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Common Cases for ENT
Pamela Nicklaus, MD, FACS, discusses protocols surrounding common ENT cases and referrals, difficulties that may arise, options for families, and therapies/support.
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Learn more about Pamela Nicklaus, MD, FACS
Pamela Nicklaus, MD, FACS
Pamela Nicklaus, MD, FACS is a Pediatric ENT Surgeon, Fellowship Director.Learn more about Pamela Nicklaus, MD, FACS
Transcription:
Common Cases for ENT
Host: Welcome to Pediatrics in Practice with Children's Mercy Kansas City. I'm Melanie Cole, and I invite you to listen as we explore common cases for ENT. Joining me is Dr. Pamela Nicklaus. She's a pediatric otolaryngologist at Children's Mercy Kansas City.
Dr. Nicklaus, thank you so much for joining us today. So when a patient presents with a history of snoring, what are some options the patient and family have?
Dr. Pamela Nicklaus: They're probably going to see their primary care specialists first, probably their pediatrician. One of the options if they're not too worried and they just noticed their child's snoring is just to observe. They've looked at kids who had actually mild sleep apnea or positive sleep studies and watched them for seven months. And in that period of time, about 42% of the kids resolved their sleep apnea. So just a watchful waiting is one option.
Another option is medical therapy. There's been a lot of research on using anti-inflammatory medicines to help snoring or sleep apnea in children. One group of researchers, the Gozals, did studies on Singulair, which is our Montelukast, Flonase, and then with the combination of the two. And they found that all three of those medications either separate or together helped children with mild sleep apnea and best when both of them are used together.
However, we've got some kids who won't put any medicine in their nose, so they would probably take the Singulair, the pill. And then rarely in some kids, the Singulair will cause some ADHD-like activity. And so the parents don't like that, so we have them then just switch to Flonase.
Other option would be to see a sleep doctor, have a full evaluation with probably a sleep study. And that would tell the severity of what the sleep apnea was. With the sleep study, we can actually document how many times a child quits breathing and what the oxygenation levels are and carbon dioxide levels and maybe able to give the parents a better understanding of what's going on and how serious it is.
And then lastly is to refer them to us, to ENT. If the family just wants to be done with things and if the symptoms are severe enough, that we would consider a tonsillectomy and adenoidectomy. And in otherwise healthy kids, about 80% will improve their sleep symptoms with a tonsillectomy and adenoidectomy.
Host: Well, thank you for that overview. Doctor, give us a little referral criteria for those primary care providers and pediatricians. When is it you would like them to recommend their patients see a specialist?
Dr. Pamela Nicklaus: Usually, we have them do a pretty good history and we want to hear that they're snoring every night. Other associated symptoms sometimes are restlessly tossing and turning all night, waking up at night, tiredness in the morning despite good bed hours. It's pretty amazing on how many kids don't go to bed at a reasonable hour or go to bed with the television on or with their computer in their hand.
Definitely, if they go to bed at reasonable hours and get a good number of hours of sleep and are still tired in the morning, that's another indication to send them to us. And then actually, we hear them obstructing at night, not all parents will hear this, but gasping for air, pausing, breaks in their breathing, those would be good reasons to send to us.
Host: Tell us a little bit about the sleep study and the demographic of patients. Tell us a little how sleep study works for the pediatric population. What's it like for them? We hear about adults sleep studies, but it's gotta be a little bit different for children going through something like this.
Dr. Pamela Nicklaus: In the adults, a lot of times at-home sleep studies are performed, but they've not been validated in children. So sleep studies in kids are most often done in the sleep lab. Now, most sleep labs that are doing pediatric sleep studies will of course be all set up for kids and allow the parents to be there right with them.
But of course, they're measuring the brainwaves and the obstructions, oxygenation, carbon dioxide; measuring the leg movements for restless leg. So it's definitely an overnight, usually in a sleep lab facility. Most of them do quite well. You'd think about putting stickers all over the children and then having them go to sleep, that they wouldn't do it. But we can get even kids with behavioral issues or developmental delays to do this study. So I think it's pretty okay, especially if the parents are allowed to be there right with them.
