"Pediatric Obstructive Sleep Apnea: A Surgeon's Perspective" Andrew Scott, MD (02/08/2023)March 06, 2023
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- 00:03So good afternoon, everyone.
- 00:05My name is Andre Zinchuk,
- 00:08and I am an assistant professor
- 00:10here at Yale University.
- 00:12And thank you for joining yet
- 00:14another edition of our joint sleep
- 00:16seminars that we conduct with folks.
- 00:19Really sounds like all over the
- 00:21Northeast now, which is great.
- 00:23And we have a very special guest today.
- 00:27And I will let Doctor already Grover
- 00:30introduce our speaker for the day.
- 00:32Take it away already.
- 00:34Alright, thank you.
- 00:36Good afternoon everyone.
- 00:37Thank you Doctor Scott for coming in
- 00:40today from Tufts and Doctor Scott is
- 00:42going to talk about pediatric obstructive
- 00:45sleep apnea and he's going to give
- 00:47us their surgeons perspective on this.
- 00:49So just by introduction,
- 00:51Doctor Andrew Scott is an associate
- 00:53professor of otolaryngology and
- 00:56pediatric Pediatrics as Tufts University
- 00:58School of Medicine in Boston.
- 01:00Uh he serves as a medical director for
- 01:03cleft and craniofacial team at Tufts
- 01:06Children's Hospital and Tufts Medical Center.
- 01:08He attended Uh Vaseline University of
- 01:11his uh for his undergraduate education,
- 01:14followed by Harvard Medical School
- 01:16where he earned his medical degree.
- 01:19He completed a residency in oral Laryngology,
- 01:22had a neck surgery through the
- 01:24Harvard system and additional
- 01:25subspecialty training and cop complex
- 01:28and pediatric laryngology through
- 01:29the University of Minnesota.
- 01:31He practices the full spectrum
- 01:34of pediatric auto laryngology,
- 01:35including open and endoscopic air research,
- 01:38very the full spectrum of pediatric facial
- 01:42plastic surgery and craniofacial surgery.
- 01:45In collaboration with his
- 01:46colleagues in neurosurgery and
- 01:48oral and maxillofacial surgery,
- 01:50doctor Scott also performs transmural
- 01:52procedures for cranius and stenosis
- 01:55and orthognathic surgeries.
- 01:58Again, thank you,
- 01:59Doctor Scott for doing this today.
- 02:04Thank you. Thank you for the
- 02:06kind introduction. Umm, I I.
- 02:07The format of these is always a
- 02:10little tricky, but I would like to,
- 02:12as much as it's possible,
- 02:14keep this fairly informal.
- 02:15If you see a typo,
- 02:18I'd love for you to point it out.
- 02:19If you have questions or corrections,
- 02:22that is welcome to.
- 02:23I think a lot of us are are are
- 02:26knowledgeable and come at this
- 02:28from different perspectives
- 02:29and and I always learn from
- 02:31the audience and these things.
- 02:33So so please speak up with
- 02:35questions as we go.
- 02:37Forward, I'm going to try to spend
- 02:39about 45 minutes and then have
- 02:41time for questions at the end.
- 02:43I am a surgeon and so I have
- 02:45a limited attention span.
- 02:47We are very visual and we like boom boom,
- 02:49boom, boom, boom.
- 02:50So this is going to be a little bit of a
- 02:54MTV TikTok, not quite to that extent,
- 02:56but lecture with lots of of quick
- 02:59changes and videos and hopefully
- 03:00that will be interesting to you.
- 03:03I have no disclosures,
- 03:04but I'm always interested in the. Closure.
- 03:07If anyone has any good ideas and this
- 03:11is the CME information and whatnot,
- 03:13I think this is boilerplate for
- 03:14most of your lectures today,
- 03:16but for those of you who need it,
- 03:17this is that information.
- 03:20Give that a second.
- 03:22I went to Wesleyan for undergrad
- 03:24and and Harvard for Med school,
- 03:27and I'm perfectly aware
- 03:28that I'm speaking to Yale,
- 03:29but I have great affection for
- 03:31anyone on the 91 corridor, so.
- 03:34So we're all,
- 03:36I have a lot of Connecticut ties.
- 03:39So the goals today are to review
- 03:42current guidelines that we have from
- 03:44the pediatric allergology literature.
- 03:46And I think that sometimes is
- 03:48an interesting perspective to
- 03:49sort of see where your surgical
- 03:51colleagues are coming from.
- 03:52There is a lot of overlap
- 03:54as you would imagine,
- 03:55but sometimes there isn't and you
- 03:57might think somebody is doing something
- 03:59kind of crazy and it may come from
- 04:02our guidelines and vice versa.
- 04:03We'll talk about a off label use of
- 04:07nasal steroids for adenoid hypertrophy
- 04:10and I'm going to talk about the
- 04:13surgical strategies that we have
- 04:15for addressing patients who still
- 04:16have residual sleep apnea after
- 04:18tonsillectomy and adenoidectomy,
- 04:20which does come up from time to time.
- 04:23And then we'll talk about some of the
- 04:26more advanced soft tissue and orthognathic,
- 04:28so Bony surgeries that we do for
- 04:31on the maxilla and the mandible.
- 04:34So this is the basic outline of
- 04:36this talk and again I'm going to go
- 04:39through it pretty quickly given our audience.
- 04:41I'm not going to go into the
- 04:44the definitions of sleep apnea.
- 04:46You are all far more knowledgeable
- 04:48about that than I am.
- 04:50But just as a basic review,
- 04:51we can all agree that this happens
- 04:54when there's intermittent upper
- 04:55airway collapse during sleep and
- 04:56there can be any number of anatomic
- 04:59or neuromuscular factors and
- 05:00that's very important for me as a
- 05:02surgeon to keep in mind because.
- 05:04Sometimes when you're a hammer,
- 05:07everything's a nail,
- 05:08and having us as surgeons treat
- 05:11everything as an anatomic problem
- 05:13will lead to failed interventions.
- 05:16You can't treat hypotonia
- 05:18with a static surgery,
- 05:20and so that's really the best way
- 05:23for us to assess patients for who
- 05:26are good candidates and who aren't.
- 05:28But that being said,
- 05:30there are still many patients
- 05:32that might be thought of as,
- 05:33oh, they don't have options,
- 05:35when in fact they do.
- 05:36And in the era of sleep endoscopy
- 05:38and being able to localize the site
- 05:41of obstruction focused surgical
- 05:43interventions in those areas,
- 05:45while not perfect,
- 05:46are definitely far more efficacious than
- 05:48when we used to just blindly try something.
- 05:51It is important to also remember that
- 05:53the criteria for sleep apnea is quite
- 05:56different than adults and children.
- 05:57The bar is much,
- 05:58much higher.
- 05:59Kids to say that cure for obstructive
- 06:02sleep apnea child is bringing
- 06:05the HIV to below one is very,
- 06:07very difficult.
- 06:10But to do so,
- 06:11to achieve absolute cure and a
- 06:13child is is not always possible.
- 06:16But that being said,
- 06:18when you look at what contributes to
- 06:21sleep apnea in children and versus adults,
- 06:24it is far more skewed towards
- 06:27obesity and other factors such as
- 06:29that for adults as opposed to just
- 06:32lymphoid hypertrophy in children.
- 06:34And while we do have adults with big
- 06:36tonsils who have their snoring and
- 06:39sometimes even sleep apnea improved.
- 06:41By tonsillectomy, it is nowhere near
- 06:43as efficacious as it is in children.
- 06:45And a big part of that is because of
- 06:47just the ratio of the size of the tonsils
- 06:49to the pharynx and the fact that what's
- 06:51causing these obstructive symptoms
- 06:53in kids is different than adults.
- 06:55But then it's makes it difficult for us
- 06:58to translate that paradigm for teenagers,
- 07:00saying that there's still children,
- 07:01even though, you know,
- 07:03sometimes we have a teenager in
- 07:05the office at 6 feet tall.
- 07:06And yes, they can't vote,
- 07:08but that doesn't necessarily
- 07:10make them have to have an HIV.
- 07:121.0 and doesn't make treating
- 07:14them as an infant logical,
- 07:16and so we do have some arbitrary
- 07:18cut offs that are based on age
- 07:21rather than developmental status.
- 07:24So looking at, you know,
- 07:26the anatomical factors and relevant
- 07:29anatomy, the mallampati scale
- 07:30I know you are all aware of.
- 07:33That's a scale for determining
- 07:34the difficulty of intubation.
- 07:36It's been hijacked for use for thinking about
- 07:39examining soft palate length and whatnot,
- 07:41and it can be a bit of a surrogate,
- 07:43but it is important for us all to remember
- 07:45that that's not what this was designed for.
- 07:48This is simply to decide whether
- 07:49you know you're going to be
- 07:51a tricky intubation or not,
- 07:52or what your mask airway might be like.
- 07:55The tonsil grading scale in children
- 07:57zero or the surgically absent are
- 08:00are practically not there.
- 08:01One, they're there but they're super small.
