Introduction
The objective of this study was to assess changes in respiratory patterns, craniofacial development, and head and neck and overall body posture in children who have undergone early adenoidectomy and those who have not.
Methods
This multidisciplinary study was conducted in collaboration with the Departments of Otolaryngology, Physical Therapy and Rehabilitation, and Orthodontics. Patients diagnosed with adenoid vegetation who did not undergo surgery (group 1: n = 31; mean age 7.90 ± 1.55 years) and those who underwent early surgery (group 2: n = 30; mean age 8.30 ± 1.39 years) were included. The control group (group 3: n = 30; mean age 8.30 ± 1.39 years) consisted of subjects with no pathology causing respiratory obstruction and normal nasal breathing. Lateral and posteroanterior cephalograms, dental casts, the Nasal Obstruction Symptom Evaluation scale, and peak nasal inspiratory flow measurements were used for evaluation. Postural analysis was conducted using 3-dimensional motion analysis with Kinect sensors. Statistical comparisons were performed among groups.
Results
A difference was found among groups in respiratory parameters, and correlation analysis showed that these parameters were consistent with each other ( P <0.05). However, no difference was observed in posture measurements among the groups ( P >0.05). Although statistically significant differences were found among groups in the skeletal, dental, and soft tissue cephalometric parameters, significant correlations were also found between intergonial, interzygomatic distance, and corpus lengths with the respiratory parameters ( P <0.05). Although no significant correlation was observed between the dental cast analysis values and the respiratory parameters, there was a statistically significant difference in intercanine distance among groups ( P <0.05).
Conclusions
Early adenoidectomy improves respiratory and craniofacial growth, resembling normal nasal breathing. Delayed surgery leads to persistent mouth-breathing and negative growth outcomes. Close collaboration between otolaryngologists and orthodontists is essential for optimal management.
Highlights
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Early adenoidectomy enhanced breathing and promoted better craniofacial growth.
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Delayed surgery may be linked to persistent mouth-breathing and altered craniofacial development.
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Skeletal and soft tissue parameters were found to be correlated with respiratory function.
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No statistically significant differences were observed in postural measurements among groups.
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Collaboration of ENT specialists and orthodontists ensures better care.
A properly functioning airway is widely considered important for the balanced growth and development of craniofacial structures. The pharyngeal airway is anatomically divided into 3 regions: the nasopharynx, oropharynx, and laryngopharynx. The nasopharynx serves as the primary route for air inhaled through the nose, and pathologic conditions affecting this region may alter typical respiratory patterns. When airway resistance increases because of anatomic or functional factors such as adenoid hypertrophy, nasal breathing may gradually shift toward oral respiration.
Mouth breathing has been associated with a distinct craniofacial appearance often referred to as “adenoid facies,” which may include a long and narrow face, reduced nostril width, a short and hypotonic upper lip, a hypertrophic lower lip, a high and narrow palatal vault, unilateral or bilateral posterior crossbite, mandibular retrognathia, increased lower anterior facial height, an open-mouth posture, and forward head positioning.
Early diagnosis and management of adenoid hypertrophy are generally recommended, as altered respiratory patterns are thought to influence dentofacial growth and development. Treatment options include pharmacologic therapy and surgical removal of the adenoids (adenoidectomy). However, persistent respiratory dysfunction may continue to present in some patients after adenoidectomy. In such patients, further evaluation by pediatricians may be necessary to identify additional anatomic obstructions. Despite its clinical relevance, there is currently no standardized protocol to assess postoperative respiratory patterns or to facilitate the transition from habitual oral to nasal breathing.
Recent studies have demonstrated that mouth breathing significantly affects craniofacial development, particularly in growing children. Mouth breathing has been associated with various dentofacial alterations, including adenoid facies, a convex facial profile, increased lower facial height, Class II malocclusion, posterior crossbite, and anterior open bite. In addition, it leads to postural adaptations, such as increased craniocervical extension, as a compensatory mechanism to maintain airway patency. A comprehensive narrative review published in 2025, which analyzed studies involving children aged 6-18 years, confirmed that mouth breathing induces not only craniofacial morphologic changes but also significant alterations in mandibular, lingual, and palatal positioning. Although the causal relationship between mouth breathing and malocclusion remains a topic of debate, current evidence supports the view that mouth breathing acts as a significant risk factor in the development and prognosis of malocclusion.
