Introduction to Vincent James' Health Journey 

We often have the most learning when it comes from our personal experiences and such is the case of my recent health journey with my son, Vincent James. He has struggled with snoring since infancy and in the past year with some focus and attention issues, that lead me to pursue a sleep study for him, which confirmed mild sleep apnea. Sleep apnea is known to be a factor in systemic health including neurobehavioral issues, which only makes sense sleep is so important for rejuvenation our body and mind. We were recommended by his ear-nose and throat doctor to do a 3-month trial with a nasal steroid, fluticasone (aka Flonase) and montelukast (aka Singular) and advised of the possible side-effects and additionally advised to seek consult with an allergist and if no improvements in 3 months to follow for a surgical consult to remove his adenoids and tonsils.

For children with obstructive sleep apnea (OSA) featuring adenoid and tonsillar enlargement (ie adenotonsillar hyperplasia) and no surgical contraindications, the primary recommendation is adenotonsillectomy—a surgical procedure to remove enlarged adenoids and tonsils. This stands as the frontline treatment for OSA, as per the American Academy of Pediatrics (AAP 2012), despite only one randomized controlled trial (RCT) confirming its benefits over watchful waiting (4). Given the research findings of the past several years, it is bananas to me that surgery in mild cases like my sons, is still being recommended when there are other, less invasive, relatively safer, and extremely effective options that could be trialed first!

Conventional Recommendations and Skepticism 

This common journey I navigate so often with my patients, I now found myself in as a parent. The main cause of disordered breathing, including sleep apnea, is enlarged adenoids which sit behind the nasal cavity in the back roof of the mouth and enlarged tonsils which are in the back of the mouth on both sides of the throat. These swollen tissues are blocking the flow of air toward the lungs causing snoring. In medicine, but especially in naturopathic medicine, we are always considering what the root causes of an issue are so that we can endeavor to correct this, using least invasive methods as a first line approach whenever possible. This is what draws many of my patients to me as a naturopathic doctor, they are seeking solutions that will address the underlying root causes of their health concern. As a parent, I was also wanting the same approach for my son, and like many patients rightly skeptical of the first line of conventional treatment offered to my him, given that neither medication typically offers lasting improvements after being discontinued and both have concerning side-effect risks with long-term use. I took off my parent hat for a moment and considered how I might be able to help better from a naturopathic approach. My first course of action was to review all possible triggers for his enlarged adenoids. 

Root Causes of Enlarged Adenoids: A Naturopathic Perspective 

1. Bacterial biofilms. Yes, ALL of our mucosal tissues, including adenoids and tonsils carry bacteria and just like the bacteria in our guts, the bacteria in these tissues can become overgrown and coated in an unfavorable bacteria profile known as biofilms that are associated with more severe inflammation and irritation. Yes, we can develop dysbiosis of our adenoids and tonsils and this will drive chronic sinus congestion as well. While not commonly considered (yet) conventionally, my hunch was that for a variety of reasons, not limited to social exposures and diet, this was a main cause for Vincent James. As a 2021 study is so aptly titled puts it, When a Neonate is Born, So Is a Microbiota. Seeding of bacteria that is vital for the health of mucosal immune tissues starts at birth and the timing of Vincent James’ snoring since infancy and other issues on my end (ie group B vaginal strep colonization) pointed me towards bacterial biofilms as a likely factor. We do have new fancy PCR DNA nasal swab tests that can help to explore this issue, which we did not pursue, mainly because any findings most likely would not have changed the ultimate approach which we came to.
2. Infections. Of course, frequent or chronic infections, such as bacterial or viral infections, can lead to inflammation and enlargement of the adenoids and tonsils. Common infections include streptococcal bacteria (strep throat) and viruses like the Epstein-Barr virus. Vincent James had one episode of strep throat this past spring, but his snoring proceeded this, but I am certain that this episode did contribute to even more inflammation, as his snoring worsened after this.
3. Allergies: Allergic reactions to environmental factors like pollen, dust, or pet dander can cause chronic inflammation in the adenoids and tonsils, leading to enlargement. After months of waiting to get into see the allergist, yesterday, Vincent James had labs drawn for respiratory allergies and we are awaiting the results to see if this might be a factor. He outgrew a few food allergies to dairy and stone fruits, so he no longer has any obvious immediate response allergies to these or any other foods, but could still have food sensitivities with delayed immune response as a contributing factor to inflammation. His allergist did recommend an elimination-challenge diet, which is the gold standard for identifying food sensitives and we will proceed with this during winter break. I have supported many patients with elimination-challenge diets, so while never a fun process, I am sure it will be informative. 
4. Environmental Factors: Exposure to pollution and other environmental pollutants may contribute to chronic irritation and inflammation of the adenoids and tonsils. Vincent James (as well as myself) had a significant exposure to mold, which I may need to write another whole blog on. Needless to say, I was glad for the knowledge I have from supporting many patients in their recovery from toxic mold exposure and/ or mold illness.

