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Podcast Transcript: Managing Pediatric OSA Like A Boss

with Dr. Ron Mitchell

We speak with Dallas Children's Hospital's Section Chief Dr. Ron Mitchell about Management of Pediatric OSA. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Observation vs Surgery in Pediatric Obstructive Sleep Apnea (OSA)

(2) Following Up On Observational Management

(3) When to Pursue a Sleep Study in Pediatric OSA

(4) Negative Sleep Study Despite Persistent OSA

(5) OSA Management in Adolescents

(6) Persistent OSA After Tonsillectomy & Adenoidectomy (TNA)

(7) Weight Control & CPAP Use

(8) Cine MRI vs. DISE

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Managing Pediatric OSA Like A Boss with Dr. Ron Mitchell on the BackTable ENT Podcast)

Ep 6 Managing Pediatric OSA Like A Boss with Dr. Ron Mitchell

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[Dr. Gopi Shah]
Hello, everyone, and welcome back to the Backtable ENT Podcast. I'm your host, Gopi Shah, and I have my co-host here today, Ashley Agan.

[Dr. Ashley Agan]
Hello there.

[Dr. Gopi Shah]
And our very, very special guest, Dr. Ron Mitchell. He's not just special because he's my boss and trained me in fellowship, but because he's our division chief, has been a pioneer in pediatric sleep disorder, breathing and sleep apnea, and has contributed to advancement in the management of pediatric OSA. Welcome to the show, Dr. Mitchell.

[Dr. Ron Mitchell]
Thank you for having me on the show. It's a pleasure.

[Dr. Gopi Shah]
I just wanted to first ask you to tell us a little bit about your practice and how you became interested in the research and management of pediatric OSA.

[Dr. Ron Mitchell]
Sure. First of all, thank you for the very kind introduction. My name is Ron Mitchell. I'm a pediatric otolaryngologist or ENT. I work in the Dallas area, and I work at UT Southwestern, where I am a professor of otolaryngology and pediatrics. I practice in downtown Dallas in Plano. I also have an office in the THR facility on Walnut Hill.

I first started being interested in sleep apnea in children mostly as a result of many parents bringing these children to my clinic. There was a shift about 20 years ago when I completed my fellowship to a bigger interest in sleep in children, airways, how the effect of poor sleep affects the children during the day. That has really translated into work that has been done both at ENT, pulmonology, neurology, psychiatry, and it has highlighted the importance of sleep in kids.

Also, as otolaryngologists, we see a lot of children primarily because they have problems with their tonsils. What we have seen over the last 20 years is the number one reason parents bring children to our clinic for tonsil problems is because they're concerned that large tonsils are interfering with their sleep, and when a child doesn't sleep well, the whole family is upset. In terms of research, there's been a 20-year period where we have gone from understanding very little about sleep to sleep being a large part of our practice.

(1) Observation vs Surgery in Pediatric Obstructive Sleep Apnea (OSA)

[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.

(2) Following Up On Observational Management

[Dr. Gopi Shah]
Dr. Mitchell, in your clinic, for the kids that you observe, when do you follow back up in clinic? Then for that observation group, who do you offer the Nasonex and the montelukast to versus just nothing at all?

[Dr. Ron Mitchell]
Yes. Many of the, again, over a period of many years, and with higher realization of sleep problems in kids being very common, I am increasingly seeing kids who are already on some type of medication. The challenge, I think, for all of us is that they've been started on a medicine, but they haven't used it a whole lot. Often what I'm seeing in clinic is when you ask the parents, "Have you used a nasal steroid spray?" "Yes." "How often have you used it?" "Twice and then stopped."

I encourage the parents to use it for six to eight weeks. I myself actually very rarely start them on montelukast, and I normally defer to the pulmonologist. Again, I see a fair number who already have been started on it. The audience, the people listening to this may be aware that there has been concern about montelukast being used, especially in older kids and affecting mood. There's been some concern that they can lead to suicidal thoughts, so on. I tend to shy away from it, but maybe we should all be more aggressive with this medication.