Various tools have been employed to assess head, neck, and overall body posture, ranging from simple posture observation charts to photographic analysis and advanced motion capture systems using segment-dependent passive markers to determine body angles and distances.
Recent studies have shown that the Microsoft Kinect system is capable of generating a 3-dimensional (3D) human body model with accuracy comparable to more expensive and complex scanning technologies. ,
This study aimed to evaluate children presenting with respiratory obstruction because of adenoid hypertrophy. Specifically, comparisons were made among children who underwent early adenoidectomy, those with an indication for surgery that was not performed, and children with normal nasal breathing. The study assessed changes in respiratory patterns, craniofacial morphologic development, head and neck posture, and overall body posture among these groups.
Material and methods
The protocol of this study was approved by the Bezmialem Vakif University Clinical Research Ethics Committee (No. 6/16, March 20, 2019). Informed consent forms were obtained from the families of all the children participating in the study. This study was designed as a retrospective cross-sectional study. Although current clinical and radiographic evaluations were performed at a single time point, patient grouping was based on retrospective data, such as surgical history and the duration elapsed since adenoidectomy.
The patients included in the study groups were selected from patients diagnosed with adenoid vegetations who presented to the Department of Otorhinolaryngology at Bezmialem Vakif University Faculty of Medicine. The control group consists of patients who visited the Departments of Pedodontics and Orthodontics at Bezmialem Vakif University Faculty of Dentistry. Three distinct groups were included in the study. The first group (group 1) consists of patients diagnosed with adenoid hypertrophy who presented at a later stage and were planned for adenoidectomy. The second group (group 2) consists of patients with respiratory obstruction because of adenoid hypertrophy who underwent early surgery and have completed at least 3 years of postoperative follow-up. The patients in this group were retrospectively selected from the archive of the Department of Otorhinolaryngology, and they were invited back by their otolaryngologist for this study. The control group (group 3) consists of subjects with no pathology or systemic disease-causing respiratory obstruction, and who exhibit normal nasal breathing. Participants in the control group (group 3) were selected by an otolaryngologist after a clinical examination by an otorhinolaryngologist that confirmed the absence of any upper airway obstruction. In addition, subjects were required to have a Nasal Obstruction Symptom Evaluation (NOSE) score within the normal range and no respiratory complaints as reported by their parents. These criteria ensured both objective and subjective confirmation of normal nasal breathing among control group participants. The workflow for creating groups is shown in Figure 1 . The patients included in both the study and control groups were aged 6-10 years, with the mean ages of the groups being 7.90 ± 1.55, 8.10 ± 1.47, and 8.30 ± 1.39 for groups 1, 2, and 3, respectively.
The workflow for creating groups.
A power analysis was conducted using gonial ratio measurements from a similar study with G∗Power software (Heinrich Heine University, Düsseldorf, Germany). The analysis revealed that a sample size of 20 patients per group would provide 85% power to detect significant differences, assuming an effect size of 0.4 and a significance level of α = 0.05. To increase the power of the study, 31 subjects (13 females and 18 males) were included in group 1, 30 subjects (13 females and 17 males) in group 2, and 30 subjects (14 females and 16 males) in group 3.
Group 1 (nonsurgical obstruction group) included (1) children aged 6-10 years, (2) diagnosed with respiratory obstruction because of adenoid hypertrophy, (3) exhibiting chronic mouth breathing, (4) no history of adenoidectomy, (5) prepubertal stage according to hand-wrist radiographic analysis, and (6) no systemic diseases or syndromes.
Group 2 (adenoidectomy group) included (1) children aged 6-10 years, (2) a history of adenoidectomy performed between 3-6 years old, at least 3 years postsurgery, (3) a history of chronic mouth breathing before surgery, (4) prepubertal stage according to hand-wrist radiographic analysis, and (5) no systemic diseases or syndromes.
Group 3 (control group) included (1) children aged 6-10 years, (2) no signs of respiratory obstruction, (3) normal nasal breathing pattern, (4) no history of mouth breathing or adenoidectomy, (5) prepubertal stage according to hand-wrist radiographic analysis, and (6) no systemic diseases or syndromes.
