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BackTable / ENT / Article
Best Practices in Pediatric Obstructive Sleep Apnea Treatment
Megan Saltsgaver • Updated Aug 7, 2024 • 34 hits
Treating pediatric obstructive sleep apnea (OSA) can be a challenging task. The decision of when to have surgery can differ for every child and family. Factors affecting these decisions can be the age of the patient, size of the tonsillar tissue, weight, symptom severity and patient and family preference. Active observation can also be used to avoid surgical management if needed. Even after surgery, patients can have persistent and bothersome symptoms. Pediatric otolaryngologist Dr. Ron Mitchell shares his approach to treating typical pediatric OSA and more unique presentations.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Treatment options for pediatric obstructive sleep apnea commonly include tonsillectomy with or without adenoidectomy and turbinate reduction.
• Excessive snoring has become a hallmark of pediatric OSA. While surgical management is proven to be very effective for treating these children, close observation might also be an appropriate approach.
• Management of children over the age of 16 should more closely follow the adult guidelines when it comes to managing their OSA. For children aged 12-16, care should be tailored based on individual development, symptoms, and tonsil size.
• If a patient has persistent OSA symptoms after tonsillectomy and adenoidectomy (TNA), it is most likely due to underlying nasal issues such as adenoid regrowth, insufficient adenoid removal, or nasal obstructions. Additional surgery might be required, such as removing regrown adenoids or shrinking the turbinates
• Surgical management can only go so far if there are underlying comorbidities that make a patient difficult to manage. Weight should be addressed if a child is severely overweight, as this might be causing persistent OSA symptoms post-TNA.
Table of Contents
(1) Observation vs Surgery in Pediatric Obstructive Sleep Apnea
(2) Adolescent Obstructive Sleep Apnea Management
(3) Persistent OSA After Tonsillectomy & Adenoidectomy (TNA)
(4) Addressing Weight & CPAP Use in Pediatric OSA Management
Observation vs Surgery in Pediatric Obstructive Sleep Apnea
According to Dr. Mitchell, our perception of normal sleep in children has evolved dramatically over the past 20 years. Initially, snoring in children was often dismissed if their parents snored as well. However, it is now recognized as a key indicator of obstructive sleep apnea, a condition that causes interrupted sleep and can lead to daytime behavioral problems and poor school performance. More recent research has demonstrated that surgeries such as tonsillectomy and adenoidectomy (TNA) can be very effective at treating sleep apnea in children.
In children with very mild obstructive sleep apnea, close observation and follow up is a very acceptable route as well. Sometimes waiting and letting the child grow is enough for symptoms to resolve. Research is currently underway to determine how this waiting period can affect a child’s quality of life, and to determine who within the mild OSA population should have surgery.
Dr. Mitchell also clarifies what observation entails. It's not a passive approach but rather an active, intensive process that may involve regular check-ins, monthly phone calls, and various non-surgical treatments such as nasal steroid sprays, saline, or montelukast, especially for children with asthma. This comprehensive approach ensures that the child's condition is closely monitored and managed, providing a robust alternative to immediate surgical intervention.
[Dr. Gopi Shah]
In terms of pediatric sleep apnea, if there's pauses on a sleep study and the sleep study is positive, we tend to take the patient's tonsils out. You've been a part of many landmark studies, including the CHAT study. I've been part of many, many clinical practice guidelines on pediatric OSA. Based on the research and your clinical practice, what are some things that you feel like are still part of your practice that you do day to day in the clinic and how you treat your patients? What are some pearls that everybody should know?
[Dr. Ron Mitchell]
Yes, sure. Again, over the last 20 years, we have gone from a period where we asked, what is normal sleep in a child? We moved away from believing that if a child snores and the parents snore, then it's all normal and doesn't cause any problems. We moved towards realizing that snoring is the hallmark of a condition called obstructive sleep apnea, where the child goes to sleep, the child stops breathing and pauses during sleep. That results in very poor interrupted sleep that then leads to behavioral problems during the day and can lead to poor school performance.