The American Academy of Pediatrics thinks that everybody should have a sleep study, but we don't have enough sleep doctors or sleep labs in the country to actually do that. So there's special populations of kids that we really recommend would get a sleep study. And those kids are our obese kids because most of the kids that are in this group are kids that we think a tonsillectomy and an adenoidectomy may not completely help these children. So those kids are kids that are obese, kids with craniofacial anomalies, kids with Down syndrome, kids with neuromuscular conditions, kids with sickle cell, kids with bleeding disorders who are very high risk to have surgery and then other kids with mucopolysaccharidosis. Those are some of our groups of kids that we would definitely want a sleep study on.
Host: So, if you do determine that a tonsillectomy, adenoidectomy is something that you would consider, for what reasons might a family not want to move forward with these?
Dr. Pamela Nicklaus: Most of them are just really worried about having surgery on their young child. They worry about the procedure itself. They worry about the anesthetic. They worry about the recovery, because it can be up to two weeks to fully recover from your tonsillectomy, and then the complications of this surgery.
And I think we take a tonsillectomy very seriously. I know everybody says, "Oh, it's just a tonsillectomy. Everybody gets their tonsils out." But one of the complications is about a 3% to 5% risk of bleeding after the surgery and bleeding ranging from a little bit to enough to come into the hospital for observation to lots of bleeding requiring emergency surgeries, sometimes even transfusions and, in rare cases, even death. So we do take this very seriously and want to make sure that the kids that are having surgery need it.
Host: So you mentioned obesity as one of the risk factors or comorbid conditions for children with snoring and ENT issues, for those children, doctor, how can a physician set realistic expectations for the patient and for the family? Sometimes patients don't want to hear about it. They don't want to hear those kinds of recommendations. How would you like them to counsel those patients so that they can work better?
Dr. Pamela Nicklaus: I usually tell these families that taking the tonsils out isn't going to really fix the condition. One that we know that kids that are obese -- and I think you have to be very careful how you talk to families about this -- but that if you look at kids that are obese, about 50% of them will have sleep apnea. So it's very common.
The other thing is that we also have looked at kids that are obese, who have had positive sleep studies and then had their tonsils taken out. And, unfortunately, we only completely resolve about 25% of these kids. And then over time, a lot of times, the sleep apnea will even come back in these children.
So a lot of these kids will end up needing a C-PAP or positive pressure ventilation after their surgery. And so if we can get a sleep study before and the sleep apnea is really severe, we might even start them on CPAP before. Taking their tonsils out, may help decrease the CPAP settings so that they don't have as much positive pressure on their faces at night and make them tolerate it a little bit better. But usually treating sleep apnea in an obese kid is a combined approach with Sleep, with probably some surgery and then with referrals to, depending on the community, nutrition or weight management clinic, which is probably going to help more than about anything with the kid's sleep apnea, although we know it's really hard to lose weight.
Host: So moving along to a different topic briefly, tell us some of the types of tongue-ties that are presented in infants and how can they potentially cause breastfeeding difficulties. Tell us a little bit about that and what therapies and support services can be provided for the family.
Dr. Pamela Nicklaus: Definitely, tongue-ties are a thing. And we grade them from grades 1 to 4, which the grade 1 would be where the tongue is actually tethered to the gum or the alveolus. And then 4 is something you don't see, but you just feel. So there's grades of tongue-ties, but there's actually other ties too that people have talked about, but probably have no effect on breastfeeding. And those are the maxillary ties or the little tethers that you see sometimes in between people whose front teeth are splayed. And then there's buccal ties that I had actually never even heard about until one of my families came in and told me that their child had it clipped, which are supposed to ties inside the mouth in the buccal region that some practitioners are releasing for breastfeeding.
But what we know about tongue ties and breastfeeding is that it is definitely a thing. And even in the middle ages, people were getting their tongue-ties sliced to help with breastfeeding. We know that the tongue is supposed to move forward over the bottom lip. And then it kind of curls and cups the breast and exerts pressure on the breast to extract the milk. So if you can't stick your tongue out enough to do that, then it can lead to nipple irritation and often a lot of pain for the moms.