Children with a history of previous or ongoing orthodontic treatment (especially slow or rapid maxillary expansion) were excluded from the study to avoid potential influence on craniofacial development. Such patients were not eligible for inclusion in any of the 3 groups. Patients with temporomandibular joint problems, cleft lip or palate, orthodontic bad habits such as thumb or lip sucking, musculoskeletal disorders affecting posture, a history of posture correction treatment, and those undergoing pubertal growth spurts were also excluded.
All participants underwent routine clinical respiratory examination by the same otolaryngologist. The NOSE Scale was used for the clinical examination ( Fig 2 ). This scale consists of 5 questions regarding the respiratory symptoms of the patients. In addition, a visual analog scale (VAS) assessment was performed, in which patients were asked to rate their respiratory quality on a scale from 0 to 10. A value of 0 was considered the “worst,” and a value of 10 the “best.” Subsequently, respiratory patterns were evaluated using the peak nasal inspiratory flow (PNIF) meter, which provides quantitative data on respiration. Patients were instructed to take a sharp breath through their nose while standing in an upright position, and 3 measurements were recorded, with the highest value being noted.
NOSE scale.
After respiratory examination, subjects from all groups were referred to the Department of Physical Medicine and Rehabilitation at Bezmialem Vakif University Faculty of Medicine for posture assessment. The analysis was conducted by the same physician using a 3D motion capture system equipped with Microsoft Kinect sensors. Using these sensors, posture analysis was performed via the “depth camera” on the sensor, without any invasive or harmful procedures for the patients.
The software determines the position and spatial orientation of joints. The Kinect system tracks 25 anatomic reference points on the body, which are shown in Figure 3 . The device is capable of measuring distances between 0.5-4.5 m. Quantitative data on head-neck alignment and overall body posture were obtained from both frontal and lateral views using the Becure software (Becureglobal, Mannheim, Germany), which was integrated with the Kinect system.
Points used in posture analysis.
A comprehensive orthodontic clinical examination was performed on the patients included in the study, and then routine orthodontic radiographic records (panoramic, lateral cephalometric, posteroanterior head x-rays, and hand-wrist x-rays), extraoral-intraoral photographs, and dental casts were obtained. All radiographic records were acquired using the same device (Planmeca ProMax, Helsinki, Finland) and with the same standardized method. All radiographs (lateral cephalometric, posteroanterior, and hand-wrist) were obtained as part of routine orthodontic diagnostic protocols in patients with clear treatment indications. No additional radiographs were acquired solely for research purposes.
All cephalograms were traced and analyzed by the same researcher using the NemoCeph software version 10.4.2 (Software Nemotec, SL, Madrid, Spain). The evaluated measurements are presented in Figure 4 , A – E .
Cephalometric variables: A, 1. SNA (°); 2. SNB (°); 3. ANB (°); 4. Wits analysis, 5; A-NaPerp (mm); 6. Pg-NaPerp (mm); B, 7. Mp-SN (°); 8. FMA (°); 9/10. S-Go/N-Me (°); 11. y-axis (°); 12. Mx-Md (°); C, 14. ANS-Me (mm); 15. Co-A (mm); 16. Co-Gn (mm); 17. S-N (mm); 18. Go-Me (mm); D, 19. U1-SN (°); 20. U1-PP (°); 21. U1-NA (mm); 22. U1-NA (°); 23. U1-OP (°); 25. IMPA (°); 26. L1-NB (mm); 27. L1-NB (°); 28. L1-OP (°); 29. U1-L1 (°); E, 30. Nasolabial angle (°); 31. E-upper lip (mm); 32. E-Lower lip (mm).
Dental impressions were taken from both maxillary and mandibular arches using Lascod Kromopan (Lascod SpA, Florence, Italy) alginate impression material using impression trays, and plaster models were obtained by pouring hard dental stone onto the measurements taken. The measurements on the model were performed by the same researcher for each group using a digital caliper. Maxillary and mandibular intercanine widths were defined as the distance between the cusp tips of the right and left canines, whereas intermolar widths were defined as the distance between the most palatal (maxillary) and lingual (mandibular) gingival points on the right and left first molars.