Some of the studies that I've been involved in have been a multisite and multidisciplinary approaches to managing sleep in children. As Gopi has mentioned, one of the biggest landmark studies is what we call the CHAT study, which looked at children with sleep apnea and looked at what happens when we take their tonsils out versus what happens when we don't and just observe them for a few months and keep an eye on them and see how things develop without surgery. We have shown that surgery is very helpful. Surgery makes the child better very quickly.
There is a group of kids, especially the kid with very mild problems, where a period of waiting and allowing the child to grow without any surgical intervention may be all the child needs. We have followed that study. Whenever we do NIH-sponsored studies, we like very catchy phrases. It used to be CHAT, now we do PATS, P-A-T-S, which stands for Pediatric Adenotonsillectomy Trial for Snoring.
We are currently looking at children who have very mild obstructive sleep apnea, and we are looking at who needs surgery, who does not need surgery, what happens to them after a year in terms of behavior, in terms of sleep, in terms of quality of life, and comparing those who do have surgery to those who don't have surgery. It's been large-scale studies that are done in five, six, seven institutions all over the country, are very labor-intensive, they're expensive, they require a lot of personnel, and we are at the tail end of the PATS study.
Now, if COVID did not happen, we would have finished the PATS study, but unfortunately, COVID has interfered in our lives in many ways, including with PATS. We hope that a year from now, we will have enough data to say, in those children who have mild sleep apnea, who should have surgery, who should not, who should have a sleep study and who should not, which I think will be very helpful to both parents and physicians in terms of directing our practice.
[Dr. Gopi Shah]
I agree. I think that will be super helpful. Can you talk about what observation looks like for those patients who you decide to observe and wait on surgery? What does the follow-up look like and how do you manage that?
[Dr. Ron Mitchell]
Yes, that's a great question, because sometimes people believe that observation means you say goodbye to the parent and you never see them again and you hope it gets better. If it doesn't get better, come back to clinic. That's not what we mean by observation. An observation may be more intensive in terms of what you do in clinic than surgical intervention.
By observation, what we have done in the study is we have allowed each site to treat these kids with whatever is the standard of care in that site. What that means is a group of kids under the observation umbrella receive no treatment other than monthly phone calls to see how they're doing. There are other children who received a nasal steroid spray, some received saline, some have received montelukast, especially if they have asthma. We are talking about the wide spectrum of non-surgical intervention. This will allow us at a later stage to see if medical therapies vary to any great extent as well as saying how does medicine or observation compare to surgical intervention.
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Adolescent Obstructive Sleep Apnea Management
Adolescents present a unique challenge in the management of pediatric obstructive sleep apnea (OSA) due to their transitional stage between childhood and adulthood. For children aged 16 and above, OSA management should be more aligned with adult treatment protocols. For the 12 to 16 age group, the approach depends on the individual child's development. Dr. Mitchell emphasizes the importance of individualized assessment, often relying on input from sleep lab professionals to guide treatment decisions.
Tonsil size also plays a role in OSA severity, though it is not always a clear predictor. While larger tonsils (four plus) are more likely to be associated with OSA, there are exceptions. Some children with large tonsils may not have OSA, while others with smaller tonsils may suffer from moderate OSA. The variability and the subjective nature of tonsil size evaluation, often done with a tongue depressor, make it challenging to use tonsil size alone as a definitive indicator for surgery.
[Dr. Ashley Agan]
To me, the adolescent group has always been an interesting group to me, because we have our pediatric guidelines for 18 and under or under 18. Yet you are adolescents between sometimes as early as 12, but really 13, 14 to 17, at what point, some of them have already hit puberty, they've had some weight gain. How do you know when your 16, 17-year-old to treat them like an adult in terms of severity versus a pediatric patient?
[Dr. Ron Mitchell]
Just some general observations. I think the minute they hit 16, they're adults. I think most specialists would agree with that. When they're under the age of 12, I think they're children. The problem is that 12 to 16. Some of it depends on the child themselves, which, as we know, a 13-year-old can be 6 foot, or a 13-year-old can look like they’re 10. I think that plays a big-- but it's something that I would encourage people to talk to the people in the sleep lab and they will give you a good idea.
