Pediatric Sleep Apnea Surgery Options & Emerging Technologies

[Dr. Gopi Shah]
Tell me a little bit about the role of DISE or SNE in your practice. When do you get them? Which one do you like? Do you decide?

[Dr. Javan Nation]
Yes. I have done SNEs. It's not a main part of my practice. I usually use it if I'm really stuck or if there's some question about how the tongue base is affecting the palate. My more go-to is using sleep endoscopy. I use it generally in two different situations. I'll do it for all Down Syndrome patients prior to TNA. There's a DISE consensus panel that came out a couple of years ago. They actually agreed with that, which is interesting because there's some people on the panel who agreed it's useful, some people said it's not useful.

I find it to be useful, especially for Down Syndrome patients because what I've found doing this for these patients is that the airway collapse pattern is different. I did a two-year-old yesterday with Down Syndrome who had huge tonsils. We did the sleep endoscopy and had big adenoids, and so he was collapsing behind the soft palate, and you could see his tonsils were huge. They had this lateral collapse completely obstructing his airway.

It's nice to know because sometimes, what I'll do is I'll do a sleep endoscopy for these patients, and they might have two or three plus tonsils, but on the sleep endoscopy, the tonsils aren't moving much. Really, what I'm seeing is I'm seeing the tongue base obstruct. That's the hardest situation for me to be in because two questions arise.

First one is should I take out their tonsils? I can see on the sleep endoscopy that the tonsils aren't obstructing when they're sleeping, so should I take them out? If I don't take them out, what should I do? I feel like right now we're in an area where the first care, first line of therapy for kids with TNAs, is to take out their tonsils and adenoids for a few reasons.

One, we don't know how the airway reshapes after you've taken the tonsils out. Even if I'm not getting an endoscopy, I'm looking and I still see it's mostly tongue base. If I take their tonsils out, we might get that lateral pharyngeal wall scarring that's going to reshape their airway that might change it, and still, ultimately, help them. I'm uncomfortable because it's not a fun surgery to go through. They have 10 days of sore throat. They're uncomfortable. There's a risk of bleeding. Having that extra information that I-- When I see it's a tonsil, I feel great about it, but when it's not, it's uncomfortable.

This is data I'm currently collecting and I'm following these patients to see how do these patients who didn't have tonsil collapse on the initial sleep endoscopy do with their postoperative sleep study? I think in the future, for a lot of these Down's patients, we reduced sleep endoscopy and we find that, I think, I'm guessing, that we might do something different and start off with TNA. We're just not there yet.

Yes. I do it for all those patients. For a lot of patients that come through the complex sleep clinic, I don't routinely do it. People have different approaches to this. Some people see the sleep endoscopy as just as diagnostic as getting a sleep study. You get a sleep study, you should get a sleep endoscopy for all these patients, and then, use that information to make a decision for what to do next.

That's not my approach. The reason why is because when you're going to the operating room, you're putting them to sleep, there's some associated risk, but really, for my decision making, if this kid can tolerate CPAP, it doesn't really matter what the airway looks like. Does it make any difference if it's the palate or the lateral pharyngeal walls? It doesn't. CPAP is going to blow it all open either way.

Our approach is to always start with CPAP. If CPAP is not working, we're going to figure out ways we can maybe get it to work because we always tell families it's safe, and it works great, just the downside is you have to use it every day. For a lot of these kids, we talked about nasal resistance before. We'll find they have small noses. They have narrow palates. We'll get them plugged in with the orthodontist and do a palate expansion, and often, do a turbinate reduction, or maybe like a revision adenoid with the goal telling the family that, in many cases, it's not going to fix the sleep apnea.

I can tell you about a patient I did yesterday, actually. He's a 12-year-old with autism, morbidly obese. He's over 200 pounds. He's 12. He has very severe sleep apnea. AHI 30 plus. We saw him in clinic and he's just not tolerating his CPAP. He's got autism. It makes sense. Even non-special needs adults, compliance is still 50%.

You can imagine for this kid. He hates it. He doesn't do well with it, but one of the reasons is that the pressures are really high. You look in this kid's nose and he's got some underlying allergies. He's got huge turbinates, small nasal airway, and he didn't have any-- He was status post-TNA. He didn't have any adenoid regrowth, but he had a huge tori. You look at his nasopharynx and the whole coin is obstructed by these huge tori. It's really interesting. I want to get your opinion on this.

[Dr. Gopi Shah]
I've seen that. Yes. Tell me about that. What do you do for that?

