OSA in children has physical and behavioral consequences. Yet it’s challenging to diagnose and determine appropriate treatments, which range from monitoring to medications to surgeries. Pediatric otolaryngologist Jordan Virbalas, MD, clarifies the condition and who’s at risk; provides assessment guidance, including a snore-scoring tool and sleep study criteria; and presents a case for intracapsular tonsillectomy, a technique with advantages that include less post-op pain.
I'm Jordan verbal is I work primarily over the Oakland campus of the Benioff Children's hospitals. Um I have no financial interests in uh the diagnosis or management obstruction of obstructive sleep apnea. If anybody does know how to monetize it, please let me know. Um The goal of today's talk will be mostly to focus on that diagnosis and management of obstructive sleep apnea and kids. Um some of the more discreet objectives will be to identify those questions that um that helped to differentiate those at higher risk of obstructive sleep apnea to counsel patients regarding the medical and conservative management of obstructive sleep apnea and then describe the risks and benefits of different types of adding a tonsillectomy. Um, obviously this is uh you know, this is a decision that is often made by the surgeons and the patients, but very, very often I hear um that patients talks say they want to go talk to their pediatrician about the sort of risks and benefits of these alternatives. And I thought that it was only fair to to discuss them with you. So just to begin when we talk about obstructive sleep apnea without a sleep study to demonstrate that it technically meets criteria for obstructive sleep apnea. What we can say is that it's it's a sleep related breathing disorder or sleep disordered breathing. A lot of kids, 3-12 of kids have some form of snoring, which is on the spectrum of sleep-related breathing disorders, but only a minority of those kids have obstructive sleep apnea. I think that this this is probably the most important slide in this deck just to realize that this is a spectrum of obstruction. Kids that have occasional snoring. That occasional snoring is a manifestation of airway obstruction, right? That is air trying to pass some tissue and because it is either making the airflow turbulent or vibrating that soft tissue that's that's occurring because of obstruction. We have arbitrarily put a line somewhere to say, well this is the point at which that's too much obstruction. But that line is probably different for different kids. And you know, while probably not important to say that, gosh, some kids probably tolerate several episodes of apnea as every hour. I do think it is important to say that there are some kids that may have like really profound daytime symptoms, kids with you know, who are medicated for a. D. H. D. Where even if a sleep study demonstrated no sleep apnea but had regular snoring. There is lots of evidence to show that regular snoring without the presence of you know app knees and hip hop me is can have some very similar consequences to formal obstructive sleep apnea. So it's important to consider this as a spectrum and that there's not a single point at which pathology begins. Um and also that the piece peak incident is between three and six years. It's probably a manifestation of the uh, the particular phenomenon of growing tonsils and adenoids in a pediatric sized airway as they get bigger. That forensic airway gets bigger. Um but the growth of tonsils and adenoids is pretty rapid around this age where that airway is relatively small. So when you have a kid who comes into your clinic and you ask them about snoring and his mom says, yeah, you know, yeah, they, you know snore occasionally. Oh gosh. You know when they're really tired, you know, they snore loudly, but sometimes they snore quietly. What can you do to try to identify those kids that you know are are really manifesting a problem breathing at night and we don't have a an easy answer for that. But there are some questions that have been shown to be more valuable than others. I am showing you this clinical assessment score. Um In part because it's a it's a reasonable clinical assessment that you can do in your office. Um But mostly just to to show that these are some considerations that have been validated and shown to be internally consistent and reliable in identifying obstructive sleep apnea and kids. Um These these scores correlate with behavioral and sleep study findings, the external quality of life findings. Again, so we will, you know, we'll talk about a little bit later about sleep study as the gold standard of diagnosing obstructive sleep apnea. Um But you know, that is that's also somewhat of an arbitrary metric. Um Nonetheless, this correlates well to um obstructive sleep apnea in uh as seen on sleep study. So let's look a little bit more at this, this uh this metric. Mhm. You can ask about nighttime symptoms. So, if a child is snoring every night or most nights of the week, well, you know, we we see that in this metric getting you'll attribute more points to to those sorts of phenomenon. Then if they are snoring occasionally. So asking whether they snore and how frequently they snore is meaningful. If they if they have a witnessed pauses, oftentimes, I don't I can't just ask that I have to demonstrate it, which everyone thinks it's super fun. So I literally well open my mouth and show them that because there are a ton of times where I'll say, you know, does your child