The closer you are to 16, the more adult-like they are, the closer you are to 12, the more pediatric-like they are. In between, it can be tough. There's no question about it. You get something that in the adult world is moderate, but in the pediatric world is very severe, or in the adult world, it doesn't even qualify, as I would say, but in the pediatric world, it's actually very significant. Again, we have actually published a number of papers from our institution about adolescents. It's a tough crowd. I share your challenge in who should you deal with as a child and who you should deal with as an adult.
[Dr. Ashley Agan]
Some of them, they have the three plus tonsils and AHI-10 is still mild in an adult and severe in a kid. That's an easier patient population to maybe counsel or/and offer surgery to. That being said, we see some younger kids that have four plus tonsils and have very mild or almost negative sleep studies. Does tonsil size matter?
[Dr. Ron Mitchell]
Tonsil size matters in aggregate, and I'll tell you what I mean by that, but it's not a predictor of severity of OSA. The big problem with looking at tonsil size is, most kids in that 4 to 8 or 4 to 10 age group have two plus or three plus tonsils. How do we distinguish between a two plus or three plus? Two people can look at the same mouth and some will say this and some will say that.
The very large tonsils, the four plus tonsils, if you look on aggregate, if you look at a cohort of children with four plus tonsils, are they more likely to have OSA and are they more likely to have more severe OSA? The answer is yes, but there are outliers. There are kids with four plus tonsils who have no OSA. There are kids with one plus tonsils who have moderate OSA.
We also have to remember, when we gauge tonsil size, we're using an instrument that was used in the 17th century, a tongue depressor. We all look in the mouth and we use a very old instrument to-- sometimes it's difficult to look in the mouth, sometimes the kid gags, so on. It may be that what you see is two, maybe a three, et cetera. On the whole, large tonsils mean a higher likelihood of OSA, small tonsils mean a less likelihood of OSA, but in the specific kid, it doesn't tell you anything.
[Dr. Gopi Shah]
Yes. Do you feel that there is more OSA in children now or that it's always been there and we just notice it now because we look for it and we test for it now?
[Dr. Ron Mitchell]
That's a very good question. The history of tonsillectomy goes something like this. In the 1950s in the US, we were doing more tonsillectomies than we do now. The population has more than doubled. In effect, in New York, on the East side of New York, there was a tonsillectomy hospital. Doing a tonsillectomy in kids was very common. Children were put to sleep for some other surgery, they took their tonsils out. Sometimes they put them to sleep for tonsillectomy to make them healthier.
Years have gone by, antibiotics have improved and the sick kid with constant tonsillitis is less common, so we're doing fewer tonsillectomies. I think two things have happened. Firstly, more kids are getting to school age with their tonsils, and there's a bigger awareness. I think both of those have contributed to us seeing more kids with large tonsils. Now, there is in the-- If you look at the literature, the science of it, some people say that more viral infections and particularly RSV leads to tonsillar hypertrophy. We have seen an increase in RSV in kids, and that over time leads to bigger tonsils.
Another theory is that there's more allergy in the community. A quarter of the kids have allergy. When kids get more allergic-type disease, the lymphoid tissue swells up and you get bigger tonsils. I don't think anyone has proven any of that. I think the bottom line, it's a combination of doing fewer tonsillectomies at a younger age and a greater awareness that tonsillectomy is highly effective for sleep-related problems, and sleep-related problems because a lot of problems at home and at school. The combination of that has led to an increased–
Currently, certainly in academic programs, 90% of the kids we do a tonsillectomy on have sleep-disordered breathing and tonsillar hypertrophy. If you look at more recently how many tonsillectomies are done in the 1970s versus now, it's actually doubled. We used to do a huge number for infection that went down by 75%, and then it's been climbing again as there's been awareness of sleep-related problems.
Persistent OSA After Tonsillectomy & Adenoidectomy (TNA)
Children who have had a TNA, yet still have persistent symptoms often have an underlying issue. Persistent OSA post-TNA is often found in children who are of normal weight but continue to have nasal problems. These children require thorough examination to identify potential issues such as adenoid regrowth, insufficient adenoid removal, or nasal obstructions. Allergies are also a common factor and may necessitate treatments like nasal steroid sprays or montelukast. A flexible scope examination may be needed to check for conditions like late-onset laryngomalacia, where the supraglottic structures collapse and obstruct the airway.