- 08:042 They're there and they're about average,
- 08:063 they're big and four they're
- 08:08enormous and touching and then four
- 08:10plus plus would be like if they're
- 08:13practically overlapping and whatnot.
- 08:15Our literature does not clearly show
- 08:17much of a correlation between tonsil
- 08:19size and severity of sleep apnea,
- 08:22and that's important because a lot
- 08:23of kids are sent. Or big tonsils.
- 08:25Ohh, it's gotta be bad.
- 08:27But sometimes the tonsils are exophytic,
- 08:30meaning they're almost pedicled
- 08:31and what you see looks huge,
- 08:33and other times they look small.
- 08:35One plus or two plus and they're very
- 08:37endophytic and they go very laterally.
- 08:38But when you're asleep,
- 08:40that same Mass Effect is apparent either way.
- 08:42And so you can have a child with two plus
- 08:45tonsils that is terribly obstructing,
- 08:47and one with four plus tonsils who snores
- 08:49but actually doesn't have any sleep apnea.
- 08:51And so it's an approximation,
- 08:53but none of this is is perfect.
- 08:56I just want to show you an example.
- 08:57I put sleep inducing quotation
- 08:58because this is a child that I saw.
- 09:00This is a pretty old video.
- 09:02It's from like maybe 8-10 years ago.
- 09:04But he was in my office for sleep apnea
- 09:07and came in and was asleep in the chair.
- 09:10And so just for Giggles,
- 09:12I put a scope in him and he was still asleep.
- 09:15And this is not under anesthesia,
- 09:17this is in the office,
- 09:17just with excessive daytime somnolence.
- 09:20And as we scope him now,
- 09:21we're looking at the tonsils that are
- 09:24collapsing almost completely on themselves.
- 09:27Posterior is up top,
- 09:28anterior is in the bottom of
- 09:306:00 o'clock of the screen.
- 09:31And now you'll see the larynx way down here,
- 09:34that the tonsils are sitting on
- 09:36the larynx and that's the cricoid,
- 09:38and the vocal folds are just about to
- 09:40come into view right there and now.
- 09:41He startles as I wake him up and
- 09:43watch how different this airway looks
- 09:45when he coughs and he's awake of how
- 09:49dramatically different this will look.
- 09:51He coughs and now everything
- 09:52opens up and that's him.
- 09:54Whoops, that's what he looks like when awake.
- 09:57And so it's a pretty big
- 10:00difference to see this.
- 10:02You could very much underestimate how
- 10:05bad his obstruction would be just by
- 10:07looking at him awakened clinic and that's
- 10:10why sleep endoscopy is so helpful.
- 10:12So looking at the epidemiology and children,
- 10:14the prevalence in kids in my clinic, I mean,
- 10:16I think the whole world has sleep apnea.
- 10:17Every single child must be
- 10:19having this because they're
- 10:20the ones who show up to see me.
- 10:21But in reality, it's actually pretty low.
- 10:23It's probably higher now than it used to be,
- 10:25but but it it it's under 10%.
- 10:30And these children often present in
- 10:32their preschool years and of that has
- 10:34to do with the size of the tonsils to
- 10:36the caliber of the pharyngeal airway.
- 10:38It's that ratio.
- 10:39And many times these kids are
- 10:40in normal weight.
- 10:41Obesity certainly can contribute,
- 10:43but the scariest sleep apnea patient to
- 10:46me in my clinic is the underweight child,
- 10:49the one who has large tonsils and is skinny,
- 10:52because that tells me that that
- 10:55kid is burning more calories at
- 10:57night to stay alive than they're
- 10:59able to consume during the day.
- 11:01When a child has airway obstruction
- 11:04that is bad,
- 11:05they will develop failure to thrive
- 11:07just from caloric expenditure and
- 11:09sometimes dysphasia if the airway
- 11:11obstruction is contributing to that.
- 11:13And so those kids that are really skinny
- 11:16and small are are often the ones that
- 11:18have the worst airway obstruction.
- 11:23So when we think about the Natural
- 11:25History of this, it would be nice
- 11:27in adults if you could just say,
- 11:28oh, just wait, wait six months
- 11:30and your sleep apnea will go away.
- 11:32I mean that doesn't happen.
- 11:34I gain weight every year it feels like.
- 11:35So, I mean that's that what
- 11:37happens to us adults.
- 11:38But in children,
- 11:39they're growing and they can sort
- 11:41of auto UN grow their tonsils,
- 11:43outgrow their tonsils.
- 11:43And so when we look at the Natural
- 11:46History of untreated sleep apnea in
- 11:48children and this was a very happy
- 11:50thing to know about when the COVID.
- 11:52Pandemic struck is that although untreated,
- 11:56sleep apnea is obviously a problem
- 11:58and certainly severe sleep apnea
- 11:59can cause all the downstream effects
- 12:01that you are all well aware of.
- 12:03Spontaneous resolution can occur in
- 12:05kids and that's up to 42% of children
- 12:09will go from mild OSA or moderate OSA.
- 12:13Again remember the pediatric
- 12:14criteria are much lower,
- 12:15moderate OSA being 5HI510 with
- 12:19with a growth spurt and their
- 12:21tonsils going down they can be.
- 12:23Care of their sleep apnea by doing nothing,
- 12:26absolutely nothing.
- 12:27And that happens 42% of the time by
- 12:30the numbers within seven months.
- 12:32Now it's need to understand that
- 12:35these are kids often with mild OSA
- 12:37and a low HIV and they're not obese.
- 12:40And if you look at their pediatric
- 12:42Sleep Questionnaire scores,
- 12:43that Michigan questionnaire,
- 12:43I'm not sure if you guys still use it,
- 12:45but we love it. It's from 2000.
- 12:48They are often ones that are like in the 33,
- 12:52you know, under 50%.
- 12:54Score of that index.
- 12:56Not the ones that are off the charts.
- 12:58But this is just another reason
- 12:59why sometimes if you just wait,
- 13:01things will get better.
- 13:02The tonsils are lymph nodes,
- 13:04and in the same way that a lymph node in
- 13:06your neck can get swollen when you get sick.
- 13:08And then it takes a little
- 13:09while to go back down,
- 13:09but eventually it might.
- 13:11Same thing happens to tonsils.
- 13:13If you get 6 over and over again in
- 13:15daycare and your tonsils are enormous,
- 13:16summer comes around and they shrink.
- 13:19And if you do that tonsillectomy in the
- 13:21spring or you don't do it come the fall,
- 13:23everyone's cure of sleep apnea.
- 13:25So those are things to think about.
- 13:29Let's see.
- 13:29I'm just seeing what's in the chat,
- 13:31making sure there's no questions there,
- 13:37So moving through here. So diagnosis.
- 13:41And again, I'm going to gloss over this
- 13:43because you were all very well aware of this.
- 13:45But for patients who appear to us in in
- 13:48clinic, and I always make the point to my
- 13:50trainees that there's a difference between
- 13:52sleep apnea and sleep disorder breathing.
- 13:54And so most of the kids that we
- 13:55see have sleep disorder breathing.
- 13:57They have symptoms of sleep apnea,
- 13:59but if they don't have a sleep study,
- 14:00you can't say they have sleep apnea.
- 14:02And the most common symptom is snoring.
- 14:05Witness pauses or arousals
- 14:08that the parent sees.
- 14:10Often if the adenoids are large
- 14:12or the turbinates are enlarged,
- 14:13or there's chronic rhinitis,
- 14:14they will have constant open mouth breathing.
- 14:17Open mouth breathing is now
- 14:19this like Internet, you know,
- 14:22horror epidemic,
- 14:23that some very well educated and affluent
- 14:27families will come in and terrified
- 14:29that their child is mouth breathing,
- 14:32they've been taping their mouth
- 14:33shut at night and there's what's
- 14:34going to happen to the palate.
- 14:36This is been a lot driven by the
- 14:38dentist and the orthodontist.
- 14:40Umm, we don't have evidence that
- 14:42shows that this really matters
- 14:44at all from a sleep standpoint.
- 14:46if your palette is narrow,
- 14:48your nasal cavities are slightly narrower,
- 14:51and if you do palatal expansion,
- 14:53it will slightly decrease nasal resistance.
- 14:56But from a sleep study standpoint,
- 14:57and certainly in adults,
- 14:58it has not been shown to make a
- 15:01meaningful difference in HIV.
- 15:02That actually is the difference
- 15:04between having sleep apnea
- 15:05and not having sleep apnea.
- 15:07But powerful expansion will improve
- 15:09your nasal airway resistance,
- 15:11and it can help with snoring.
- 15:14But these kids will have restless sleep and
- 15:15a lot of chronic nasal obstruction symptoms.
- 15:18And what we do is is is administer
- 15:20that Michigan questionnaire,
- 15:22which often will ask parents the
- 15:24questions in just the right way.
- 15:26I'm always amazed that they will answer
- 15:29one way on the questionnaire and then
- 15:32their response to me asking the same
- 15:34question will sometimes be different.
