Beyond Tonsils & Adenoids: Digging Deeper Into the Pediatric Airway

There are 5 main arterial blood sources in each tonsil and many veins as well. Russian and Eastern European patients who say that when they were younger, the ENT doctor would just like cut the tonsils out with them awake and use some kind of solution to stop the bleeding and put some packs there. And then they were given a bucket to spit the blood into. We do not do that.

Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. I'm a certified myofunctional Therapist, feeding specialist, podcaster, business owner, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up-to-date information in the orofacial myofunctional therapy, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct. Oral rest posture. Tongue up, lips closed, teeth apart. Breathe through your nose. Let's get started. Hi and welcome back to the Untethered Podcast. Today we have Dr. Ariel Grobman joining us. Dr. Grobman is a board-certified otolaryngologist based in South Florida. He completed both his medical degree and ENT residency at the University of Miami Miller School of Medicine, where he graduated at the top of his class and went on to complete advanced clinical training in otology and neurotology. Dr. Grobman treats pediatric and adult patients across 2 offices in Miami and Hollywood. with a particular focus on airway health, nasal breathing, sleep disorder breathing, and helping kids thrive through better breathing and communication. He's a member of the American Academy of Otolaryngology, Head and Neck Surgery, and the Triological Society, and serves as the medical director of a surgery center in South Florida. As a husband and father of 3, he brings a really personal understanding to the work he does, and that comes through in how he approaches care for families. Dr. Grobman, welcome to the podcast.

Thank you so much for having me.

So I'm excited to chat because I know we were both presenting at a conference in South Florida, and I feel like I was grilling you a little bit with some questions that I feel are just so common from the pediatric community that we serve and other therapists. And so I am excited to chat today because I know we're going to dive into some of these topics.

Yeah, it was really great that you came and introduced yourself to me. And I think sometimes in private practice, you know, I show up to the operating room, I show up to the office, I interact with patients and their families, but we don't necessarily have that same collegial interactions that sometimes people get in the academic world. So when we have an opportunity to present and meet people from other specialties and realize that there are so many things in common and so many things that we can maybe inform of each other and our colleagues and collaborate, happy to jump at an opportunity like this.

Yeah. Well, and I appreciate it. So let's just dive straight on into one of the biggest topics I think that comes up most frequently in That being tonsils and adenoids. And I think it's something that is such a high-value topic because parents are sometimes told that their tonsils are fine or they're told they need to come out and they don't always get a good explanation as to either one, why a surgery's recommended and/or why nothing's really being recommended at all. And so we tend to get a lot of families back into our practices, not necessarily from you, but from other PDNTs across the nation. And families are like, I'm not really even sure what came of that appointment, right?

Yeah.

So I'd love to turn it over to you and learn a bit more about what your are for figuring out, you know, how do you all assess and how do you decide what child gets what treatment plan, if you will?

I like it. The bell rings and we just go straight to haymakers. So yeah, I mean, this is obviously a really important topic. And I think the most important thing is that guidelines exist for a reason. You have a lot of different conversations, you know, and different concerns. If they're saying that there's a lot of nighttime, a lot of nighttime noisy breathing, poor sleep quality, and/or any kind of inspiratory stridor, you have to think about changing airway in neonate and young toddlers where you basically can have weakness of the laryngeal superstructure and laryngomalacia and things like that. And then adenotonsillar hypertrophy in that population can be much more disruptive than it is to kids with a little bit of a larger airway. So, but for the most part, as a private practice ENT, I'm seeing parents between— with kids between age 2 to 5 who are saying, my kid snores. Okay, my kid snores. Okay, so snoring— what is snoring? Obviously it is noise caused by upper airway resistance during breathing, and Snoring itself is not a pathology. It is a sound, but it's a sign of some kind of resistance. So I don't think that snoring itself is a red flag, but it can be a little bit of like the tip of the iceberg of something larger that is more of a problem. So when the adenoids and the tonsils are enlarged, you have— it's very important to note that I don't believe in black or white. It's usually some kind of continuum, and there's typically shades of gray of how bad, how big the adenoids are, how large the tonsils are, how well the child is adapting to this upper airway obstruction, and talking to the parents and seeing kind of like what, how dangerous the situation is, right? So if it's just routine snoring with some noise and it's not in every single position, And it's not every night, and it's you know most nights are free of snoring and free of upper airway noise. Then a kid who let's say has horrible breathing on a nightly basis, I'm a little bit less concerned. Okay, so when the patients and their parents are are very concerned because the breathing is terrible, you know I ask the parents: Have you sat in the room with them breathing? And if a parent says to me. I'm so concerned that they either need to sleep in my bed with me or in the room with me, or I have to go sleep in their room because I think that they're not breathing safely. That's a real red flag. And I immediately put that patient into a more dangerous category of someone that, you know, maybe we're thinking sleep apnea. And when a parent says that they're afraid for their child's wellbeing, like, I, you know, it's very eye-opening for me. And I don't want to ignore that. So I think assessing the danger is the most important thing to start with. I'm sure you'll have some follow-up questions, but that's the initial experience.

Okay, amazing. And I think that's helpful to understand like the difference. How well is a child adapting to what's going on? How frequent, how intense, like what's the duration, all of that. When do you refer for sleep studies? And if you do, like what triggers like a referral? Is it these kids who you feel like are in danger zone or are you at that point like, we don't even need a sleep study. You know, there's other things we can do to immediately start working or helping this child.

