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Does this Patient Really Need an Antibiotic? Eustachian Tube Dysfunction and More · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmins, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit.
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We're talking about eustachian tube dysfunction. I'm here with Dr. Marissa Early.
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She's with University Health and UT Health San Antonio.
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Thank you so much for being back here today. Thank you so much.
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This has been such a fun opportunity.
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Well, and it's such an opportunity for our listeners. We're,
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as we know so much of treating patients with ear infections,
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it falls to them because it can be really hard to get in to see a specialist.
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You are the head of our pediatric ENT division.
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Yes. And it's such an honor to be here with you today.
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One statistic I read was that 40% of kids have eustachian tube dysfunction. Absolutely.
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So eustachian tube dysfunction also is just sort of the disease of being a little kid.
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So not to oversimplify, but the eustachian tube is just the natural drainage
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pathway from behind your eardrum, that middle ear space, to the back of your
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nose, right where your adenoids actually are, which becomes important in management.
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And in kids that are under five to six years old, their eustachian tube's not mature.
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So it's not at its adult 45 degree angle.
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It's almost horizontal. So gravity can't help any of that fluid that builds up naturally drain.
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It is floppy because their cartilage isn't fully mature and it just doesn't
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function that well in a lot of kids.
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And so up to 90% of kids by the time they're five will have had at least one
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episode of otitis media with effusion and eustachian tube dysfunction is probably
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the biggest cause of otitis media with effusion.
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And so, yeah, a lot of people have it. It's worse, I think, when it goes into
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adulthood. We're a bunch of wimps when it comes to symptoms.
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And so with COVID, I've seen a lot more parents complain of eustachian tube
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dysfunction and kind of that effusion and full ear feeling.
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So we really have to give our pediatric patients some credits for being pretty
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darn tough to tolerate a lot of these symptoms.
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So, and how do you identify if it is eustachian tube dysfunction,
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and especially in an older child, because it can last longer,
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for example, with my daughter who's 13.
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Yeah. So we're
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It can be tough. You have to capture both the symptoms.
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And then a lot of times, if you're having a hard time getting into ENT,
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if you can get a kiddo into audiology, that can give you more information.
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And if you have a pneumatic otoscope, that can give you more.
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So putting those pieces together, if a kid comes in and they complain, my ear feels clogged.
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You don't see earwax. The eardrum doesn't look like there's an active infection.
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So you're like, what is going on is this eustachian tube dysfunction. I'm not sure.
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If you have a pneumatic otoscope, which is the kind of otoscope that has a little
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bulb on the outside with tubing, you want to use a speculum tip that will seal
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against the ear canal so that when you poof the air, it's not escaping.
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And then a trick that I learned too is you hold the bulb ever so slightly depressed
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as you put the speculum in the ear.
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And that way you can look for negative pressure by releasing your hand,
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which will create a little vacuum
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and then poof, which will be positive pressure, moving the eardrum in.
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So you can really see the in-out movement of the eardrum, which is normal.
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So eustachian tube dysfunction, you may see that it's already baseline retracted
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and it will make a much more dramatic movement outwards at you,
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but it can't be poofed in anymore because it's being sucked in by negative pressure.
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And so that's one way to tell. And if it moves, at least you know it's not a
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straight-up effusion. It's not completely blocked by fluid.
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If you can send them to audiology, what you'll typically see is on the tympanogram.
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So when they use their tympanometer or tympanometry, that is looking at eardrum movement and pressure.
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Negative pressure, which is a type C tympanogram, is just like I described with
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the pneumatic otoscope.
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It's under negative pressure, so it does move, but it's already sucked in.
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So there was fluid that's trying to drain down the eustachian tube and it's
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creating this vacuum drag situation on the eardrum.
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A type B tympanogram means the eardrum's not vibrating, and then you have to
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look at what the external canal volume is, or ECV,
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because if it's usually less than one milliliter of volume, the eardrum is intact,
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and so that means there's fluid behind it. The eardrum can't move.
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But if it's a flat eardrum, a type B tympanogram, with external canal volume
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that's elevated, like 1.5 and higher, then that means there's a hole.
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So there's either a tube or a perforation in there. And the air is just rushing
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through the eardrum and not being reflected back to the probe.
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And then a type A is considered normal.
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And the eardrum makes a nice peak when you use the tympanometer.
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So those, as well as symptoms of popping ears in older kids who do know how to kind of valsalva,
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hold their nose, keep their mouth closed, and blow to pop their own ears,
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if that gives them some relief, that will often signal eustachian tube dysfunction.
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Typically, these kids are also allergic-type kids, and that's part of what's
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predisposing them, making their
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mucus stickier or making their eustachian tube a little more inflamed.
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And so those are some of the things that, as a pediatric or family medicine
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provider, you're looking for.
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In terms of management, you want to treat the symptoms.
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And so if they do not have any other allergic symptoms, don't go to antihistamines
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and nasal steroid sprays.
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No studies show that that helps in non-allergic children with no nasal symptoms.
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We used to think, oh, if we can just decrease the mucosal inflammation by using
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systemic antihistamines or by using topical nasal steroids, that's going to fix everything.
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But really, that's not what the studies showed.
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And so getting kids to either aerate it on their own, teaching them how to like
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kind of poof open their own eustachian tube or treating symptoms if they have them.
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And then otherwise, if it's chronic eustachian tube to the point that it's causing
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hearing loss or fluid building up
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or significant pain, sometimes we end up having to do ear tubes for that.
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Fluid is easy. Like that makes sense to us. If there's fluid behind your eardrum,
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it's causing hearing loss.
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Then yes, that's a problem. Of course. eustachian tube dysfunction alone,
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like a lot of negative pressure and discomfort and fullness and popping is not
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always the most obvious reason for tubes.