- 15:36So occasionally you have to
- 15:37sort of double check that.
- 15:41Just seeing if there's any.
- 15:43I just saw a text thing come up
- 15:45for the chat but I'm not seeing
- 15:47able to read it I guess OK.
- 15:52Let's listen to this kid.
- 15:59So she's asleep in her car seat.
- 16:01You can see her abdominal retraction,
- 16:05super sternal retractions.
- 16:07She's clearly pretty obstructive.
- 16:09This is the child of a physician who brought
- 16:12in this video sort of as a curiosity.
- 16:15She wasn't particularly worried.
- 16:18So sometimes parents are pretty
- 16:20underwhelmed by this sort of thing,
- 16:22and other times they are.
- 16:24They're terrified.
- 16:25But parents will tolerate this for a while.
- 16:29They kind of think it's cute,
- 16:30and we have to sort of let them
- 16:32know that this is not normal.
- 16:33Children shouldn't be snoring,
- 16:35and the sound that you're hearing there is.
- 16:39You can describe it as Strider,
- 16:41but the it's probably more
- 16:42accurate to call it sturdier,
- 16:44which is a term that everyone knows or uses.
- 16:46But that's basically the sound of snoring.
- 16:48And especially the sound of
- 16:50snoring when you're awake.
- 16:50So someone who's.
- 16:53In your office and you think they're snoring,
- 16:54you turn around in their
- 16:56wake that's sturdier,
- 16:57that's sort of the open mouth breathing
- 17:00nasal obstruction and and that's really
- 17:02what we're looking for and asking about.
- 17:03Strider is at the laryngeal level
- 17:06and that's more musical like a
- 17:09sound like what we call the Ringo
- 17:11Malaysia in the in the infants.
- 17:13Starter is often caused by nasal obstruction,
- 17:16obstruction of the soft palate level.
- 17:18And so here you can see
- 17:20in the lateral neck film,
- 17:21which we actually don't get that often now,
- 17:22but you always can.
- 17:23If you have a patient that
- 17:24can't tolerate nasal endoscopy,
- 17:26you will see that adenoid which is
- 17:28is partially blocking the nasal
- 17:30pharyngeal airway right here.
- 17:32So we can see the borders of the
- 17:33adenoid here in the soft palate here
- 17:35and there's a column of air and that
- 17:36patient is able to breathe there.
- 17:38But the adenoid really should be about
- 17:39half the size and so this will cause
- 17:42some degree of nasal obstruction.
- 17:44And so this is a view on nasal endoscopy
- 17:47of a three to four plus adenoid,
- 17:49it's it's four plus would
- 17:51be completely obstructed,
- 17:52but it's pretty close.
- 17:53And so this is the patients left
- 17:56nasal cavity.
- 17:57So this is the nasal septum and the
- 17:59adenoid is filling that area and this
- 18:01is pretty much the same view but with
- 18:04the adenoid removed or shrunk back
- 18:06that we would call this A1 plus adenoid.
- 18:08It's present but it isn't larger obstructive.
- 18:11So you can see that's a pretty
- 18:13big hole that is plugged.
- 18:14By that adenoid and in children
- 18:17who are obligate nasal breathers,
- 18:19they they really want to
- 18:20breathe through their nose.
- 18:20A large adenoid is is debilitating.
- 18:23It's hard,
- 18:23they can't chew because they can't,
- 18:25and they can't drink because
- 18:26they need to be able to breathe
- 18:28through their nose while they eat,
- 18:29and that can cause coughing and
- 18:31dysphasia because they can't coordinate
- 18:33their suck swallow breed sequence.
- 18:35This is the Eustachian tube Orpheus.
- 18:37What's popping your ears on the airplane?
- 18:40When you swallow or chew gum it will open
- 18:42your ears and you can see it's
- 18:44completely blocked by the adenoid.
- 18:46So many of these kids will have
- 18:48a serious effusions, you know,
- 18:50fluid behind their eardrums.
- 18:51And so the overlap of children that have
- 18:54conductive hearing loss because of ear
- 18:55fluid or recurrent otitis media and also
- 18:58have large adenoids is very, very high.
- 19:00And that's why if you're looking at past
- 19:01medical history or past surgical history,
- 19:03you'll see a lot of these kids have had
- 19:06tubes and adenoids at the same time or
- 19:09adenoids and tonsils with ear tubes.
- 19:11That's why, because that's
- 19:13where they overlap is.
- 19:15So sleep study.
- 19:16I would argue is not really
- 19:18necessary in healthy children
- 19:20with sleep disorder breathing,
- 19:21if they have a high enough score and
- 19:24they're struggling to breathe enough
- 19:25and it's disrupting their sleep and
- 19:27leading to what we can all guess
- 19:29is at least sleep fragmentation,
- 19:30then you have what you need to do surgery.
- 19:33That's what insurance says.
- 19:35And so if a child is otherwise healthy,
- 19:37we will take their tonsils and
- 19:39adenoids out based on those symptoms.
- 19:40You don't have to necessarily
- 19:42get a sleep study.
- 19:43That matters because you guys know how
- 19:46long the wait is for sleep studies.
- 19:48And in the era of RSV,
- 19:50and every kid is now sick with
- 19:52that calling at the last minute and
- 19:54all the cancellations are COVID.
- 19:55The access for sleep studies is very,
- 19:58very difficult.
- 19:59And so if we send every single snoring
- 20:03healthy child for a sleep study,
- 20:05there would never be the opportunity
- 20:07to to assess those that really need it.
- 20:11Of course it's important for adults
- 20:12and older kids if you're going
- 20:14to use it for CPAP titration,
- 20:15but if the answer is the kid is big tonsils,
- 20:17we're going to take them out.
- 20:18You're probably not going to get a post
- 20:20op sleep study if all symptoms resolved,
- 20:22so we don't reflexively get it.
- 20:25Hartfield in otolaryngology says these
- 20:28are the absolute, like essential.
- 20:31Instances in which one must
- 20:33get a sleep study.
- 20:35If you do not get a sleep
- 20:36study in these cases,
- 20:37you are out of left field and probably
- 20:40not practicing the standard of care.
- 20:42And so that's important I think
- 20:43for you guys to know, you know,
- 20:45if you're in charge of a sleep center,
- 20:47understand like why is this kid getting this?
- 20:50If their BMI for age is above the
- 20:5298th percentile and some say 95th,
- 20:54they have to get a sleep study.
- 20:55If I take that kid to the OR
- 20:57without a sleep study,
- 20:59that is not,
- 21:00that's a direct violation of our guidelines.
- 21:03And the reason why is because the pretest
- 21:06probability of patients with these issues,
- 21:08the pretest probability of they're
- 21:10having severe OSA is very high.
- 21:12And so if you just turn a blind eye to it
- 21:14and go and take out the tonsils or adenoids,
- 21:17your complication rate afterwards,
- 21:18your likelihood of needing to all of a
- 21:21sudden go to the ICU minimally to admit
- 21:23them afterwards is very, very high.
- 21:25So patients with sickle cell anemia,
- 21:28obesity of mucopolysaccharidosis or some
- 21:30sort of storage disease, craniosynostosis.
- 21:33Cleft lip and palate rail ban sequence,
- 21:36micrognathia, craniofacial stuff,
- 21:38anyone with hypotonia, Charcot,
- 21:41Marie Tooth, cerebral palsy,
- 21:43those kids all need sleep studies.
- 21:45And then there's the
- 21:47recommendation that like look,
- 21:48if they're under two that's that's
- 21:49pretty young to take their tonsils out.
- 21:51You probably want to sleep study
- 21:52that says it's OK to do that.
- 21:54I would just make the argument that
- 21:55by the time you get the sleep study
- 21:56and it comes back, they're over too,
- 21:58because they rarely are.
- 22:00Are are presenting that young,
- 22:02it can be helpful for the infants,
- 22:04especially if there's something
- 22:05else happening.
- 22:06And then the big one, and I had a
- 22:08a perfect example of it on Friday,
- 22:10is parental disagreement.
- 22:11So Dad's an engineer and he's
- 22:13super data-driven and he wants to
- 22:15know exactly what we're treating
- 22:17and why and how bad it is.
- 22:19And Mom is like this kid can't get up and
- 22:22to for school in the morning and you are,
- 22:25you know,
- 22:25asleep on the couch, dad.
- 22:26But I'm watching them obstruct all the time.
- 22:28I don't need a sleep study,
- 22:29like let's just make this go away.
- 22:31The wait time for sleep study and then
- 22:34surgery as opposed to surgery alone
- 22:36is a on average four to five months.
- 22:40So it's a significant delay and that.
- 22:42Matter to some families.
- 22:46Why we get sleep studies is to determine
- 22:48and risk stratify who has to get
- 22:51admitted to our hospitals afterwards.
- 22:53And so the three hard recommendations
- 22:54for kids who must get admitted after
- 22:57tonsillectomy and adenoidectomy,
- 22:58this is not for adenoids alone.
