972-566-8300

7777 Forest Lane, B432, Dallas, TX 75230

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Pediatric Airway

The surgeons of the Dallas ENT group are frequently asked to evaluate pediatric patients with noisy airway; or even neonates and infants with significant obstruction.  In assessing a pediatric patient, the question arises if the airway is abnormal, is the problem in the upper or lower airway, and if abnormal; what is the nature of the pathologic problem?

Initial consult involves evaluation of the airway in terms of airway movement and respiratory effort, such as airway noise and movement of the chest.  

History involves the time phase such as the recent onset, progressive nature of the problem, or if the patient is a neonate or newborn.  The signs and symptoms of chest movement, retraction, quality of the noise, level of consciousness, and adequacy of air exchange and oxygen saturation is determined.  

Most children referred to the practice are seen in the office within the first 2‑3 months after birth with symptoms of mild airway noise.  A complete history and evaluation is obtained.  Our office provides the evaluation of the airway with a small fiber optic scope that can be easily passed through the nasal airway to assess the airway above the vocal cords.  Frequently, the child experiences reflux of stomach acid that is controlled with medications such as Prevacid or Nexium in addition to elevation of the head of the bed.

The Procedure

Those children that have more complicated problems will need to undergo a laryngoscopy and bronchoscopy.  This involves evaluation of the airway under anesthesia with a lighted scope.  Frequently, the lighted scope is passed below the vocal cords to determine any pathology or abnormality of the trachea or bronchi.

Airway compromised in the newborn presents a challenge.  The history of prematurity, traumatic delivery and distress at birth is quickly assessed.  The patient may have an obstruction of the back of the nose requiring placement of a ventilating tube and later correction of the blockage of the nasal tissue.  Laryngoscopy at the bedside may reveal abnormality of the vocal cords or a web between the cords.

A respiratory distress and airway noise at 1-3 months may indicate a small vessel enlargement below the vocal cords, referred to as a subglottic hemangioma, but most commonly, laryngomalacia, is an immaturity of the cartilage of the epiglottis allowing for simple collapse during inspiration.  With control of the reflux, the infant will outgrow the abnormality during the first 12 months of life.

As noted, evaluation is frequently performed in the office with the availability of the flexible scope.  Essentially may require a more extensive procedure under general anesthesia.

The surgeons with the Dallas ENT group have developed an expertise in the evaluation and treatment of patients with airway obstruction.  In those patients with significant anomalies, the craniofacial plastic surgeons are consulted as well as an additional pediatric ENT expert to provide the maximum benefit for the evaluation and treatment of the pediatric airway.

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Evaluation & Treatment of Sleep Apnea

What is Sleep Apnea

Sleep apnea is a potentially serious and sometimes life threatening condition affecting 2% of women and 4% of men.  Patients with sleep apnea not only snore, but also experience episodes of respiratory obstruction and apnea with interruption of breathing for periods of greater than 10 seconds.  The episodes of pauses of breathing and snoring are obvious to the sufferer’s bed partner.

Untreated Sleep Apnea

Multiple studies over the last 25 years have revealed that episodes of apnea with decrease in blood oxygen and an increase in blood carbon dioxide places a significant stress on the patient’s cardiovascular system leading to hypertension and an increase incidence of heart attacks and strokes.

Evaluation

Most of the patients referred to the Dallas ENT Group have been evaluated by a sleep medicine physician with a sleep study.  These are patients that have failed CPAP.

Those patients that have not been evaluated by sleep medicine physician, do undergo an extensive history of their snoring and apnea determining whether or not the patient experiences daytime drowsiness, true apneic episodes and respiratory pauses, and symptoms of nasal obstruction.  A complete head/neck exam including blood pressure, pulse rate, weight, height, calculation of body mass index, and neck circumference is obtained.  The patient is referred to a sleep center for evaluation and possible therapy with the CPAP.  The patients do undergo “a split night study”.  The first half of the night determines the extensiveness of the sleep apnea.  The second half of the study allows the technician to determine the proper mask fit and pressure required.

How CPAP works

The CPAP results in the pause and pressure that opens the collapsing airway.  This allows for adequate airway expansion, ventilation, and oxygenation.  The CPAP functions in a biphasic fashion.  Expansion occurs followed by relaxation to allow for exhalation.