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And I would counsel a parent and a patient very carefully about what their expectations
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are, but it is sometimes an indication for ear tubes as well because those are
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pressure equalizing tubes.
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And the hope is that while the tube stays in place in the eardrum,
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their eustachian tube is maturing and or you're getting whatever inflammatory
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process like allergies and things like that under better control so that when
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the tube falls out, they won't just be in the same boat.
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And do we know why for some older kids, for adolescents, they may also have
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eustachian tube disorder and adults?
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So we think that it may have to do, especially in older kids,
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like school-aged and older, sometimes it's the adenoids.
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And so your eustachian tube opens right in the back of your nasopharynx,
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and it's literally right where your adenoids sit.
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And so in adults, unfortunately, we often have to scope through the nose to
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make sure that there's not a mass because adults are not supposed to have adenoid tissue.
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So if you're an adult with eustachian tube dysfunction, I'm sorry,
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but your ENT will probably shove a camera down your nose.
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If you're a kid, we may or may not, depending on your symptoms,
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but it often does help to look at that eustachian tube opening with a camera
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because I can either see are there horrible allergic changes because I can see
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mucosa that's been inflamed for a long time or the adenoid's very enlarged and
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we need to talk about removing those.
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They used to actually have providers perform
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adenoidectomy at the same time as ear tubes always now
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we really reserve that for if a child has
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a separate reason for an adenoidectomy meaning they have chronic runny nose
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recurrent sinusitis severe nasal obstruction you scope and you see big adenoids
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things like that and then they also have ear problems yes by all means do ear
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tubes an adenoidectomy if it's their first set of tubes.
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If it's a second set of tubes, there is some literature still to support,
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and they're older, potentially doing adenoidectomy with a second set of ear tubes.
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So I usually tell parents, I will look and see if there's any tissue there.
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And then adenoidectomy alone is rarely indicated as management unless the adenoids
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are just so massive that that's the obvious reason that their eustachian tube's not working.
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So how is life different for a child with eustachian tube dysfunction or an adolescent?
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Good question. I think if you ask them, a lot of it is they feel frustrated
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by a lot of their symptoms because that fullness and popping can impact their
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hearing, particularly in crowds or when there's a lot of background noise.
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And so just like you feel frustrated asking your kid, like repeating yourself
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or saying what, or they're saying what to you rather, they feel frustrated too.
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They don't want to have to ask you to repeat yourself.
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And sometimes kids will start to get shy in school because they don't want to
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have to keep asking the teacher to repeat themselves.
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Eustachian tube dysfunction can feel worse at night. So sometimes they can develop
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more sleep problems and they won't totally know how to explain to you why.
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They just feel uncomfortable.
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And so flying can be an absolute nightmare.
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Obviously, kids are not typically becoming pilots, but if they fly or travel
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a lot with their parents, every time they fly, it's going to be very painful.
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And when I cared for adults as a resident, we would sometimes do ear tubes on
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flight attendants or pilots that had bad eustachian tubes.
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What do you recommend in preparation for flying or during that flight?
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So I usually have a little thing that I will recommend to parents and I'll tell
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them, take a bottle of Afrin with you. Okay, here's my big warning.
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In general, I hate Afrin. My residents, if they heard this, would be like,
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that's not true. You love Afrin.
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So on one hand, I do. It's a great medicine, but it has a very high potential
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for abuse. Not because you feel high, but because your blood vessels in your
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nasal mucosa become dependent on it. sometimes after even more than just five days of use.
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So I tell parents no more than three consecutive days of use,
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and I scare the bejesus out of them if I can about how their kid's going to
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get addicted to Afrin and they won't be able to breathe without it and blah, blah, blah.
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But after I paint a scary enough picture, I say take it about 20 minutes before you take off.
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And if it's a very long flight, do it when the pilot says that you're starting your descent.
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One or two squirts up each nostril tastes terrible. I warn them ahead of time
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to have something delicious for their kid to eat.
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Just like a lot of parents know to chew gum or chew gummies
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or suck on a lollipop if they're a little little kid a bottle and
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then that way they're moving their palate which will help pull the eustachian tube
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open and then if the child is old enough
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for it to be safe sometimes I'll even have them give Sudafed if they have really
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bad eustachian tube function because that will work systemically but it tends
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to decrease the edema of our nasal mucosa and our eustachian tube mucosa So
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that's what I typically recommend before flying, as well as chewing gum,
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if they know how to kind of pop their own eustachian tubes,
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doing that frequently. But it is hard.
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And in general, with eustachian tube dysfunction, it's important to keep the ear as dry as possible?
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Yes. So you don't want, I think of it like you're already at one strike, right?
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Like you are already a little bit predisposed to an ear issue and an eardrum issue.
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So keeping your allergies under great control, avoiding even just like long,
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long periods of headphones, because that creates an artificial vacuum and kind of seal over the ear.
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And it can make that sensation very uncomfortable for people.
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A lot of people with mild eustachian tube dysfunction don't like noise canceling
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headphones because they,
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clog everything off in your ear canal, and then they also are emitting a frequency
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and a pressure that can just become very uncomfortable.
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And so for some people who can't tolerate it, you may have a little bit of eustachian
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tube dysfunction. No big deal if it's not affecting your day-to-day life.
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But I try to encourage kids, I know you don't want to take medicine every day,
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but if we have proven allergies, we have to do everything we can to optimize
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your nasal and ear mucosal health and get those symptoms under control.
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Otherwise, we're going to be looking at ear tubes.
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And in an older kid who swims underwater, who has a better vocabulary to tell
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you how everything feels, having a hole in your eardrum is also not the most comfortable thing.
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Little kids tolerate it great, but older kids will often complain that shower
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water hurts. If they dive underwater, it hurts.