- 22:59This for tonsils and adenoids is age
- 23:02under three years and HI above 10 and
- 23:05assassinator that's 80 or below or below 80.
- 23:09And so the ones I showed you are are
- 23:11that we say must get a sleep study.
- 23:13They're the ones that the highest likelihood
- 23:15of having a high HIV and a saturator.
- 23:18And so that's sort of how we determine that.
- 23:22Treatment options.
- 23:23Cpap is probably the first
- 23:25line treatment in adults.
- 23:27I mean, I think that's fair to say
- 23:29that PAP therapy is is is there.
- 23:32We don't commonly use it in kids,
- 23:33but you can. I have multiple
- 23:35children on CPAP and they love it.
- 23:37I have a couple of like morbidly obese kids,
- 23:40one of them who was on bypass and
- 23:42she used to come home and put her
- 23:44Bipap mask on to do homework because
- 23:46she just felt so much better.
- 23:48The poor thing was so pickwickian that
- 23:51when she had her PAP on, she just felt.
- 23:55Better breathe better and she would just
- 23:57do her homework with her PAP on awake,
- 23:58so many of them feel like it really,
- 24:00really helps.
- 24:02She had big tonsils too,
- 24:05but she was so large that it enters.
- 24:08HI was so high that if she
- 24:09did make it through surgery,
- 24:11she was still going to end up
- 24:12needing to be on PAP therapy,
- 24:13and so it isn't really worth the
- 24:16risk of putting a kid with multiple
- 24:19comorbidities through surgery.
- 24:20In fact,
- 24:21the way I got to meet her was that
- 24:23some other doctor tried to do a
- 24:25T&amp;A on her and she had horrible
- 24:28post obstructive pulmonary edema
- 24:30right as they were intubating her
- 24:32before they even did surgery.
- 24:33And so in that setting they
- 24:35never even touched her tonsils,
- 24:36they never did surgery and
- 24:38they transported her to our ICU
- 24:40in fulminant pulmonary edema.
- 24:41And by the time we checked our A1C
- 24:44and saw the degree of of right sided
- 24:48hypertrophy and whatnot all you know.
- 24:50Downstream secondary effects of
- 24:52her sort of metabolic syndrome.
- 24:53It was tapped.
- 24:54Therapy's been the best for her.
- 24:57And so those are who we decide to do that.
- 24:59If you do have to desensitize this
- 25:01child as CPAP, for lack of a better term,
- 25:03this is how it works.
- 25:04You've met them to the hospital.
- 25:05You put the PAP mask on them,
- 25:06the kid takes it off,
- 25:07you put it on, they take it off,
- 25:08you put it on, they take it off.
- 25:09And you do this for like 2-3 nights in
- 25:11a row until you finally break the child.
- 25:14And then they wear their CPAP.
- 25:15And so that's what an admission
- 25:17for CPAP looks like.
- 25:18These are the surgeries that we do.
- 25:21And so these are tonsils and adenoids
- 25:24and then the other sleep procedures.
- 25:27TNA cures 65% of pediatric OSA,
- 25:30higher rate of improvement and curing,
- 25:34But if you really stick them back in
- 25:37your sleep center and really look
- 25:39to get their HI below one is 65%.
- 25:42The others go from an HIV of 14 to
- 25:45an HIV 1.6, but that's not cure.
- 25:47So technically if you're really
- 25:49looking for that it's 65%.
- 25:51But in terms of responding to for
- 25:53all intensive purposes being much,
- 25:54much better that's that's higher
- 25:56that's probably. Close to 90%.
- 25:58The recovery is rough from tonsillectomy.
- 26:01A lot of my colleagues undersell it,
- 26:03but it's brutal.
- 26:04It's especially for a teenager.
- 26:06It's two weeks of eating glass.
- 26:08The bleeding rate for a teenager is 10 to to.
- 26:13Is probably close to 10%.
- 26:15For a younger child who's three to six,
- 26:18it's probably closer to 3%.
- 26:21But children die every
- 26:22year from tonsillectomy.
- 26:23So you got to be sure you really need to
- 26:25do it and it's the right thing to do.
- 26:27There are other surgeries you can do
- 26:29for those that fail and that's what the
- 26:31rest of this talk is going to be about.
- 26:32And those run the gamut from
- 26:35just nasal stuff.
- 26:36Sometimes we do that just to
- 26:37improve nasal resistance to CPAP
- 26:39therapy so people can come down
- 26:40on their PAP settings and that
- 26:42may be the difference between,
- 26:43you know belching and feeling
- 26:45like you're you're,
- 26:46you're feeling your stomach with air
- 26:48because your PAP levels are so high,
- 26:49but then when you fix the septum and.
- 26:51Leave the terminates.
- 26:52You don't clear their sleep apnea,
- 26:53but now they can come down to maybe
- 26:55like 6 or 8 centimeters of water,
- 26:57and then they don't get all
- 26:59of that swallowing of air.
- 27:00And they're not,
- 27:01they're not opening their
- 27:03upper esophageal sphincter.
- 27:04So for a preop assessment,
- 27:06we look at their comorbidities,
- 27:08decide if they need inpatient
- 27:09or outpatient based on age,
- 27:10whether they need a sleep study
- 27:12and then based on that whether
- 27:13they need to pick your bed and
- 27:15you run the risk of bleeding.
- 27:16You ask about, you know,
- 27:18risk factors in the family,
- 27:19people who have bleeding after surgery.
- 27:21And then you counsel people on, you know,
- 27:23how the recovery is going to be.
- 27:25So here's your typical case,
- 27:263 year old girl,
- 27:27she's got a pectus excavatum
- 27:29and she's got some asthma,
- 27:30but otherwise she's pretty healthy.
- 27:32She gets her TNA,
- 27:33she stays overnight for airway observation.
- 27:35Because she's just over three
- 27:37and she had bad asthma.
- 27:39She does great, goes home the next day.
- 27:41She's seen four weeks post-op.
- 27:42She's was back to herself at seven days.
- 27:44They're snoring completely gone,
- 27:45and now the parents have to go
- 27:47into a room and make sure she's
- 27:49alive because they can't hear her
- 27:50from outside of her room anymore.
- 27:51She never gets a sleep study
- 27:53before the surgery,
- 27:54and she never gets a sleep
- 27:55study after the surgery.
- 27:56And that's how most of these things go.
- 27:58But what do we do if that kid
- 28:00comes back a few years later
- 28:02and the TNA doesn't help?
- 28:04So then we need to do a thorough exam
- 28:06and we scope them in clinic with
- 28:08laryngoscopy or we consider doing a
- 28:10sleep endoscopy in the operating room.
- 28:12And this is very important to localize
- 28:14the site of obstruction and make
- 28:16sure that we know what is happening.
- 28:18You do not have to do this for a
- 28:20child prior to TNA because almost
- 28:22all the time it's the tonsils and
- 28:24adenoids that are causing the issue.
- 28:26And so it's just unnecessary
- 28:27prolonging of anesthesia and everything
- 28:29to do this from a resource standpoint.
- 28:31But if I see a kid with OSA
- 28:33who's got teeny tiny tonsils.
- 28:34And they're sleep studies positive.
- 28:37I will book them for a T&amp;A,
- 28:38but a sleep endoscopy prior
- 28:40and sometimes make a game time
- 28:42decision and switch things up.
- 28:43So what are the frequent culprits for this?
- 28:46So severe septal deviation
- 28:47or enlarged turbinates?
- 28:48That's usually snoring more than sleep apnea.
- 28:51The other one is something
- 28:52called tubal tonsil hypertrophy,
- 28:53which is when if you remove the adenoids.
- 28:57And umm, you are you,
- 29:00you finished taking those out.
- 29:02The adenoids will not grow back necessarily,
- 29:04but the lateral pharyngeal wall here
- 29:06where this you station tube Warface
- 29:08says we'll grow lymphoid tissue
- 29:10and that can become obstructive.
- 29:12And so they come back for ohh,
- 29:14my adenoids grew back.
- 29:14And you're like really my adenoids
- 29:16usually go back but OK and then you look,
- 29:18and that's what the problem is,
- 29:19we give them nasal steroids
- 29:20and makes them a little better.
- 29:22It often doesn't completely
- 29:23solve the problem.
- 29:25You can then take them back to the
- 29:26operating room and cauterize and resurface.
- 29:28That area with something called the
- 29:29collator and then when you put them
- 29:31on nasal steroids to prevent the
- 29:33lymphoid tissue from coming back,
- 29:34that usually does the trick.
- 29:36Then you could have lingual
- 29:38tonsil hypertrophy.
- 29:38So these are the tonsils at the base
- 29:41of the tongue that are now huge.
- 29:43Because we've removed the
- 29:44tonsils and the adenoids.
- 29:45The body is determined to grow lymphoid
- 29:47tissue somewhere so it grows it in
- 29:49the back of the tongue where it can.
- 29:50Then the bottom here is a child
- 29:52with tongue based obstruction.
- 29:54So the lingual tonsils are not large.
