Chapters Transcript Video Pediatric Nasal Congestion Thank you Maria and thank you everybody for being here. It's an honor to speak with you today and I hope this is a chance to answer any and all questions um You might have about the mysteries of the nose which I know, um maybe sort of an understudied area in medical schools. Certainly. Um unless you're an ent, there's a lot about nasal anatomy and physiology and treatment of conditions that may not be um at the forefront of people's minds. So I'll go over some of our, the more common reasons for nasal congestion as well, the less common reasons and sort of my approach is to um to managing it. Um And yeah, so thank you. So I have no disclosures. Um My objectives today will be to review common causes of nasal congestion in the pediatric population, uh to recognize or help kind of guide when to refer nasal congestion to us as otolaryngologists and um to review some evi evidence based management treatment options um for pediatric nasal congestions, both um from the sort of general practitioner standpoint and also as an antique. So when you think about referring to us, this might be an image that comes to mind. This is uh a picture of a nasal endoscopy. Um It's one of our, I'd say big diagnostic workhorses in terms of diagnosing structural components related to nasal obstruction and um and nose and your uh excuse me, nose and throat pathology um in Children and adults. So some of you may have undergone this scope if you're sending kids over to us with concern for um nasal obstruction or, or issues lower down in the throat. This is uh a scope, but this is what a scope exam looks like. And it is possible to do this in in all range of kids often with their participation. And um I often try to sell it as a magic school bus type approach to examining the inside of their body. So a lot of kids are, are pretty fascinated by that. Um But with this test as well as other uh you know, both both history and and uh good physical um some diagnostic modalities, we can diagnose a lot of things. Um when thinking about the causes of nasal congestion, there really isn't a bucket that fits. Um you know, that's, that's sort of like one thing is contributory, oftentimes an atomic or congenital conditions are affected by physiologic or acquired conditions. So I think about this sort of its Venn diagram, we think about um you know, both what's happening and then how we treat these things. So starting on the right with the big sort of an atomic buckets that we think about or I think about specifically as a surgeon since that's primarily my role in managing this, I'd say, um the, by, by, in a way in most kids um of school age, you know, we think about adenoid hypertrophy as a contributor to nasal congestion. Um, inferior turbinates are another common um reason why some kids might be congested either periodically or um, constantly and I'll, I'll kind of break that down a little bit. And then as we go down this list, things might become a little less um less common or less impactful depending on the age of the kid. So things just like narrow nasal passages at varying points in the nasal airway septal deviation. That's something we commonly hear about in the adult population. It does impact kids too. But I'd say um this is something that isn't like the, the very top reason why most kids have an an comic reason for congestion or obstruction. And I'm kind of using these terms in um in, in parallel um vestibular stenosis that's really referring to the front of the nose and coin atresia. Uh more in the back. And oftentimes we hear these last two in our neonatal or um or young baby population in terms of physiologic reasons why congestion happens. Of course, the the big common ones are infectious, triggers the normal slew of childhood bacteria or viruses that cause um you know that cause ur I sometimes this can be compounded by a bacterial infection. Um And we can talk a little bit about what uh uh a secondary bacterial infection looks like in kids. And how about how sinusitis presents? Um allergic triggers are, are very common. Um And as well as environmental irritants that aren't allergic. So, depending on where our populations are coming from, um I can tell you kids from the Central Valley have a lot of environmental um components that perhaps kids in other parts of the coast or, or other areas may not same with, you know, Children in, in fire prone regions. Uh We definitely get a fair amount of referrals and there's, there is a distribution of environmental factors that are not necessarily allergic, that can impact um nasal congestion and uh you know, and, and the inability to breathe through the nose trauma is, is something that can contribute to nasal congestion and lead to some structural deformities. Sometimes these present outside of the context of, of facial trauma. Um nasal polyposis is is something we often get um referrals for which is definitely appropriate. It's fairly rare in the pediatric population and I can talk a little bit more about that. Um Sinonasal tumor is also rare and then uh in kids, especially with any unilateral congestion. Um you know, you might be thinking about nasal foreign body um especially if there's a good history for that. Um So these are I think some of the, the big ones um to kind of lay this out, I'm gonna go over the anatomy and the nodes and I think a picture is worth 1000 words. So a lot of this, I'll, I'll kind of present on um what various forms of nasal obstruction or congestion can look like and how different an atomic pieces may play into this. So, um for a lot of, you know, you in general practice, this may be the only you really have into the nose. So here's a cute little baby button nose. And um we're looking at what's called the nasal vestibular, the nasal opening. So this is the nares, this is a soft tissue component of the nose and nasal congestion or obstruction can, can start right here, especially obstruction due to congenital reasons. Um You can have narrowing in babies, sometimes the the external valve, which is this sort of opening here can be really collapsed. And as uh you know, as you probably know, neonates are obligate nasal breathers. So, um sometimes obstruction through both the nose just in the very front can cause a bit of impact in terms of their ability to breathe through the nose. Um If you look in the nose, you'll be able to see the turbinates. The turbinates are definitely an important structure. They uh contribute to nasal congestion in a number of ways there. Uh There's three paired structures in the nose and then plus the sinuses which are scattered throughout the, the face under the eyes, in between the eyes and then in as we develop into adults, uh we have sinuses but kind of up above the eyebrows as well. Um These are all part of our, our noses function to uh filter air and to clean it, clean out. Um you know, potential um toxins part particulate in the air before it hits our lungs. So this is in part why mucus is produced. It's uh you know, we have mucociliary clearance happening throughout our uh our nasal cavity and the shape of the turbinates as well as the, the sinuses in part are, are, their role is really to clear out the nose before air hits our lungs. The turbinates also humidify air um and uh and regulate temperature. So they warm air as it comes through the nose. So the nose is important. Turbinates are important um in their role in warming air, they can swell and they're, they're very vascular in structure. And so they do swell periodically throughout the day. There's something