pause when they're breathing at night? That cause no, not at all. And then I do that and they say, oh, absolutely, that's exactly what she does. Um So, asking some of these questions about the pausing, the duration of pausing, are you seeing them work harder to breathe, or they do they have those gasping, catch up breaths afterwards. Do you hear choking while they sleep? Are they sleeping with their neck extended? All of those things have been shown to be two more closely correlate with an underlying obstructive sleep apnea. Daytime symptoms are also important. Um so hyperactivity is one of the most, and poor concentration is one of the most studied consequences of obstructive sleep apnea in kids. And it is, you know, somewhat contributes to this, this uh, predictive scale. So it is somewhat predictive of obstructive sleep apnea. If they have daytime hyperactivity, I do find that this is a tough question. Um if I say, oh my gosh, you know, do you is your is your child, you know, does your child have difficulty concentrating in school or more hyperactive compared to their peers? And a lot of families will sort of shrug and be like, he's a five year old boys bananas. I don't know, like teachers don't complain a lot of times. I'll use whether the teachers have concerns as a surrogate for for this particular question um or whether they have like how much stuff has been taken off the shelves in my office during our conversation as a surrogate answer for this question, um mouth breathing, chronic gonorrhea, both contributory physical exam findings. These are the things that we've been taught to look for right mouth breathing, hyper nasal speech. Um You know, less commonly, the adenoid face is the um sort of like the long, tall mid face with the bags under the eyes, um that high arched palate and tonsils sizes what we, you know, always always jump to. Um So this score has been uh, has been validated and has shown a difference between the mean scores of those kids that ultimately were determined by sleep study to have obstructive sleep apnea and those that did not Um if you choose a cut off score of 32, Um, it's a fairly sensitive test, 77%, it has a positive predictive value of 82%. Um again, like actually, you know, going through each element of this test is, I think, you know, not necessarily for every kids, but just having a sense of what sorts of questions have been shown to be predictive I think is really healthy. The next option. The, the only objective measure we have, right. It's super. It's frustrating both for providers and for family to say that we are going to decide uh, you know, whether your child needs treatment potentially need surgery based on what you report their symptoms to be. Um, You know, most parents, I find that most of my parents, my patients, patients, patients parents um are better at parenting their kids than I am because when my kids are asleep and that door is closed, that is the wind. I don't go back inside. I don't know whether they're snoring. I don't know whether they're waking up, but I find that a lot of parents are able to answer these questions. Um some of them are like me and I say, I don't know like I don't hear snoring um in, you know, I do well sometimes point out in patients that want to go back and our parents want to go back and look more closely. That snoring is most prevalent during rem sleep. And if they sneak in in the sort of our before the child typically wakes at night, that might be the time of sleep where rem is most likely most prominent And that might be a good time to observe them sleeping rather than when they've just fallen asleep at like 9:30 PM. Um But when that's not a good option when parents are not interested in making this decision or where they're perfectly, you know their observations which they're perfectly confident in, don't really push us. One way or another, a sleep study is an option. Um The vast majority of Children with sleep sleep disordered breathing um are treated without a sleep study. Um So I did not define those those abbreviations STB sleep disordered breathing. P. S. G. Polly sonogram, a sleep study. Um So it's not it's absolutely not necessary as a reserve, the reserve sleep study use for only certain occasions. The american Academy of Otolaryngology, head and neck surgery suggest that we use them for medically complex kids. Um That's primarily just because they're higher risk for anesthesia and higher risk for surgery. So before making a surgical decision a decision about the risks and benefits of surgery. It's more appropriate in those kids to have as much information as possible. Um Similarly if the need for surgery is uncertain, you know, you have a, so a kid today who's snoring, you know some days of the week but it's you know it's about half the day, maybe a little more than half the nights of the week. Never seem to be struggling to breathe, no pauses. But he has a diagnosis of A. D. H. D. And I want to know, you know I don't wanna I don't wanna under treat his obstructive sleep symptoms. So I'm going to get a sleep study for. Um And and then you know it's not uncommon that I look at a kid anatomically. Everything is is normal. The tonsils are normal. No nasal obstruction. Have either gotten a lateral neck film or put a camera in their nose to look at their adenoids. And the adenoids look normal. But parents report really dramatic persistent snoring, dramatic pauses at night. I want to get a sleep study to confirm the presence or absence of those symptoms. So