We really work quite directly with our lactation specialists and definitely want any kid that's having breastfeeding issues to have a lactation specialist to work with. We do clip a lot of tongue-ties in our office, but we do that in conjunction with our lactation specialists, looking at the child prior to the procedure and then again, being there after the procedure, because releasing the tongue-tie doesn't help every child. I think those are our best support services that we have.
Host: Isn't that interesting? So in the cases we've discussed today, doctor, what research or discoveries would you like to share with other physicians? And what do you feel is the biggest takeaway for pediatricians from our segment today?
Dr. Pamela Nicklaus: I think one of the things -- and we didn't really get into this with tongue-ties -- is that we have really poor research on this. Our Academy of Otolaryngology comes out with a lot of clinical practice guidelines on different areas. We have one for sleep apnea and tonsillectomy. But for tongue-ties, there wasn't enough good research to do actually a Clinical Practice Guidelines, which makes guidelines based off of good research. And the only thing we could come up with was a clinical consensus statement.
So we know that there needs to be a lot more research on tongue-ties and who needs their tongue-ties released. But I think our Academy has it on their website. And if anybody wants to look it up, I think it's got some great recommendations on who should be sent for a tongue-tie release and what expectations should be for the families.
This population of moms are just so vulnerable. I mean, they're trying to breastfeed, do the best thing for their kid, often will have breastfeeding pain and go to a website and see that everybody else is getting their kids tongue-tie clipped and want this done. I think having doctors know what's right and what's recommended is really helpful for them. And our ENT Academy does have that clinical consensus statement out now.
At Children's Mercy, we have a large pediatric otolaryngology section. And we're always happy to see your patients, or if you have questions about anything, happy to answer those for you. You can go to the Children's Mercy website and, again, we'd be happy to take any questions and help you with any referrals.
Host: Thank you so much doctor for joining us today. What an interesting episode.
To refer your patient or for more information, you can visit ChildrensMercy.org to get connected with one of our providers. This has been Pediatrics in Practice with Children's Mercy Kansas City. Please also remember to download, subscribe, rate, and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.
Common Cases for ENT
Host: Welcome to Pediatrics in Practice with Children's Mercy Kansas City. I'm Melanie Cole, and I invite you to listen as we explore common cases for ENT. Joining me is Dr. Pamela Nicklaus. She's a pediatric otolaryngologist at Children's Mercy Kansas City.
Dr. Nicklaus, thank you so much for joining us today. So when a patient presents with a history of snoring, what are some options the patient and family have?
Dr. Pamela Nicklaus: They're probably going to see their primary care specialists first, probably their pediatrician. One of the options if they're not too worried and they just noticed their child's snoring is just to observe. They've looked at kids who had actually mild sleep apnea or positive sleep studies and watched them for seven months. And in that period of time, about 42% of the kids resolved their sleep apnea. So just a watchful waiting is one option.
Another option is medical therapy. There's been a lot of research on using anti-inflammatory medicines to help snoring or sleep apnea in children. One group of researchers, the Gozals, did studies on Singulair, which is our Montelukast, Flonase, and then with the combination of the two. And they found that all three of those medications either separate or together helped children with mild sleep apnea and best when both of them are used together.
However, we've got some kids who won't put any medicine in their nose, so they would probably take the Singulair, the pill. And then rarely in some kids, the Singulair will cause some ADHD-like activity. And so the parents don't like that, so we have them then just switch to Flonase.
Other option would be to see a sleep doctor, have a full evaluation with probably a sleep study. And that would tell the severity of what the sleep apnea was. With the sleep study, we can actually document how many times a child quits breathing and what the oxygenation levels are and carbon dioxide levels and maybe able to give the parents a better understanding of what's going on and how serious it is.