called the nasal cycle where the turbinates are actually alternating and swelling about every 90 minutes. So if you were to look in a patient's nose or even in yourself, you may notice that every 90 minutes or so, one side of the nose uh may feel more obstructed than the other. I think this is um pronounced or often noted at night. If you're sleeping on one side. Um You'll notice that it's easier to breathe out of the top side typically. And that's because the lower or the, the terminate, that's sort of on the downward side. If you're sleeping on your side is going to be full of, of more blood. Um, during that time, so much of the time when I'm asking about nasal congestion, I'm asking, you know, is this periodic, is it alternating sides? Um could the turbinates be playing a role? These structures also um get inflamed, they respond to allergens, they respond to getting sick. So, um you know, kids may have fairly normal breathing outside of sick episodes or seasonal allergies. Um but when we think about treating allergies and what, what one of the things that we're actually treating is in part inflammation of the turbinates um as well as the mucus production. Um and uh the, you know, the different, the different uh sort of underlying physiologic factors that contribute to allergy and, and the production of, of mucus and inflammation in the nose. So, a lot of our medical management in part is targeting, targeting these an atomic structures. Um In some cases, some kids or adults have turbinates that are slightly bigger than usual. And so they are almost chronically or constantly getting congested. Um even with the slightest sort of trigger that is not uh an atomic. Um so that nasal scope that I showed a photo of this is what a normal nasal endoscopy looks like these are a couple of still shots on the left. Here, we see a turbinate um on the left side and then this is the nasal septum. You can see kind of a cavern and on anterior rhinoscopy, this is what you're seeing. So if you're sticking your otoscope in a kid's nose past that nasal vestibule or the soft part of the nose, you may see this and um you can definitely see the inferior turbinate on both sides. They're pinkish structures. This is kind of mid terminate, but I'll show you what the front of the terminate looks like as well. Um And on the right here, this is the back of the nose. So um you can see the nasal pharynx back here. It's kind of a nice dark cavern. If you were to follow that downward, you would, you would hit the um the larynx in the airway. Um I wanna point out too, this is the Eustachian tube orifice here on the right on the far right here, this little um structure here. So, adenoids which live in this area and I'm about to show you um you know, this is why um many kids suffer from e station two dysfunction and the sequela of that specifically recurrent ear ear infections, um or chronic infusions, adenoids play a role in that and nasal obstruction from adenoids plays a role in all of that. So, adenoid hypertrophy, this is um by far and away, I'd say as an ent one of the most common things we see or at least think about when we have kids coming in with nasal congestion and obstruction. Um You know, they are an an atomic structure. They grow in response to uh they're part of our lymphoid system. They grow in response to um to exposure to viruses and bacteria, same with tonsils, of course. Um They sit in the very back of the nose and as I mentioned, they kind of sit right in front of the East Asian tube um opening. So, and your kids who are just constantly congested, you know, in, in between sick episodes, there may be perhaps getting worse over time. This is definitely something to think about. Um they don't always present with big tonsils. So you may have a kid who's like specifically got nasal congestion and maybe less of the symptoms of sleep disordered breathing or sleep apnea, which we think about with, with, you know, both tonsil or hypertrophy as well as adenoid hypertrophy. Um But yeah, these sit right in the back of the nose and they can definitely be sort of a big sponge of bacteria as well as just trap um the ability to drain the nose. So in kids too, adenoid hypertrophy is the most common reason for sinusitis. Kids have underdeveloped sinuses, like I mentioned at the beginning, the frontal sinuses, which of these appear don't actually develop until later in life as well as the sphenoid sinus is the one in the back. So, adenoids are often the culprit. Um and something we, we think about treating when we have a kid with bacterial sinusitis episodes. This is what um adenoid hypertrophy looks like on a scope exam. So this for comparison is that normal big wide opening. If I put a scope in a kid's nose with adenoid hypertrophy, sometimes you can't even see the airway um because these are, you know, quite obstructive. So this is, you know, again, um in your kids under, under about age 10, these, these are uh a very common culprit of nasal congestion. Um This is a lateral neck X ray. It's gonna be useful in terms of diagnosing adenoid hypertrophy. I don't often um you know, I don't necessarily recommend doing this upfront. Um But there are parents who one don't want me to put a scope in the nose or, you know, I just wanna know um what, what the adenoids are like if I have a kid with small tonsils and I'm thinking about taking to surgery and I need to confirm that there is sort of an an atomic reason. Um Both of these tools are, are fairly good. Um This right here is a little bit of bulk uh in the back of the nose. So it's not um sometimes it, it can under or underestimate the size of the adenoids or the impact of the adenoids. So it has to really come in conjunction with symptoms of nasal congestion. So, um I know we're, we're all muted. So I won't actually make you answer this. But I have gone referrals for this uh you know, this kind of clinical picture and ignore the like scrapy stuff on the kid's face. But what I'm really pointing out is this pinkish ball here. So um this is an example of a, of a turbinate and a normal or perhaps a little bit of an inflamed inferior turbinate. You can often see these just by elevating the nose and looking into the nasal cavity, they'll be on the right side, they'll be pinkish. Um They're, you know, I think when they're big, they can be a bit a bit confusing and in some cases, they can look like masses but they, you know, you, you're looking at, at both sides, you can often see too if you were to stick your um your otoscope into the nose a little bit that they follow the entire length of the nose. So you can kind of differentiate that from a nasal mass. So again, I, I talked pretty extensively about turbinates and their role in nasal congestion. Um but it is something that I'm thinking about as an ent pretty frequently. This is a comparison. So this is um a, you know, possibly a, a nasal polyp we got can call it just the polyploid mask. We don't know what it is specifically. But you can see that these are a little more boggy or pale. Um They don't have that pinkish hue of the nasal mucosa. Um you know, you might see a few of them, people often refer to them as like a collection of grapes um in their appearance. Um they can be unilateral or bilateral. But this is, you know, if, if you were to look on anterior r this is, you can see kind of a differentiation here. This is not a turbinate, this is something else going on. So this would definitely be a reason to refer to us. Um If you were to notice something like this on exam, a few other, just an atomic obstructions, things that