Episode 171 : Breathing Shouldn’t be Audible with Hallie Bulkin, MA, CCC-SLP, CMT, COM, QOM

Hi and welcome to episode 171 of the Untethered Podcast. Today it's your host Hallie Balkan joining you and we are going to spend some time chatting about the symptoms of orofacial myofunctional disorders. We are going to continue into a series of episodes on various symptoms and today we are starting with breathing and how it should never be audible, we should never hear breathing, snoring is not normal. And and while these things may be common, again, they are not normal. So the other thing I want to mention is if you're an SLP and ot, rdh, PT or DDS dentist of some sort, dental provider, please go to the myomembership.com and hop on our list, our wait list, because we're going to open the doors soon and we want you to know when doors open. We don't want you to miss out. So again, go to the myomembership.com doors are opening soon and let's get started. Quick disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Hey everybody and welcome to this series that we're going to be doing on symptoms of orofacial myofunctional disorders. The first one that I want to talk about today is mouth breathing, audible breathing, being able to hear air enter and exit your body. We should not typically hear breathing if we are nasal breathing. Breathing should be quiet or silent. And it's so interesting and I'm going to get into all kinds of details on this, but it's so interesting because when we have a child or an adult, even a patient, who goes from mouth breathing, snoring, audible breathing, to not doing that, we actually have parents call us and tell us, oh my gosh, I was so freaked out. Or even a spouse, right? Or a significant other say I was so freaked out because the child, the adult, the person, I couldn't hear them. I was like getting really close to them to see if their chest was raising up and going back down. Like, were they actually breathing because they were so used to hearing not just audible breathing, but sometimes snoring. And so the reason why I want to spend an entire episode talking about audible breathing and mouth breathing, it can be audible whether it's coming from your nose or your mouth, but we're going to focus on both. If you're nasal breathing and it's audible, there's still probably an obstruction at play or enlarged inflamed tissues. We have to look at what's going on in the nasal cavity. I've talked recently about my procedures that I had done to allow for proper nasal breathing. And so there'll be a bigger focus on like mouth breathing and you know, why we don't want to be doing that and what we can do instead. But I want to highlight what we typically see in mouth breathing. Right. We typically see, obviously the lips are apart. The tongue often sits low in the mouth and forward. We often have a deficient maxilla or mid face region, meaning that it did not grow to the way it should have because our tongue is supposed to act as a expander. It's supposed to hold and it's form and hold the shape of our upper palate, and that helps to direct the lower palate and the growth of the lower palate as well. And when that doesn't happen and we have a narrow palate or a high palate or a high and narrow palate, our tongue doesn't fit up there. That's what leads to it sitting lower in the mouth and oftentimes forward, sometimes against the teeth, between the teeth, between the lips. Right. So and we see this in children and adults. This contributes to other orofacial dysfunction. Right. And that is a lot of what we're going to talk about. That's what we talk about actually a lot on the podcast in general. I talk about this in my courses, but this goes on to. It stimulates vertical growth. Right. We get this like longer, more narrow face instead of a brighter, wider smile and jaws. And the other issue is that when we're not using our nose. Right. We've talked about this in the past too. When we're using our mouth, our mouth does not filter air and that leads to the additional obstruction sometimes of enlarged tonsils and or adenoids, amongst other issues as well. So, you know, there are a whole bunch of other symptoms of mouth breathing. But what I really want to focus on is why what happens and why we're mouth Breathing and what we can do to work towards eliminating this habit. Right. And if you're just like, I don't want to listen to this whole thing, I just want to know who can help me. You want a myofunctional therapist. You want somebody who is trained in orofacial myofunctional disorders. You want somebody who, you know, if you also have eating and, or speech concerns, and that person will probably, if it's speech will definitely be an SLP trained in myo. If it's potentially feeding, it could be an SLP or an OT trained in myo. If they're just general, like mouth breathing, breathing concerns, you're like, my feeding is fine. My, you know, my speech is fine. Then an SLP and OT, an RDH, a dentist, any one of those individuals. And sometimes PTs may be trained in this as well. Any of those individuals are. It's within their scope to address orofacial myofunctional disorders. And so you would want to seek one of them out. Now, let's talk about what leads to this. Right? Like, why does this even happen? Well, we mentioned development. So in utero, we develop our swallow by 12.5 weeks, like right after the end of the first trimester. We basically are now swallowing utero the way that we're going to swallow for life. You know, that's a swallow we're going to be born with unless something else changes. And then basically, like I said, it's a swallow we have for life unless something interferes, either positive or negative. Right. It could be orthodontia, it could be other things. The point is we need to be looking at this at