In some cases, additional surgery might be required, such as removing regrown adenoids or shrinking the turbinates. Addressing nasal issues is crucial for these children, and it often involves teaching parents and children how to tolerate nasal sprays. Dr. Gopi Shah suggests starting with a saline mist to help the child get used to the sensation, gradually working up to nasal steroid sprays like Nasonex.
[Dr. Gopi Shah]
Interesting. Next question is for patients who have obstructive sleep apnea and they have tonsillectomy and adenoidectomy, and then in that post-op sleep study still have OSA, what do we do with those patients? What's next? Is CPAP feasible? Is there more surgery that can be done?
[Dr. Ron Mitchell]
Actually, this is an increasing part of my practice. What we are increasingly realizing is there is a proportion of children who after a tonsillectomy and adenoidectomy continue to have problems. How do you identify them? How do you deal with them? Who are they? What's their demographics? What's their comorbidities? It's a big subject. In our department, every child who has a tonsillectomy actually gets a phone call with a number of standard questions and there are yes, no answers. Things like, does your child still snore? Does your child-- have things improved significantly in terms of behavior and so on? If they answer that things haven't improved, we offer them a clinic follow-up appointment.
In terms of who are the children who continue to have problems after a tonsillectomy, they come under well-defined categories, and how you manage each one of them is a big difference. At one end of this spectrum of kids with what we call persistent sleep apnea are the kids who are normal weight, have had their tonsils and adenoids out, have probably improved but continue to have problems. In these kids, most of the problem I tell people is in the nose. These kids need to come back to clinic, they need to be examined. A proportion of them may have adenoid regrowth or the adenoids have not been removed sufficiently and there isn't enough space at the back of the nose.
Allergies are also very common in these kids. Again, in our department, we have an otolaryngologist who specializes in allergies. Think in terms of allergies, think in terms of using a steroid spray, in terms of using a montelukast. I think if possible, these kids should undergo a flexible scope in clinic to also look at the larynx and make sure that they don't have what we call late-onset laryngomalacia, where the supraglottic structures actually collapse on themselves and cause an obstruction at the laryngeal level.
Most of these kids, the problem is in the nose. Some of them will need to go back to the operating room to have their adenoids removed, some may benefit from shrinking of their turbinates. Again, it's a fairly significant cohort of kids.
[Dr. Ashley Agan]
For that group, do you have any tricks on getting kids to tolerate nasal sprays? I feel like when I talk about nasal steroid sprays, patients or parents will frequently look at me like it's crazy to think that their child would be able to tolerate a nasal spray.
[Dr. Gopi Shah]
Yes, I keep a very straight face. I tell them to use a saline mist even to start and spray their arms so they're not scared of having the bottle and then spray close to their face, just with a mist, like saline mist, and to the point where they can tolerate the mist in their nose. I tell them it's not going to happen in one night, it might take a week. Then slowly once they get comfortable with that, try the Nasonex. We all see it a lot, not just for sleep-disordered breathing. I would say that runny nose "sinusitis" kid as well the allergy kid.
Addressing Weight & CPAP Use in Pediatric OSA Management
Managing pediatric obstructive sleep apnea is particularly challenging in children who continue to have symptoms post-tonsillectomy and adenoidectomy (TNA). Continuous Positive Airway Pressure (CPAP) therapy can be an option, but often has a limited role in mild OSA cases due to compliance issues and potential effects on facial growth. In overweight children, weight management is crucial, as even a 10% reduction can significantly improve symptoms. Surgical management can only go so far if a child is significantly overweight, highlighting the importance of addressing weight issues with families and adopting a collaborative approach to treatment.
For children with Down syndrome or other genetic conditions, persistent OSA is particularly challenging. These children often require a multidisciplinary approach, including flexible scope evaluations, allergy assessments, and sometimes additional surgeries such as lingual tonsillectomy or tongue base reduction.