we sometimes see. So septal deviation again is I'd say not uncommon in kids, but less frequently a cause of major obstruction that we would do something about. Um they, the septum doesn't really cause congestion or that, you know, the, the rhinorrhea, this the periodic swelling. Um you know, the drainage, it's, it's really um a fixed structure and it's not going to respond to certain medical management. But, you know, sometimes it's something obvious you can see in this little baby, the nose is off to one side. So that might suggest a uh septal deviation. They're, they're not always obstructive, even something that looks like this may not be causing a functional problem. And um these are challenging to fix in kids, we really reserve uh fixing them unless they're, they're very, very obstructed and it's impacting their quality of life. But just to give you a couple of examples of this, this is the septal spur. So this is the midline of the nose and there's this big kind of structure jutting out and impacting the turbinate. So if that turbinate gets big, it's going to block the nasal um passageway, most likely if you have a very obvious um septal deviation or or bony spur, that looks like this. This is another example of a um this is vestibular stenosis. So this is an older child that um patient of mine, but she had, she had, had a birth trauma um and has been living with a smaller nasal vestibule. So that can cause significant um obstruction. Um oh and this is a photo of Coin Latresia a a snapshot of AC T scan. So Coin Latresia happens more in the back of the nose where either the bone or the um or the lining of the nose, the soft tissue mucosa is stenosed and in babies who are newborns who are ate nasal breathers, you can often be fine with one side um being patent, but if both are blocked, it's often a surgical um emergency or urgency for us and it is often diagnosed in the in the hospital kids. Um you know, common way is if um passing it a nasal um suction and they can't pass posteriorly or passing it, trying to pass a feeding tube and it can't post posteriorly. That's, that's often a reason why these get diagnosed other times, um babies have obvious unilateral nasal congestion um or, or drainage and they're coming to us for that reason and sometimes we diagnose this. So other considerations when we um excuse me, when we think about um working up nasal congestion, um you know, some of these are, they're pretty obvious, just basic um you know, HP I points but just to kind of dive in a little bit. Um you know, thinking about causative factors, certainly Uris and allergens are often exacerbating or, or even just the underlying reason why kids have uh have this issue, as I mentioned. Um these can be compounded by inferior turbinate hypertrophy or adenoid hypertrophy. They can definitely be sort of causative to adenoids getting bigger over time. Um So, you know, with things like viruses and, and what do we, you know, when, when we think about treating this? Um I think, or I guess at first when we think about referrals to us, um Critic City is important, I think if, if you're having a kid with bilateral nasal congestion for more than three months, you've tried some medical management options and they're not getting better. That's definitely a a reason to try and um a and it's impacting their life negatively. I think it's a reason to, to think about referring um chronicity is also um helpful and in trying to figure out what exactly is going on, something that is more constant um in between sick episodes. Um you know, perhaps they've undergone an allergy work up and you don't have a clear um etiology for it may suggest something structural um versus periodic. So again, like turbinates, even a adenoids too can swell and then shrink over time. So if they're shrinking back down and, and the congestion is improving, um there, you know, the nasal drainage is improving, that might be um something that was just due to seasonal or um environmental modifiable, um modifiable issues if things are unilateral and very clearly always happening on one side. That is another thing to, to be considerate of and, and perhaps escalate to a referral, um alternating sides. That's a question I often ask and that's often um a good marker of whether or not the turbinates are playing a role in their symptoms. Um because of that nasal cycle, which I talked about, um you know, associated symptoms. I think these go from uh sort of, you know, normal run of the mill kids stuff to potential red flags. So, rhinorrhea, you know, sneezing itchy eyes, um those are all fairly common symptoms that we might see in association with nasal obstruction, purulent purulence. We, you know, especially if it's been lasting for uh for um you know, more than a week or so, you're starting to think about sinusitis and perhaps doing a bacterial culture or, or treating if it's been um long course with, with pulin or foul smelling drainage epistaxis. Um you know, very, very common on its own with kids. I often ask about obstruction in the setting of epistaxis. I think allergens and other IRS can certainly um cause epistaxis. But I think if you have a kid who has unilateral epistaxis, a lot of obstruction on that side, you do want to start thinking about structural problems that might be underlying that um such as a mouse, um, vision changes and external swelling, of course, are, are more of a red flag symptoms that something uh more serious could be going on. Um, in terms of thinking, you know, I guess about referral, but also just how much this is impacting a kid life, you know, as you all know, kids are very frequently congested, I probably see, um, you know, in my, in my view, almost every kid is congested because that's my my sample size. But um, you know, I think it really matters or when I think about treatment options, at least from my vantage point as a surgeon, how, how annoying is this or how impactful is this on their life? It's just kind of mildly annoying, you know, runny nose, you know, here and there, even if it's, if it's frequent versus is this impacting their sleep, is this impacting their feeding specifically neonates? Um, or, or young Children um, is it impacting their daytime quality of life? You know, I think post COVID, I had a lot of kids who just like, were being taken out of school all the time, um, because they were constantly having a runny nose and, um, you know, so I think the severity of how it's impacting their life is important in terms of guiding treatment and then age is age is definitely something to think about it. I think the reasons for nasal congestion in the neonate as well as like how much it might impact a kid who is an obligate nasal feeder or nasal breather. Um you know, in those early few weeks of life versus in childhood and some of the structural reasons why childhood kids might have issues. Um you know, adenoids being the most common, as I mentioned, um versus teens who are not likely to have big adenoids and may have more of a a bony problem or um you know, if we have unilateral obstruction in teens, um we start to per perhaps, perhaps think about other um other, more concerning things and endoscope exam. It might be something that I've been doing more um more routinely on my my older, older Children um rather than kids in childhood who have more common reasons for nasal congestion. Um and then, yeah, you know, associated conditions. So I had mentioned this with the adenoid slide but recurrent ear infections, um chronic ear effusions or hearing loss. Um Those are all things that may, you know, that