birth. We need to be addressing what does the palate look like? What does the mouth look like? Are the lips together? Where does the tongue sit in the mouth? These are important things to address because our health is everything and breathing is life. If we cannot breathe, we basically need to be hooked up to machines to live. It boggles my mind why the most important, number one critical factor to our being is not addressed. It's not screened for at birth. Yes, we look to see, okay, is the baby blue and there's the APGAR score and everything. But we're not truly doing an airway evaluation and that needs to change. Number one, that's a whole other podcast episode. But why do we need to look at this? Well, when we hear audible breathing, when we hear snoring, because audible breathing may not be snoring. It may just be loud breathing or breathing that we can hear when that's happening. There is highly likely a sleep disorder at play. This could be interfering with the body's ability to sleep and get proper restorative sleep. But it's not just a matter of how long we sleep or know, okay, we went to bed at 8 and we woke up at 8. The kid got 12 hours of sleep. No. Well, what was the quality of that sleep? And I have some really great podcast episodes with Ken Hooks that we have reported talking about quality of sleep. In fact, he. The last time we recorded together, he went over my. My home sleep test results where we died. He diagnosed me with upper airway resistive syndrome, uars. And we talk about how maybe traditional sleep studies would have missed this. And it would have been said that I was fine, except for what actually happened was I didn't have a ton of apneic moments. I maybe had a couple during the entire night. What happened for me was every single time I went into REM sleep, that deep restorative sleep, my body was like, nope. And it threw me awake, right? But I'm not waking. I'm actually not waking up. I'm not cognizant of the fact that this is happening. It's sending me back up into a lighter sleep level. So I'm not officially waking up, but I am then kind of falling back down into a deeper level of sleep and then waking up again, or at least coming to a higher level of arousal, not necessarily fully awake. Had no idea this was going on until he reviewed the raw data from my home sleep test. So we have to look at this because there's a greater incidence of sleep disorders of snoring, of audible breathing, sleep apnea. And I will tell you, this puts our body in a constant state of stress and our nervous system cannot regulate itself, which is one of the things that we should be able to do when sleeping, but we can't if our sleep is impaired. And so our quality of sleep here is decreasing. That's the bottom line, which is a problem. This leads to all kinds of behaviors which we're going to talk about. I'm going to talk about that in the next podcast episode. But we see, you know, we see like kids getting. And adults getting diagnosed with adhd. They have this ADHD like, presentation. They have inattention, lower productivity, brain fog, fatigue. You know, they don't feel rested upon waking. This is a problem. There's so many people in our society these days walking around with their heads in a cloud, like, literally because of all the brain fog, and they're just Being told, oh, you have adult adhd? Well, maybe they do, but has anybody actually tested their sleep first? And what about the kids before we medicate them, are we sitting down and going, hey, has anybody looked in your mouth? Have you had a myo eval or a feeding eval or oral motor, you know, sensory, oral motor eval based on whatever the symptoms are that are presenting? Right. Great. We, you know, you were tested for ADHD and you appear to qualify. But before moving forward with either a learning disability label or an ADHD label, and I'm not anti label, I have adhd, probably a result of my, of my sleep disordered breathing that I've had my entire life, that I didn't always know about until, you know, sometime in the past decade that we've been working on actively for a while now. Right. The bottom line is that people, adults, adults, parents don't know to ask about this. So we as providers need to be asking these questions. We need to be asking whether it is a pediatrician, a dentist, an ent, an orthodontist, speech pathologist, ot, pt, rdh, you know, especially those of us who spend a lot of time in with people already in our therapy rooms, our offices are, you know, in a chair in front of us. If you're an RDH or you're an SLP or OT already working with these, these patients, we need to be asking these questions. It should absolutely be part of an intake, it should be part of an evaluation, it should be an ongoing discussion, especially if we have concerns, you know, as we're going through the dynamic treatment process. And so we need to be looking at why do we present this way? Right. Medication is just slapping a band aid on the issue. We're not addressing the root cause. And is there a such thing as adhd? Is it real? Yes. Nobody is doubting that, but I doubt that a large number of children and adults who've been put on these medications truly have like actual adhd, like a chemical. It is a chemical initiative with chemical balance in your brain. I'm saying the wrong terminology, but bear with me here. It has to do oftentimes with the frontal cortex. And I've done a lot of research on this because of getting the diagnosis myself. And you know, we're basically saying that there's interference with development of the brain by diagnosing individuals with adhd. And look, there's nothing wrong with that because there are some phenomenal people who are, you know, really creative and really successful. And we see that ADHD can actually be a Superpower, right? It's