Pediatric Sleep Apnea Diagnosis & Imaging: Collaboration is Key

[Dr. Gopi Shah]
When you say you'll get your history together, I think that's super interesting. I'm glad you have that perspective because I want to know what you look for specifically as a pediatric otolaryngologist in your history? What if you were now being in a multi-D clinic simultaneously with your partners and other specialties, what else do you now pull into your history? Or are you looking for that's like, "Oh Yes, I need to, this is important as well."

[Dr. Javan Nation]
Oh, that's such a great question. I've pulled more medical stuff into my history. For the younger patients, I'm going to ask about reflux. I think about vomiting at night because the pulmonologists are very concerned, right? They don't want to fit this patient with the CPAP and put a mask over their mouth if they have vomiting issues. I think a lot about it, so a lot of these patients will have G-tubes and we think a lot about the feeds and if they're getting continuous feeds at night, all those safety things that the pulmonologists are considering that I'd never really thought about before, I now consider.

From the craniofacial surgeons, I've learned a lot about when they can intervene on the craniofacial skeleton. They were the ones who actually taught me to start looking at the teeth. The plastic surgeon would always look at the teeth, he'd look at the bite, he'd look for a crossbite, he'd look at mixed dentition, and I used to think like, "Why is he looking at this? Why does this matter?" Really for him, before he can do anything, he has to get the teeth set up just right. He's going to have them see the orthodontist, orthodontist going to get him in braces, do the expansion, whatever they have to do. , before he can do any changes to the skeleton.

The teeth are so important and it helped me appreciate that because a lot of these patients, what you see, especially like the cerebral palsy patients who've never eaten, don't have those bite forces. The bite forces really help the craniofacial skeleton grow, especially transversely. These patients who've always had an open-mouth posture have never fed, they have these extremely narrow palates. You can picture some of these patients, right? Low functioning cerebral palsy, never ate a day in their life. Essentially their maxilla is just caved in, right? In some cases, it's almost like the molars are touching in the back, just because they've never used it, right?

It helps me appreciate that because now it makes sense like when I'm trying to put a scope in their nose, why there's just no nasal airway. There's so much nasal resistance because that craniofacial skeleton just collapsed in on itself. All this is important. I also look a lot at clues that the teeth give me. I can tell, I look to see if they're grinding. Sometimes the parents don't realize what's going on at night. If you see a kid that has just worn facets on their teeth and they're completely flat, you know they're grinding. This might be a little controversial.

[Dr. Gopi Shah]
I was going to ask you, don't all kids grind between three to six years of age or no, is that true?
[Dr. Javan Nation]
No, not necessarily.

[Dr. Gopi Shah]
How common is grinding affiliated with obstructive sleep apnea? Is it usually in, along with other symptoms like snoring or mouth breathing pauses, or can grinding isolated be a concern? Let's go into a little bit because I've always been curious and I've never known how to place that well unless they have their other constellation of obvious sleep disorder breathing symptoms, because I just don't understand it well, I don't think.

[Dr. Javan Nation]
Right. I don't think anybody does. The way I think about it is we don't. You asked the question, how often is it associated? We don't know. I haven't seen a study that's actually looked at that exactly. Because I think there's other things that can lead to grinding. The kid's stressed out or there's anxiety issues, they can certainly grind. My framework for thinking about this is, if they're grinding, they're likely to have high nasal resistance.

There seems to be an association with nasal resistance, which leads to mouth breathing, which can lead to grinding. What that's telling me is the kid's, not breathing well through the nose at night. I don't think it's diagnostic, but it clues me into the fact that there's something going on with their airway.

[Dr. Gopi Shah]
That makes sense.

[Dr. Javan Nation]
Hopefully, we learn more. I know there's some people who put too much emphasis on it and with a lot of these things, especially with myofunctional therapists, I feel like sometimes there's too much certainty on what these signs and symptoms can mean. The honest approach right now is that we just don't know what we're still learning and trying to figure it out as much as we can. I think there's definitely a role and there are important signs to pay attention to, even if we can't use it for diagnostic purposes.

[Dr. Gopi Shah]
You're right and I think that, what our colleagues notice in other fields, that's why you have this amazing multidisciplinary clinic for complex sleep. When I was in Dallas, sometimes we would include our pediatric dentists and some of our rounds and clinics because a lot of our patients would be referred from our dental colleagues a lot of times for their screening before they're doing any sedation in clinic. It's the same where it's like the light bulb moment about the teeth, that's important.

I never noticed it when one of the pediatric dental colleagues was like, "Yes, we should look at this because of this." I'm like, "Oh, okay." Or there's obviously something more than just having to be open to listening and then understanding, thinking about how it may or may not apply and in what scenarios. I think it's a great point.

[Dr. Gopi Shah]
That's interesting. Before we get into sleep studies and imaging, I do want to quickly ask you any special tips, tricks that you have for just a basic physical exam. What are you looking at and what do you check for when this child or this baby comes into your clinic?

[Dr. Javan Nation]
Let's just talk about a typical patient. First thing I'm looking for is watching the patient breathe as I'm getting the history from the family. Thank God. We just got masks off in our clinic and this has been so great because it's so important to actually see what their mouth looks like and see what they look like when they're breathing. From the second they walk in, you can hear them breathing and there's a great sign.

I stole this from Norm Friedman, but he calls it the Darth Vader sign. These are the kids who walk into your clinic and they sound like Darth Vader. Huge clue there. This kid has nasal resistance. Is it allergies? Is this turbs or is his adenoids to be determined? You know this kid is not breathing well through his nose.

