"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.
04:34OK.
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,
13:33OK?
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.
14:46Yes,
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.
17:43Good.
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?
18:40Why?
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.
22:45So.
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,
25:34snoring.
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,
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,
39:05uh,
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.
39:18Um,
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.
40:21Success.
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,
42:02fluticasone,
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
47:34tonsillectomy.
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.