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And so I don't love having to put ear tubes in older kids.
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And what do you do about that, though, when it hurts to dive low underwater?
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So they'll usually have to do like silicone putty earplugs or like a swimming
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headband, which thankfully older kids can usually manage it themselves.
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Little kids, it's an epic battle to try to keep them in their ears and stuff like that.
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But for older kids, they often, once they see that it gives them some relief
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to keep the water out, they'll be okay with using it. And I haven't heard of the swimming headband.
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They're very cute. So there's some brands like Max, M-A-C-K,
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Apache V-S is one of my favorite earplugs. swimming headband brands.
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But whenever I go to our National Academy meetings, there's all sorts of other
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companies out there that specifically make them. You can usually find them on Amazon.
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And I would say female patients more than male patients tend to like them because
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they look similar to like just a headband, but they just cover your ears like that.
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And they have like a little pouch over the ear part. So it's not just like a
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snug silicone band on your whole head.
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And then you're not doing a whole swim cap because you could do a whole swim
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cap if you want, but that is a tremendous amount of effort. Yes.
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I know one mom who's a friend of mine, she took her daughter to pediatric urgent
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care and she would get lots of antibiotics, but she really had eustachian tube
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dysfunction. Is that something you want to caution against?
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Yeah, I think there's a lot of variables that go into giving antibiotics.
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I think there's a tremendous amount of pressure on providers.
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So I do have an enormous amount of sympathy for urgent care,
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primary care, where you have irate parents in your office that just want their
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kid to feel better and just want you to do something right now.
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And they think that that's going to help. And you don't always have the time
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to explain to them, well, actually, this is what eustachian tube means.
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And maybe they do or do not even have fluid. Certainly, if they don't have fluid,
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in no way, shape, or form are antibiotics going to help.
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And even if they do have fluid if they don't have high fever, a lot of pain, and it's.
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Pus behind the eardrum. Antibiotics don't get rid of fluid. That's what I tell parents.
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It can sterilize the fluid. It can kill bacteria in it, but it will not get rid of the fluid.
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And so I would say many, many kids come into my office very shortly after an
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urgent care visit being started on antibiotics, and then they don't have fluid.
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They just were having some pain from eustachian tube dysfunction.
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And then once their nasal congestion broke and their eustachian tube was able
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to pop, they felt better and the antibiotics had nothing to do with it.
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But then because their symptoms got better after starting antibiotics,
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it solidifies that whole kind of song and dance in parents' heads.
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So try not to be afraid to gently break that cycle, but do it in a way that
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you're supportive of parents and you explain to them, I know you want your child
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to feel better and I want them to feel better too. Let's do Tylenol. Let's do ibuprofen.
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Let's maximize our nasal breathing. Let's do some sinus rinses.
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But here's what I see and here's why that's not going to work.
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And I think once you start to do that same phrase over and over and over,
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you feel more comfortable as a provider and parents can sense if you feel comfortable
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with what you're saying.
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You know, my practice patterns change dramatically from when I was a baby brand
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new attending to being eight years out.
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And I think you need to have that confidence in yourself to be able to say this to parents.
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But in the day and age of surveys and reimbursements potentially being tied
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to survey results, which has nothing to do with outcomes, as we all know,
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that's a whole other talk I would love to give on another podcast.
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I think that a lot of providers feel the pressure to just do something and if
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you can just resist antibiotics.
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And it's tough. One pediatric practitioner was saying to me,
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and I know this family will probably go somewhere else and that practitioner
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will give them the antibiotics and then I've just lost that patient.
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I know. All we can hope is that.
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If we can get enough of us to stop doing it, then they won't be able to find anybody else.
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And then when their child gets better and they're like, huh,
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they got better and I never even got the antibiotics, maybe that will reinforce
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it. But that's why we do these things.
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And that's why I take the time to educate my parents or at least provide them
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with something written.
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I am not naive enough to think that every parent reads everything I give them by no means.
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But I do think that it gets through to some parents and that's all I can hope for.
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Anything else, Marissa? This is so enlightening about eustachian tube dysfunction.
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Anything else you want the pediatric practitioner to know? So I think a lot
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of parents will say, well, is it their tonsils causing this?
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And that's an interesting question. It's sort of a yes and no kind of thing.
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It's usually not the tonsils as much as it is the adenoids, like we talked about,
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for where they're located. but certain palate shapes can also predispose you
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to eustachian tube dysfunction.
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And so the obvious ones are cleft palate because your palate,
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the soft palate in particular, is a muscular sling in the back of your roof
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of your mouth and it is attached to the eustachian tube opening.
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And so it helps regulate eustachian tube pressure.
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That's why chewing, yawning, swallowing can help pop your ears,
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especially when you're flying.
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And so cleft palate kids do not have that pull because their palate is wide open.
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So they're almost all cleft palate kids get ear tubes placed because they,
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until their palate's repaired when they're a bit older, they do not have good
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eustachian tube function.
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But sometimes if you've had big tonsils and adenoids for a while and you've
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had obstructed breathing, you start to get this long, tall face with a high arched palate.
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And then your palate is a little less functional in the direction of pull. And so...
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It's like, which came first, the chicken or the egg? Would this have happened anyway?
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Who knows? But if they're having like obstructive sleep apnea type symptoms,
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they're snoring, they have restless, poor quality sleep, and not all parents
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watch their kids sleep. I don't judge that.
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You got things to do. You're sleeping, they're sleeping. And so you may not
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know, but if a kid has large tonsils, even if the parent doesn't say that they
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snore, have that in the back of your mind that if their palate just looks super narrow and high arched.
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Maybe that is contributing to some of the reestation tube dysfunction.
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And then we live in, I mean, this was years ago I checked, but at the time we
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were like the fifth worst city in the United States for allergies.