Statistical analysis
The data were analyzed using the SPSS software (version 27; IBM, Armonk, NY). Intraexaminer reliability was assessed by reevaluating 5 randomly selected lateral cephalometric radiographs from each group after a 4-week interval. Bland-Altman plots and the intraclass correlation coefficient (ICC) were used to assess agreement and determine the reliability of the measurements. The normality of data distribution was tested using the Shapiro-Wilk test. For group comparisons, independent samples t test, 1-way analysis of variance, and Kruskal-Wallis tests with Bonferroni-adjusted post hoc analyses were employed. P <0.05 was considered statistically significant.
Results
The comparison of demographic characteristics of participants across the study groups is presented in Table I . The results of the ICC analysis conducted to assess intraexaminer reliability indicated a high level of agreement between the repeated measurements, with a mean ICC value of 0.93.
Table I
Comparison of demographic data among groups
| Variables | Group 1 | Group 2 | Group 3 | P value | |||
|---|---|---|---|---|---|---|---|
| Min/Max, n | Median, % | Min/Max, n | Median, % | Min/Max, n | Median, % | ||
| Age, y | 6-10 | 8 | 6-10 | 8 | 6.5-10 | 8 | 0.57 |
| Gender | 0.71 | ||||||
| Female | 13 | 41.9 | 13 | 43.3 | 14 | 46.7 | |
| Male | 18 | 58.1 | 17 | 56.7 | 16 | 53.3 | |
Note. Chi-square test was used for gender, whereas Kruskal-Wallis test with Bonferroni correction was applied for age.
Min , minimum; Max , maximum.
Statistically significant difference was observed between groups 1 and 2, as well as between groups 1 and 3 across all parameters of the NOSE scale, PNIF measurements, and VAS evaluation ( P <0.05; Table II ). Correlation analysis revealed a significant negative correlation between the NOSE scale and PNIF and VAS scores. In contrast, a significant positive correlation was identified between PNIF and VAS scores ( P <0.05; Table III ).
Table II
Comparison of the respiratory parameters among groups
| Group 1 | Group 2 | Group 3 | Post-hoc | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Min | Max | Median | Min | Max | Median | Min | Max | Median | P value | 1-2 | 1-3 | 2-3 | |
| Q1 | 0 | 3 | 2 | 0 | 3 | 4.5 | 0 | 2 | 1 | <0.001∗ | <0.001 | <0.001 | NS |
| Q2 | 1 | 4 | 3 | 0 | 4 | 1 | 0 | 2 | 1 | <0.001∗ | <0.001 | <0.001 | NS |
| Q3 | 0 | 4 | 3 | 0 | 4 | 0 | 0 | 3 | 0 | <0.001∗ | <0.001 | <0.001 | NS |
| Q4 | 0 | 4 | 2 | 0 | 4 | 1 | 0 | 3 | 0 | <0.001∗ | 0.009 | <0.001 | NS |
| Q5 | 0 | 4 | 2 | 0 | 3 | 1 | 0 | 3 | 0 | <0.001∗ | 0.002 | 0.01 | NS |
| Total | 4 | 19 | 11 | 0 | 17 | 4 | 0 | 10 | 2.5 | <0.001∗ | <0.001 | <0.001 | NS |
| VAS | 1 | 9 | 4 | 1 | 9 | 8 | 0 | 10 | 8 | <0.001∗ | <0.001 | <0.001 | NS |
| PNIF | 30 | 65 | 45 | 40 | 100 | 65 | 45 | 80 | 60 | <0.001∗ | <0.001 | <0.001 | NS |
Note. Kruskal-Wallis test with Bonferroni correction was used for statistical analysis. The asterisk indicates statistical significance.
Q , question; Total, the total sum of the scores given to the questions; Min , minimum; Max , maximum; NS , not significant.