- 29:56But you can see the epiglottis is
- 29:57plastered to the posterior pharyngeal wall,
- 29:59not from lymphoid tissue,
- 30:00just from the tongue falling backwards.
- 30:02And then that's causing some degree of
- 30:05airway obstruction if you jaw thrust
- 30:06them or got them an oral appliance
- 30:08that would pull things forward.
- 30:10But oral appliances are tricking
- 30:12kids because they're constantly
- 30:13growing and they're losing teeth
- 30:14and it's not covered by insurance.
- 30:16And so that is a tricky thing for a kid,
- 30:20but sometimes I have had one or
- 30:22two over my career pay for and
- 30:24get an oral appliance,
- 30:25have it adjusted and it
- 30:27helps them a little bit.
- 30:28And then finally, Laryngo Malaysia,
- 30:30tracheal Malaysia.
- 30:30And so this is a sleep endoscopy of
- 30:33a child who's storing like crazy but
- 30:35didn't have any tonsils or adenoids.
- 30:37They've got some lymphoid tissue
- 30:38with the tonsils used to be,
- 30:39but now you can see there are retinoids
- 30:42or prolapsing in every time they're
- 30:44breathing and that's sleep dependent.
- 30:46Laryngo Malaysia.
- 30:47So or state dependent depending on
- 30:49on how you say it, where you're from.
- 30:52And so if we do what's called a super
- 30:54glodo plasty and open up the larynx,
- 30:56that will take care of that problem.
- 30:59All right. So let's look at some other cases.
- 31:02So this is an 8 year old boy
- 31:03who had a T&amp;A when he was five.
- 31:05He did great and now he's back in
- 31:07your clinic. Three years later,
- 31:08symptoms have returned.
- 31:10We scope them in clinic.
- 31:11This is the scope view.
- 31:12In clinic, it's upside down from the sleep
- 31:15endoscopy videos that I've been showing you.
- 31:17So in general, when an otolaryngologist
- 31:18talks to you about airway and you're like,
- 31:21why are you showing me a
- 31:23disorientation and this orientation,
- 31:24we're hardwired to think of our clinic
- 31:27exams this way, where the posterior.
- 31:29Andrew Wall is at 12:00 o'clock and
- 31:32the tongue is at. 6:00 o'clock.
- 31:33But in the operating room we
- 31:36switch it around 180 degrees.
- 31:37We'll show you these videos
- 31:38and nothing twice about it.
- 31:40We don't even see it.
- 31:41But I try to as I was putting the
- 31:43stock together, I'm like, Oh yeah,
- 31:44I should try to keep that straight.
- 31:45So that's why you will sometimes see this.
- 31:48So he's a little overweight and not obese.
- 31:50He has no adenoids, no tonsils.
- 31:51And then he's got this tongue
- 31:53based obstruction.
- 31:53And so now in the OR when you
- 31:55do your sleep endoscopy again
- 31:56the orientation switched here.
- 31:58Now you can see like it looks even
- 32:00worse and this is that epiglottis
- 32:01getting pushed backwards by those.
- 32:03Big, heavy, lingual tonsils.
- 32:06This is a video from my friend Vikash Modi.
- 32:09I do a bunch of these surgeries,
- 32:10but I'll be honest with you,
- 32:11I I don't always video them.
- 32:13But he's great about taking videos.
- 32:16And so I asked him to borrow this
- 32:18and he's he has great videos.
- 32:19So these are large lingual tonsils,
- 32:21and this is exactly what I do.
- 32:23So we take this thing called a poblador
- 32:25that kind of liquefies the lymphoid tissue.
- 32:27And sometimes you've got to readjust
- 32:30your laryngoscope to get all the
- 32:32different areas and nooks and crannies.
- 32:34And so here he's ablating all
- 32:36that lymphoid tissue down to
- 32:38the actual tongue musculature.
- 32:40And this is a lingual tonsillectomy.
- 32:43You can find a plane and dissect it all off,
- 32:46but it's challenging and you run
- 32:47the risk of a lingual artery bleed,
- 32:49which is a very bad problem.
- 32:50And so most of us just ablade it like this.
- 32:53And when you're done now all that
- 32:55lymphoid tissue has been released
- 32:57and now this is your epiglottis.
- 32:59And that lymphoid tissue is better
- 33:01in cases where the epiglottis is
- 33:03prolapsed backwards and you remove this
- 33:05lingual tonsil and it doesn't just
- 33:07spring back to where it needs to be.
- 33:09You can resuspend the epiglottis,
- 33:11and this is called an epiglottis apexing.
- 33:13And we take sutures and we grab the base
- 33:15of tongue and this is all operating
- 33:17down the shaft of the laryngoscope.
- 33:20So it's tricky.
- 33:21It's like operating through a
- 33:23toilet paper roll and then you grab
- 33:27the mucosa over the epiglottis.
- 33:29And you tighten these sutures down
- 33:31and it pulls that epiglottis up
- 33:33into the base of tongue and lifts it
- 33:35forward so it can open your airway.
- 33:38And so this is after you've cut your
- 33:40knots and that's sort of now what
- 33:42your airway is going to look like.
- 33:44And then this is in clinic again,
- 33:45orientation switched and that epiglottis
- 33:47is now pulled upwards and you can
- 33:51now see the airway much better.
- 33:53Um, here's another kid, 2 year old girl.
- 33:56She's snoring.
- 33:57Apneic pauses at night, occasional gagging.
- 33:58You ready to do your tonsillectomy?
- 34:00She's got no tonsils, no adenoids.
- 34:01What's going on?
- 34:02So you scope her and now she's got this
- 34:04big cyst called the molecular cyst
- 34:06that's sitting by the base of her tongue.
- 34:08So we take her to the OR, we remove that.
- 34:10It's going to solve all your
- 34:12problems and she's better.
- 34:13But she's still snoring a lot and now
- 34:15this is what's happening to reply glottis.
- 34:17Every time she breathes,
- 34:18it gets pulled down.
- 34:20And the reason it's prolapsing is because of.
- 34:23That cyst has weakened the epiglottis.
- 34:25It's not as strong as it normally is.
- 34:27And so then this is a case when we
- 34:29would do that epiglottic paxi again,
- 34:31which I just showed you here.
- 34:34There's no lingual tonsils,
- 34:35so you don't have to do that
- 34:37Co bladder removal.
- 34:38Here you would just in the operating
- 34:41room put this laryngoscope in and
- 34:43then with a laser or cautery roughen
- 34:46up the area of the vallecula,
- 34:49which is what's right in there.
- 34:51And then so this is where the
- 34:53CO2 laser removing that mucosa,
- 34:55making it raw and sticky.
- 34:57And then now you place your sutures
- 34:59and that will pull that epiglottis
- 35:00up towards the tongue and remove
- 35:02that retro lingual obstruction.
- 35:06Then we can get into the syndromic kids,
- 35:08and these are the population
- 35:09that I take care of the most of.
- 35:10And so this is a child with
- 35:12Treacher Collins syndrome,
- 35:13with he has mild Treacher Collins,
- 35:15but still causing significant
- 35:17obstructive sleep apnea.
- 35:19A lot of times these
- 35:20kids will have a high IQ,
- 35:21but they're saturator is
- 35:22really what scares you.
- 35:23He's completely unable to tolerate
- 35:25CPAP and he was supposed to have
- 35:27a trick at another institution.
- 35:28They came to see me the day before
- 35:30the track as like a last ditch
- 35:31effort from like some creature
- 35:33Collins Facebook outreach because
- 35:34I take care of a lot of kids with
- 35:36TCS and I saw him and actually
- 35:38he just had four plus adenoids.
- 35:40That was his main problem.
- 35:41He had basal tongue obstruction but
- 35:42the adenoids were the real issue
- 35:44so we removed his adenoids and now
- 35:45he doesn't need to track it was
- 35:47that simple but he's still snoring.
- 35:48And so we repeat the SLEEP study and
- 35:51the ADENOIDECTOMY has helped him.
- 35:52Hi of 44 to 27 still severe.
- 35:55Sat Nader is like nominally better
- 35:57if not at the same and he's
- 35:59hypoventilating and so he needs a
- 36:01surgery and this is all tongue based
- 36:03obstruction and he has a small jaw.
- 36:05And so with a sleep endoscopy,
- 36:07this is what things look like.
- 36:08And if you jaw thrust him you can
- 36:10see how this would open his airway.
- 36:11So we need to do a surgical job thrust
- 36:13and the way we do that is something
- 36:15which is an orthognathic surgery
- 36:17which is called mandibular distraction.
- 36:19And so this is his.
- 36:20CT scan and we will plan a osteotomy
- 36:22through the mandible here and we
- 36:24attach hardware on either side and we
- 36:27then are done in the operating room
- 36:29and we wait for two or three days.
- 36:31And as the bone is starting to
- 36:33heal but not fully healed,
- 36:35we then start to slowly separate
- 36:37the bone and the millimeter a day.