Those patients that tolerate CPAP are seen back in the surgeon’s office for follow-up and encouragement to continue to use the therapy.

CPAP v.s. Surgery

The majorities of patients evaluated by the Dallas ENT Group have already undergone a sleep study for symptoms of snoring and/or sleep apnea and have failed CPAP.  This occurs conservatively in 50% of the patients and some studies suggest as high as 70% to 80%.  In the last several years, significant advances have been made in decreasing the failure of CPAP associated with computerization; but the high rate of noncompliance remains.  In addition, the mask fit and headbands have been modified to ensure proper fit and pressure adjustment.

The Surgical Institute for Sleep Apnea (SISA) was created to evaluate those CPAP failures.  The multidisciplinary team faces a challenging approach to maximize the therapeutic benefit to the patient.  There are very few programs in the country that effectively evaluate and treat the large number of CPAP failures.  Stanford University Sleep Program was developed a number of years ago and remains a standard for other multidisciplinary teams.

Evaluation & Diagnosis with Therapeutic Conditions

Those patients that failed CPAP therapy are referred to the multidisciplinary team of the Surgical Institute for Sleep Apnea.  The patients are evaluated extensively; reviewing their medical history and sleep studies as well as any therapeutic approach that they have tried.  In addition, a full head/neck physical examinations performed by members of the 3 disciplines including orthodontics, ENT, and Craniofacial plastic surgeons.  The orthodontist evaluates the patient’s occlusion, maxillary and mandibular relationship.

After complete evaluation, the multidisciplinary team will discuss the findings and recommended to the patient the appropriate therapy.

Therapeutic Options

The patients that failed CPAP have complex findings based on the physical exam including the weight, maxillofacial, and orthodontic structure; in addition to the range of parameters that the sleep study reveals including such findings as the lowest level of oxygenation during obstruction and the frequency of obstruction with a measured “apnea-hypopnea index.”  The sleep architecture is reviewed specifically determining the amount of time that the patient spins and REM (rapid eye movement sleep).  REM sleep should be at least 25% of total sleep time.  During REM sleep, the patient produces the neurochemicals that are required for alertness, focus, and attention during the day.

Frequently, patients have mild to moderate sleep apnea and are candidates for the oral appliance.  The oral appliance is an upper and lower acrylic splint that stabilizes the mandible to prevent the lower jaw and tongue from decreasing the airway space resulting in snoring and sleep apnea.  The orthodontist has the expertise in performing the proper fit, in addition to adjusting the appliance with follow-up visits to maximize the posterior airways space.

Maxillary Mandibular Advancement Surgery (MMA)

The airway is in essence confined by the upper and lower jaws.  By moving the upper jaw maxilla and the lower jaw mandible forward, the entire airway can be enlarged.  In this procedure, the upper and lower jaws are moved forward in relation to the remainder of the facial bones.  This enlarges the space behind the tongue and soft palate making obstruction less likely.  Maxillary mandibular advancement surgery (MMA) is often performed in conjunction with tongue advancement procedures.

Although the procedure sounds complex, Drs. David Genecov and Raul Barcelo are craniofacial plastic surgeons internationally known for performing these procedures frequently.  The MMA addresses the problems immediately with a good long-term result.  The success rate has been documented as high as 90%.

Tongue & Hyoid Suspension

The multidisciplinary team may make the recommendation for a tongue and hyoid suspension, rather than a maxillary mandibular advancement (MMA).

The procedure is performed by making a 3-4 cm incision under the chin through a transverse crease in the neck.  The resulting scar is not visible because of the location of the crease.  Dissection is performed to the level of a bone, referred to as the hyoid.  A specially design inserter places a small titanium screw into the back side of the mandible, in the midline, adjusting the right and left of this midline screw.  The small screw cannot be palpated nor felt.  Two heavy permanent sutures are internalized inside the tongue.  These sutures provide for a sling to prevent the tongue from falling back in the airway.  The sutures are not noted by the patient.

Two additional lateral sutures are used to loop around the hyoid bone at the base of the tongue, advancing this bone anteriorly and superiorly toward the chin.  The result opens the upper airway or advancing the base of the tongue.  The sutures are not noticed by the patient.

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