let's look at what we get when we look at the result of a sleep study. So they're going to they're going to total the number of apnea And hypotheses that occur every hour apnea in a child is a pause that is to breath cycles in duration. So it's quite a while right? So a lot of parents will say like it causes all the time. And and you find that that's really just sort of a, you know, a second or two Very it's very unlikely that that will count as an apnea on a sleep test. Um A hypomania. There are a couple of different definitions, but typically it's a drop in an the the the air flow through the nose and mouth with a concomitant drop in oxygen level. Um, the, so you can, you can see again that in sleep study the duration of those pauses. The definition of a hypothermia is, you know, it's it's very smart, thoughtful people came up with these definitions, but there's no uh, there's no nothing to say that, You know, a drop, 30 decrease in volume of air through the nose and a concomitant. 3% drop in oxygen is, you know, is a problem, but a, you know, 2.5% drop in oxygen is not. So these cutoffs are are necessarily arbitrary. We also look at the lowest oxygen saturation if the age i is, you know, Only a few times an hour, but the oxygen is dropping below 80%. We'll still call that a severe obstructive sleep apnea. So that is that can be a meaningful metric to um I think it is important to look at how we define obstructive sleep apnea based by the number of events per hour. If we have a child who is, who has a severe obstructive sleep apnea, that's more than 10 events per hour, that's an event every six minutes. So if parents are peaking their head in the room, watching their child breathe for a minute or two and don't see an apnea, they could they could still have a really profound obstructive sleep apnea that's being overlooked. So, if parents described to you witnessed pauses and gasping and choking, that's that's pretty telling that the kid has a problem. So once we identify a problem, whether that's based on clinical signs and symptoms or whether it's based on a sleep study results, what are our options before we send somebody to see a surgeon? Well, If it's a mild or moderate obstructive sleep apnea, we have studies that show us that if we repeat that in a year, about 50 of them are going to get better. So in somebody with no daytime symptoms where they're not complaining about hyperactivity or, or uh, attention deficit, it's reasonable to consider observation. I probably air on the side of treating, but that may just be a bias. In my perspective. It is, it is many of these kids improve over the, over the course of the next year. That may just be because the degree of obstruction is uh is a not just a matter of tonsil size, which is unlikely to change dramatically in a year, but it's trying to look in my mirror or my camera how big the council is relative to the pharynx. So if the Ferencz grows really dramatically over the course of the year, there was going to get better. So it's about a 50% chance that the airway grows more than the council and about a 50% chance that the council grows more than another option. Supportive respiratory care, noninvasive positive pressure. So CPAP is something that we can use for usually reserved for severe obstructive sleep apnea. Um, but not always. Um There are some kids with mild obstructive sleep apnea that are either core surgical candidates who want to try CPAP. I find that this is um not often very well tolerated. Um So it's not there. There are very few patients that I that I that I use CPAP as a first line treatment. Um International steroids have been shown to both improve these obstructive symptoms, improve ai and shrink the volume of adenoids. So that is a reasonable first line treatment. Um I put this photo up here because it is one of a I think the only photograph I found on the internet that showed appropriate use of um of a nasal steroid. Keep in mind that the front of the nose is just nostril. There's no swollen tissue in there, There's nothing to shrink there. So when people put their the Flonase up the nose in in this direction is just gonna hit the nostril and drip back out and provide no benefit. So just like this guy is doing, you gotta point the the nozzle back a little to the side. So I tell him to point to the ear on the same side. You can also see that this is an adult who very carefully is covering the contra lateral nostril and probably taking a deep breath in while they do it. Kids are crummy at that, they're super bad at using nasal steroids and that's why directing it is additionally important because they're just not going to coordinate that sniffin at the same time. So you really wanted to hit the turbulence. You wanted to go back and hit the adenoids which are way back between the ears. Um And then finally Monta Lucas is a is a treatment that we that has been shown to shrink the volume of tonsils and uh improve the H. I. In a number of studies I would like to point out two things. Number one, all of the studies that I have seen and are aware of were sponsored by people who manufacturer Montella Cast and number two it is now carries a black box warning from the FDA. And this is no longer an appropriate indication. Shrinking councils and adenoids is no longer an appropriate indication for management of counselor hypertrophy and obstructive sleep apnea and kids. Um That is due to some of most kids taking um Monte Lucas will have a certain amount of jitteriness um like they sort of