[Dr. Javan Nation]
As long as you're just addressing the posterior cushion, you can shrink it down. I've only seen one study on it. I think it's a Korean study where they talked about addressing the torus for sleep apnea, and that was their approach. When we're doing eustachian tube dilation, a lot of times, we'll shrink down that posterior cushion.

That's what I did for this kid. I just used the suction coterie and just put it on the posterior cushion, keeping it away from the opening of the eustachian tube, and shrunk it down, and it worked great. I did a turbinate reduction, shrunk down the tori, and it got to the point where when I was done, I could put the scope in, and I could actually see his nasal pharynx instead of just these big bulky torus obstructing his choanae.

[Dr. Gopi Shah]
Would you do a DICE on a kid like that?

[Dr. Javan Nation]
Yes. I did a DICE.

[Dr. Gopi Shah]
That would make sense.

[Dr. Javan Nation]
Right. For any of these patients who are coming from the complex sleep clinic, if I go to the OR, I'm going to do a DICE just because it gives you more information.

[Dr. Gopi Shah]
You're not taking them especially just for the DICE to the OR? I know you kind of touched on that. Some people would say, "No. We're going to go to the OR. Get a DICE. That's part of my information." Usually, they're going to the OR for something else.

[Dr. Javan Nation]
Usually. It's not routine.

[Dr. Gopi Shah]
That's how I usually do it, too. Yes. That's how I usually would do it, too, and it's because of that extra anesthesia. That being said, the information-- there is more, potentially other information. You know what I mean?

[Dr. Javan Nation]
For sure. Yes. That's our approach. If we go to the OR for any reason, I'm going to do a DICE on these patients. It just gives us more information. When I did a DICE on this patient, the area of obstruction was his torus. You could actually see those tori coming together and obstructing his nasopharynx. Yes. It's interesting because he had so much nasal resistance that downstream in his oropharynx, that was all collapsing as well because he was just working so hard to try and pull air through his nose.

Hopefully, I got his nose open. We were very blunt with the family that, "This procedure is not going to fix your sleep apnea. You're not going to wake up and it's gone, but our hope is that we can make it more comfortable for you to wear your CPAP mask." If we could potentially get him just a nasal airway mask, kids tend to do better with those. If we can get that nasal resistance down-- We haven't proved this. This is our hypothesis, so it's still in the process of collecting data, but our hypothesis is if we can decrease nasal resistance, we can make it more comfortable to wear the mask and increase compliance.

[Dr. Gopi Shah]
No. It makes sense. Two quick questions about the DICE. You'll do it before and after the procedure that you're addressing, whether it's turbinate reduction, you're going to do it like before the turbinate reduction, and after turbinate reduction, or TNA before the TNA, and after the TNA? Is it just your kids with severe or from the complex sleep clinic?

[Dr. Javan Nation]
What do you mean after? Do you mean during the same anesthetic event?

[Dr. Gopi Shah]
Yes. Let's say the child has an AHI. It's a five-year-old. Let's say otherwise healthy. Let's say slightly overweight for some reason. It has an AHI of 30 and 2, 3+ tonsils. You plan for TNA. Do you do a DICE for a child like that or who do you decide needs a DICE? If you're going to do it, do you have a pre-procedure scope, and then, whatever you're doing at the time of that surgery, and then a post-procedure scope or a DICE?

[Dr. Javan Nation]
Yes. I used to do a DICE for all patients who are high-risk for postoperative sleep apnea. That meant I was doing a lot of obese patients. I stopped doing that just because I found it was too high-risk for these patients, and it wasn't changing what I did.

[Dr. Gopi Shah]
That induction for those kids, it can get south fast.

[Dr. Javan Nation]
For sure.

[Dr. Gopi Shah]
They're high risk. It depends on how comfortable and how the patient also tolerates anesthesia.

[Dr. Javan Nation]
Right. These obese patients, they're not down to the patient. They don't have the complexity to the collapse that they do. Yes. There's a few times I'd have this 250-pound, 300-pound patient on the table trying to do a DICE, and the anesthesiologist is working really hard to maintain that airway. I ask myself, "Is this a risk? Is it worth it?" I came to the conclusion I don't think so for these patients just because it's not changing my management.

The Down Syndrome patients, it's not necessarily changing my management, but the instance of these kids having residual sleep apnea is so high, and it can be so varied. Is it tongue-based? Is it a floppy epiglottis? I do a bronchoscopy for all those patients as well with Down Syndrome.