- 36:39We extend that mandible forward and
- 36:41as long as you do it slowly enough,
- 36:43you stretch the nerve within here
- 36:45and you let that bone keep growing,
- 36:47growing and then you can basically
- 36:48jaw thrust him and move that jaw.
- 36:50Forward now we overcorrect him
- 36:52and he will need a surgery on
- 36:54his maxilla when he's older.
- 36:56But remember these are all baby
- 36:57teeth and so they fall out and
- 36:59the new ones come in and they
- 37:01often align in a better position.
- 37:02And so here he is after 10.5 millimeters
- 37:05of advancement of his mandible.
- 37:07This is his scar on his jaws.
- 37:09Now forward and we go back,
- 37:11remove the hardware and this
- 37:12is the bone that we've grown.
- 37:13You can actually see it.
- 37:15And that's brought his jaw forward
- 37:17to centimeter and now it's really
- 37:19just tongue based obstruction.
- 37:20And then you repeat your sleep study
- 37:22and you think it's going to be better,
- 37:24probably not cured.
- 37:25And you see this and you're like,
- 37:26that's awesome.
- 37:27Let's never get another sleep study.
- 37:28So that's a kid who's gone from 27 to .9.
- 37:31That's a mic drop as a surgeon.
- 37:33And then, you know, 6872 to 91%.
- 37:36And so he no longer snores
- 37:38and he's doing great.
- 37:40Now as he gets older and
- 37:42starts to outgrow his jaw,
- 37:44he will start to have some symptoms.
- 37:46And then we follow him with sleep studies.
- 37:47And if it's bad enough,
- 37:48we do another surgery.
- 37:49But this is a child.
- 37:50It was supposed to have a tracheotomy
- 37:52and now he has cured sleep apnea
- 37:55with that orthognathic surgery.
- 37:56And you can see now as time goes on,
- 37:59his front teeth are on,
- 38:01his upper teeth are in
- 38:02front of his bottom teeth,
- 38:03so he actually does not have
- 38:05an underbite anymore here.
- 38:06He does a little bit on the sides,
- 38:08but he's able to eat normally.
- 38:10This is a kid with Piero band
- 38:12sequence and Down syndrome,
- 38:13which is pretty remarkable.
- 38:15He was trached but behaviorally difficult,
- 38:18so he just pulled his tricked out
- 38:19and threw it across the room.
- 38:21And refuses to wear it.
- 38:22And so now severe sleep apnea.
- 38:25So we do this jaw distraction that will
- 38:27lengthen both this part of the jaw,
- 38:29the raymus and the body.
- 38:31And this is how much we grew for him.
- 38:33And he still has a small
- 38:34jaw and a small shin,
- 38:35but this was the difference between
- 38:37severe obstructive sleep apnea and
- 38:39getting him down to like an HIV.
- 38:40And I think he was like 7 and he's 20.
- 38:44And so for Down syndrome HIV,
- 38:467 satinath or if it was
- 38:5088 will will tolerate.
- 38:52And he's a candidate,
- 38:53you know, later he could have a
- 38:55hypoglossal nerve stimulator.
- 38:56That could be a possibility, though.
- 38:58He would take off his,
- 39:00his, you know, magnet,
- 39:01throw it across the room
- 39:03and that would be that.
- 39:04And then finally,
- 39:05nonsyndromic 16 year old girl I've
- 39:07been following since she was eight
- 39:09when I did a tonsil and adenoidectomy.
- 39:12She still was snoring so we did sleep
- 39:14endoscopy and she had laryngomalacia
- 39:16and tongue based obstruction.
- 39:19and she got another sleep study at age 12,
- 39:22mild sleep apnea,
- 39:23and we just sort of limped along like that.
- 39:26And she did OK.
- 39:27But then she started to get worse,
- 39:30tied daytime somnolence.
- 39:31And so she was on CPAP not
- 39:33tolerating it by age 16.
- 39:35And then
- 39:36when we do our sleep endoscopy,
- 39:38she has bad airway obstruction
- 39:39to the point where I have to
- 39:41put a nasal trumpet in her.
- 39:43And here I'm feeling for the thyroid
- 39:46medical, so and the distance.
- 39:49On the thyroid. To the mandible.
- 39:52And you can see on your CT scan
- 39:54they're like right on top of each
- 39:55other and that's why she has
- 39:57this tongue based substance. And
- 39:59so in this case the best thing
- 40:00to do is bring her jaw forward.
- 40:01And you could do that with the
- 40:03distraction like I showed you,
- 40:04but in an older kid who's 16
- 40:06and pretty much done growing,
- 40:08you can just do an MMA mandibular
- 40:11maxillary advancement.
- 40:12And so there we bring both jaw
- 40:14and maxilla forward and this is
- 40:16one of the only surgeries in the
- 40:17sleep literature that's shown
- 40:19to be pretty high reliability.
- 40:21And so we do that for her and then
- 40:24bring everything forward and played
- 40:26her maxilla or mandible to maintain
- 40:28her occlusion and that cured her sleep apnea.
- 40:31All right.
- 40:32We are almost done.
- 40:33I just want to say a couple
- 40:35things about infants.
- 40:36Because infant sleep apnea is different
- 40:38than older kids sleep apnea and
- 40:41very much different than adult sleep apnea.
- 40:43Infants are obligate nasal breathers.
- 40:45If you have an adult and you just.
- 40:48Clothes pin their nose shot at night.
- 40:50They will open their mouth.
- 40:52They'll be miserable and uncomfortable.
- 40:54They'll wish they had Afrin or something to
- 40:55open them up because it's a terrible cold.
- 40:57But they're fine in a baby.
- 40:59If you plug their nose completely,
- 41:01they will die.
- 41:03They are obligate nasal breathers.
- 41:05They absolutely must be able
- 41:06to breathe through their nose,
- 41:08at least a little bit.
- 41:09When we have babies born with a rinia,
- 41:11meaning no nose,
- 41:12they obstructed birth and they are.
- 41:15They can't eat and we have
- 41:16to do a tracheotomy for them.
- 41:19And so the nose is very important
- 41:20in the baby in a way that we don't
- 41:23think about it as mattering so much.
- 41:25In older kids and adults.
- 41:28When a baby has nasal obstruction
- 41:30and they often present to me,
- 41:32I see at least three a day with bad
- 41:34nasal obstruction, obstructing,
- 41:36stopping, eating.
- 41:37We usually just put them on some
- 41:40nasal saline or nasal steroids and
- 41:43infants will get this sort of progesterone,
- 41:46maternal estrogen withdrawal.
- 41:48Thing that happens where their
- 41:51noses will get very,
- 41:52very swollen and sometimes will,
- 41:54they'll have a lot of problems.
- 41:55We call it rhinitis of infancy.
- 41:56It usually wears off around three
- 41:58to six months of age,
- 42:00but if you can't wait that long,
- 42:01if you give them nasal steroids,
- 42:03it often just completely eliminates
- 42:05it within two weeks.
- 42:06And so that's a that's a nice move
- 42:08in your back pocket for infants with
- 42:11nasal obstruction that's related to edema.
- 42:13On those that can't breathe
- 42:15and eat and have Strider,
- 42:16we do a supraglottic plasty
- 42:18for those with narrowed.
- 42:19Interform apertures,
- 42:20the openings of the nose.
- 42:22Here we will do a drill out of
- 42:24that to open their nose up.
- 42:26If they've coined latricia,
- 42:27so a dead end in the back of their nose,
- 42:30then we will fix that and then
- 42:32you can expand their pallets.
- 42:34And I just told you how it
- 42:36helps with snoring.
- 42:36It's not going to make a big
- 42:38difference for sleep apnea
- 42:39in adults and older kids,
- 42:40but it helps in younger kids and it
- 42:43really helps in infants if that's
- 42:45actually what their problem is.
- 42:46And then there's baby jaw distraction.
- 42:48I showed you a 17 month.
- 42:50But we do it in newborns
- 42:52and of course tracheotomy,
- 42:54this is a newborn with Piero
- 42:56band sequence in Micronesia.
- 42:58And you can see the tongue is so far back,
- 43:01it's in the baby's nose,
- 43:02it's actually prolapse through a
- 43:04cleft palate and that's the nasal
- 43:06septum in the midline back there.
- 43:09And that tongue is touching the nasal
- 43:12septum through the powerful flap.
- 43:14And now the baby is 100% obstructed.
- 43:16That happened this year.
- 43:19Oh good, that's
- 43:20genuine apnea. Yeah,
- 43:21that's genuine happiness after
- 43:22we do our jaw distraction, this
- 43:24is the same baby four days later.
- 43:296 millimeters of activation
- 43:31that we brought his jaw forward,
- 43:326 millimeters at this point and
- 43:34now he's supine hanging out,
- 43:36giving me the side eye.
- 43:38So bringing that baby's jaw forward
- 43:40just 6 millimeters at that point
- 43:42will make that much of a difference.
- 43:44Piriform aperture stenosis.
- 43:45This is the normal pyriform aperture,
- 43:48pear shaped. That's why it's pure form.