not something to be discarded and thrown away or something negative like, I embrace my adhd. I love it. It's who I am. However, before we just go around diagnosing and medicating, it's the medication I take issue with. Before we go around diagnosing and medicating, children especially, we have to be looking at their sleep. We have to be looking at their oral rest, posture. Where are their lips at rest? Where's their tongue? Are they breathing through their nose or their mouth? Are their teeth together or apart? What do their jaws look like? Do they come together normally? Are they wide enough? Do they sit far enough forward or are they retruded? Are they sitting back? These are all things that impair our airway and in turn can cause ADHD like behavior. We have to be looking at the whole child, the whole adult, the whole person to figure out what do they actually present with. Okay, so off that soapbox, there's just a much greater incidence of sleep disorders and also a big, you know, a big uptick in ADHD diagnosis and medications. So it's something I feel very passionately about. But what I. The other thing I want you to understand is that in severe cases of like, sleep apnea, right. Obstructive sleep apnea, research shows that there is a 10 to 16 point drop in, in IQ for children with chronic obstructive sleep apnea compared to their same age peers. Okay. There's. There's some other numbers too that I will see if I can pull up what we're recording right now that I want to share. But what we see in a lot of these kids also, even at a young age is these, like, classic, like head and neck forward posture as the body kind of rolls forward at the shoulders. Because we're trying to stay alive, it's our body putting us into a position where we can breathe more easily. Our body is always going to compensate to maximize our airway or what our airway is not doing to make it easier for us to breathe if our airway is not maximized and we cannot nasal breathe. What I'm saying is the body compensates. It figures out another way to make it happen. Might seem cool that our body's super smart and can compensate like this, but. But it's really not cool because it's creating a lot of negative impact and taking a major toll on our body as a whole. Okay, so those are some things to think about when it comes to audible breathing. If you hear audible breathing, we should be looking at okay, is this patient mouth breathing or nasal breathing? Okay, they're nasal breathing, but I can hear it. Are they congested? Do they have a cold? Are there allergies at play? There could be a number of things going on that we might need to rule out. You know, when you get a cold and your nose is all stuffed up, you now become a obligatory mouth breather. Like, you have to breathe through your mouth because your nose is clogged. Like, you don't have another choice. Now, imagine living like that 100% of the time, and you don't necessarily hear people complain about it because it's what they know that's what's normal for them. But that doesn't mean that it's healthy. Right. And it doesn't really mean it's normal compared to what should actually be happening. Right. It may be common, but it's not normal. That's another thing we say a lot, and in some of these more recent episodes, it's common but not normal. It's not functional. It's not where we want you to be for optimal health. It's not giving you the best lease on life to be able to go out and live your day. And I don't mean skydive and climb large mountains. I just mean go to work, make food for your family, take a shower, do the daily activities that you need to do to get through the day and feel like you still have energy and you're not completely zonked out a quarter of the way through the day or halfway through the day or, you know, by 3pm Right. Meaning that 3pm pick me up. There's people who need it, there's people who don't. Let's look at airways and figure out if that has something to do with it. Right. I talked recently about my nasal surgery. And so for me, I had enlarged turbinates and I had enlarged adenoids. Right. And so increased snoring oftentimes may be the result of something like enlarged nasal turbinates. And then those of us who have enlarged nasal turbinates may also be at an increased risk for frequent sinus infections, chronic sinusitis, things like that. Right. We also might find that we might sneeze more often than normal. We might feel like we can have a congested nose. Sometimes it's more on one side or one part of the nose that compared to another as well. Those of us with enlarged nasal turbinates are prone to mouth breathing more often than snoring. It all makes sense. It all comes together here. And then Headaches, fatigue. I mentioned the chronic sinus infections. These are all symptoms of enlarged turbinates. We may even see some nasal swelling outside of our nose because of how enlarged the turbinates are. A lot of us have. Not a lot. I'm in a community of individuals who address this. So a number of us have had knees, you know, we've had our terminus reduced or we've had a turbinate reduction. Right. And it can change how you breathe drastically if it's creating a blockage in your nasal passages. So when we say that mouth breathing issues cause inflammation, this is what I'm talking about. You may be able to see it externally, you may not be able to, but oftentimes you can't see it internally until you either look up the nose or somebody scopes, you know, sends a little camera up your nose or shines a light up your nose, like if you're at the ent, for example. But we need to also just look at, like, the face for inflammation because that may also point us towards an airway issue. And again, this is something that you can, you can go and have an orofacial myofunctional evaluation. If