[Dr. Ron Mitchell]
I think it’s worth mentioning that what we're trying to do is avoid further surgery, and using a nasal spray, tough as it may be in young kids, it's still preferable to doing a surgery in a kid. In these children, CPAP has a very limited role. Most of the sleep apnea is mild. It's unusual that that kid will need any PAPS therapy. The other thing is that we always have to remember that CPAP in kids, other than compliance is difficult, it also may affect facial growth. We could end up in a situation where a child is using CPAP that affects facial growth and leads to adult OSA.
In those, in the normal-weight child, I would heavily encourage avoiding CPAP, letting the child grow using sprays, allergy evaluation. If the adenoids have regrown, consider removing them. Can the child benefit from shrinking the turbinates? Then we have the two tough categories here. We have seen a worldwide increase in pediatric obesity. Children who are obese are more likely to have OSA. They're more likely to have severe OSA and they're more likely to have persistent OSA after TNA.
Of course, the solution seems very simple. If a child is overweight or obese, you lose weight, snoring gets better. Even a 10% loss of weight has a significant effect on their sleep and general well-being. In some kids who are overweight, what we can tell the parents is don't even aim for a weight reduction, aim for the child being the same weight a year from now. I think that's a good goal with these kids. In those kids, again, they need a flexible scope through their nose, make sure the adenoids are not regrown. In obese kids, get the involvement of a nutritionist, or if you in your own hospital, have a weight management clinic, think about that. Again, follow the child up, don't discharge and never see them again.
These kids, if they have moderate to severe OSA, CPAP should be considered. There is a problem here that there's increasing evidence that tonsillectomy may make these group of kids gain more weight. Some people jokingly say that, as they sleep more, they have more energy to eat more. It is a consult. Again, CPAP may make their OSA better, make them more energetic and they eat more and put on more weight. That needs to be discussed with the family.
The third group of kids are the children with craniofacial and genetic problems and your muscular kids, et cetera. The main child in that category are the Down syndrome kids. Down syndrome, 70% to 80% of them have OSA. You take the tonsils out. Even the ones who have a normal sleep study after tonsillectomy may, in years to come, go back to having OSA, either because of tone issue or weight or a combination of both. These are the toughest kids we deal with.
I know Gopi deals with them as much as I do, and they're not easy. If you take the extreme of those kids, these are the kids who have severe sleep apnea after tonsillectomy. They do not tolerate CPAP because of behavioral problems and compliance issues. What do we do with those kids? This is an area that has changed significantly in terms of how we investigate and what we do. In these children, again, we want to do a flexible scope in the clinic, make sure there's no adenoid regrowth, make sure that the airway looks normal, and we routinely will send them for a CPAP trial.
Now, all the kids with Down syndrome, half of them do very well if you have a sleep lab where the people are engaged in a maximizing compliance. If it's simply giving the machine to the family, your success rate will be less than 5%. We have a sleep psychologist, we have someone engaged in CPAP, and we have a very effective multidisciplinary approach to this, but the kids who have persistent OSA on CPAP, about half of them will either not use it sufficiently every night or will just not tolerate it at all. We also have to remember that how do we define good-
[Dr. Gopi Shah]
Toleration.
[Dr. Ron Mitchell]
-CPAP? We define it as four to five hours per night, five days a week.
[Dr. Gopi Shah]
At least 50% of the time that they're asleep.
[Dr. Ron Mitchell]
If I ask Ashley and Gopi, how would you feel with four to five hours a night, five nights a week?
[Dr. Ashley Agan]
I'd be tired and cranky.
[Dr. Ron Mitchell]
That's the 50% who are successful. Then there's everyone else. These kids are a challenge because in the non-COVID era, you want to, as much as you can, mainstream them at school, you want them to get an education, you want to maximize their speech and their development and their general well-being. On the other hand, we are defining good sleep as four to five hours, five times a week. This is an area-- In the ones who fail CPAP, we will consider what we call a sleep MRI or a cine MRI, where we sedate them, put them under anesthesia, get an MRI scan and look at the sites of the airway that are most likely to lead to airway construction.
In Down kids, 90% of it is the tongue base. These are the kids where we can do a fair amount for. Now, it does not mean that you're going to move a child from severe OSA to no OSA, but you may move a child from severe OSA to mild OSA. They don't need CPAP, and you can work on other issues such as trying to at least minimize any weight gain. We also, in some of them, consider palate surgery in addition to tongue base surgery, depending on what we find on the cine MRI.