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And so, yes, I do love San Antonio, but we're shaped a little bit like a basin
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and it's a beautiful climate. I love living here.
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But not everything dies off like it does in the Northeast. So we have a heavy allergen burden.
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And any kind of respiratory mucosa inflammation from allergies,
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which includes the lining of your eustachian tube, is going to predispose you
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to symptoms, including eustachian tube dysfunction.
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So some kids, you know, are not going to want to take medicine for you every day.
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And especially for older kids, I say, fine, it's up to you.
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Mom can't, or dad, can't hold you down and force you to take medicine.
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You're older now, and so you have to want to do this.
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And if you don't want to feel better, then you also can't complain about it.
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So you have to do a little bit of the tough love for the older kids that can
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understand it because they are in control of their symptoms.
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I like empowering them, but it's the reverse too. If they don't want to take
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their medicine for their allergies, then they do not have the right to complain
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about their ear discomfort.
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Marissa, you do a special type of surgery, a special way of doing a tonsillectomy that.
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Doesn't take as much tissue? Yeah. So I have been here in San Antonio at UT Health since 2016.
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And when I started here, I think that parents probably thought I was crazy because
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I'm like, hey, I do this great technique called the intracapsular tonsillectomy.
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And they're like, I'm sorry, what? Because nobody else in town was doing it.
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And like I had mentioned before, I've done all my training in the Northeast.
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I went to medical school in New Jersey, was at SUNY Downstate in Brooklyn for
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residency, and then NYU for fellowship.
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And we had been doing intracapsular tonsillectomy for quite some time.
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And so it was interesting to me some of those geographic variations.
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But I stuck to it because I'm a big believer that this is a superior technique
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for the kids that are good candidates, which are most of them.
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But basically, when you think of a traditional tonsillectomy,
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what we would have had as kids, that's a complete or extracapsular tonsillectomy.
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So the tonsil is a little ball of lymphoid tissue that has a little net around
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it, so to speak, that's its capsule.
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And so extracapsular means you go behind the tonsil and its capsule.
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You're taking some of the muscle of the palate of the throat.
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And even though it's not a lot, it causes much more pain. It causes scarring.
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And you're crossing and opening all those blood vessels that are coming in on
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the backside of the tonsil.
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So it increases your risk of postoperative bleeding as well.
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And so that is a very appropriate and safe surgery for kids that need it.
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So kids who have had a peritonsillar abscess before, where they've had an infection
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behind the tonsil, people who
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maybe they have an indication for tonsillectomy, but very small tonsils.
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And so you just want to get every last little bit out.
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But for most people who need a tonsillectomy, especially kids,
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that is more for obstructive symptoms or just for recurrent tonsillitis and
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sore throat, intracapsular means you use a device.
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I use one called a coblader, but I also trained with one called a microdebreeder.
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And you melt that tonsil tissue away from the inside out, going up to,
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but not violating the capsule. So you don't violate any of the muscle.
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You don't violate any of the blood supply to that area. So a dramatically reduced
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risk in bleeding, dramatically reduced pain after surgery, and the same improvement
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in sleep symptoms and infectious symptoms.
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And especially when we're talking about eustachian tube dysfunction and the
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importance of a great functioning palate, I have seen kids have a surprising
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amount of scarring after a well-done tonsillectomy, one that I've done myself,
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one that one of my great colleagues has done themselves.
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You can't control how the body scars
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that's the tough thing about being a surgeon is that I
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can do everything right and then the rest of it is up to how the body's going
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to heal and so sometimes people can have some palatal issues after an extracapsular
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tonsillectomy but typically not after intracapsular because it is not violating
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any of that musculature and so.
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Now, in the most recent studies that there have been about 30% of all tonsillectomies
23:54
are done via intracapsular, which even a few years ago, it wasn't that high.
23:58
And I think as knowledge of the technique spreads, because we've been doing
24:03
it for 20 plus years, it's only going to go up and up and up,
24:07
especially if you live far from a hospital.
24:09
And, you know, if you did have a tonsil bleed at home, it could be really dangerous
24:13
trying to get to the hospital.
24:15
So I think of the great state of Texas and how big it is and how far some of
24:18
my patients come to see me.
24:20
The thought of them having a tonsil bleed at home and not being able to get into me is very scary.
24:25
And so this just gives me that extra peace of mind that it's a safer operation
24:30
and it has less risk of complications.
24:33
What about for the immune function? Is it better there?
24:38
Great question. So we know that our tonsils and our adenoids are part of our immune system.
24:42
Just like a lymph node, they're made of that same kind of tissue.
24:45
And so there really haven't been any US-based studies that show there's a dramatic
24:51
drop in our immune function when we get a tonsillectomy or adenoidectomy.
24:56
But it is in our oral cavity, and then our adenoids are in our nasopharynx, the way back of the nose.
25:02
And so the idea is that this tissue, when antigens or things that are dangerous
25:08
to us enter our airways, they're.
25:14
Some studies in Denmark showed a decrease in immunity and an increased risk
25:19
for upper respiratory infections for that reason, we presume,
25:23
because you just can't capture and start that immune response.
25:26
This was with complete or extracapsular tonsillectomy, not with intracapsular.
25:30
And so physiologically, it makes sense that you're leaving some of that tissue there.
25:36
It can start an immune response. And I think what will be interesting to see
25:40
down the line is sometimes kids will redevelop sleep apnea symptoms years after
25:46
they've had a tonsillectomy and adenoidectomy.
25:48
And then we'll do something called a drug-induced sleep endoscopy or a DICE,
25:52
which is where you look with that flexible camera that I have in the office,
25:55
but you do it in the operating room, looking from the nose to the voice box,
25:59
and you're looking for their site of obstruction because you already took out
26:03
the standard of care, the tonsils and the adenoids.