When do I observe them without intervention? It's when the parent tells me that they just do not think the child will tolerate any medication. Sprays in the nose tend to be effective after the age of four or five and tend to be very ineffective below that age. Occasionally, you'll see a kid where the kid just loves it and uses it and the parent is there, but more often than not, it doesn't happen to the younger kids.

If it seems or if the kid has some behavioral problems, I'm thinking particularly about autistic kids or some kids with Down syndrome, you may not be able to use any medication. In those kids, you may want to see them in six to eight weeks and ask the parent to observe the kids. We live in an era where many, if not all, parents have phones. What I always tell them is, "Go into the child's room at night, an hour or two after the child has gone to bed, and take a video clip and bring it to me, and let's look at it together." That's always a good way of assessing how the kid is doing. I think it's fair to see them again after two months.

(3) When to Pursue a Sleep Study in Pediatric OSA

[Dr. Gopi Shah]
Do you repeat the sleep study in like a year, or how do you make that decision?

[Dr. Ron Mitchell]
First of all, I think the first question is probably, when do we get a sleep study? For the purposes of our study, as an entry criteria, they all get a sleep study. In many kids with mild symptoms or a short history, I don't go ahead and get a sleep study at the beginning. I will actually not get a sleep study, send them out with treatment, see them again.

Now, again, at that point, when do we get a sleep study? When the child is a high-risk for surgery, and by that I mean the kids who have a lot of comorbidities, Down syndrome or significant obesity, craniofacial problems, neuromuscular disease. We also get sleep studies when a child has very small tonsils or adenoids and the symptoms don't seem to go with what we see on examination, or sometimes the parent just wants a confirmation of the diagnosis. I think that's a perfectly good reason to get a sleep study.

We also need to appreciate that we would not be able to get a sleep study in every child who snores, we need to be selective in it. We need to select those kids who will benefit most from a sleep study, which will help us in terms of the decision-making and the management of that kid if they do go ahead with surgery. I will rarely get two sleep studies after a period of observation because they tend to be very similar, and we should go by symptoms and quality of life.

[Dr. Ashley Agan]
That makes sense. If a mom or dad comes in and it looks like they have a video where the patient is continuing to have sleep-disordered breathing or obstruction and there's concern for that and you already know that there's mild obstructive sleep apnea, then you might start thinking more about surgery. Is that right?

[Dr. Ron Mitchell]
I would like to see a minimum of three months of symptoms. I would like to see an attempt at treating it medically, if possible. I would like to confirm that the child has both night-time and day-time symptoms. It's not simply that the child snores, but there are some consequences to it. Does the child wake up tired? Does the child have attention or hyperactivity problems? Is the child basically grumpy? All parents know what that means.

(4) Negative Sleep Study Despite Persistent OSA

[Dr. Gopi Shah]
Ashley and I were talking about this. How often do you have a negative sleep study, but there's some snoring and concern for attention and two plus tonsils? How do is a TNA appropriate in those kids or not?

[Dr. Ron Mitchell]
This is what we are actually studying, PATS study, it's exactly this chat. One of the issues that I always discuss with the parents is, "If we do get a sleep study and it shows that the condition is very mild, are you willing and happy to observe the child?" If they tell you that, "Whatever the sleep study shows, I want a tonsillectomy because the child's day-to-day life is affected significantly on this," there's really no reason to get the sleep study. In this situation-- The first thing to say, avoid the situation where the parent wants to proceed with surgery regardless of a sleep study.

We do occasionally have children who were sent for a sleep study either by the pulmonologist or the PCP and they're seeing us with the sleep study and the sleep study is very mild. I think this is a situation that, first of all, after the PATS study, we will know a lot more about what we should do because we will have data comparing the child who has surgery to the child who has been observed for a year.

In the absence of that data, I think this is an area that really lends itself to shared decision-making. What I mean by that is, you have to sit down with the parent, you have to talk about the risks and benefits of the surgery versus the risks and benefits of observation. If the child is having a lot of problems, we know that a sleep study that shows very mild OSA or no OSA does not mean that the child doesn't have behavioral problems or quality of life issues. It makes it less likely that you need to do surgery immediately, but that child may benefit from the surgery as much as the child who has severe OSA, in terms of behavior and quality of life.