Other possible causes of enlarged adenoids and tonsils, which were NOT a concern for Vincent James include: Gastroesophageal Reflux Disease (GERD), Genetic Predisposition, Passive Smoke Exposure, Immune System Issues, Obesity.

Literature Dive: 'Protecting the Gates'

Having considered all the possible causes for my bambino, as I do for many of my patients, I dove into the literature. One concept I discuss with my patients is ‘protecting the gates’ a phrase I’ve borrowed from my fabulous colleague, Dr. Jill Crista. We know the nasopharyngeal tissues are harbingers of viruses and many bacteria and irrigating these tissues with saline can help to cleanse, dilute, flush out viruses and bacteria that might be causing problems. In exploring if simple nasal saline might help to correct Vincent James’ snoring, I was excited to come across a 2021 double-blind, randomized, controlled trial in JAMA Pediatrics, which compared the effects nasal steroid, mometasone furoate, (similar to what was recommended for my son) to saline spray (which his ENT said we could try but “probably won’t work”) for sleep disordered breathing. I like a challenge, and I am pleased to share that after 3 weeks with saline, xylitol and propolis nasal spray, Vincent James’ snoring, which he’s had since infancy has fully resolved, which is consistent with the findings of this study, known as the MIST trial (1). We have used nasal saline spray on and off for Vincent James in the past, for a week or two at a time, but never twice daily for beyond three weeks, the benefit seems to be with time. Patience is key with this approach. I also had Vincent James using two other nasal sprays including, povidone iodine nasal spray and cromoglicic acid (aka NasoCrom), that I will discuss in more detail below, but first the unsurprising, but awesome findings from the MIST trial findings… 

The Unsurprising and Amazing MIST Trial

The MIST trial, conducted as a multicenter effort, enrolled 276 children aged 3 to 12 years who exhibited significant SDB symptoms. The trial's primary aim was to determine whether intranasal mometasone furoate, a corticosteroid, proved more effective than intranasal saline in alleviating symptoms and improving the quality of life in these children. Participants were randomly assigned to receive either mometasone furoate (50 μg) or saline (0.9%), with one spray per nostril daily for a duration of 6 weeks. The study's primary outcome measure was the resolution of significant sleep disordered breathing symptoms (SDB), as reported by parents using the SDB Score (1).

Key Findings and Implications: Nasal Saline for the Win! 

The results of the MIST trial revealed a striking similarity in treatment effects between the mometasone and saline groups. Both nasal sprays demonstrated a resolution of symptoms in approximately 41-44% of participants, with no statistically significant difference between the two groups (1). 

This finding challenges the notion that intranasal corticosteroids might have a superior impact on SDB symptoms compared to saline. Importantly, it suggests that primary care settings could consider a first-line treatment approach with intranasal saline, potentially sparing almost half of children with SDB from the need for specialist referrals (1).

Adverse Effects and Considerations

As with any intervention, the trial observed some adverse effects. Epistaxis, or nosebleeds, occurred in 9.7% of the mometasone group and 15% of the saline group. Nasal itch/irritation affected 9.7% and 18% of the mometasone and saline groups, respectively (1). These adverse effects, while present, did not significantly sway the overall findings of the trial. The relatively comparable rates between the two groups underscore the importance of weighing benefits against potential drawbacks in the pursuit of effective and tolerable interventions for pediatric SDB (1).

The saline spray we are using for Vincent James additionally contains xylitol, which moistens and soothes the nasal mucosal walls, helping to prevent the tissues from becoming irritated and helps to prevent the bacteria to adhering. Previous studies have demonstrated the benefits of xylitol saline nasal spray over saline nasal spray in chronic sinus irritation (10).

The MIST Trial is Helping to Flip the Script

In conclusion, the MIST trial challenges existing paradigms in the treatment of SDB in children. It’s helping conventional medicine flip the script towards nasal irrigation, which has long been used in traditional and naturopathic medicine. Additionally, it helps us understand duration of use is also important. The comparable efficacy of intranasal saline to mometasone furoate opens up new possibilities for managing SDB symptoms in primary care settings. This study invites a reevaluation of current guidelines, suggesting that almost half of children with SDB could find resolution without the immediate need for specialist referrals (1). The MIST trial stands as a beacon, urging healthcare providers to reconsider and refine their approaches to sleep-disordered breathing in the youngest members of our communities.