26:05
And a lot of times we see in kids who've had a TNA in the past,
26:10
the tonsils on the back of their tongue called the lingual tonsils have hypertrophied
26:14
or grown over the years in response to antigens that have been entering our
26:18
upper aerodigestive tract.
26:20
And so many of us feel that by leaving that little bit of tissue,
26:25
we may also help prevent lingual tonsillar hypertrophy because you still have
26:29
some functional tissue.
26:30
And we do have what we call kind of follicular rests or little teeny islands
26:36
of lymphoid tissue scattered along the back of your throat.
26:39
That's what those bumpy, cobblestone-y looking things on the back of your throat are.
26:43
And so I think it's really interesting. We don't have all the answers just because
26:48
science is not always perfect and it's hard to do these studies.
26:52
But I do think we help protect the immune system and help prevent some of that
26:57
hypertrophy of other tissue unexpectedly that can happen with a full tonsillectomy.
27:03
So, and what are the indications for a tonsillectomy? Where do we stand right now? Yeah.
27:09
So I think my generation, and for reference, I'm 40.
27:13
So like born in the 80s, our generation was sort of in that period where people
27:17
felt like we were doing too many tonsillectomies.
27:20
So I feel like I'll get a lot of support from my 40-year-old colleagues who
27:24
are like, I should have had my tonsils out because I had a ton of infections,
27:26
but the doctors didn't want to do it because people were just doing a ton,
27:31
a ton, a ton of tonsils fine.
27:32
And the pediatric world, it seems to be going back and forth.
27:35
Yes, err on the side of taking out tonsils.
27:39
No, err on the side of don't. And so I think, again, I'm very guideline-driven.
27:44
Where I did residency downstate in Brooklyn, my chairman, Rich Rosenfeld,
27:48
is sort of like the king of ENT guidelines.
27:51
I don't know if there's a guideline that he's not on. And so I believe in them
27:55
very wholeheartedly because they're a collection of the best evidence.
27:59
And they're constantly updated and they score their recommendations,
28:04
like how strongly do we recommend this?
28:06
And so we have recommendations for tonsillectomy for children.
28:10
And the two primary reasons are going to be broken down into infectious reasons
28:15
and obstructive reasons.
28:17
So infectious is your recurrent strep tonsillitis, or even if you don't have
28:22
a positive strep test every time, if you have severe symptoms,
28:26
so you're having fever, lymphadenopathy, you're missing school,
28:30
even if that strep test is negative, it still matters if you're having really
28:34
severe tonsillitis episodes.
28:36
So we call it the Paradise Criteria, named after Dr.
28:40
Paradise, but it's seven infections in one year, five infections per year for
28:46
two consecutive years, or three infections per year for three consecutive years.
28:51
So basically a horrific year or multiple years of pretty bad years.
28:57
And what those studies have shown is that if you don't meet that criteria,
29:01
you'll probably grow out of it and be fine.
29:03
And then I think one of the hard jobs pediatricians and family medicine doctors
29:07
have can be like, oh, are they a carrier?
29:10
Are they this? Are they that? That's a whole other thing. We can totally get
29:12
into it. But talking strictly infections, that's one of the main reasons.
29:17
Tonsillitis, strep infections. And then for obstructive symptoms,
29:21
that's going to be either documented sleep apnea from a sleep study or what
29:26
we call sleep disordered breathing, which is those symptoms,
29:29
but not necessarily having a sleep study.
29:31
So snoring, restless sleep, excessive movement.
29:35
Sometimes bedwetting, because the brain may wake up a little bit after a kind
29:40
of sound, and it wakes up enough to know, oh, I have to go to the bathroom,
29:45
but not quite enough to know, and I should get out of bed to do that.
29:47
And so a lot of kids will revert back to bedwetting, daytime fatigue,
29:52
ADHD type behaviors can be from sleep disorder, breathing or sleep apnea.
29:57
And so that by and large is our biggest indication for surgery these days.
30:02
What about if a child just has enlarged tonsils after a certain age? What age?
30:07
I tell them if your tonsils are big and not causing problems, you can keep them.
30:11
And so if they're symmetric, like we're not worried that, and it's rare that
30:17
in a child you'd be worried about a tumor.
30:19
If anything, sometimes doctors may be worried about a lymphoma.
30:22
So I have done a tonsillectomy to rule out lymphoma.
30:25
But it's extremely rare with symmetric big tonsils where they're both the same size.
30:29
But if they're not snoring and not having infections, they're not chronically
30:33
mouth breathing, they should continue to shrink down.
30:35
So we just leave them alone. A pediatric practitioner I was talking to today,
30:40
she wanted me to ask you, so she had cancer as a child, and she had a lot of
30:46
strep infections, though, but they didn't take her tonsils out because of concern
30:52
for her immune function.
30:55
What would you recommend, because she has some patients with cancer,
30:59
what would you recommend if it's indicated that they may need a tonsillectomy?
31:05
So I think intracapsular technique would be pretty much it's my baseline preferred
31:11
technique, but that would be a perfect candidate for it, right?
31:14
We want to either relieve obstruction or hide or get rid of some of those nooks
31:18
and crannies where strep bacteria can hide.
31:20
And that's predisposing people to infections because that's what we presume
31:23
is happening. I tell parents, I can't take out your kid's whole throat,
31:26
so they still can get strep throat, whether you do an intracapsular or an extracapsular tonsillectomy.
31:32
I'm just giving it less places for the bacteria to hide.
31:36
And so I think in that case, intracapsular would be a great technique so you
31:41
still have some of that active lymphoid tissue.
31:43
And I'd be curious what the hematology oncology literature shows now,
31:48
because even being immune suppressed, I'm not sure that they would provide enough
31:55
immunity that if you were sick or had obstructive sleeve apnea,
31:58
that it would be worth leaving them there.
