible nasal mucosal congestion in these children.
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Affiliation(s)
- Lotta E Haavisto
- Department of Otorhinolaryngology, Turku University Hospital, Turku, Finland
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Parker AJ, Yuen HK, Slate EH. Dental care utilization among dentate adults with asthma: findings from the 2008 Behavioral Risk Factor Surveillance System. J Public Health Dent 2012; 72:334-41. [PMID: 22747573 DOI: 10.1111/j.1752-7325.2012.00344.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study investigated dental care service utilization among dentate adults with asthma and identified factors affecting dental care use among this population. METHODS Data from 414,509 adults in the United States who participated in the 2008 Behavioral and Risk Factor Surveillance System were used to estimate the percentage of dentate adults with asthma who had at least one dental visit within the past year. RESULTS The proportion of respondents with asthma who had at least one dental visit within the past year compared with the general population was significantly lower (67.4 percent versus 71.2 percent, P < 0.001 for dental visit for any reason; 64.3 percent versus 69.6 percent, P < 0.001 for dental cleaning). The adjusted odds of a dental visit for any reason within the past year for those with asthma were 0.86 [95% confidence interval (CI), 0.81-0.91], and for dental cleaning 0.82 (95% CI, 0.78-0.87) times that of those without asthma, respectively. Multivariable modeling showed dentate adults with asthma who are male, high school or less educated, unemployed, lower income, current smokers, and have lost more than six teeth were less likely to have a dental visit within the past year. CONCLUSIONS Compared with nonasthmatic individuals, dentate adults with asthma had a lower frequency of dental visits in the past year. Given a higher risk of oral disease among this population, healthcare providers should focus more effort on educating certain subgroups of patients with asthma on the importance of regular dental care.
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Affiliation(s)
- Anthony J Parker
- Division of Biostatistics and Epidemiology, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Haavisto LE, Vahlberg TJ, Sipilä JI. Correlation between acoustic rhinometry and visual analogue scale in children with no nasal symptoms: a prospective cohort study. Clin Otolaryngol 2011; 36:129-33. [PMID: 21401889 DOI: 10.1111/j.1749-4486.2011.02292.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Acoustic rhinometry is an objective tool to evaluate nasal obstruction. The aim of this study was to evaluate the usefulness of visual analogue scale (VAS) as a subjective tool for nasal obstruction and the correlation between acoustic rhinometry and VAS in children with no nasal symptoms. DESIGN Unilateral acoustic values and VAS were measured at baseline and after decongestion of the nose. SETTING Tertiary academic hospital. PARTICIPANTS The study included 124 children aged between 7 and 14 years with no permanent nasal symptoms. RESULTS At baseline, the mean minimal cross-sectional area on the right side was 0.392 cm(2) (sd 0.094), and on the left side 0.360 cm(2) (sd 0.093), whereas the mean VAS on the right side was 7.43 (sd 2.50) and on the left side 6.81 (sd 3.01). After decongestion, the mean minimal cross-sectional area on the right and left sides were 0.421 cm(2) (sd 0.087) and 0.373 cm(2) (sd 0.11), respectively, whereas the mean VAS on the right and left sides were 8.77 (sd 2.02) and 8.54 (sd 2.14), respectively. At baseline, a significant correlation was found between VAS and minimal cross-sectional area, but no correlation was found between VAS and acoustic values after decongestion. CONCLUSIONS We conclude that VAS shows potential as a subjective tool to investigate nasal obstruction in children over 7 years of age. There was a correlation between VAS and acoustic rhinometry in children with no nasal symptoms at baseline. No correlation was found in children with decongested normal nasal airways.
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Affiliation(s)
- L E Haavisto
- Department of Otorhinolaryngology, Turku University Hospital, Turku, Finland.
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Steinsvåg SK. [Nose and lungs--two of a kind]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:1982-4. [PMID: 19823201 DOI: 10.4045/tidsskr.08.0394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Diseases in the upper and lower airways often occur concomitantly, and evidence indicates a close relationship between them. Optimal treatment of airway disease requires knowledge about this relationship; the article presents an updated overview of the field. MATERIAL AND METHODS This paper is based on extensive clinical experience with airway disease, own research and literature studies. RESULTS It is well documented that patients suffering from asthma have rhinitis more often than those without. Likewise, those suffering from nose and sinus disease, e.g. allergic rhinitis, sinusitis and nasal polyposis, have an increased incidence of asthma. Treatment of disorders in one airway compartment often has a positive impact on the airways in general. INTERPRETATION Disorders in the upper and lower airways should be considered as the same disease to a larger extent than they are today. Patients with disease in one airway compartment should be considered for pathology elsewhere in the airways. Therapeutically, the airways should be regarded as one entity.
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Affiliation(s)
- Sverre K Steinsvåg
- Øre-nese-hals-avdelingen, Sørlandet sykehus, 4604 Kristiansand og Øre-nese-hals-avdelingen, Haukeland universitetssykehus, Norway.