are associated with uh with potential reasons for congestion or obstruction in the nose, um often specifically the adenoids. So, um those are when I have a kid coming in with um these issues specifically related to the ears. I'm often asking about nasal congestion, um that might guide how I treat them. Um surgically other things like postnasal drip and chronic cough. I'm involved with our um with our joint uh speech language pathology and ent clinic as well as our air digestive clinic. So we'll see a lot of kids with chronic cough or postnasal drip that's leading towards um you know, the uh global sensation in the throat, maybe even voice changes. And so sometimes the nasal congestion or the sequela of, you know, allergies, uris, et cetera can be leading to downstream effects or other um other um impacts on the ear, nose throat um to do this. So, so in terms of management of, you know, more run of the mill nasal congestion, you know, you have kids with bilateral rhinorrhea, trouble breathing out of the nose. Um These are sort of the first line things to think about and oftentimes before um you know, a referral. Um this, this is sort of what uh I think, you know, I, I would be thinking about um antihistamines. You know, there's a lot of kids who get referred, who've been on, say Claritin or something and I, I think it's an impactful medication when you have, um, aller allergic um, symptoms. So, you know, maybe clear seasonal triggers, um, itchy eyes, sneezing. I'm often asking about that. Um, overall it can be less effective in terms of treating nasal obstruction, um, than some of the other pharmacologic agents. So, intranasal corticosteroids is something that we as ENTs absolutely love. And in a, you know, in a, in a reality where we get just so many referrals for this problem, um we have started guiding um referring providers to actually really trial um a course of intranasal steroids for, you know, specifically for nasal congestion. Um it's not only impactful in treating allergic rhinitis or some of the inflammation from, you know, ur I et cetera, but it can actually reduce adenoid size. There are trials demonstrating that a 4 to 6 week consistent use of um intranasal steroids can reduce adenoid size and improve nasal bleeding. So this is why we sort of have that as a uh as an initial um stop point for referral or, or a guideline. Is that um trying this or at least offering this to kids has, has been shown to be impactful in terms of um providing long term improvement in breathing. Um you know, when I talk to families about this, um also to, you know, uh nasal sorry, this is a typo that should say nasal next. But Moaz is uh is approved down to age two. So you can actually try this on fairly young kids. Obviously, there's a challenge sometimes in how to deliver this. I often have parents do this before bed, um especially in, in kids who have a lot of concern for snoring or um sleep disorder, breathing symptoms. You know, I think just thinking about it, if they're laying flat, it's gonna kind of go backwards and bathe the back of the nose and even the tonsils. And those are some of the structures that we hope to treat with this. Um In addition to treating some of those underlying um environmental triggers, um but it does take consistent use. It can't be used just for two weeks at a time or even just like here and there. It's uh the, the data that we have really is is more for a consistent 4 to 6 week trial. I think the other thing too is if kids continue to get sick, they may rebound after words. And so it's hard to sometimes distinguish a failure of intracortical steroid or intranasal steroids with um the, you know, normal run of the mill uris that are happening over and over again. The last couple of years have been really rough in terms of kids just getting hit, um you know, repeatedly with, with uris. Um but it is a fairly effective and safe treatment option. Um You know, I don't think there have been great studies or there there really isn't good data on it, impacting growth. That is something I get a question about a lot. Um You know, most, most common side effects are things like a nose bleed or dryness. So in kids with nosebleeds, it can be challenging to give them phonies. Um, but I'd say that this is one of our workhorse medications. Um, Monte Luca or Leoine receptor antagonist, there are also studies that demonstrate that these, these can reduce lymphoid tissue or adenoid tons as you may know. Um these do come with a black box warning for pretty severe behavioral changes in some kids. So I think um some of us are more reticent to um to add these on. I always talk about the black box warning um for families. Um and I often don't get a lot of by and on using it. But it is another alternative, especially in, in um kids who clearly have anointed and uh tonsil hypertrophy and are trying to avoid surgery. Um decongestants, you know, not great for long term use. They can cause rebound congestion, um especially nasal sprays. And so we really advise against using a nasal decongestant for more than up to three days. But in kids who are really struggling, especially in the setting of a of a acute uri there there an option as well. Um You know, before that and I think the most conservative and impactful thing to do is also to offer nasal saline irrigation. It's safe for all ages. Um And it's, while it seems like it might be challenging, you know, to get a kid to do a nutty pot, um there are ways to, to try and make it easier and toddlers, you know, using like a five or 10 CC syringe and just squirting it up. There can be really helpful in terms of just flushing out mucus, flushing out allergens, um helping to um the hypertonicity of saline can even kind of draw out some of the inflammation from the structures such as the adenoids and the turbinates. So this can actually really be be helpful. Um When I prescribe this in conjunction with Flonase, I advise them to do the saline irrigations first. Um and the Flonase after so that you're not just washing out the saline um humidifiers are helpful just in maintaining moisture in the air, especially in dry environments and um suctioning um obviously can be great for infants who can't blow their nose um or, or younger kids who can't blow their nose. So that's those are all just sort of basic non medical symptomatic relief options and ones I'm routinely um recommending to, to families and then addressing any other underlying causes. So, antibiotics, if there's a confirmed bacterial sinusitis or concern for that. Um and then of course, allergen avoidance and environmental modifications. It as as is possible, not always easy. So, when should you be considering a referral to the likes of me and my colleagues. Um, you know, I think as I sort of mentioned before, if this is something that is chronic, um, and you've trial trialed or at least offered intranasal steroids for 4 to 6 weeks and you have a kid who's continuing to have nasal congestion and obstruction, um, that might be a reason to refer if there's a suspicion for allergic triggers. Um, you know, and you've trialed some over the counter antihistamines and allergy referral is often something that we recommend. I, I often, you know, I feel like I am sort of like a plumber or, or the person who's very impactful at dealing, dealing with a structural problem, but I do always really counsel families on if there is a component of allergy. Um then I, I can't really fix that underlying physiologic problem with surgery. So, um you know, thinking about whether or not an allergy referral is appropriate