32:00
And then in a similar vein of oncologic reasons,
32:05
sometimes we have to do tonsillectomy for former transplant kids because they
32:10
can have something called post-transplant lymphoproliferative disorder,
32:13
where because of the immunosuppressives that they're on, the monovirus, Epstein-Barr virus,
32:19
can run a little rampant and it makes that lymphoid tissue huge.
32:24
And so an easy way to get a sample of tissue as opposed to making it cut in
32:28
the skin and taking a lymph node out is to do a tonsillectomy.
32:31
And you can still do the intracapsular technique. I just cut off a piece,
32:35
send it to the lab, and then I melt the rest away.
32:37
And so that has been another reason that I've been asked for some more medically
32:40
complicated kids to do a tonsillectomy.
32:43
So, and also at what point, Marissa, would you like a child to get a sleep study
32:50
before they come and see you? What's your recommendation there?
32:53
I love this question. And I think this will save pediatricians and family medicine
32:57
doctors a lot of headaches in life. We have a guideline on it.
33:01
So polysomnography or sleep study before tonsillectomy is typically recommended
33:06
for kids under two years old, kids that are obese,
33:11
kids that are syndromic, kids with craniofacial abnormalities,
33:15
or kids who their exam just doesn't fit the symptoms.
33:18
So the parents are saying they're the worst snorer on earth.
33:21
You can hear them a room away.
33:23
And then they have these teeny tiny one-plus tonsils.
33:26
Something ain't fitting. So maybe it's a central sleep apnea.
33:29
Maybe it's something else. If it really is severe sleep apnea,
33:32
I would certainly change my surgical plan if they came to me with teeny tiny tonsils.
33:36
So those are the only kids that need a sleep study before surgery or parent request.
33:41
Sometimes you have very data-driven parents or parents that are very scared,
33:45
and I can tell them all the perils of untreated sleep apnea,
33:50
but sometimes until they see, oh, their oxygen dips or they're pausing X number of times per hour,
33:56
sometimes their fear of surgery just cannot be overcome.
33:59
And so sometimes if a parent wants it or if they seem like they're having a hard time deciding,
34:05
I may offer a sleep study in a child with really obvious symptoms and even an
34:10
obvious exam who doesn't otherwise meet criteria, just so that I can talk to
34:15
the parent in a better way about,
34:18
look, they're pausing 10 times an hour.
34:20
Their oxygen, which should be 100 all night is dropping to 76.
34:24
We know that that's not good. We, you know, need to be able to help fix this.
34:29
So I do not think every young healthy child needs one.
34:33
So age less than two, syndromic, obese, exam does not fit symptoms, so small tonsils.
34:41
Those are the main reasons.
34:43
Marissa, anything else you want to say to the pediatric practitioner that we
34:47
haven't covered here today.
34:48
This has been so wonderful. Thank you so much for being here. My pleasure.
34:52
This is, I think, any opportunity to work hand in hand and be able to talk about
34:59
these things is helpful.
35:01
I guess thinking of kind of things that parents ask me or some of my pediatrician
35:05
friends ask me, ear tubes are, I tell parents, ear tubes are like magic.
35:09
They stay in for 12 to 18 months. I don't do anything. You don't do anything.
35:12
Either me or your pediatrician will tell you when they're out.
35:15
But surgically, we put ear tubes in the anterior inferior quadrant of the eardrum.
35:21
That is the safest place.
35:23
Your corda timpani is not there. So the little nerve that gives you taste that
35:27
runs through your middle ear is safely away from there. Your ossicles are away from there.
35:32
But on some kids, you have to, you're not just looking straight in their ear,
35:36
you have to kind of turn your otoscope like you're looking to the tip of their nose.
35:40
And so a lot of times parents will be like, oh, the pediatrician just said they
35:43
don't see the tube anymore. And then I look and I'm like, I see it. It's right there.
35:47
But because it is in that anterior inferior quadrant, sometimes you can miss
35:52
it just looking in the ear.
35:54
A lot of us use colored tubes. So they're usually blue or green. Some are white.
35:58
That would be helpful. Yeah. And then tube drainage.
36:03
So an ear infection with ear tubes will have drainage.
36:07
It has to have drainage. So if you look in an ear and you see an open tube,
36:12
even if the eardrum looks weird or not see-through, that's probably just scar tissue.
36:17
So if there's no drainage, even if the kid says their ear feels funny,
36:21
it is not an ear infection. They don't need oral antibiotics.
36:25
And if you have ear tubes, you should
36:27
not need oral antibiotics for an ear infection. It should only be drops.
36:31
So Ciprodex drops because they can get through. And if they're too expensive,
36:34
because Ciprodex, for whatever reason, is outrageously expensive with some private insurances,
36:40
I like ofloxacin otic as an option, or I'll sometimes prescribe ciprofloxacin ophthalmic,
36:47
because the ophthalmic preparations of eardrops are just sterile preparations
36:51
of the exact same medicine and sometimes are covered by insurance. It makes no sense.
36:55
So you can get creative with some of that.
36:58
The only thing I wouldn't recommend for ear tubes is certain antibiotics are ototoxic.
37:03
So anything ending in mycine that comes in eardrop form, don't do it.
37:08
For drops? For drops. No neomycin, no tobermycin, none of that.
37:12
No mycines. Those are bad for the ears, especially if you have a hole in your ear.
37:16
And even if you don't have tubes, if the child doesn't have tubes, stay away from that?
37:19
If they don't have tubes and they don't have a known hole and you're treating,
37:25
like, because there is a medicine called cortosporin, which I think is pretty
37:28
commonly given for otitis externa.