had a cup of coffee and then I find that a certain percentage of them, whether it's just the way that they interpret that generate this, they feel a great deal of anxiety and have extraordinary, extraordinary uh mood, liability and anxiety. So um so that is no longer um indicated for management of structures so that the kids I do. So with regard to management of nasal congestion and adenoid hypertrophy, this is taken from the Cochrane Review. Um It shows that five of the six randomized controlled trial that they looked at, which covers an array of nasal steroids um showed good efficacy relative to a placebo. I think it is important to note that in almost all of these studies, they were looked, these kids were looked at for at least four weeks. Um It is very often that I hear patients will come to me and they'll say, yeah, I tried that, that, you know, Flonase, you know, for for you know every day for a week and it didn't make any difference. So, you know, I stopped it, Um it's very unlikely to make any difference in a week. I say it's not it's not considered a trial until they failed after a month, and I really recommend two or three months to try using it. Um Similarly, this is not a PRN medication so patients will come and say like yeah I never really you know stuffy nose, I use it but it doesn't help. There are medicines that work that way, right? So Afrin and neo safran squirted in your nose. It works right away. Nasal steroids are not one of those medicines. It does not work right away. It may loosen mucus and help you sneeze it out but it's not gonna cause any significant decrease in the size of the turbine. It's it's certainly not a significant decrease in the size of the adenoids. So in kids who don't want to use nasal steroids have failed nasal steroids. Um and we want to help manage obstructive sleep apnea. We have lots of targets and you're kindly local otolaryngologist can help identify the most appropriate targets. So you know if you have Big giant adenoids in the back of the nose, that's a nice easy one. Big tonsils back here. Um turbinate hypertrophy. You can cause nasal obstruction. It's not typically a meaningful cause of obstructive sleep apnea, but it can contribute to it. Um Superglue capacity is it helps to address obstruction at the level of the epiglottis or super galactic tissue. Lingual tonsillectomy is reducing some of the obstruction of the tongue base. Um And a tongue based reduction removes the bulk of muscle at the tongue base. That's that's a relatively uncommon surgery reserved primarily for Adults or teenagers, often with trisomy 21. So as you can see just by the way I describe these, the sort of the mainstay of surgical management, obstructive sleep apnea and kids is adenoid ectomy in town selectively. So I'd like to talk a little bit more about that. Um Admiral, tonsillectomy is both a well is super common because it has been shown to be really effective. This is the the largest study on the efficacy event of tonsillectomy in Children. Um it was a randomized controlled study of 464 Children um excluded the very severe obstructive sleep apnea, excluded the very severely obese Children and excluded those Children who were medicated for A. D. H. D. And looked at a whole battery of outcomes. So not just sleep studies but sleep symptoms. Um And a number of neuropsychological assessments, behavioral ratings, quality of life ratings and cognitive tests. And ultimately they showed a significant difference in a in a lot of these areas. Um If zoom Power Point allowed me to look at my notes, I can tell you exactly what each of these things are. Um The Nipsey is was not found to be significantly different as you can see. That is a psychometric test that that is done with a uh clinician. Um He has to do with tower building. Um So if you want your Children you have a child who is not an effective tower builder at Newtown selected is not the surgery for them. Um But some of these other skills, the Conners rating scale I believe is a behavioral rating scale. Um The brief scores, another measure of executive function. Um Then the sleep related breathing disorder. This score is a metric of uh of uh signs of sleep disordered breathing. Um And then a quality of life score. And then obviously the h I most of these are you know, very significantly different before and after admit tonsillectomy. So we're seeing a really effective surgery and this is why a lot of, you know, it's one of the most common surgeries and Children in the United States. So why don't we just do this for everybody, all these kids who are snoring if there, if it has, you know, potentially such a tremendous impact. Well, there are side effects too. So there are meaningful complications of 10 selected one of the most significant ones. You may have kids who you have seen in the week following their tonsillectomy and they will tell you that this surgery hurts and they are right. It is kind of crummy from a pain control standpoint. Um kids who tends to be little kids are um do really well and are not really bogged down by pain. That is probably primarily a function of the fact that they just have not had a lot of council infections and so they don't have a lot of adhesions between the tonsil tissue and the muscle. And the surgery is just a little bit simpler. So the dissection was less painful in partially because I think teenagers sort of know better, right. They wake up and they're like, no, this is not how I'm supposed to feel this or throat is terrible. It hurts