They're really the ones I'll do before the TNA, just the patients with Down Syndrome, I'll do a DICE prior to the TNA, but same anesthetic event. I can talk about my techniques. It's been kind of funny. I feel like it's always evolving. I'm really happy with my current cocktail right now.

I used to use Dr. Koltai's cocktail where you would give one to two mics of dexmedetomidine and ketamine. Then, you just wait for 10 minutes, and then, start your DICE. That was fine, but some of the issues I was having with the ketamine was there were a lot of dysphoric issues. They'd wake up dysphoric. It would take them a long time to wake up as well.

Norman Friedman, for example, uses dex only. I was noticing that if it was just dex, I was having a hard time getting him to that state quickly. We actually increased how fast we give it. What we're doing currently is we're doing one to two mics per kilogram of dex over five minutes. We're pushing it really quickly. Then, I don't start the sleep endoscopy until five minutes later.

It's been working out really, really well. The patients are waking up quicker. We're not having as many of those dysphoria issues. Yes. It gets them into that nice state where they're snoring and they're just deep enough that you can put a scope in their nose without them waking up and swatting it out, but you're not getting that artificial collapse as well.

[Dr. Gopi Shah]
Is that something you came up with your anesthesia colleagues?

[Dr. Javan Nation]
Exactly.

[Dr. Gopi Shah]
Is it actually the same anesthesia provider that you work with for these patients?

[Dr. Javan Nation]
There's some that are more into it than others. With those ones, we always brainstorm and have this conversation, like, "Well, let's try this. Let's try that." Then, the other ones will just be like, "Oh, what's your cocktail? How are you doing it these days?"

[Dr. Gopi Shah]
Yes. That's right.

[Dr. Javan Nation]
Right? They always ask me that every time because they know I'm always changing it. That's where we're at now. I'm pretty happy with the one to two mics per kilogram of dex over five minutes.

[Dr. Gopi Shah]
In terms of bringing this to your practice, have you been able to train with your adult colleagues on the actual surgical procedure? Have you had the opportunity to travel and see other surgeons? This is, it's so exciting. It's something that you've been a part of in terms of building this practice for the last 10 years. Now, you have a new surgical tool, a new skill set set to develop mid-career. Tell me about that experience developing something new and different.

[Dr. Javan Nation]
Yes. Inspire, the company does a great job of teaching. Really, from the beginning, they've been very careful about making sure surgeons don't get complications. They have a great educational component built into their training. They have these guys that go around the country and they'll sit down with you, they'll have you come, and do the training course. It's four hours of didactics, sitting in the classroom, talking about dissecting out the hypoglossal nerve.

What's interesting is, we see the hypoglossal nerve, not all the time in head and neck surgery. It's not what we necessarily look for. We look for 11 or 7. We'd see it but we don't necessarily look for it or dissect it out, but in this situation, you're looking for it, and you're dissecting it out. You're actually looking distally on the nerve for the protractors and the retractors.

What you're trying to do is you're just trying to cuff the nerve, the portion of the nerve that stimulates the protractor muscles that pushes the tongue forward, leaving the retractors out. You don't want this to like the tongue to go back. That's interesting. We never learned that before. That's brand new.

They do a great job teaching you how to identify that. They do a great job showing you how to get down to 12, how to get the mylohyoid out of the way, and give yourself that good visualization and approach, how to dissect it out, how to stimulate it. Here, I'd say as an otolaryngologist, it feels very much within our wheelhouse. We're comfortable in the neck. We're comfortable in that area.

The part that made me probably most nervous was working in the chest. The other part of this is you have to put the lead into the chest. You make an incision over the second intercostal space, dissect down to it, and then, you're actually putting the sensing probe between the external and internal intercostal muscles. We do pec flaps and things like that, at least within the residency. As a pediatric otolaryngologist, I don't do peck flaps anymore.

[Dr. Gopi Shah]
I haven't done a pec flap in about 15 years.

[Dr. Javan Nation]
We've been in the area, but it's not an area that we're super comfortable being. At least I have to say I wasn't super comfortable being there. They do a great job. They have a cadaver dissection course. You go in there and you practice in the cadavers and they have-- the reps show to your first handful of surgeries to really walk you through and be there for you. It's great. Yes.

Where I started off in my hospital was I wasn't able to do it on kids under 18 yet just because it didn't have FDA approval. We have a sizable amount of patients who are special needs, who are still part of our practice. When you're at Dallas, you know that there's these CP kids and special needs kids who just don't really transition well to the adult world. We just keep them with us. We're comfortable with them, they're comfortable with us. We're built for that type of thing in our clinics. We'd have these 19, 20 plus patients.