Additional Nasal Sprays: Povidone Iodine and Cromoglicic Acid 

Povidone Iodine Nasal Spray 

Given the likelihood of bacterial biofilms, I decided to incorporate povidone-iodine (PVP-I) nasal spray once per day. PVP-I long been studied and utilized as a biofilm disruptor, meaning it helps break through the film of overgrown bacteria that can coat the tissues. Also, unsurprisingly a recent 2023 invitro (lab) study by Hale and colleagues found that, Nasodine, an iodine-based nasal spray, exhibited a remarkable ability to nearly eliminate bacterial biofilms within 6 hours of exposure, suggesting its potential utility in chronic sinus inflammation (4).

Additionally, several studies have demonstrated povidone iodine spray’s ability to reduce viral load in the nasal sprays and we know that viral load is very much a factor in how much mucosal inflammation will develop in the nose and throat (3, 11).

Povidone Iodine Nasal Spray Adverse Effects and Considerations

I have personally hopped on the povidone iodine nasal spray bandwagon cautiously and I am still a cautious passenger. Similar to saline spray, there is a risk for nasal irritation and nose bleeds with regular povidone iodine nasal sprays, but beyond this, my caution, despite all its amazing benefits, including as a biofilm buster, is the well-known risk of chronic iodine, even at lower doses, to create oxidative stress in the thyroid, as I discussed in this previous blog post. Additionally, there is a dearth of studies on the impact of consistent and prolonged use of povidone-iodine on thyroid function. While overt hypothyroidism was reported in an elderly individual gargling a high potency 7% povidone-iodine daily for over 10 years, smaller cohort studies noted mild TSH increases after 6 months of daily povidone-iodine mouth rinse and in the treatment of chronic rhinosinusitis (8). In SARS-CoV-2-infected patients, TSH levels rose in approximately 40% of those using povidone-iodine for 5 days, normalizing 7–12 days later, with no significant changes in T3 and T4 levels (8). The potential predisposition of individuals with subclinical thyroid disease to hormonal changes and the necessity of thyroid disease screening before regular povidone-iodine application remain uncertain. Despite these concerns, I became cautiously more comfortable, including with my own son, after reading Quek and colleagues 2022 study findings on the DORM trial: Stable thyroid function despite regular use of povidone-iodine throat spray for SARS-CoV-2 prophylaxis (8).

DORM Trial Findings and Study Limitations

This study examined the effects of prolonged povidone-iodine throat spray use on thyroid function in men participating in the DORM trial. The findings showed no significant differences in thyroid indices between those using povidone-iodine and controls, suggesting the absence of thyroid dysfunction in individuals with normal or subclinical thyroid function. The study implied that povidone-iodine might be safe for individuals with subclinical thyroid disease, potentially obviating the need for routine screening before application. However, it's important to note that the study included relatively young and healthy men, and did not involve older individuals or those with symptomatic thyroid disease. Additionally, direct measurements of circulatory iodine levels were not conducted, and the study focused on a specific demographic, limiting the generalizability of the findings.

Cromoglicic Acid Nasal Spray

Even though we are uncertain Vincent James is dealing with allergies, while were awaiting work up with his allergist, we decided to also use cromoglicic acid nasal spray (aka NasoCrom) twice daily. Why?

Breathing Easy: The Power of Cromoglicic Acid for Respiratory Health

Derived from khellin plants, cromoglicic acid boasts anti-inflammatory properties, making it a key component in managing disordered breathing. Commonly found in nasal sprays like NasoCrom, it stabilizes mast cells, reducing histamine release and alleviating symptoms associated with allergies and respiratory conditions. Importantly, it comes with minimal side effects, reinforcing its reputation as a safe and efficient option for respiratory well-being (7).

Despite its efficacy, cromoglicic acid is not as widely utilized as steroid nasal sprays like fluticasone (Flonase). Steroids are preferred for their more potent anti-inflammatory effects, providing quicker relief for symptoms. Additionally, steroid nasal sprays often require less frequent dosing, contributing to their popularity among healthcare providers and patients. However, cromoglicic acid remains a valuable alternative, particularly for individuals who may have specific health concerns or sensitivities necessitating non-steroidal options AND also for those of use who are rightly concerned about the many concerning side effects associated with long-term steroid usage - especially in children.

Conclusion: From Unsurprising Findings to Personal Triumph 

In the realm of pediatric health, where every parent seeks answers that address the root causes of their child's ailments, the journey from snoring to silence became a profound learning experience. The MIST trial, challenging conventional norms, illuminated the efficacy of intranasal saline in treating sleep-disordered breathing in children. Beyond this revelation, a personalized exploration of biofilm disruption and careful consideration of environmental factors brought forth innovative solutions. The cautious incorporation of povidone-iodine nasal spray, despite its thyroid-related concerns, mirrored a balance between groundbreaking findings and the need for further study. As we continue to refine our approaches to childhood sleep apnea, this journey becomes not just a personal one but a beacon urging healthcare providers to reevaluate and redefine their strategies, ultimately offering hope to parents navigating similar paths.