more when I swallow, I'm not going to swallow and they spit into a cup for a week and they get dehydrated, they feel even worse. Um, so managing pain in teenagers is a unique challenge after another counselor. Um, the the other concerns we have obviously, you know, bleeding, postoperative bleeding is a huge concern after a drop down select city and respiratory failure. So we have the, you know, lots of kids will spend the night in the hospital because we are concerned about their recovery, right? Remember these are kids who are coming in because they're not breathing well at night. Um So if we replace their big tonsils and adenoids with surgical swelling, if we take into account the variability of their ability to metabolism the anesthetic. And sometimes if their pain is poorly controlled, give them opiates to manage their pain that subsequently generate a respiratory depression. You know, where we're in a situation where respiratory failure, respiratory compromise is a really meaningful postoperative complication. So I want to look a little bit more closely at pain. Um what are our treatment options? Right, so we have ibuprofen which is really nice for surgical pain but it increases the risk of bleeding. We have opiates, great for pain, but it exacerbates respiratory depression. We have steroids great for paying great for surgical swelling. It's actually a recommendation from the American Academy of Otolaryngology that all kids undergoing tonsillectomy get a dose of steroids. So we do use this pretty liberally. A single dose, not any postoperative dozing. Um There's some good data to show that that that it does impact the rates of bleeding postoperative lee. And um probably the main reason we don't give standing steroids after tonsillectomy is that it drives kids bananas. Um So it's just not a reasonable treatment option. So when you are, when we're trying to manage pain post operatively, you can see that the decisions become really complicated. And if you have a have a patient in your office is struggling with post operative pain. You know, you're facing the same decision. It's been a while like so lots of uh lots of people have sort of pushed back and said that you know, Ibuprofen is not likely to increase the risk of bleeding. Recent uh meta analyses have shown that although the increase is modest, there is a meaningful increase in the risk of bleeding after uh after tonsillectomy with ibuprofen use. I still use it, still think it's a good medicine. I still think it's worth the worth the risk relative to using opiates opiates. We used to use coding for this for pain control regularly. This was the standard thing that I gave every patient after tonsillectomy and my training. but into 2010 we started seeing documentation of life threatening respiratory depression by Children who are ultra rapid metabolize ear's of codeine. These are kids who have a fully functional, multiple, fully functional copies of the particular cytochrome P 4 50 enzyme cyP two D six and safety. The coding is metabolized in morphine. codeine is isn't analgesic by itself, it does have respiratory depressive affects by itself But morphine is 10 times stronger. So if you are an ultra rapid metabolize er of coding you will very rapidly convert coding to morphine and you know incur this this you know risky respiratory depression. Now we have because they can't use coding anymore. They put a black box warning on that we've started using or lots of people started using HYDROcodone turns out just like codeine is metabolized to morphine and causes a big increase in the serum levels of morphine. HYDROcodone is metabolized the HYDROmorphone. We haven't seen the same impact from respiratory depression but we're really limited in what opiates we can use here. I and I think the most worrisome data that I've seen are come from this article in Jama Internal Medicine. This is focused on adolescents and young adults. But they took 15,000 opiate naive adolescence And compared them to 30,000 age matched controls. The 15,000 adolescents underwent a dental procedure and were given a single prescription for opiates And then they looked at these 15,000 kids and said well relative to the other 30,000 kids. were they more likely to fill another opioid prescription Between 90 and 365 days later? This was a limited dental procedure 90 days later they're not receiving an additional prescription for pain from that dental procedure. Also did they get a new i. c. d. nine code diagnosis for opiate dependence or overdose? And we see the adjusted risk ratio of getting another prescription was 6.8 higher in kids who received the opiate prescription And 3.8 higher that they had a new diagnosis of opiate dependence. That is a 6 6.8 absolute risk increase for persistent opiate use And a 3.8 absolute increase for opiate dependence. I'm really cautious about using opiates after surgery now I'm taking a little time to go through all of these different the challenges of pain management after tonsillectomy as a way of introducing you to inter capsule or at Newtown selected or inter capsule. Town selected inter capsule, tonsillectomy is a method of removing the vast bulk of an enlarged council and leaving behind a small cuff of tissue against the muscle. The proponents of this surgery say it's got it's associated with less pain. So we have to worry about all those that complicated pain control regimen. They'll say there's less bleeding after surgery and it's equally effective in terms of managing obstructive