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Belli JFC, Chaves TC, de Oliveira AS, Grossi DB. Analysis of body posture in children with mild to moderate asthma. Eur J Pediatr 2009; 168:1207-16. [PMID: 19132386 DOI: 10.1007/s00431-008-0911-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 12/10/2008] [Indexed: 01/03/2023]
Abstract
The mechanical alterations related to the excessive use of accessory respiratory muscles and the mouth breathing observed in children with asthma may lead to the development of alterations in head posture, shoulders, thoracic region and, consequently, in alterations of body posture. The purpose of this study was to assess body posture changes of children with asthma compared to a non-asthmatic control group matched for gender, age, weight, and height. Thirty children with asthma and 30 non-asthmatic children aged 7 to 12 years were enrolled in this study. Digital photographic records were obtained for analysis of the body posture of the children by computed photogrammetry. The intraclass correlation coefficient and Student's t test (p < 0.05) were used for statistical analysis. There were no significant differences between groups for the angles analyzed, except for the knee flexor angle. These results demonstrate that children with asthma did not present postural alterations compared to non-asthmatic controls since the only angle for which there was a significant difference between groups showed weak reproducibility. The findings of this study do not support the notion that children with asthma present alterations in body posture.
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Krumenauer R, Amantéa SL, Lubianca Neto JF, Brasil AP, Reginato R, Padoin AV. Determination of parameters related to nasal inspiratory pressures in children utilizing valved-holding chambers (valved spacers). Int J Pediatr Otorhinolaryngol 2009; 73:451-6. [PMID: 19147235 DOI: 10.1016/j.ijporl.2008.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 11/25/2008] [Accepted: 11/27/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The administration of medication by the nasal route using valved spacers, may be an alternative for the concomitant treatment of allergic rhinitis and asthma. The aim of this study was to determine if children are capable, in using a spacer and face mask, of opening the inspiratory valve using only nasal inhalation. METHODS Prospective cross-sectional. The study included 85 children aged 4-9 years. Four types of valved spacers connected to a digital vacuum manometer were evaluated. The patients were prompted to inhale through their nose and the pressure reached in the first curve, maximal peak and time between the start of the inspiratory action and the first effective inspiration (opening of the valve) were determined. The results were compared with factors such as age, weight, BMI, gender, and presence of rhinitis or asthma. RESULTS In two of the spacers, the valve opened in 98.8% of the tests with nasal inspiration only. The spacer ACE holding chamber showed initial and maximal inspiratory pressures that were significantly greater than with the others (p<0.001). No correlation was observed between the parameters examined for each spacer and the patient variables considered. CONCLUSION The results suggest that children 4-9 years old are able to open the spacer valve with only nasal inspiration. The spacer ACE holding chamber was shown to be significantly more effective than the others tested. Studies that demonstrate that air inspired nasally reaches the lungs effectively are necessary so that this airway can be utilized for the administration of therapeutic agents.
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Affiliation(s)
- Rita Krumenauer
- Department of Otorhinolaryngology, Santo Antonio Children's Hospital, Complexo Hospitalar Santa Casa de Porto Alegre, Brazil.
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Straszek SP, Moeller A, Hall GL, Zhang G, Stick SM, Franklin PJ. Reference values for acoustic rhinometry in children from 4 to 13 years old. ACTA ACUST UNITED AC 2008; 22:285-91. [PMID: 18275635 DOI: 10.2500/ajr.2008.22.3147] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite a growing number of studies using acoustic rhinometry (AR) in children, no reference material exists that incorporates the entire age and height interval of preschool children up to puberty for a range of rhinometric variables. The aim of this study is to provide a reference range for nasal volumes and minimum cross-sectional areas (MCAs) in healthy nondecongested children aged 4-13 years old. METHODS Two hundred fifty-six primary school children (mean, 7.95 years; range, 3.8-13.1 years; 123 boys/133 girls) were measured by AR. Variables were MCA (first, second, and absolute minimum) and nasal volumes from 0 to 4 cm (Vol0-4), 0 to 5 cm (Vol0-5), 1 to 4 cm (Vol1-4), and 2 to 5 cm (Vol2-5) into the nasal cavity. Height and weight were measured and atopic status was determined by skin-prick test. Age and current and past respiratory health were recorded from a questionnaire. RESULTS In multiple linear regression models height was the main predictor for all AR variables although weight also was a significant predictor of MCAs. There was no association between any AR variables with sex, atopy, or hay fever but children with current wheeze (within last 12 months) and asthma had decreased nasal patency. CONCLUSION This article presents the most extensive current reference material for AR in nondecongested prepubescent healthy children. The presented reference material will facilitate the interpretation and evaluation of future and present epidemiologic studies based on AR in children.
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Affiliation(s)
- Sune P Straszek
- Department of Environmental and Occupational Medicine, Institute of Public Health, University of Aarhus, Aarhus, Denmark.
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