you're under 4, that's usually a feeding eval. If you're over 4, you can do a traditional myo eval, and that's going to point you in the right direction of maybe what's going on and. Or what other professionals you need to see to address audible breathing, snoring, sleep apnea and the light and the, you know, and so on and so forth. So there are also adenoids and tonsils, and we've talked about these in the past as well. Like, if our adenoids are enlarged, then again, we may not be able to breathe through our nose, depending on how enlarged they are. And we have symptoms like we've talked about, but we can. We often see like this. We call it venous pooling or bags under the eyes. Eyes look really fatigued. That is a symptom of enlarged adenoids and. Or we call these allergic shiners. It could be allergies that are causing the adenoids to become enlarged and. Or the tonsils to become enlarged. So these are things, again, that we want to rule out. And that's part of what a myofunctional therapist is going to help address with you. I've had this issue with my own kids. Lily had really enlarged tonsils. She, we had an appliance, we expanded. Her tonsils shrunk. Now, I was told by the myo community to Withdraw that comment. I posted it in the Facebook group asking if other people had seen this, because there was three months of expansion that happened with the ALF appliance during cold and flu season. Her tonsils were. Were like a three plus, like, almost touching. They didn't look super healthy. And I saw them shrink down. They were almost hidden behind her tonsillar pillars. Like, I almost couldn't see. See, I mean, they weren't there anymore. Her airway was. Was open. It was amazing. And so I posted in this group, basically saying, hey, this is a group with like, you know, thousands of myofunctional therapists and other related professionals that, you know, are active. And the group moderator basically messaged me and said, take that down. Like, you're like, basically telling me it was impossible that expansion that expanding skeletally could impact soft tissue. And I was like, I think it's all connected. But hey, you know, there's no research to, you know, support this right now, so, sure, whatever. I'll take it down because I just don't want the drama. But now we're seeing this more and more, and there's an interesting case study that's been under review that saw a 43% reduction in tonsil size with skeletal expansion in a child. So we are seeing this clinically. This is when we open that airway and we make it so that the individual can breathe properly. That helps the soft tissue inflammation reduce. We are seeing this. It's very exciting. All right, so let's talk about, you know, I mentioned before the whole long face thing with the mouth breathing and another reason why we don't necessarily want to mouth breathe, but something as simple as an allergy can lead to enlarged tissues, as we've been talking about, and then cause the face to become kind of long and narrow. There's this abnormal facial growth that help. That happens in dental malocclusion, right, where our jaws are not sitting together, they're not wide enough, our jaws are not coming together properly, there's not enough room for the teeth or the tongue. There could be a whole host of things going on. So what I want to also add is that a lot of people with tethered oral tissues also default to mouth breathing due to that low resting tongue posture and the inability to successfully nasal breathe for whatever reason. We've covered some of the reasons, right. Some of the issues that may be leading to inflamed tissues or nasal blockages and so on and so forth. Unfortunately, if it's so severe that your dentition is working against you, you may end up, if you don't already have, if you don't have this issue, it can become so severe that, like your upper teeth impinge or rest on the lower lip, and then you don't actually have the ability to keep your lips closed at rest. I've had kids where this is, this is an issue. Had adults with this too, but more, more children. And this can lead to other compensations. Obviously it does lead to other compensations, but the point is we have to be looking at the physical ability of the patient. What can they actually do? Based on their current skeletal structure, their current anatomy? We're seeing this in three year olds. In really severe cases. It's happening younger and younger, especially in cases of obstructive sleep apnea. It's something to be aware of. People like to reference photos of Napoleon Dynamite because he's got the lips apart and even though his teeth look like they sit together, his, his face is long and narrow. He has those allergic shiners or those eyes. He just looks like he's got allergies, like he might not sleep enough. He looks tired. This is what we're talking about when we talk about a longer face. Hopefully that helps explain what I was talking about a little bit more there. The other thing I want to mention, because I'd mentioned allergies before and mouth breathing, we need to rule out allergies. All it takes is a major allergen in the home to cause inflammation and to lead to everything. I'm explaining you could have the most beautiful anatomy and a severe allergy to something could lead to these types of issues that we're talking about. Okay. So it's really important to make sure that one, you can breathe through your nose, that you don't have an actual physical blockage, enlarged tissues, or something skeletal like a deviated septum, and two, are there any allergies? Right. So the other thing that I want to point out is that these changes in appearance can lead to emotional issues for our children. For teens and adults too. Right. I've had children come to me who are really embarrassed about their