sleep. The detractors, people don't like this surgery say, well, I don't know if I believe the data about the bleeding risk. I've heard a bleeding risk after inter capsule down. Select me. And they'll say that well if you leave a little bit of tonsils tissue behind, it's likely to grow again and that risk is too high. I think those are both reasonable concerns. But I would like to take this opportunity to discuss them. So, extra capsule tonsillectomy. This is the tonsils sitting right up against the muscle of the throat. I dissect right between the council and the muscle. Take out every last little bit of tonsil tissue. At least as much as as physically possible, throw in the garbage. It's all gone. Don't throw in the garbage. I sent it to a pathologist but it's all gone. An inter capsule tonsillectomy. Just like you saw in the video sort of erases that council and leaves just that last little layer against the muscle by protecting that muscle. I'm not operating against the muscle so that pain is better not disturbing that vascular interface between the muscle and the council. So I think a lot of the concerns about inter council council ectomy were assuaged by the meta analyses that are coming out in the last three years or so. This was a review of 25 studies, 8000 participants. They showed less pain throughout the first week. Post op day 01357 less less pain. Medicine was needed, a shorter time to resuming normal diet and fewer re admissions after surgery for dehydration. Also fewer readmissions to go back to the operating room for postoperative bleeding. The you can see that, you know, actually, for the most part, even when we started doing this, this type of procedure 20 years ago, everybody pretty pretty well recognized that pain control is much better. Most studies, no matter how small showed an improvement in pain control relative to the traditional extra capsule tonsillectomy. And this meta analysis is no different. It shows that the the powered intra capsule tonsillectomy is favored relative to the extra capsule time to resume normal diet. Right? So that's that's very similar to pain control. So it's not hugely surprising that that's that's better postoperative. H. I write. So gosh, if I'm leaving behind council tissue, is that a risk for persistent obstructive sleep apnea? In our studies show no, there's like both. The individual studies show that it's equally effective and managing obstructive sleep apnea. Um But also the men analysis shows it's equally effective. Post post tonsillectomy hemorrhage was a bit of a sticking point. There were there were some studies that showed a improvement in post tonsillectomy hemorrhage. So two of these six studies showed, you know those alone, admittedly I think telling me they were the two largest studies showed that the risk of bleeding was lower with um uh inter capsule or admit on selected me and the, sorry. The overall the men analysis also shows that the risk is So let's look at the other concern that I think is really valid is are these are these tonsils growing back? Right. We know that tonsils continue to grow Through age eight or 9 years. So if a kid undergoes a partial tonsillectomy and leaves council tissue behind, will that regrow? This study showed that of the 1700 patients who underwent inter castle tonsillectomy, 11 patients required revision. My own experiences. I've probably done this surgery on the order of about 1200 times and I have taken back to Children for revision surgery. As a side note, I don't think either of those was for regrowth. one was a child who who had residual obstructive sleep apnea due to severe obesity, but they weren't tolerating CPAP and the family worried that some residual consultation, that removing some residual consul tissue would would could benefit them. And we understand the risk and benefits of the limited benefits of removing that little bit. We agreed to try it. Um And the other one was uh was a very oddly shaped council and I think a significant amount of council was growing deep into the pharyngeal musculature. Um it was just not appreciated at the time of surgery. So the risk in my practice is even far less than the roughly one in 200 that's shown here on point. Yeah, yeah. In the setting of recurrent tonsillitis, I personally take out every last little bit of tonsil tissue, so that's a different indication for tonsillectomy. Um The indication for tonsillectomy for recurrent strep tonsillitis Is kids who are undergoing six or who have six documented strep throat infections in one year Or three strep throat infections every year for three years. So very few Children meet that threshold. And indeed in this study that I'm about to tell you about most, most people did not. But we define these authors defined recurrent tonsillitis a little bit differently associated with pain and symptoms leaving work. Um, you know, having chronic sore throat and it showed in these adult patients that the symptoms after adding a tonsillectomy improved. This is some of the lists of questions that they asked to create this score for recurrent sore throat. And it showed that this gentler partial tonsillectomy was significant, significantly improved the scores for the for for adults with recurrent tonsillitis, chronic sore throat. So why aren't more people not doing this surgery? Um, I don't know except to say that people, you know, we again, it's one of the most common surgeries that are performed in the United States and otolaryngologist feel like they do it really well and