And then lastly is to refer them to us, to ENT. If the family just wants to be done with things and if the symptoms are severe enough, that we would consider a tonsillectomy and adenoidectomy. And in otherwise healthy kids, about 80% will improve their sleep symptoms with a tonsillectomy and adenoidectomy.
Host: Well, thank you for that overview. Doctor, give us a little referral criteria for those primary care providers and pediatricians. When is it you would like them to recommend their patients see a specialist?
Dr. Pamela Nicklaus: Usually, we have them do a pretty good history and we want to hear that they're snoring every night. Other associated symptoms sometimes are restlessly tossing and turning all night, waking up at night, tiredness in the morning despite good bed hours. It's pretty amazing on how many kids don't go to bed at a reasonable hour or go to bed with the television on or with their computer in their hand.
Definitely, if they go to bed at reasonable hours and get a good number of hours of sleep and are still tired in the morning, that's another indication to send them to us. And then actually, we hear them obstructing at night, not all parents will hear this, but gasping for air, pausing, breaks in their breathing, those would be good reasons to send to us.
Host: Tell us a little bit about the sleep study and the demographic of patients. Tell us a little how sleep study works for the pediatric population. What's it like for them? We hear about adults sleep studies, but it's gotta be a little bit different for children going through something like this.
Dr. Pamela Nicklaus: In the adults, a lot of times at-home sleep studies are performed, but they've not been validated in children. So sleep studies in kids are most often done in the sleep lab. Now, most sleep labs that are doing pediatric sleep studies will of course be all set up for kids and allow the parents to be there right with them.
But of course, they're measuring the brainwaves and the obstructions, oxygenation, carbon dioxide; measuring the leg movements for restless leg. So it's definitely an overnight, usually in a sleep lab facility. Most of them do quite well. You'd think about putting stickers all over the children and then having them go to sleep, that they wouldn't do it. But we can get even kids with behavioral issues or developmental delays to do this study. So I think it's pretty okay, especially if the parents are allowed to be there right with them.
The American Academy of Pediatrics thinks that everybody should have a sleep study, but we don't have enough sleep doctors or sleep labs in the country to actually do that. So there's special populations of kids that we really recommend would get a sleep study. And those kids are our obese kids because most of the kids that are in this group are kids that we think a tonsillectomy and an adenoidectomy may not completely help these children. So those kids are kids that are obese, kids with craniofacial anomalies, kids with Down syndrome, kids with neuromuscular conditions, kids with sickle cell, kids with bleeding disorders who are very high risk to have surgery and then other kids with mucopolysaccharidosis. Those are some of our groups of kids that we would definitely want a sleep study on.
Host: So, if you do determine that a tonsillectomy, adenoidectomy is something that you would consider, for what reasons might a family not want to move forward with these?
Dr. Pamela Nicklaus: Most of them are just really worried about having surgery on their young child. They worry about the procedure itself. They worry about the anesthetic. They worry about the recovery, because it can be up to two weeks to fully recover from your tonsillectomy, and then the complications of this surgery.
And I think we take a tonsillectomy very seriously. I know everybody says, "Oh, it's just a tonsillectomy. Everybody gets their tonsils out." But one of the complications is about a 3% to 5% risk of bleeding after the surgery and bleeding ranging from a little bit to enough to come into the hospital for observation to lots of bleeding requiring emergency surgeries, sometimes even transfusions and, in rare cases, even death. So we do take this very seriously and want to make sure that the kids that are having surgery need it.
Host: So you mentioned obesity as one of the risk factors or comorbid conditions for children with snoring and ENT issues, for those children, doctor, how can a physician set realistic expectations for the patient and for the family? Sometimes patients don't want to hear about it. They don't want to hear those kinds of recommendations. How would you like them to counsel those patients so that they can work better?
Dr. Pamela Nicklaus: I usually tell these families that taking the tonsils out isn't going to really fix the condition. One that we know that kids that are obese -- and I think you have to be very careful how you talk to families about this -- but that if you look at kids that are obese, about 50% of them will have sleep apnea. So it's very common.