teeth. They are so embarrassed they will not speak or eat around other people outside of their home, even their own family members, they may go hide in their bedroom to eat, and the parent allows it because they need the child to eat. If we consider the fact that we are dealing with humans, and this is really a message to all the professionals listening who may have very specific feelings about their appearance. On top of airway issues that are impacting their sleep Their school performance, which we're going to talk about in the next episode, putting them into fight or flight instead of rest and digest. We talked about earlier about how the nervous system is not going to be able to regulate itself. They're going to be in this constant state of fight or flight. We have a potential mental health crisis on our hands. Think about how many children could be experiencing this and adults and how many lives can be changed. If we start looking in the mouth, we start early expansion or just expansion, skeletal expansion in general, plus MYO and other related supported therapies. Professionals based on the case. Right. So this is what happens over time, right? We can go from having that cute little baby with a tiny little open mouth to having an adult with a whole host of symptoms and issues. And that's the problem. We need to be addressing this earlier and earlier. If nothing is done, you're going to develop into that chronic mouth breather profile. And you know, even if at the age of 10, you still look great, that long and narrow face can develop by age 17. Right. With a receded chin or mandible, your lower jaw, that forward head posture, a shorter upper lip, changes in the nose over time. This is what we want to avoid and why we want to assess as soon as possible, even at birth. So with that, I want to circle back on the whole reason why we are focusing on airway and sleeping and breathing is because we should not hear somebody breathe, especially awake or asleep, which is basically 100% of the time. If you hear, that's a problem. If you hear snoring, that's a problem. If you hear any noise, right, that's a problem. So we really need to be looking at why do we hear something? Let's have an assessment. The snoring is never normal. I know, we think it's cute. It's become normalized. It's become like normalized in movies and TV shows. And you know, a lot of professionals in the medical space don't know, nor don't know that snoring is not normal. And they hear their children snoring and they're like, yeah, but that means everybody snores. No, no, no, they don't. Right. We should not hear a child or an adult breathe when awake or asleep. Breathing should always be silent. Okay? So let's keep that in mind and remember, and if it's an issue, I want you to seek an evaluation with an orofacial myofunctional therapist. As I mentioned, if you have trouble finding somebody in your area, you can always Message me on Instagram at Hallie Balkan. Because we need to be looking at what is going on, right? What are the symptoms? And when I say what's going on, I mean, like, what's going on inside the mouth? Does the tongue fit in there? Is the palate big enough to fit the tongue? Is there a tongue tie restricting the tongue? Is it holding it to the floor of the mouth? Is the tongue going, you know, low and forward because of that? Like, what is going on on? We have to look at this because there are a lot of side effects of sleep apnea. And in adults, by the time you get to adulthood, you could, like I mentioned, brain fog. There could be anxiety, depression, arrhythmia, high blood pressure, congestive heart failure, type 2 diabetes, impotence, obesity, low blood oxygen levels, stroke. Like, there are a number of things that can happen in sleep apnea, and we do not want to see this, but we are sleeping, seeing sleep apnea in both children and adults. So it's really important that we take this seriously and that we realize that we need to work with a team who knows what they're doing and can truly help us because research shows. And this is going to take us into our next episode. But research shows that children with sleep disorder breathing symptoms score significantly lower than those without sleep disorder breathing symptoms on tested executive function. So we have to be looking at our PEDs, our pediatrics. How are they doing in school? What are they. I'm going to wrap this up because I don't want to go. I want to save this for the next episode. But what's going on and what is pointing us to the fact that there is a problem, even though we are not really quite sure how to solve that? Seek out a myofunctional therapist. Google myofunctional therapist in my area. Or you can look up, like, SLP and OT practices, for example, and see if they do myofunctional therapy. You can look up dent. It's harder to find it in a dentist office right now, but you can look up our, you know, RDHs, dentists, myofunctional therapy, SLPs, OTs, malfunctional therapy. You know, just type in these different keywords and see what pops up in your area. And like I said, if you can't find anybody, please reach out at Hallie Balkan on Instagram and I would be happy to try and connect you with somebody because I do have a lot of resources and colleagues in this space. So we're going to continue the conversation on snoring, but talk about the impact on neurocognitive function in the next episode, so join me there. Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com forward/the untethered podcast if you found value others you know this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page at Halle Balkanbiz, on Instagram at Alibulin. And you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes, where you can also subscribe to be kept up to date on the latest podcast episodes.