- 43:50And then this looks like a box
- 43:52or a keyhole and that makes
- 43:54very very narrow nasal cavities.
- 43:57So we drill that out.
- 43:58Or you can actually make Bony cuts here,
- 44:01attach hardware and expand the palette.
- 44:06This is called a Sarpy or a surgically
- 44:09assisted rapid palatal expansion.
- 44:10So you make cuts here and here and
- 44:12right here in the midline attach a
- 44:15distractor and it will allow you to open it.
- 44:17I'm showing you a larger patient and this
- 44:19is a 10 year old with Apert syndrome,
- 44:21which is craniosynostosis with
- 44:23premature fusion of the skull sutures.
- 44:26The suture,
- 44:27as orthodontist will tell you
- 44:28in the mid palatal suture here,
- 44:31is open and stays open until
- 44:33you're like 1318 years old,
- 44:35which is why you can attach a paddle.
- 44:37Spander turned that key.
- 44:38It hurts like hell,
- 44:39but it expands your palate.
- 44:41That says the suture is open in
- 44:43syndromic children that have
- 44:44premature fusion of their sutures,
- 44:46such as this kid with Apert syndrome.
- 44:48The pallet can't grow or expand
- 44:50and look at her teeth.
- 44:52And so the only way to expand them,
- 44:54since it's completely fused,
- 44:55is to make these cuts,
- 44:57reopen that suture with an
- 44:59osteotomy and attach your hardware.
- 45:01And now we make that pallet longer, wider.
- 45:03And that helps a lot with their dentition,
- 45:05and it does have the side effect
- 45:07of improving the nasal obstruction.
- 45:08You can do this to an infant,
- 45:10but infants don't have teeth.
- 45:11And so here we are,
- 45:12having drilled out that pyriform
- 45:14aperture on this infant.
- 45:15Here's our this has prematurely
- 45:17fused in utero, so we reopen it.
- 45:20There's our cuts and the distractor
- 45:21that we put on them.
- 45:22Because they don't have teeth
- 45:24is a little acrylic plate.
- 45:25We screw it into the palette
- 45:27and then we can turn this.
- 45:30And that will open the palette and that
- 45:33will relieve their nasal obstruction.
- 45:35But it's very uncommon.
- 45:37I think I've done like 3,
- 45:39but but it, it, it can be used.
- 45:41And so those are like the most aggressive
- 45:44Bony orthognathic interventions
- 45:45in infants and young children.
- 45:47So we've reviewed the pediatric ENT
- 45:49perspective regarding the workup and
- 45:51management of sleep disorder breathing
- 45:52and if you have a sleep study,
- 45:54obstructive sleep apnea,
- 45:55we talked about surgical strategies
- 45:57for regressing for addressing both
- 46:00recurrent and persistent airway
- 46:01obstruction after T&amp;A and we talked
- 46:04about some orthognathic procedures.
- 46:06And at that point,
- 46:07I'm going to stop and open it
- 46:08up to questions.
- 46:09Please feel free to unmute yourselves.
- 46:15Thank you, Andrew.
- 46:16I just had a quick question since uh,
- 46:19we do see some of these kids,
- 46:21uh with you, uh, what you know,
- 46:23we parents typically ask us about the
- 46:27regrowth of the tonsils opposed TNA.
- 46:30But the adenoids we always talk about,
- 46:32regrowth of adenoids can occur if
- 46:34they are allergic and have allergies.
- 46:36Seasonal allergies.
- 46:37What about the lingular
- 46:39tonsillar hypertrophy?
- 46:41How how often do you see big currents
- 46:43with these or adenoids in general?
- 46:45Yeah, those those are great questions.
- 46:48So First off, I think you want to
- 46:50think about the age of the child.
- 46:52So the chances of the adenoids growing back,
- 46:54regardless of the technique you use are much
- 46:57higher if you remove the adenoids underage 2.
- 47:00So kids who have adenoidectomy under
- 47:02two and it's sort of self selects
- 47:04for those that have some sort of bad
- 47:06disease or problem to begin with.
- 47:08Those are the ones who are
- 47:09more likely to have regrowth.
- 47:11It's still low,
- 47:12but it's more common if you're removing
- 47:14the adenoids than a kid over 2/3, even four.
- 47:17It would be very unlikely for
- 47:19those adenoids to come back.
- 47:21It's really the younger kids that do that.
- 47:23The tonsils.
- 47:24We have two ways of removing them.
- 47:25One is called an extra
- 47:27capsular tonsillectomy,
- 47:28which is their standard tonsillectomy.
- 47:30And then there's something called
- 47:32a tonsillectomy or an intracapsular
- 47:35And that's where we shave the tonsils
- 47:37down and we remove them from the inside out.
- 47:40So the tonsil is like an egg with a
- 47:43shell that sits in the tonsillar fossa.
- 47:45And when you do tonsillectomy,
- 47:46you remove the entire tonsil,
- 47:48including the shell like a hard boiled egg.
- 47:50It all comes out for tonsillectomy.
- 47:53You leave the shell and you take
- 47:54out the egg white,
- 47:55the egg yolk,
- 47:56everything and that shell stays,
- 47:58and then you cauterize the shell and
- 48:01that has a lower bleed rate and a
- 48:04little bit better pain afterwards.
- 48:07The downside of it is that it has a higher,
- 48:11though not high but higher chance
- 48:14of regrowth.
- 48:15And I have definitely like a few times a
- 48:18year I see regrowth from tonsillectomy.
- 48:21I don't do a lot of tonsillectomy
- 48:22in younger kids.
- 48:23Because I've seen so many regrowth and the
- 48:25parents are pretty unhappy when that happens,
- 48:27because now you got to go through
- 48:29the whole thing all over again.
- 48:31And so, but for those that don't regrow,
- 48:33you know you've you've got an
- 48:35easier recovery and and it worked.
- 48:37So plenty of places will do that but
- 48:40otherwise the tonsil shouldn't grow back.
- 48:42If you do an extra capsular tonsillectomy
- 48:44and then the lingual tonsils,
- 48:45we you know, ablate them down and
- 48:47they usually do not come back.
- 48:49I personally have never seen
- 48:51lingual tonsils return,
- 48:52but it can happen.
- 48:53You're more likely to grow lymphoid
- 48:55tissue in a weird place than to
- 48:58regrow your lingual tonsils.
- 48:59I'm going to get to another question.
- 49:01Somebody asked about ages of CPAP.
- 49:04I have started plenty of infants on CPAP.
- 49:07You will do a super glottic
- 49:09plasty and they'll get better,
- 49:10but not good enough.
- 49:11You put them on CPAP and we can wean
- 49:14them off cpap by 910 months of age.
- 49:16And then their sleep studies fine
- 49:18and they're good to go.
- 49:19But it really helps them for
- 49:21gaining weight because if you have
- 49:23a kid with such bad laryngomalacia
- 49:25that they're weak and hypotonic
- 49:27from their failure to thrive
- 49:28and you do your intervention.
- 49:30And they still can't quite catch up.
- 49:31You're catching up to weakness
- 49:33and hypotonia and that that CPAP
- 49:35sort of allows them to rest.
- 49:36And so that's just a few months.
- 49:38I've had other kids with cerebral palsy
- 49:41who have been on CPAP for years and years.
- 49:44The downside of that is that it
- 49:46can cause mid face retribution if
- 49:48those straps are tightened up and
- 49:50you're yanking it back enough.
- 49:51And that may require an
- 49:54orthodontic intervention,
- 49:55but you can do it for a while.
- 49:56You just want to be able to readjust
- 49:59your settings, right?
- 50:00Because like your pressure
- 50:01settings will change as the child
- 50:03grows and and and time goes on.
- 50:05Another question was really we
- 50:07see patients with an increase in
- 50:09HIV after TNA in Down syndrome.
- 50:11Yep, absolutely.
- 50:12That can happen and is a bummer.
- 50:17And that's a lot of sort of hypotonia
- 50:20at play and interval growth at play.
- 50:23It's less likely that a Down syndrome,
- 50:26OK with Down syndrome who's done
- 50:28growing will have a TNA and then.
- 50:30Be worse.
- 50:31I suppose it could happen,
- 50:32but there's also the test retest
- 50:34reliability of your sleep study.
- 50:36But often you will see a child who's
- 50:38younger with downs and then you
- 50:40do their T&amp;A and they're better.
- 50:41And then as they grow their
- 50:44mid face deficiency,
- 50:45their retro paddle obstruction,
- 50:46their relative macroglossia because
- 50:48the rest of their mouth isn't growing,
- 50:50but their tongue still growing with them.
- 50:52That contributes more than that's going
- 50:53to give you more of the severe OSA.
- 50:55That is a population that needs to
- 50:57be followed closely and it's also a
- 50:59population that sometimes you need to decide.
- 51:02Like how closely do you want
- 51:03to be doing this?
- 51:03Because each time you follow
- 51:05and you get that sleep study,
- 51:07like you feel obligated to
- 51:08do something about it.
- 51:09And for some kids, like wow,
- 51:11this is really important for
- 51:12heart strain and whatnot.