for families as well. It's a good idea. Um obvious reasons to refer to as if there is something, you know, an obvious structural um component, sorry about the typo again, um that won't respond to medical management or time. So, you know, if you see a nasal mask, um if you very clearly see a septal deviation, um perhaps you have a, you know, an X ray that shows adenoid hypertrophy um or, you know, we often get the, the referral for adenoids and tonsils in conjunction. Um So those are all reasons to consider referral. Um And then, you know, if it's not just isolated congestion and um and say snoring, but really something that is impacting a baby or a kid's ability to feed or participate in daytime activities or contributing to obstructive sleep apnea symptoms, which is very common, especially in the setting of big tonsils as well. Um Then those are reasons to refer. Um You can though I should mention trial Flonase for um for adenotonsillar hypertrophy. There, the same studies show that there's a, there can be a reduction in tonsil size in some kids. So it's a, it's a reasonable conservative treatment option if you're using it for that 4 to 6 week trial. Um And then anytime you see unilateral obstruction or clear drainage, that's another reason to consider a refer referral. Um If there's a history of a foreign body um in the younger kids or, or potentially older kids sticking something up their nose, a visible mass or any swelling of the eye or face, um could be a concern for tumor or an acute sinusitis gone bad. Um So these are reasons to refer, get them in urgently um in terms of when and how we treat nasal congestion surgically. So, um you know, when there is an identifiable structural problem that's impacting quality of life or is just a surgical urgency or emergency like a, like a tumor or mass, um that has, you know, oftentimes been refractory for the, for the former at least impacting quality of life, um, refractory to medical management. Um So, adenoidectomy is by far and away, the most common procedure that we're doing. Um, you know, when there is hypertrophy with symptoms, unresponsive to medical management time. Um This is often done in conjunction with tonsillectomy for kids with sleep disordered breathing or OS A. Um and often done in conjunction with ear tube placement for kids with acutis media and chronic middle ear fusion. Um There, there's, there's an age guideline on that. Um So we're not typically doing that in, you know, super young babies. It's, it's fairly rare to have a, a neonatal a toddler with adenoid hypertrophy, not impossible but rare. Um So over the age of four, that's when we are, we're seeing um more adenoidectomy um done in addition to your tubes for recurring keto titi media. Um I'm really asking questions about whether or not they have nasal obstruction or congestion and helping to guide my surgical management based on that. Um For, for the, you know, if they're presenting specifically with your symptoms. Um Inferior turbinate reduction is something that we do fairly frequently. I it's um it can often be done in conjunction with adenoidectomy. So anytime I'm taking a kid for say an adenoidectomy alone for nasal congestion, I'm looking to see if their turbinate may be um impacted. Um Again, this is very common to see inferior turbinate hypertrophy with underlying medical problems such as allergies And so, um, when we, when I, when we see this and when I counsel patients on or families on reducing them surgically, um, we're not removing them, we're just making them smaller and kind of pushing it off to the side. Um And I always counsel that this is not gonna necessarily fix the underlying problem medically. So, um, that's something, another thing to know about both adenoid surgery and for your turbinate surgery is that it, we're not removing these structures, adenoids make up the back wall of the nose. So I like to give the analogy of like mowing a lawn or making it much smaller. We, we do adenoids through the mouth actually. And then turbinates are done through the nose. So there are no cuts on the outside of the face, but both have the potential risk of um regrowth or re res swelling. Um It's not, you know, super common that it becomes a bad enough problem that they need a second surgery. But um sometimes, you know, kids will still need something like Flonase to bridge them if they are in the middle of acute ur I episode or um seasonal allergies. Um even after reduction of these structures, septorhinoplasty, it's much more rare in kids, um you know, fixing other structures but, but there are cases where, where either or some um element of that is done. And then endoscopic sinus surgery is also rare in kids because um true chronic sinusitis is fairly rare. Most kids who have things like sinus sinus with polyposis have underlying conditions or immune um you know, immune deficiencies perhaps that are, that are um are also contributory. So I'm also, I'm often working with other specialists, um immunologists, allergists, et cetera to, to help treat kids in conjunction um rather than just offering surgery. Um but things like tumors and acute sin complicated sinusitis with orbital or intracranial involvement, um polyposis, these are things that are treated with endoscopic sinus surgery, same with Coen atresia. Um Yeah, that's sort of the, the overview of, of much of what we do with the nose and what we do with nasal congestion and obstruction from the ent standpoint. Um These are just some references and yeah, that's, that's all I had for you guys today. Great. Thank you. There are a handful of questions. Go ahead. Um Yeah, stop sharing. I'm gonna put the QR code up for anybody who wants to scan um to do the EV and then we will answer the questions one second. Bring it up here. There we go. Ok, let's see here. Let me bring it up. The first question is asking at what age does is surgery done for nasal septal deviation? Yeah, great question. Um The sort of the, the, the general answer is we try to wait as long as possible towards the towards adulthood. Um There are cases. So, and, and where that's coming from in part is, um, some historical, um, evidence that, um, mid face development may be disrupted by doing extensive surgery to the mid face specifically. Um, but there are nuances to that and, um, you know, there are parts of the septum, I think that can be addressed earlier in life, um, in the, in the right kids. So I've had kids who have complete obstruction in their nose and it's, you know, it's really impacting their ability to breathe at night. Perhaps it's ability, it's, you know, they, they even have sleep apnea from it or are unable to tolerate something like a CPAP machine because of it. So there are cases where we might consider a limited septoplasty. Um I think another challenge in kids is they by, by remo, when we do a septoplasty, we're removing um cartilage from the middle of the nose as well as some bone in some cases and that can weaken the structure of the nose. Um, in adults, we often, you know, it can be a healing process of up to six months. And so kids who are really active in sports or playing contact sports or maybe got an injury from a contact sport. We have to really try to advise to not address the sep septum until we're done with those high risk activities that might end up with the nose fractured again or sort of injury to the repair. So I don't think it's as simple as, you know, oh, we're gonna mess up midface development, I think, um, actually the date on that is, is not really as, as compelling. Um, but it's kids are