37:30
As long as you're pretty darn confident that they don't have a hole in their
37:34
eardrum that has neomycin in it, it should be safe.
37:38
Just most of those are for more refractory, like antibiotic-resistant stuff,
37:44
so it's rare that you would have to resort to that.
37:47
Call us if you're ever getting into trouble.
37:50
And is there anything, Marissa, for the practitioner we haven't covered today?
37:54
I know we've covered so much. Anything else you want to mention?
37:57
I kind of love, I feel funny admitting this, but I kind of love the otoscopes
38:03
that attach to phones that parents can use, like the little stick ones that
38:06
are 40 bucks or so on Amazon, because they can actually take a picture of the eardrum.
38:11
Sometimes I even use them in the office to show them what I'm looking at.
38:15
So don't feel like you're being a cop out if you're using that either in the
38:19
office or you're telling your parents to use it, because I think you can often
38:23
get a much better view of the eardrum than just a regular otoscope.
38:27
And sometimes, especially slightly older kids like toddlers are going to be
38:31
mad at you no matter what.
38:33
But you may have a five or six-year-old that's scared until they can see what
38:36
you're looking at. And so if you've thought about, hey, should I use this in the office?
38:40
Heck yeah, it's super cheap, easy technology, all things considered.
38:44
And it takes a good look at the eardrum and you can usually take a really good picture of it.
38:49
So you can get that on Amazon. How do you know you're getting the right one?
38:51
So I've tried a couple of different
38:54
brands and so I tell parents as long as it's in their price
38:57
range and has some reasonable reviews do it and
39:00
attach it to the phone and it just like plugs into the bottom of
39:03
the phone and it usually will have instructions on
39:06
if you have to download a special app or if it's just through your camera app
39:09
and it is super easy so I usually have a screenshot that of different ones from
39:13
Amazon that I'll put in my discharge instructions for parents and I tell them
39:16
by no means you have to do this but my particularly curious parents or parents
39:21
who kind of want to monitor ear tubes with me, they tend to like it.
39:25
And even my non-medical parents do amazing with it. And is this only for the child with ear tubes?
39:31
It could be for anything because kids get ear infections. And so if you're just like, is this weird?
39:35
I don't know what this is supposed to look like. Some of my anesthesia friends
39:37
will send me pictures of their kids' ears because even those of us that have
39:41
been to medical school, not everybody keeps an otoscope at home.
39:44
Those things are expensive and they're heavy and they break.
39:46
And so I think it is one of the few.
39:50
Things available to the general public, ear, nose, and throat technology related
39:53
that I actually really do like.
39:55
And what do you recommend the pediatric practitioners say to their patient,
39:59
or what do you say directly to parents?
40:01
Like, look for this, this, and this, and that's when you need to go in to maybe have antibiotics.
40:06
So I'll usually say, and it depends if you have an electronic portal and if
40:09
you want to open yourself up to this, and I have not, knock on wood,
40:12
had parents abuse this, but I say, if your kid is having severe symptoms and
40:16
you're able to take a picture of the eardrum,
40:18
that can help me know what's going on. And so sometimes it can save you a visit.
40:22
And if you're able to bill for a telemedicine visit because you look at the
40:25
picture and you talk to the parent for a few minutes, great.
40:29
And so I don't necessarily even prep them for what they should or should not see.
40:32
I just more say like if you are worried because your kid is complaining of something,
40:37
then take a look, take a picture, send it to us.
40:40
And a lot of parents are just excited to see an ear tube, but I think it would
40:43
be too much effort to explain this is what an ear infection may look like.
40:47
So I more deal with it on a case-by-case basis.
40:49
Or as a tool to be able to take a picture and send to your provider.
40:53
Yeah. Because telehealth is really hard for ENT. I'm sure Pete feels that way too.
40:57
Like, I can't see it over the phone. So with this, you can.
41:02
And Marissa, we like to talk in pediatrics now about having a life outside of
41:06
medicine. In our last episode, you talked about your three labs,
41:10
yellow, chocolate, and black lab.
41:13
Yes. And they just sounded adorable.
41:15
Well, hopefully we can include some photos of them.
41:18
What do you like to do in your spare time? So I love to be outside.
41:23
Anything I can do outside, I will.
41:25
So even if it's not with my dogs, running, hiking, swimming,
41:29
I have a pool, which is awesome because growing up in New Jersey,
41:32
we did not like nobody had pools.
41:34
I really like reading and not hardcore serious things.
41:38
I read like a lot of fantasy and sci-fi. So right now I'm doing the Stephen
41:42
King Dark Tower series. So I'm on book four.
41:45
You recommend it? I love it. I love Stephen King. My mom loved Stephen King.
41:49
And I grew up reading kind of like horror genre.
41:52
The Witcher series, like the, it was a video game and then a book series.
41:56
And then the TV series with Henry Cavill. The book series is seven books,
42:01
I think. And it is outstanding.
42:03
And just spending time with friends. My family lives back in New Jersey,
42:07
so I'm going home over the holidays to see my family and my little nephews.
42:12
Spending some time in New Jersey and New York. Yes.
42:16
I miss my pizza and my bagels. That is what I'm most snobbish about having moved
42:21
away from the Northeast.
42:22
And you have some favorite places you go to there. Definitely.
42:26
You're a natural early riser we were talking about. I know you recommended a
42:29
certain type of alarm clock that helps you? Yes.
42:32
So I get up anywhere between 4.30 and 5.30 every day, which seems like a god-awful
42:37
time of day, particularly because it is so dark.
42:39
But I have one of the sunrise alarm clocks. And so mine is set so that 15 minutes
42:45
before it goes off, it starts to slowly turn on.
42:47
And so I never judge parents if they co-sleep with their kids as long as they
42:51
do it safely because I co-sleep with my dog.