- 51:13But for other kids,
- 51:15depending on how highly functioning
- 51:17Down syndrome they are, you know,
- 51:20the, the, the mild.
- 51:22Let's admit it.
- 51:23The mild neurocognitive effects on
- 51:24the nonverbal Down syndrome kid.
- 51:26That may not be worth the struggle of
- 51:29putting that mask on every 10 minutes
- 51:31all night long on a combative child.
- 51:34And so one has to think about about that.
- 51:39That's a broader discussion.
- 51:42All right, keep them coming.
- 51:43What else you got?
- 51:47Hey, Andrew, very nice talk.
- 51:49Really fun to see the other side of sleep
- 51:52apnea management when we oftentimes are.
- 51:55That's not involved in these more
- 51:57invasive procedures and obviously
- 51:58they work in the right person.
- 52:00So one question I have
- 52:01for you is that you know,
- 52:03there's in the sleep apnea literature,
- 52:05there's some data coming up for us to,
- 52:07you mentioned epiglottic
- 52:09prolapse or collapse and kids.
- 52:11And so it's starting to get some
- 52:13literature showing that you can sort of
- 52:15pick out who has that collapse in adults.
- 52:17And we know that those individuals
- 52:18tend to do worse with CPAP,
- 52:20you know, makes the collapse
- 52:21worse and they can't tolerate it.
- 52:23And so I was trying to think of
- 52:25what are the surgical options?
- 52:28You know, for adults,
- 52:29if you're aware of them and
- 52:30you know and if so,
- 52:32do you have a sense of success
- 52:33of these procedures because at
- 52:34least personally I have at least a
- 52:36couple of patients that have that
- 52:38pattern of epiglottic prolapse and
- 52:39have a really tough time with CPAP
- 52:41and maybe they're like better,
- 52:42a little bit better with oral appliance,
- 52:44but and So what?
- 52:47Perhaps is occurring how low it is
- 52:49that you really have to Jack the
- 52:50pressure up and then they're the
- 52:52ones that it's going through their
- 52:53upper softgel sphincter and they
- 52:54can't tolerate and they hate it.
- 52:57So our field is interesting.
- 53:00So like we all do adult and pediatric
- 53:03training as our general core residency.
- 53:06But then if you do a sleep fellowship
- 53:09that's all adults and if you do Pediatrics,
- 53:11you don't do any sleep other than
- 53:13just whatever we just talked about.
- 53:15Now there is some important overlap.
- 53:18And I definitely do much more
- 53:20adult flavored sleep surgeries
- 53:22than most pediatric allergists.
- 53:24But there are some pediatric allergology
- 53:27sleep interventions that are pretty
- 53:29Mickey Mouse basic to us that sleep
- 53:32adults sleep otolaryngology trained people
- 53:34will have never seen and never done and
- 53:37have no idea what you're talking about.
- 53:39So if I showed you know Tucker Woodson like
- 53:42the the lingual tonsillectomy with epilepsy,
- 53:46he would be like,
- 53:47I don't even know what that is.
- 53:48So they don't do that in adults.
- 53:50They'll do hyoid suspension.
- 53:52They'll suspend the hyoid to the mandible or
- 53:56or try to Pepsi the epiglottis up that way.
- 53:59But the data shows that doesn't work.
- 54:02If you do you triple P
- 54:05and a hyoid suspension,
- 54:06you will lower your HIV more than
- 54:08any one of those individually,
- 54:10but you still don't lower it
- 54:11enough to cure the sleep apnea.
- 54:13And those with higher BMI and those
- 54:16with higher HI are predictably.
- 54:18Gonna fail.
- 54:19And so those procedures though
- 54:21still have use.
- 54:23So you could do them and then
- 54:25maybe tolerate CPAP more because
- 54:26your pressures aren't as high.
- 54:28And so that's where I think that sleep
- 54:30surgeries are not always a cure all,
- 54:33but they can be a really helpful
- 54:35adjuvant to PAP therapy.
- 54:37And this is where I think like as the
- 54:40surgeons we want to be the Cowboys
- 54:41that come in and save the day.
- 54:43But it isn't always going to be like that.
- 54:45But there's still an important
- 54:47use of of helping someone.
- 54:49Going down on their pressures that
- 54:50might improve their compliance.
- 54:52And then in doing that you,
- 54:54you do this intervention and
- 54:56it's still useful.
- 54:57And if it's the difference
- 54:59between tolerating PAP therapy,
- 55:00you're not talking about therapy,
- 55:01then that is a successful surgery.
- 55:04It's just the definition of success
- 55:06in surgery is meeting expectations.
- 55:09That's the definition of success.
- 55:11So you just got to be honest
- 55:12about what you can and can't do.
- 55:14I think that some of these kids
- 55:15surgeries where you're wrapping up
- 55:17the base of tongue and your Pepsi,
- 55:18that epiglottis up, umm,
- 55:20I think that could be very helpful
- 55:22for some adults.
- 55:23But adults are very good at communicating
- 55:26when they are not happy with you.
- 55:28So that kid is much tougher.
- 55:30So the the TNA in a grown man is like
- 55:33gets a bell and rings it for their spouse.
- 55:37Bring me I can't talk,
- 55:39I can't eat too.
- 55:40Two weeks of agony,
- 55:42a month of medical leave and the
- 55:44three-year olds on the playground.
- 55:46You know, the next day running around
- 55:47like nothing happened with you.
- 55:48Saw that epiglottis up on a 40 year old man.
- 55:51They're going to be like, I'm choking,
- 55:52I'm dying. I know I would be.
- 55:54And whereas the child maybe can't
- 55:57talk yet or is nonverbal and they
- 55:59just take it and then they're fine.
- 56:01So I think it,
- 56:02it could be a leap to do those things.
- 56:05But I think there are things Pediatrics
- 56:07could help adults and there's definitely
- 56:09the adult stuff helps pediatric,
- 56:10but there's not enough cross pollenization
- 56:13within our own field in that regard.
- 56:15So long answer to your question, sorry.
- 56:18OK. Thank you.
- 56:22And if anyone else has a question,
- 56:23please feel free to let us know.
- 56:25We can unmute you or. You could post one.
- 56:30I don't see any more questions in the chat.
- 56:34I'm imagine you guys have had
- 56:36a lecture on hypoglossal nerve
- 56:38stimulation and all of that.
- 56:39You know, that's our latest pancia.
- 56:42As they expand the indications of that,
- 56:44you're going to see all
- 56:46the failures rolling in.
- 56:47If you haven't already, that's OK.
- 56:50Just know it's coming.
- 56:52When you make the criteria so strict,
- 56:55which you know they inspire does on purpose,
- 56:58then you know you're going to get your FDA.
- 57:00It's going to be good.
- 57:01And as soon as you start
- 57:02expanding and saying, oh,
- 57:03let's, let's bend the rules
- 57:04a little bit on this one,
- 57:05that's when those start popping up.
- 57:07So don't be discouraged
- 57:08when that starts happening.
- 57:09If you know what's coming,
- 57:10you will feel better about it.
- 57:13And so do you do inspire in
- 57:15adults and kids or just adults.
- 57:17So I have trained to do it and but
- 57:20I in practice I have not done it.
- 57:23My colleague who does PEDs has done
- 57:27been doing them in adults as well.
- 57:30So but I in the end was like I don't
- 57:32want to start seeing adults and filling
- 57:35my clinic with adult inspire patients,
- 57:38but I think it could be really helpful in
- 57:41pediatric cerebral palsy in particular.
- 57:43We've been doing it in downs
- 57:45and it's been helpful,
- 57:46but there are plenty who have failed and
- 57:48it's it's a good thing to try and downs,
- 57:50but it's really going to
- 57:52be the best in hypotonia,
- 57:54not just there's too much
- 57:56anatomic issues for downs.
- 57:58So it will be helpful,
- 57:59but where it will really
- 58:01crush it is in CP or people,
- 58:03hypotonic kids that it's
- 58:04going to be unbelievable.
- 58:09Yeah, we get an
- 58:10IRB in that population and and
- 58:13compassionate exemption is tricky.
- 58:15We've been sending our downs kits
- 58:17to doctor Hartnick and now last
- 58:21pioneer, yeah. We do it here. So
- 58:24he's. Yeah. So, you know,
- 58:26he's done, uh, several.
- 58:27But in reality when you look at
- 58:29the numbers, it's not that many.
- 58:31And he now is getting paid for it,
- 58:34but for the first, you know,
- 58:36eight years mass linear,
- 58:37just ate the cost of every
- 58:39device in every surgery.
- 58:43So tricky. OK.
- 58:46Good to know.
- 58:47Well, all right, very good.
- 58:48Well, thank you, Andrew.
- 58:49I think already and very nice,
- 58:52very nice session.
- 58:53Look forward to hearing from you
- 58:55sometime in the future and I
- 58:57will see you guys in one month.
- 59:01Thank you again for the everybody.
- 59:02Thank you. Great day everyone.
- 59:05Thank you.