challenging to do the surgery on. They're also, they also are continuing to grow. And so, um, it can impact, you know, I think it's unpredictable in terms of the outcomes for septoplasty on Children. Even in adults, a septoplasty sort of has a timeline or a, a time, um a lifespan of about about 20 years. So, um the nose is continuing to grow and change as we as we get older, even into our elder years. So, um so yeah, it's surgery on the septum is, is dicey on a kid who's going through a lot of developmental changes. Um That said we can often address um part of that like the inferior turbinate hypertrophy is a very common reason why like if you have a septal deviation and the turbinate is also big, it's gonna cause a bigger problem. So we might not address septum, but by addressing the turbinate, we can give them a better nasal airway. Thank you. Next question. Asking any thoughts on what interventions for a kid with constant throat clearing? Yeah, this is so I get this referral sometimes um in our joints, uh sl pe and T clinic. Um you know, I think when it's there is a component of behavioral um habit that has developed and sometimes it's developed because of a very real underlying problem. So the most common and easily treatable things are things like postnasal drip or thinking about reflux um in kids and adults. Both of those things can be very sensitive to the larynx and the larynx is a very sensitive organ, it can get hyper sensitive and kids can develop these sort of compensatory um mechanisms. And so in terms of treating it trialing Flonase, I know I sound like a broken record on Flonase but doing a six week trial of Flonase, um you do need to do Flonase for at least six weeks for postnasal drip to really resolve, but it can help shorten the time um having them replace. So, awareness is part of it. So sometimes um kids are not aware, sometimes parents are aware, but kids are not aware. So sometimes it's building awareness. Um We'll often do that by doing a scope exam and showing them that there's nothing in the back of their throat or, or maybe I'll say, oh, it looks like your, you, your nose looks pretty irritated. This is something that we might, that might be contributing. And I'm, I'm kind of giving them the same spiel that I'm giving you guys um especially in our older kids. Um So, awareness building and then replacing the behavior with something like water. So, um you know, rather than rope clearing, if they get in the habit of bringing a, you know, a bottle of water with them to school and just taking a little sip of it and trying to clear that feeling through a swallow, they can kind of rewire, rewire the brain a little bit by doing that. But yeah, it's a challenging problem and if you've tried those things and it's still going on, then you can refer to us and they'll often get a scope by me and then, um, work with my S LP on, um, on behavioral mitigation strategies. Thank you. That's questions asking for under the age of two. That would be the nasal steroid. What would be the nasal steroid of choice and dose parents are usually reluctant? Yeah, of course. Yeah. So, I mean, I kids under age two, it can often, I often see that it's sort of like a multi hit problem, like maybe they have a little bit of a neuron nasal passage. Um sometimes congestion can be from reflux of breast milk or formula. And so it's a back of the nose problem. So thinking about feeding strategies to help mitigate that, I wouldn't necessarily put them on reflux medication first. But I would try things like uh bright feeding, reducing the, you know, the maybe the volume in one sitting of feeds. If there's kids who are spitting up constantly, it's because they're taking down like a ton of milk and at the very end of feeds are spitting up. Um Again, I work very closely with my S LP on, on kids with this problem. And um, so there, there are some just, um, you know, feeding strategy modifications that you can make to address that posterior reflux um using a, a baby section or encouraging them to do that. And then in kids who do have, um, you know, true sort of inflammation or narrowing, um, you can do a, I'll, I'll often do like a dexamethasone eye drop. Um, so I'll do 33 drops to the nose. I try to limit it, you know, it neonates to about a week. Um We do that for kids who have a unilateral obstruction, even if it's not a true coen atresia or something, you can have a really narrow nasal cavity that can make it hard for kids to feed. So just giving them a little bit of space with a steroid, um can, can sometimes help and, and sometimes it can help with the diagnosis. If they're not recovering from that, then um, there might be something else going on. But yeah, I often use steroids sparingly in the under two um group and it's sort of, it's, it's essentially off label like I'm using a, you know, dexamethasone eye drop, but I have seen, I have seen it be impactful in, in kids. Thank you as questions asking which new antihistamines do you recommend? Um I don't know if I really have the best answer for that. Um I think that the antihistamines in general do a good job of treating um, the sort of sneezing, rhinorrhea, um, itchy eye piece of it. And I, I think anything that is second generation that is not going to cause a lot of drowsiness would be far preferred. I don't think Benadryl is a great drug for kids with constant nasal congestion, um, or even sleep problems. I think it, the, you know, the, the down the, the negative potential effects of that are, are far outweigh the benefit. But yeah, most, you know, second generation non-drowsy um antihistamines, if they do about the same, they're not really going to treat inflammation though. So it's not a first line, you know, as an enti I really use it adjunctive. I'm not often using it to address the structural component or the inflammatory component of this problem. Thank you. That's questions asking. Should we do intranasal steroids? Once or twice a day, once a day is really, I think all that's needed. Um I also, you know, with kids over over four, I'll, I'll do Floy is just the generic brand. I don't, I, I think um you know, it can be the adult Flonase. I just, I reduce it to one spray instead of two. So um if that's easier for some patients to just get it cheaply or access it, then that's ok. But yeah, I, I stick to one spray per day. I think how you do it is important knowing that it's impacting the turbinates which are on the side as well as the adenoids in the back. Um, you know, putting it in, aiming it a little bit laterally or up towards the, the ears, I guess is, is 11 thing that you can say to families and, and getting it in there, um, is gonna be better. It's also gonna help avoid something like a nosebleed nose bleeds tend to happen in the septum in the middle. So if you're hitting that septum with Flonase, you're just gonna drop the septum and, and precipitate a bleed potentially. So, um yeah, but if you're doing it accurately, then then one sprains instead of two. and once a day is fine, right? That's one saying it seems very difficult to order sleep studies. Is there any justification in using the Apple watch or recording at night, et cetera prior to referring for ent or sleep study when Os A is suspected? Yeah, that's a um sleep studies are a very challenging exam to get just from a resource perspective. Um And you know, I think because they last all night, I, I don't, I mean, I can tell you my, my work up for, for using them. So if a kid has obvious big tonsils and adenoids and has symptoms including, you know, very loud, snoring, apneic