The other thing is that we also have looked at kids that are obese, who have had positive sleep studies and then had their tonsils taken out. And, unfortunately, we only completely resolve about 25% of these kids. And then over time, a lot of times, the sleep apnea will even come back in these children.
So a lot of these kids will end up needing a C-PAP or positive pressure ventilation after their surgery. And so if we can get a sleep study before and the sleep apnea is really severe, we might even start them on CPAP before. Taking their tonsils out, may help decrease the CPAP settings so that they don't have as much positive pressure on their faces at night and make them tolerate it a little bit better. But usually treating sleep apnea in an obese kid is a combined approach with Sleep, with probably some surgery and then with referrals to, depending on the community, nutrition or weight management clinic, which is probably going to help more than about anything with the kid's sleep apnea, although we know it's really hard to lose weight.
Host: So moving along to a different topic briefly, tell us some of the types of tongue-ties that are presented in infants and how can they potentially cause breastfeeding difficulties. Tell us a little bit about that and what therapies and support services can be provided for the family.
Dr. Pamela Nicklaus: Definitely, tongue-ties are a thing. And we grade them from grades 1 to 4, which the grade 1 would be where the tongue is actually tethered to the gum or the alveolus. And then 4 is something you don't see, but you just feel. So there's grades of tongue-ties, but there's actually other ties too that people have talked about, but probably have no effect on breastfeeding. And those are the maxillary ties or the little tethers that you see sometimes in between people whose front teeth are splayed. And then there's buccal ties that I had actually never even heard about until one of my families came in and told me that their child had it clipped, which are supposed to ties inside the mouth in the buccal region that some practitioners are releasing for breastfeeding.
But what we know about tongue ties and breastfeeding is that it is definitely a thing. And even in the middle ages, people were getting their tongue-ties sliced to help with breastfeeding. We know that the tongue is supposed to move forward over the bottom lip. And then it kind of curls and cups the breast and exerts pressure on the breast to extract the milk. So if you can't stick your tongue out enough to do that, then it can lead to nipple irritation and often a lot of pain for the moms.
We really work quite directly with our lactation specialists and definitely want any kid that's having breastfeeding issues to have a lactation specialist to work with. We do clip a lot of tongue-ties in our office, but we do that in conjunction with our lactation specialists, looking at the child prior to the procedure and then again, being there after the procedure, because releasing the tongue-tie doesn't help every child. I think those are our best support services that we have.
Host: Isn't that interesting? So in the cases we've discussed today, doctor, what research or discoveries would you like to share with other physicians? And what do you feel is the biggest takeaway for pediatricians from our segment today?
Dr. Pamela Nicklaus: I think one of the things -- and we didn't really get into this with tongue-ties -- is that we have really poor research on this. Our Academy of Otolaryngology comes out with a lot of clinical practice guidelines on different areas. We have one for sleep apnea and tonsillectomy. But for tongue-ties, there wasn't enough good research to do actually a Clinical Practice Guidelines, which makes guidelines based off of good research. And the only thing we could come up with was a clinical consensus statement.
So we know that there needs to be a lot more research on tongue-ties and who needs their tongue-ties released. But I think our Academy has it on their website. And if anybody wants to look it up, I think it's got some great recommendations on who should be sent for a tongue-tie release and what expectations should be for the families.
This population of moms are just so vulnerable. I mean, they're trying to breastfeed, do the best thing for their kid, often will have breastfeeding pain and go to a website and see that everybody else is getting their kids tongue-tie clipped and want this done. I think having doctors know what's right and what's recommended is really helpful for them. And our ENT Academy does have that clinical consensus statement out now.
At Children's Mercy, we have a large pediatric otolaryngology section. And we're always happy to see your patients, or if you have questions about anything, happy to answer those for you. You can go to the Children's Mercy website and, again, we'd be happy to take any questions and help you with any referrals.
Host: Thank you so much doctor for joining us today. What an interesting episode.
To refer your patient or for more information, you can visit ChildrensMercy.org to get connected with one of our providers. This has been Pediatrics in Practice with Children's Mercy Kansas City. Please also remember to download, subscribe, rate, and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.