Table III
Correlation analysis among respiratory patterns and dental, skeletal parameters, and posture
| Variables | NOSE scale | PNIF | VAS | |||
|---|---|---|---|---|---|---|
| r | P value | r | P value | r | P value | |
| SNA (°) | 0.245 | 0.040∗ | −0.322 | 0.008∗ | −0.304 | 0.010∗ |
| SNB (°) | 0.169 | 0.170 | −0.228 | 0.040∗ | −0.181 | 0.140 |
| ANB (°) | 0.264 | 0.010∗ | −0.187 | 0.070 | −0.283 | 0.006∗ |
| Witts (mm) | −0.110 | 0.380 | −0.03 | 0.790 | −0.020 | 0.840 |
| PP-SN (°) | −0.328 | 0.007∗ | 0.379 | 0.002∗ | 0.318 | 0.009∗ |
| y-axis (°) | 0.253 | 0.016∗ | −0.216 | 0.004∗ | −0.205 | 0.045∗ |
| Anterior facial height | 0.035 | 0.780 | 0.139 | 0.260 | 0.070 | 0.540 |
| Posterior facial height | −0.166 | 0.117 | 0.201 | 0.056 | 0.201 | 0.227 |
| Facial height (%) | −0.090 | 0.460 | −0.029 | 0.810 | −0.009 | 0.940 |
| FMA (°) | 0.287 | 0.006∗ | −0.195 | 0.044∗ | −0.227 | 0.031 |
| Anterior cranial base | 0.200 | 0.090 | −0.140 | 0.250 | 0.030 | 0.790 |
| Go-Me (mm) | −0.030 | 0.750 | 0.070 | 0.550 | 0.002 | 0.980 |
| U1-SN (°) | −0.140 | 0.240 | 0.100 | 0.410 | 0.110 | 0.350 |
| IMPA (°) | −0.150 | 0.210 | 0.120 | 0.300 | 0.120 | 0.330 |
| L1-NB (°) | 0.080 | 0.500 | −0.020 | 0.850 | −0.110 | 0.370 |
| U1-L1 (°) | 0.004 | 0.970 | −0.070 | 0.550 | −0.030 | 0.800 |
| Nasolabial angle (°) | −0.010 | 0.930 | −0.040 | 0.730 | −0.090 | 0.450 |
| Upper lip (mm) | 0.307 | 0.003 | −0.259 | 0.013∗ | −0.368 | <0.001∗ |
| Lower lip (mm) | 0.161 | 0.128 | −0.236 | 0.054 | −0.156 | 0.140 |
| Overjet (mm) | −0.010 | 0.920 | −0.040 | 0.730 | 0.160 | 0.770 |
| Overbite (mm) | −0.060 | 0.610 | −0.090 | 0.460 | 0.010 | 0.990 |
| Intergonial distance | −0.249∗ | 0.010∗ | 0.300∗ | 0.004∗ | 0.177 | 0.093 |
| Interjugular distance | 0.035 | 0.780 | −0.040 | 0.750 | 0.006 | 0.960 |
| Interzygomatic distance | −0.123 | 0.244 | 0.296∗ | 0.004∗ | 0.070 | 0.508 |
| Right ramus length | −0.067 | 0.526 | 0.028 | 0.790 | 0.088 | 0.404 |
| Left ramus length | 0.039 | 0.712 | 0.075 | 0.479 | 0.043 | 0.688 |
| Right corpus length | −0.165 | 0.118 | 0.235∗ | 0.025∗ | 0.292 | 0.005∗ |
| Left corpus length | −0.129 | 0.110 | 0.311∗ | 0.003∗ | 0.216∗ | 0.039∗ |
| UR6-UL6 (mm) | 0.020 | 0.860 | 0.130 | 0.290 | 0.030 | 0.770 |
| LR6-LL6 (mm) | −0.030 | 0.980 | −0.020 | 0.590 | −0.020 | 0.820 |
| UR3-UL3 (mm) | −0.010 | 0.870 | 0.150 | 0.220 | 0.170 | 0.150 |
| LR3-LL3 (mm) | −0.010 | 0.990 | 0.140 | 0.250 | 0.010 | 0.920 |
| A-head (°) | 0.020 | 0.810 | −0.120 | 0.330 | −0.090 | 0.450 |
| A-shoulder (°) | 0.030 | 0.780 | −0.040 | 0.750 | 0.006 | 0.960 |
| A-Pelvis (°) | 0.020 | 0.860 | 0.130 | 0.290 | 0.030 | 0.770 |
| R-head (°) | 0.110 | 0.340 | −0.020 | 0.590 | −0.020 | 0.820 |
| R-shoulder (°) | −0.200 | 0.100 | 0.170 | 0.150 | 0.120 | 0.300 |
| R-pelvis (°) | −0.080 | 0.500 | 0.080 | 0.510 | −0.010 | 0.930 |
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