Usually, on the day of surgery, we also do a drug-induced sleep endoscopy, which is basically using a flexible instrument through the nose and looking at any obstruction at the level of the palate, tongue base, and looking at the airway. That directs what we do for them. The most exciting part of this is, as we look forward, we are beginning to insert hypoglossal nerve stimulators in these kids. That's probably the most encouraging and forward-looking way to manage these kids, because with the nerve stimulator, essentially when it works, the parent can sit in their own bed with a dial, increase or decrease the amount of stimulation the kid has. It's a pretty amazing device.
We need more data, we need FDA approval and so on, but I can see that in the next 10 years, how we deal with children with Down syndrome is going to be transformed. Down syndrome and OSA will be transformed, but it's not suitable for every child.
[Dr. Ashley Agan]
How often do you feel that after a lingual tonsillectomy or tongue base reduction that there's a rebound or recurrence of severe OSA? You've got the patient down from-- they've had the TNA, they still have severe OSA. You did the advanced sleep surgery, it's improved. Then a year or two later, we're right back at severe. Do you see that often?
[Dr. Ron Mitchell]
Yes. We keep some data, we follow some of the-- not all of these children because some are lost to follow up, but the main issue seems to be weight. In the child who-- and just to mention anecdotes, I remember one child who came to see me with the mother, the child was overweight, significantly overweight. The mother basically said that they're in this situation where the child is so grumpy and badly behaved and so on that if she sends the kid to school, they call her up and send the kid back home because the kid hits other people. All the kid wants to do is sleep and eat and they get heavier.
That child did undergo tongue base reduction. The mother really was very engaged, getting the child moving, bought the kid a bike, bought the whole family a bike. The kid lost 30 pounds. I still see the kid because the kid actually has ear tubes, T tubes that I follow the kid up for. The kid never had the OSA again. We did two sleep studies. The challenge is that when they gain weight, which I think inevitably they do as adolescents, even when you start from severe, you take the tonsils out, you make them mild, you wait, they gain weight. Again, you do a tongue base, they gain weight and you're going to go back to severe OSA. The ones who don't tolerate CPAP at all are extremely tough. Yes, we do see it. You need to talk to the family about weight, weight, weight.
[Dr. Gopi Shah]
How do you have that conversation? Ashley and I were talking about this. It's not something that I did a lot of in my training. It's not something that I feel that comfortable addressing. How do you discuss it?
[Dr. Ron Mitchell]
I always say to the parents that tongue base surgery, palate surgery is tough, but I can only do half of what needs to be done. The surgery will make it better. It's very tough. The child will go through a very tough two weeks as will the parents. That surgery without addressing weight will make things better but only for a temporary period of time. It's got to be an agreement or an understanding between you and the family, that you do half of it, they do the other half.
If they're unsuccessful, it may be that they just cannot, the child will get better, but probably will relapse into where they were. It may give them a year or two, and maybe that's okay. Maybe things will change over a year or two, but it's-- and I do discuss with every one of them the tracheostomy, that, "Ultimately, we do have a procedure that takes obstructive sleep apnea away in these kids, and it's called tracheostomy." I tell them, if they have severe OSA, we have done tongue base surgery. The cardiologist is very concerned about the effect of severe OSA on the heart. The next option is a tracheostomy, although it comes, as we know, with a lot of issues.
[Dr. Gopi Shah]
Right. As one of our partners put it, we talk about smoking as a risk factor for cancer. Weight reduction and weight gain should be in the discussion for OSA.
[Dr. Ron Mitchell]
Yes, and I discuss with every single one. When a Down syndrome kid is obese, the chances of that kid becoming normal weight is very small.
Podcast Contributors
Dr. Ron Mitchell
Dr. Ron Mitchell is a Professor and Vice Chairman of the Department of Otolaryngology at UT Southwestern Medical Center and serves as Chief of Pediatric Otolaryngology. He specializes in pediatric otolaryngology and airway conditions.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2020, September 20). Ep. 6 – Managing Pediatric OSA Like A Boss [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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