[Dr. Gopi Shah]
Do you feel that with COVID, you're more or less likely to get a sleep study in these kids?

[Dr. Ron Mitchell]
Yes. It's interesting, we went through a period where the sleep lab was not working. We didn't do any sleep studies for over two months. There was a lot of demand from parents who wanted sleep studies, who were disappointed that we couldn't do the sleep study, especially the ones who were already scheduled and had to be postponed. Since we opened the lab, which was like at the end of May, there are many parents who now say to us, "We're too worried to come to the lab for a sleep study." We've gone from turning people away to trying to convince them that the sleep lab is a safe environment.

Do I send people, more or less? I actually do send fewer people for a sleep study because the concerns about distancing the need for a test before a sleep study means that we don't do as many sleep studies as we used to. The bottlenecked get one has increased, and I do send fewer kids, and I probably spend more time with the parents talking about what is the most likely finding of the sleep study and is there a way to avoid it, and that way, we avoid having to test the child, keep the child for a whole night in the lab, et cetera.

We also are not currently doing any CPAP titrations. There are some places around the country that have started to, but that is considered a much higher risk situation. We currently are not doing that. We may start next month.

[Dr. Gopi Shah]
Is there a role for home sleep studies, particularly for patients who are concerned or worried to go to the sleep lab? We do home sleep studies quite a bit, I would say, in adults. I don't know if it's as feasible in children, but is that something that you're using more?

[Dr. Ron Mitchell]
Yes. We do not use any home sleep studies. The adult and the pediatric population in that respect is very, very different. In the adult world, in many patients, you need a home sleep study before you can even consider an in-lab study. That's not the case in children. Now, we know that in children, getting a home study is difficult. The data comparing home sleep studies to in-lab sleep studies is actually very disappointing.

We do occasionally do simple oximetry studies. What we're looking for is just a screen to look at the very severe OSA. We do understand that a normal oximeter still may mean that the child has sleep apnea, but it probably excludes the very severe sleep apnea. Again, we don't do a whole lot of them. Because in children, the first-line management is tonsillectomy and adenoidectomy, as opposed to the adult world where the first line is CPAP and BiPAP, our need for sleep studies is actually not as great as it is in the adult population.

That may change in the next year or two. There's quite a bit of work on what we call abbreviated studies that we may be able to get at home. There's always a question, how does a home sleep study compare to video recording and how does that compare to a full night polysomnography? I think in children, the jury's out as to the usefulness of it.

(5) OSA Management in Adolescents

[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.

(6) Persistent OSA After Tonsillectomy & Adenoidectomy (TNA)

[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]
Okay. Thank you. Actually, this is an increasing part of my practice. I always say that the best way to cure OSA, you see the child, don't do a sleep study, take the tonsils out and never see them again and never contact them again. Then you cure all of them, because you congratulate yourself--

[Dr. Gopi Shah]
That was a joke.

[Dr. Ron Mitchell]
Yes. 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.

(7) Weight Control & CPAP Use

[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.

(8) Cine MRI vs. DISE

[Dr. Gopi Shah]
Then one last thing, not everybody has the ability to do cine MRI. You need a radiology protocol. You need radiologists that know how to read a cine MRI. You need anesthesiologists that feel comfortable sedating and spontaneously breathing a child with severe OSA. In terms of cine and a DISE, do you feel like an MRI is better than a DISE? Do you think the DISE or the drug-induced sleep endoscopy by itself was sufficient?

[Dr. Ron Mitchell]
I think they're complementary. I think if you're in a place where a cine MRI just can't be done, which was the case in Dallas 10 years ago-- and it comes under two categories. In some places, they just don't have it as an option. There are also some places around the country that will tell you they do cine MRIs, but they fail about 50% of the time. As you mentioned, it's anesthesia. Cine MRI should not be done by the anesthesiologist who is available and should not be read by the radiologist who is available. It's a very specialized area. There needs to be a team of radiologists who are really devoted to it.