42:53
And so usually the littlest or the youngest, I guess he's not that little,
42:58
but my chocolate lab, all three, I have a king size bed, me and my three dogs.
43:02
And so my youngest lab will usually start to wake up and stretch and then kind
43:06
of army crawl over and like lick my forehead as the alarm goes off.
43:10
So I'm usually happy and awake even before I hear the alarm sound go off.
43:14
And I think that makes a big difference. Just having the light come on naturally.
43:18
There are some expensive brands like Hatch is the popular one.
43:21
Mine is some knockoff Amazon brand, but I've had it for five years and it is awesome.
43:27
Is there anything you do for your ear health or vitamins or anything you eat
43:31
in particular, but just like an inside scoop into the mind of the ENT doctor? Yeah, the ENT.
43:37
So I never stick Q-tips far in my ear. I will say I do not like water in my ear.
43:44
So I talked earlier, maybe in one of the other episodes, about making a wick
43:48
with paper towel where you twist it, twist it, twist it into like a little fine point.
43:52
You don't want to do tissue or toilet paper because it's too soft.
43:55
And then you hold it at the opening of your ear canal, if you can be a safe
43:59
Q-tip user and just use it to like wick that moisture out, that's what I do
44:05
because wax is protective of your ear canal.
44:08
So just barely put it in. Just barely in. Like I kind of tilt and shake my head
44:11
a little bit and it is just to get the water out after I shower.
44:14
That's the only time that I use them.
44:16
And so I tell my patients they're not allowed to use them because they are not otolaryngologists.
44:21
But jokingly, I'll usually tell them If you're really just cleaning either the
44:24
outside of your ear or right at the ear canal opening, so you're just wicking
44:28
that moisture, that's okay.
44:30
I do in-ear headphones, but I always try to wipe them with an alcohol swab after,
44:35
and I don't leave them in for too, too long.
44:37
I love running with aftershocks, which are the bone-anchored hearing technology.
44:43
So they're the headphones that kind of sit up towards the front of your head,
44:47
and they send the sound signal directly through your bone to your nerve and your cochlea.
44:51
And that way your ear canal is open. You can hear traffic and everything like
44:55
that, but you can still have some music going or talk on the phone.
44:58
And so I tend to use those when I'm walking my dogs or out and about so that
45:01
I'm not obstructing my ear canals and I'm not missing anything from the outside world.
45:05
Awesome. And you can just order those online? And I think they have other brands,
45:10
but Aftershocks with a Z is one of the main brands and I really like theirs.
45:16
I'm obsessed with carbonated nasal saline spray right now.
45:21
I love carbonated water to drink, and so I thought it was going to be absurd
45:25
because the thought of putting carbonated water up my nose sounds horrible,
45:28
but it comes in an aerosolized can,
45:31
and it's just saline, but I feel like normal saline spray to me doesn't get
45:36
to my whole nasal passages and everywhere I want it to go, and I don't always
45:41
have time or energy for a rinse,
45:42
even though I'm a big believer in them and I do them very frequently.
45:46
But twice a day, every day, I use carbonated saline spray. And I just do like
45:49
one squirt up each nostril, blow my nose, and I feel like it gets all the allergens,
45:54
the dust, the dog dander, whatever is in there out.
45:57
And it is much more refreshing than just regular saline spray.
46:00
The only brand I've used so far, I haven't admittedly looked to see if there's
46:03
non-brand name, but NealMed is the one I use.
46:06
And like I said, I have no financial disclosures with NealMed.
46:08
I just really like their stuff.
46:10
But that's my go-to for sinus rinse bottles and then their saline spray.
46:16
They have some good nasal suctions. Like for babies, I usually,
46:20
for all baby showers, will give them either the nose Frida,
46:23
which is like a little, looks like a little straw with a filter in it that you
46:27
put up to the baby's nose and you suck on the end of. Boogers don't go in your
46:30
mouth. They go into the filter.
46:31
And NealMed has one called Naspira that is both a bulb and that suction with a filter.
46:37
And so I think that's a parent's secret weapon for babies that are congested
46:42
besides doing nasal flushes, just sucking any boogers out so they can have better breathing.
46:47
And can the nasal spray like twice a day, like you mentioned,
46:50
can it work as well as fleshing out like at the neti pot?
46:53
Not quite as well, but it's certainly easier and better tolerated.
46:57
And the reason I say that is, especially in older kids and adults,
47:01
because our sinuses are air-filled spaces, some of that solution is going to go into them.
47:06
And I've had moments where like hours later in the day, I'm leaning over tying
47:09
my shoe and all of a sudden a gush of fluid will come out. and that's just because
47:13
the congestion got better and then everything was able to release.
47:18
And so that's very cumbersome if you're leaning over patients all day like we are.
47:22
So I almost never do a rinse in the morning. If I do a full rinse, it's at night.
47:27
And so this with the spray, I don't worry about my nose like actively draining
47:31
on somebody later in the day.
47:33
So I think it gives you a really good wash without the risk of that.
47:37
So maybe not quite as wonderful as a full rinse, but pretty darn close.
47:41
And doing it too much, can it be drying?
47:44
So technically, if you're using like the right tonicity of saline,
47:49
no, meaning if you're not making it overly salty, because we're salty.
47:53
And so you want it to have some degree of saline.
47:57
So that's why I tell parents, it's not like using a nasal steroid or something
48:00
like that. You can't really overuse it.
48:02
You want to be gentle to the nasal tissues. Don't shove it up there too hard.
48:05
But otherwise, it's very, very safe. Dr. Marissa Early with University Health
48:11
and UT Health San Antonio. You're our expert on pediatric ENT.
48:17
Thank you so much for being here today on Pediatrics Now.
48:20
Thank you for having me. Great job. Yay!
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Music.