[Dr. Gopi Shah]
And they're awake.

[Dr. Javan Nation]
This is when they're awake, exactly. That's your first clue is what does their breathing sound like the second they walk in? I just watch them. As I'm talking to the parents, I'm looking at the patient, I'm watching them breathe. Do they have an open-mouth posture? Are they breathing comfortably through their nose? That type of thing. Then in the exam, I'm looking at the ears, looking in the nose. If they have the Darth Vader sign, I look in their nose and their turbs are wide open. I can't see the adenoids. Sometimes I imagine I can. What do you think? Sometimes I feel like I see a little shine all the way in the very back, but I'm not sure it's the adenoids unless I put a scope in.

[Dr. Gopi Shah]
I know. I think I've had that where I've thought I've seen the adenoids on anterior endoscopy maybe twice in my lifetime of looking at the nose as an otolaryngologist so I don't know. I feel like I need a scope to get a look.

[Dr. Javan Nation]
It's like a mirage back there. It's like I think it's there. Clinically I know it's there because the nose is open and I can hear them breathing so I know the adenoid is big. I don't have to do anything more to really make that diagnosis but every once in a while I look back there and it's like a mirage. It's like, "I think I see it," but I'm like, "I'm maybe just making this up. I don't know."

[Dr. Gopi Shah]
Do you usually scope for an adenoid eval? Because you had mentioned. We see these, "I think the adenoids have grown back." That's especially important, especially for the kids that have mild to moderate sleep apnea. Maybe it's not the severe kid but the AHI is 6 and they already had a TNA normal weight. Do you scope or do you get a lateral neck X-ray? What are your thoughts on that?

[Dr. Javan Nation]
This is a patient and they've already had a TNA, I'm going to scope without question. If they're in a complex sleep clinic, they're going to get a scope because it's really the best way to assess what's going on with the airway. Now, if I'm in general ENT clinic and I'm seeing a three-year-old with mouth breathing, Darth Vader sign, and the turbs aren't big, I'll talk to the family and I'll feel the patient out.

Some of these kids are really shy. You look in their ears and they're uncomfortable with that. You look in their nose and they start crying. I don't usually force a scope on those patients. In many cases, if they're under five, I'll just get a lateral neck X-ray just to confirm. I find that families aren't comfortable going to the operating room. Some are, but most aren't comfortable going to the operating room without something a little bit more diagnostic than just my clinical history seeing they have big adenoids.

[Dr. Gopi Shah]
If the tonsils are big, I don't push it. Obviously, there's something with it to do but if I'm thinking just isolated adenoid, you're right. Sometimes having something more concrete is helpful. You're right. Families and as a parent, it's nice to know what the clinician is using to make that decision and I can understand-- I think what you just said about learning to speak the similar language, whether it's with our partners or subspecialists or cross specialists with our family, that's what all this is about. Sometimes the X-ray might be similar-- You know what I mean? Coming to a common ground in that setting as well.

[Dr. Javan Nation]
For sure. I know a lot of people who take a different view where they say, "I don't want to expose this kid to radiation so I'm going to do the scope." They're not that bad. They're really quick. The other issue you run into with the X-rays is you have to know your X-ray text or you have to do it in a place where you're comfortable because if they don't do it properly, it's useless. In my practice, we have our clinic at our main area at the hospital setting. If I send them for an X-ray there, these X-ray techs have been doing this lateral neck X-ray for years and they're super good at it.

There's a lot of people who say, "Oh, you shouldn't get X-rays or neck X-rays because they're not accurate," but what I've found is that they give me a sense of what's going on, especially if you have a good tech who gets to do the X-ray, you know what's going on.

We have satellite clinics and so if I'm somewhere different and they're going to an outside institution with their X-ray, I'd think about it differently, probably. I'd probably do a scope just because I don't want to get the X-ray and have it be non-diagnostic.

[Dr. Gopi Shah]
Every once in a while, this is not common, but I've had kids with very, very narrow nasopharynx and it's just a big eustachian tube on the X-ray because when you scope them or in the OR put them to sleep, they don't have much adenoid tissue. Every once in a while-- I do think the technique sometimes and the consistency and the history can make a difference. On the physical exam, you mentioned how they are breathing when they walk in. We've talked about posture. We've talked about adenoid evaluation. Any other key things that you're looking for on a physical exam?

[Dr. Javan Nation]
We talked about their teeth. I pay attention to this. I look for crossbites, anterior, posterior crossbites. This is the clue that they have a high arch. A high arch is a hard thing to measure in many cases, especially for an otolaryngologist. We ask each other, "What does that mean they have a high arch? Does it mean they have a crossbite? Or they might not have a crossbite but still have a high arch. Usually, we just say, "It looks high. It doesn't look nice and wide."

What I've found, talking about speaking the same language with people, is if I send them to see an orthodontist and they don't have a crossbite and I send them to see an orthodontist for a high arch and they don't have a crossbite, the orthodontist will generally say, "No, I don't think we should do expansion," unless you have one of those specialty orthodontists who's very focused on the airway. What they'll do is, they'll do the expansion, and then if it really throws off the bite or the occlusion, they can tip the teeth later to fix that occlusion.

If you send them to see an orthodontist who's maybe not as clued in, what they're looking for is that crossbite. They'll say, "You don't have a crossbite so there's no reason to do an expansion." That's what I'm paying attention to. We talked about the grinding and then, obviously, looking at the tonsils.