episodes, restlessness, behavioral challenges. Um in conjunction with an obvious structural problem, I am not mandating a sleep study in order to um to consider surgery. Um not all families want to pursue surgery. Some families wanna know how severe symptoms are. I think in terms of getting a referral accepted if you can identify all of those things that I just said, um, or all of those symptoms in the absence of big tonsils and big adenoids, which are far and away. The most common reason why kids without other comorbidities, um, have sleep apnea. Um, then it's justifiable, I think too, if you're really, if you're worried about very severe sleep apnea, then that's another reason to, um, that, you know, that you may be able to get a referral for sleep study. I know some places sort of mandate that it comes through ent, which I don't necessarily think it's appropriate, but I do think that they don't, they're not always, um, necessary in terms of diagnosing what's going on and they're not always necessary in terms of treating them either with Bonas or, uh, surgery. So I think it's really about, um, when is it appropriate to order a sleep study? And my, um, my general three bullet point thoughts on that are if you don't have an obvious structural reason for it, if it's very severe or the third. And this is a little dicey it, if, you know, if parents are really hesitant to pursue treatment, I, I guess the, this, this third one is also like in order to qualify for CPAP, you need a sleep study, which a lot of kids don't tolerate. And since adenotonsillectomy is highly impactful in the majority of kids who it's appropriate for. Um, you know, that's, that's often a better choice. Thank you. Might be a little bit of a repeat. It's a two part question. Uh The first one is asking what age do you recommend starting Flonase or nasonex? Which ins do you recommend in very young age group under two years? And do you recommend an ent referral for asymptomatic incidental septal deviation noted during annual well visits um to address that last one first. No, if they're asymptomatic and you are, you are sure certain it's susceptible deviation. Do you don't need to do anything? Just just, you know, they, you can let you can counsel them about it and let them know that if they start developing nasal obstruction, there, there's something to do about it. Almost everybody has some level of septal deviation. Um coming through the birth canal is, is a way that many people acquire just mild septal deviation. Um I think we don't know why everyone even has it, but it's very rare to have a perfectly straight septum. So, no, it's not symptomatic. No need for a referral. Um, moa zone is indicated down to age two when Flonase or fluticasone is, is uh age four. So those are sort of, I think the guidelines to be used for age. Um And then yeah, younger than two. I don't think there's any clear FDA approved indication or steroid. But um, I'll often do a, a dexamethasone drop. Ok. Thank you. Um, what are complications of surgery for septal deviation? Um, yeah. So se septal perforation is one possible complication, um, where you have a hole in the septum. Um I think the unpredictability of how the sort of soft part of the nose can develop is another, um, persistent obstruction is another, there's, it's just addressing septal deviation alone may not be sufficient in terms of treating nasal congestion or nasal obstruction specifically. Um And then the normal things are like pain and bleeding. Um from, from, yeah, surgery, little scar in the nose can happen too. That's questions asking if you can clarify the youngest and oldest ages that you do aid omy tonsillectomies and ear tubes when do tonsils and adenoids shrink on their own. Yeah, great question. Um It is somewhat variable. Um There isn't a hard and fast rule about this either, you know, I'd I'd say in general, um we try to avoid doing it under age two, but there are definitely exceptions to that. Um And why certain kids, you know, the adenoid and tonsillar growth is happening as a result of uh you know, exposure to childhood viruses and illnesses. Um in the majority of kids, some kids do have a bit of a genetic component, but it's very rare that I look in a baby's nose and I see massive adenoids very, very rare. Um So yeah, it's, it's likely not what I'm going to be doing in a neon A, I'd say there is a handful of kids who get it around age one. and I would say we try to be as conservative as possible and also avoid, um, you know, anesthetic risks, um, under age two. as well. I think post operatively two, it becomes more challenging. So my general, I'd say maybe comfort or feeling about it. Um But one that I think is often shared in our practice is like somewhere between three and seven is a very common age to have your adenoids and tonsils removed between seven and eight, the structures of the head and neck, including the station tube. Um As well as the adenoids start to regress tonsils, sometimes regress, sometimes don't. There are, there are adults who have really big tonsils. You do not need to just like the, the septal deviation question. You really don't need to take out tonsils just because they're big. Um It's really if they're causing obstructive symptoms or, or recurrent tonsillitis. But um but yeah, I would say like the number of kids that I'm doing tonsil surgery for or adenoid and tonsil surgery decreases a lot into the teen years. But anywhere between like eight and 10 years, II, I want to make sure that these structures are actually big before I take them out for breathing. Thank you. Um That's what I'm saying. We noticed lots of recurrent sinus congestion associated with her very anxious patients. Is there a known correlation or cause? That's a great question. Um Not that I'm aware of. Um I do think there is like a level of anxiety though around or I'd say like I think one's level of anxiety about nasal congestion can sometimes be magnified. So um I think there are some families and certainly I'm sure you guys see this perhaps even more than I do. Um Who just, yeah, we just have a very strong concern that something's wrong and I, I this is all on my own opinion. I don't know if this is from COVID. Um I don't know if this is, you know, from other, I, I don't always know like what, where that anxiety comes from. If the kid doesn't have objective problems in my view, that's, you know, issues that are impacting their sleep or, or sort of on the spectrum to sleep, apnea, sleep disorder breathing. Um if it's impacting their, their daytime quality of life. Um, but if it's just congestion alone, I, you know, I, I guess the way that I address that is, um, you know, sometimes the scope exam is, is therapeutic in the sense that it shows us that there is nothing structurally wrong. And I try to explain that to families. Um, when I do have that the families who are anxious. Um Yeah, I mean, there could probably be an argument to be made about like if you have sleep apnea. Um And it's that is triggering behavioral issues including things like anxiety and, and, you know, um restlessness that that may be a way to sort of backwards answer that question. But yeah, I don't think anyone specifically looked at nasal congestion and anxiety alone. This question is asking, what percent of the time do you do a TN A versus Antoin neomy? You touched on this. But I was curious as to a rough percentage. I usually tell parents that in the old days they routinely took out both together, but now ent leaves tonsils more often. Um It, I would say often if I'm doing a tonsillectomy for sleep