I can tell you, in the last 12 months, we have not failed to get a cine MRI in a single child. It should be 90% successful. It's a team effort. It's a lot of managing the airway in a child with severe OSA in a way that the child is spontaneously breathing. You get an MRI without a lot of movement and interference so you can actually interpret it. Cine MRIs are by far the best investigation to look at the tongue base. DISE is a very effective investigation to look at the palate and look lower at the airway. They do complement each other, but you can function as an OSA, as a pediatric OSA surgeon with DISE.

Cines are nice, and certainly, there are times when on a DISE, you will not see so much a tongue problem, or it may actually overemphasize the tongue base problem and the cine conflict with it. Cines are not as good for looking at the palate. I think you benefit enormously from actually putting a scope and looking at how the palate constricts.

There is a lot of interest in the dental and orthodontic community about the relationship between OSA, facial growth, dental health, orthodontics, and prior to the COVID area where conferences were more common, it was a very-- it's a hoax topic, and I think otolaryngologists need to be aware of that there's a lot of interest that nasal obstruction can lead to facial growth issues. There is some concern that in the child where you take the tonsils and adenoids out, but they haven't been breathing through their nose for several years, they continue to be mouth breathers and that affects the growth of the midface, the jaw, et cetera.

I think we're going to hear a lot more in that area, and this concern that the child doesn't breathe through their nose becomes the 10% or 20% of adults who are not obese but still have OSA because of crowding of their oro and nasopharynx. I think we're going to hear a lot more about that. There are certainly orthodontists who are beginning to say, "I do not want to start treating the child's teeth when the tonsils are three plus or four plus. Suddenly we are, as otolaryngologists, seeing many more referrals from our dental colleagues, and I think we should be aware that they are concerned about nasal breathing.

There's a saying in the dental world that you should breathe through your nose and you should eat through your mouth. When that converges, you have a problem. I would encourage otolaryngologists to partner with the dental world, because I can tell you that when I go to meetings and they ask me to speak about this subject, some of them feel very nearly angry that they're worried about the tonsils, they're worried about nasal breathing, they send them to an otolaryngologist who sends them back saying, "It's not much of a problem."

I think otolaryngologists should have a working relationship with dentists. Remember, dentists are looking at the oropharynx every time they look at the child's mouth. When the child is not breathing well, their mouth's breathing, the tonsils seem to be obstructed and they're sending them to you. I think communicating with the dentist is a good thing.

[Dr. Gopi Shah]
Yes, I agree. I think we should definitely be at the table.

[Dr. Ron Mitchell]
What I do is I get the dentist's name and I send them a copy of my letter. I don't want to tell you how many times they will get back to me saying how grateful they are that I communicated with them.

[Dr. Gopi Shah]
Yes, definitely.

[Dr. Ron Mitchell]
The only other thing to mention is, during these COVID times, it'll be interesting where sleep medicine lands itself. What I mean by that is, we're not as able to do sleep studies as we used to be because of requirements for distancing and testing and so on. We never had enough pediatric sleep labs to satisfy demand, and we could see a time when it's just going to get worse. We're fortunate in Dallas that we actually have the largest pediatric sleep lab in the US here, but we're down to half the capacity and the demand is increasing. We live in interesting times, that's for sure.

[Dr. Gopi Shah]
Wow, that is so great. What an awesome conversation. I feel like I've learned so much. Thank you, Dr. Mitchell, for-

[Dr. Ashley Agan]
Thank you, Dr. Mitchell.

[Dr. Gopi Shah]
-your time. This was a great conversation. I feel like we could go for another hour. I hope you'll come back and talk to us again.

[Dr. Ron Mitchell]
Thank you. It's a pleasure. You're very impressive hosts.

[Dr. Gopi Shah]
Thanks, Dr. Mitchell, and he doesn't say that just because he's our boss.

[Dr. Ron Mitchell]
I like, actually, the combo. I think it adds something to it. Thank you. Bye-bye.

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.