 References

1. Baker A, Grobler A, Davies K, Griffiths A, Hiscock H, Kubba H, Peters RL, Ranganathan S, Rimmer J, Rose E, Rowe K, Simpson CM, Davidson A, Nixon G, Perrett KP. Effectiveness of Intranasal Mometasone Furoate vs Saline for Sleep-Disordered Breathing in Children: A Randomized Clinical Trial. JAMA Pediatr. 2023 Mar 1;177(3):240-247. doi: 10.1001/jamapediatrics.2022.5258. PMID: 36648937; PMCID: PMC9857783.
2. Coscia A, Bardanzellu F, Caboni E, Fanos V, Peroni DG. When a Neonate Is Born, So Is a Microbiota. Life (Basel). 2021 Feb 16;11(2):148. doi: 10.3390/life11020148. PMID: 33669262; PMCID: PMC7920069.
3. Guenezan J, Garcia M, Strasters D, Jousselin C, Lévêque N, Frasca D, Mimoz O. Povidone Iodine Mouthwash, Gargle, and Nasal Spray to Reduce Nasopharyngeal Viral Load in Patients With COVID-19: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2021 Apr 1;147(4):400-401. doi: 10.1001/jamaoto.2020.5490. PMID: 33538761; PMCID: PMC7863011
4. Hale SJM, Lux CA, Kim R, Biswas K, Tucker S, Friedland P, Mackenzie BW, Douglas RG. In vitro Nasodine Can be an Effective Antibiofilm Agent for Biofilms that May Cause CRS. Laryngoscope. 2023 Oct;133(10):2490-2495. doi: 10.1002/lary.30558. Epub 2023 Jan 16. PMID: 36644968.
5. Kuhle S, Hoffmann DU, Mitra S, Urschitz MS. Anti-inflammatory medications for obstructive sleep apnoea in children. Cochrane Database Syst Rev. 2020 Jan 17;1(1):CD007074. doi: 10.1002/14651858.CD007074.pub3. PMID: 31978261; PMCID: PMC6984442.
6. Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, Mitchell RB, Amin R, Katz ES, Arens R, Paruthi S, Muzumdar H, Gozal D, Thomas NH, Ware J, Beebe D, Snyder K, Elden L, Sprecher RC, Willging P, Jones D, Bent JP, Hoban T, Chervin RD, Ellenberg SS, Redline S; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013 Jun 20;368(25):2366-76. doi: 10.1056/NEJMoa1215881. Epub 2013 May 21. PMID: 23692173; PMCID: PMC3756808.
7. Minutello K, Gupta V. Cromolyn Sodium. [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557473/
8. Quek AML, Ng MY, Teng O, Lim NA, Ng GJL, Yang SP, Hartman M, Tambyah PA, Cook AR, Seet RCS. Stable thyroid function despite regular use of povidone-iodine throat spray for SARS-CoV-2 prophylaxis. Ann Med. 2022 Dec;54(1):3299-3305. doi: 10.1080/07853890.2022.2108132. PMID: 36399104; PMCID: PMC9677975.
9. Torretta S, Drago L, Marchisio P, Ibba T, Pignataro L. Role of Biofilms in Children with Chronic Adenoiditis and Middle Ear Disease. J Clin Med. 2019 May 13;8(5):671. doi: 10.3390/jcm8050671. PMID: 31086039; PMCID: PMC6571864.
10. Weissman JD, Fernandez F, Hwang PH. Xylitol nasal irrigation in the management of chronic rhinosinusitis: a pilot study. Laryngoscope. 2011 Nov;121(11):2468-72. doi: 10.1002/lary.22176. Epub 2011 Oct 12. Erratum in: Laryngoscope. 2012 Nov;122(11):2611. PMID: 21994147.
11. Zarabanda D, Vukkadala N, Phillips KM, Qian ZJ, Mfuh KO, Hatter MJ, Lee IT, Rao VK, Hwang PH, Domb G, Patel ZM, Pinsky BA, Nayak JV. The Effect of Povidone-Iodine Nasal Spray on Nasopharyngeal SARS-CoV-2 Viral Load: A Randomized Control Trial. Laryngoscope. 2022 Nov;132(11):2089-2095. doi: 10.1002/lary.29935. Epic 2021 Nov 9. PMID: 34724213; PMCID: PMC8662040.