My first patient was a patient that had cerebral palsy, pretty-high functioning with very severe sleep apnea. She just absolutely couldn't tolerate her CPAP. She was our first and she was very small. She had very small muscles, dissecting through her pec major was two spreads [chuckles] and you're already through it, but it went great. Yes. We just got her activated a couple of weeks ago. Things to think about is I haven't seen anything published on other people and planning these types of patients yet.

One of the challenges is getting her habituated to the stimulation. So far, she's doing great, but it's something we thought about. It's like this is already a patient that has CP, has sleeping issues, how much stimulation will it take before she's going to awake? We thought about doing a slower ramp instead of just doing a 30-day ramp, doing a slower ramp where we just slowly, slowly increase how fast we're turning up the stimulation. These are challenges that we have to think about. We're excited to see how our outcomes are going to be with these patients.

[Dr. Gopi Shah]
That's really exciting. One group of kids that we haven't talked about. We didn't have a multidisciplinary sleep clinic, but we had a round, a quarterly round, that were pulmonologists, our PDNTs would come together, and discuss some of our difficult patients.

Once a year, we'd have a child with the question-- Does this child need a tracheostomy? Tell me about your experience with tracheostomy for the indication of obstructive sleep apnea. It's not common, but there are those kids out there. I think we're still probably getting closer to where other technologies may be helpful to avoid some of those, but some of these are tiny infants, under two, or really medically-complex kids where it's hard to know what's going to help them. Tell me about your experience with that.

[Dr. Javan Nation]
Yes. I'd say probably the most common ones, if they're infants, where that question comes up, would be the children with Pierre Robin. What literature has shown for those patients is if they have other comorbidities, or they're part of a syndrome, then, a distraction won't be as helpful for kids that have bilateral choanal atresia. If it's part of a syndrome and they have bilateral choanal atresia, we don't always get a sleep study for these patients, but they're obviously obstructing. They're obligate nasal breathers. Sometimes, you want to be the hero and go in there and do a choanal atresia repair for that.

For a lot of these patients, I don't think that's the right thing to do. If there's lots of comorbidities, they're not doing well. I think a trach is probably the right answer for them, the best way to help them. Work gets really complicated and there's no set criteria between institutions, maybe like a child with cerebral palsy.

These kids are interesting because you look at them, and while they're awake, they essentially look like they're sleeping as far as their airway tone goes. You see them obstructing in front of you, and you'll do an awake laryngoscopy, and watching their airway looks very much like what a sleep endoscopy looks like.

I've actually done that where I've done awake endoscopy and I've done a sleep endoscopy, and it doesn't really change. For a lot of these patients, I don't feel like I need to do a sleep endoscopy because I'm getting that information while they're awake.

You said, "Are there criteria?" There are no set criteria. This is something that we always talk about with other otolaryngologists, like, "When do you trach this patient? When is this patient sent to you for a trach? How do you make the decision to do it or not?" It's a big decision to make when you do a trach or not.

[Dr. Gopi Shah]
I find it really difficult.

[Dr. Javan Nation]
Yes.

[Dr. Javan Nation]
We just had a patient with CP that came through our complex sleep clinic and that came up, like, "Should we do a trach or not?" Our plan was to do a sleep endoscopy and a TNA, but in the meantime, before we actually had surgery, she got admitted to the hospital because she was having episodes of cyanosis.

She gets admitted to the hospital and mom comes in and mom says, "I've talked to other people who say trach is not a big deal. I think I'd actually like to do a trach." He said, "Well, trach works great. A trach will fix this problem, period, but, is it time yet?"

While she was in the hospital, we actually got her fit with a BiPAP that she was tolerating. I spoke to the pulmonologist, and I was like, "Should we consider a trach?" The point that they brought up that I really appreciated was that she didn't have the social support for a trach.

For a trach, you need to have two full-time providers that are available. This particular mom was a single mom, and grandma lived across the border in Tijuana. For this child to get a trach, you're going to basically take her out of her home, and she's going to end up in our long-term care facility.

Mom might say, "Oh, yes. Trach's not a big deal." That's what we tell families, too. It's reversible. In many cases, not always. It's not the end of the world, but it is a big decision. In many cases, if you don't have that proper care, they might not be able to go home with you. There's all these things to consider. For me, I personally really appreciate having all the different providers on-board to make the decision before moving forward.