don't feel compelled to change. Um And I find that referring providers similarly will say, well I'm not I'm not familiar with this, this partial procedure, it seems like it's going to be under anesthesia anyway, take the whole thing out. Um And I, which is which is a phenomenon I find very persuasive, but if my goal is solely to make it so that this child doesn't undergo a second anesthetic. The risk of postoperative bleeding after a traditional tonsillectomy, About two or 3%. The risk of bleeding in coming to the emergency room is probably about 3%. The risk of going to the operating room is about 2%. The when you compare that to the risk of going back to the operating room three years later, in a controlled fashion To do a revision surgery. In the tonsils being .6%. Still the risk benefit ratio favours inter capsule or and no tonsillectomy. So while avoiding a second anesthetic is is absolutely a right correct consideration or appropriate consideration. I still think that favors the gentle er surgery with a much easier recovery period. So let's sort of stop. And in summary we'll look at the way that I when when kids make it to my office. What are the things that I look for in a cave of snow? So one you know in one instance I have the history of the exam are consistent with obstructive sleep apnea. I see big tonsils or I have a lateral neck film. Or I look in the nose and I find big adenoids so it makes sense to me that they are snoring, even gasping, choking, pausing in their breathing. Medical Management. With medical management, with Flonase is an easy 1st step. Um I use this in most kids, Flonase is FADA approved for kids um four and up. I use it for a short term in kids even down to age two years old. And for kids who are unsuccessful in medical management or who opt against medical management. Inter capsule tonsillectomy is my first line treatment option. Um and then CPAP is always a reasonable option. And I'll have that conversation with kids where I think the risk of residual obstructive sleep apnea is really high. So kids with craniofacial anomalies. Kids with severe obesity. Trust Me 21 um uh where I think that they might be willing to tolerate a mask at night. I will say the risk, you know, the risk of us going through surgery and continuing to require CPAP is high. So would you like to try CPAP first and if that works then it's curative. If it fails, then we can consider surgery when the history and exam are not consistent with obstructive sleep apnea associated associated with adding a tonsillectomy. Um I can do a complete airway evaluation. Um I can treat another presumed problem whether that's a, you know, allergic rhinitis, a deviated nasal septum um or get a sleep study. Um The kids who are more likely to get a sleep study for are those kids who are at high risk of residual obstructive sleep apnea. Same thing. Right. If it's reasonable to try CPAp upfront, it's a good option for lots of kids. Um I do get most of my sleep studies are for kids with where the symptoms are a little bit equivocal. Um or kids who are not interested in surgery or their high risk for certain. There are a few kids who would benefit from a total tonsillectomy. In kids who are legit have, you know, six strep throat infections in a year. I'll try to take out every last little bit of council because I don't want some stubborn and intransigent infection to be left behind. I also frequently recommend extra capital tonsillectomy and kids where the risk of residual U. S. A. Is quite high. So just like the kid I told you about who had severe obesity, it's a really challenging situation to have undergone an inter capsule tonsillectomy. See this little lump of consul tissue in the back of the throat and wonder if removing it might help. So for clarity sake sometimes, you know, I'll talk to the family about this and say it may be worth removing every last little bit so that we never have that question going forward. My practice for pain control for all kids with inter capsule tonsillectomy. I just do Tylenol, ibuprofen, nothing else. And I tell them when you can stop using the ibuprofen stick with Tylenol um In extra caps, extra capsule tonsillectomy. Under the age of five, I do the same thing. Those kids do really well for bigger kids. Um I will include a half dose of oxyCODONE that they can use for breakthrough pain. So in summary there are elements of the physical exam and history that can identify kids for high risk of obstructive sleep apnea. Um That can be used to help identify a diagnosis. Help to determine whether a sleep study or referral is necessary or help determine whether to begin. Um Blueness. Non surgical management of Osa includes observation, totally reasonable nasal steroids and sepa and the inter capsule er or partial tonsillectomy is associated with less pain, reduced risk of postoperative bleeding. It is a really great option for lots of kids. I do want to take a moment to pitch to you guys, the multidisciplinary air digestive clinic we have at both campuses of the Benioff Children's Hospital in Oakland. Um These are kids with complicated airway or complicated swallowing problems. Um That includes aspiration, persistent aspiration, chronic cough strider with reflux or just asia or history of airway scarring. This is a clinic where we're seeing patients with colleagues from gastro neurology, pulmonologist, e swallow therapy and nutrition. So this is a really great option for some of these kids with complex air digestive swallowing disorders.