disorder, breathe breathing, especially in kids who are under their years or, you know, under that sort of 8 to 10 cut off. I'm almost always reducing adenoids too. Um especially if they have your problems, especially if they have nasal congestion. Um The reverse is there are kids, I'd say especially younger kids who only have adenoid hypertrophy. And so I do spare those kids from needing the tonsil surgery. So they're having, you know, chronic nasal congestion. Um if there's a question. So I think sometimes um a sleep study can help determine like severity of sleep apnea. Um There's also something called a drug induced sleep endoscopy where we can put a camera in the nose when we're thinking about tonsils and adenoid surgery. And, and we often do this, if there isn't a clear an atomic reason or problem or maybe we're, we're not sure if the tonsils are really contributing. Um, we could, we can pass a, a scope while the child is sedated and see how much the tonsils are contributing. So, if they're not, if they're not compressing or they're really, really small, I'll often leave them behind if they're, if they're borderline or kind of compressing the air which I can see with that exam. Um Or if they have say a moderate um result on their sleep study, then uh you know, I'll often uh offer to take the tonsils out as well. But yeah, there are cases where it's just nasal destruction and it, it's very clearly um adenoid hypertrophy. So the tonsils get to stay likewise. If this is for an ear problem, I'm not addressing the tonsils. Thank you. Do you recommend limiting nasal steroids to a few months and, or taking breaks? And what dose do you recommend? Yeah, I mean, this is one where me and an allergist may give you different advice. Um You know, I think our data suggests it's fairly safe for, for long term use. I think though that if there is a structural component to it, um and you're needing to use it all year round, then I think that becomes a discussion with families about and maybe this is the one that I'm having. I'm, I'm diagnosing an obstruction. Um specifically the the obstructive components that can respond to Flonase are tom are um adenoids and turbinates. So, reducing those may be able to decrease their, their reliance on Flonase. Um but they might be relying on Flonase because of allergies um or, or underlying allergic triggers. And so that II, I am not very impactful at, at fixing. Um So a general rule of thumb, you know, I'll, I'd say the setting in which I am prescribing. This mostly is for kids with sleep disordered breathing or sleep apnea. So who have big tonsils or big adenoids or both? And so I will try them for six weeks, I will see them at three months and I'll say try it for six weeks, come off of it. Um, let me know how that went in terms of like, did it, your symptoms resolved, did your symptoms resolved, but then they came right back. Um, you know, it's a little bit challenging if they're getting sick a lot. So I'll, I'll kind of ballpark parents, I'll say, look, you might need this through the winter months or you might need this during seasonal allergies. If you're somewhere between like three and four months a year on Flonase, that's not, that's not a bad, you know, that doesn't seem too, too bad to me. Um, if they're in that more than that and they have a structural reason that I could fix. And that's, those are the kids that I'm, I'm offering surgery to. Thank you. I'll take four days. Do we refer a patient who only has rhinorrhea unilateral when looking down only? Um That's a great question. So the concern with that is a CS F leak. So, so yes, I think that's a, that's a reasonable reason for referral. Um You could also have like a unilateral mass. Um I'd say it's fairly rare to see that. Um And the way that we do that is through something called the tilt test where you have a child lean forward and then you, you see just like, you know, something very visibly draining. Um But yeah, if it's, if it's like hazy and you're not sure if it's both sides, I would, I would travel on, on flo first. Um But yeah, if, if it's, you know, you've done that and, and they still have it, that's a reasonable refer. This is in regards to you mentioning the DEXAsone eye drop, uh They're wondering would Ciprodex ear drop also be used for the under two population for nasal congestion. Um Ciprodex is a combination of Ciprofloxacin and dexamethasone. So I wouldn't use it for just nasal congestion alone. Um I would use a dexamethasone exclusive eye drop sometimes to Crox is like um insurance won't cover it. It's a combination drug. So Luxin drops and um and dexamethasone for the ears. But yeah, I never give Ciprodex to the nose really. Uh That's question asking. Do you always do Rhys copy during initial exam, I have experience that I have to make a special request. Um I don't always scope, I don't, I don't always scope. I always look in the nose. So I do anterior rhinoscopy, which is essentially using um a nasal speculum which is just a little device to like help widen the nose and and a uh an otoscope. Um but a scope is really dependent on the symptoms. And I would say like, you know, if a kid clearly has, um, you know, if they referred to me for sleep disordered, breathing big tonsils, I can assume to some degree that they also have big adenoids. And if they're going to be set up for surgery, there's no real need to put a kid through a, a scope exam. Um because I can look and see their adenoids during surgery if I'm already removing their tonsils. So there are times when I would defer the scope exam. Um But if there's, if the, the concern is really just nasal obstruction, then I would say more times than not. I'm scoping them. Thank you. The next question asking the current trend is either to do annoy or tonsillectomy. Lymph noid issue is also uh if it has tendency for hypertrophy, I bel I feel both to be done at the same time. Um I'm not sure I understand the question. Ok. Do you wanna go to the next one? The next one's asking do patients with selective IG A deficiency have more or less or same nasal congestion problems. These are challenging patients to treat. These are, these are the ones that I'm working with um with immunology on. Um I would say that they in my experience and granted like I probably see a very, I may be seeing a subset population of kids who do suffer from nasal congestion. But these, these are hard kids to treat where I think surgery is not always um you know, super helpful. I I do think adenoidectomy is done in the setting of a lot of kids with these immuno deficiencies um in the hopes that we're sort of reducing one of the areas where there's a significant bacterial burden. I sort of mentioned this in the beginning of my talk, but the adenoids, I like to just say they're like a giant sponge of bacteria in the back of the nose. So, treating them in some sense is an attempt to reduce that, you know, the kind of cryptic nature of it, the sponge like quality of it to get it to, to not be a harbinger of bacteria. But yeah, honestly, it's, it's hard to treat an underlying immuno deficiency with surgery. All right. That was a marathon of questions. Thank you so much for answering them all. We went over a little bit. Um So thank you so much for your time and your great presentation today. We really appreciate it. And if you could all fill out your evaluation so you can get your credit for CME. Have a great day and we hope to see you on November 12th for CME on endocrine newborn screening. Thanks again, Doctor Jacobson. Thank you all. Bye bye. Thanks. Bye bye. Created by