Great question. So that kind of leads into the next thing that I was going to talk about, which is the physical exam. You know, assessing just their general appearance, their comfort, how they're breathing, and/or their speech is really important. If I see a kid whose mouth is hanging down, mucus is coming out of the nose, and they're struggling to breathe, and they're just making this inspiratory— we call it stirrer, which is basically like awake snoring. All the time, instantly I'm thinking that they're quite obstructed. If they have obvious adenoid faces and elongation of their philtrum, also a red flag. And then we go into the oropharyngeal examination. If, you know, they've got— first thing I look at is I look to see their Friedman palate position or their Mallampati, which is basically how much of a view of the posterior pharynx Can you get just by looking in the back of the mouth? Is— do they have a large tongue? Do they have a small mandible? Is their tongue obstructing the view of the oropharynx, or can I see the uvula? Can I see the tonsillar pillars on the side? And can I see the posterior pharyngeal wall? So more space obviously means more room for airflow through the oral cavity and oropharynx. But as you know, and most of your audience knows, the adenoids are in the back of the nose, right? So All the way in the back where my finger is, that's where the adenoids would be, which you can't see with a standard bedside exam. Now, we can use a few proxies for the adenoids in our physical exam, which are enlarged tonsils, pretty much a package deal with enlarged adenoids. So a lot of people may not know that if the kids have effusions, which are middle ear fluid buildup. They likely have enlarged adenoids. Maybe I'll just like pause on that for a second, and that's a little caveat. The adenoids being in the back of the nose basically can block the drainage from the Eustachian tubes, and the Eustachian tubes drain from the ears into the nose, and then normal liquid would drain down into the throat. So our ears actually make liquid. When the adenoids are so big. They can essentially block the doorway, and that liquid can back up in the ears, and you get these effusions in the ears. So if I see a kid who's got these chronic effusions, I'm already thinking without visualizing their adenoids they probably have enlarged adenoids. So finally, and this is a really important point for any kid where you're considering: Do I need a sleep study? This kid's not breathing well. Am I gonna have to operate on him? Nasal endoscopy. A nasal endoscope is a very skinny. Slim instrument. We can put a little bit of numbing and decongestant spray, and we can pass it goes through the nose all the way to the back of the nasopharynx. We can visualize to see whether the adenoids are enlarged, and we can look into the oropharynx too and see the larynx, the voice box. I would do all of those things before ordering a sleep study, right? The sleep study I typically use when I've done all the physical exam things that I just mentioned, and I still don't know what the heck is going on. Why are they sleeping so poorly despite having very patent open anatomy? Is there some kind of craniofacial disorder, sleep problem, any kind of developmental issue that we— that I'm missing? And what can the sleep study give to me that the physical exam did not? So we are not guideline zombies who just blindly follow and everything is the guideline. So I think it's so important to have proper conversations with my patients' parents, to sit and listen to the kids breathe and speak in front of me and assess how comfortable or struggling they are to get proper airflow, hear what has been tried and what has failed, and then examine. Put your hands on the child, use your instruments to try to understand what's going on when the lights are out and they're trying to sleep, and then asking the parents to tell you what they're hearing, what the experience is. So, you know, when I see a patient who comes to me with a concerned parent for adenotonsillar obstruction, you know, I start with basically Getting a history and finding out what's happened, and I think obviously we have to divide our discussion probably into different age groups because there are different concerns and different red flags that you have at different stages of life. So if I have parents who are coming to see me within the first ten months of life, I'll leave it at that.

Yeah, no, that's helpful. And I've always wondered too, because I feel like put a child into an unfamiliar room with unfamiliar people hooked up to all these things, and like, are you even getting the most, you know, valid results or accurate results? Is the kid actually going to sleep? Are they sleeping as long as they normally would? Like, so, and I don't know if it's more age-based or not, but I've always just also wondered like, if there are things we can do to avoid having to put a child through a sleep study, you know, it's nice to know that there are and what those things are. I've always just kind of wondered about. The results side too. Yeah.

And, you know, for children and going back to the guideline, if you suspect sleep disorder breathing and sleep apnea, we typically rely on the parental report. Are there any witnessed apneic episodes? If so, that's your sleep study. They have received the diagnosis of obstructive sleep apnea or high suspicion of obstructive sleep apnea. Coupled with physical exam findings, which can explain why they're apneic, is actually an instant criteria to go to consider surgery. So the sleep study in many cases is used, I think, by ENTs who are comfortable with a pretty in-depth physical examination as a last-ditch effort or to explain something when the situation is just not so clear.

Yeah, that makes sense. And so how are your younger patients reacting to the nasoendoscopy? Like when you have to scope them, are they pretty receptive to that or do you get a lot of struggle?

Well, no one's asked me to do it again on them. You know, I think it's really important to have a good discussion. First of all, you need to have the right setup in your office. You need to have a slim fiber optic scope, not like the old school garden hoses. You need to Some lubricating gel, and you need to have set the tone with the parent. You know, I'm not on an adult. It's a very straightforward thing, and I could you could come to my office, Helly, and I can do a nasal endoscopy on you, and you'd say, oh wow, that really wasn't so bad. We have to do that again in another few months. I would allow it. But if you talk to the parents and you say, you know, I would say in cases where the tonsils are huge, they have obvious sleep disordered breathing, and. Witness apneas. We don't even need to do a nasal endoscopy. I know that surgery can help this child, but in a case where the tonsils are kind of small, but they seem to be so nasally obstructed that I just have to visualize the adenoids to make a call between this kid is going to be okay with nasal sprays or I'm going to have to take them for an adenoidectomy. So I tell parents, listen, do you want me going in blindly for surgery and maybe we get surprised? Or do we put some numbing spray? We hold your child. We do it together. It does take 20 to 30 seconds only, and I'll put a down payment for their future therapy bill because of how much you traumatize them. And we just get it done. And you know, it's really not bad. And almost every single time, the parents are really grateful, and they're saying like, "I'm so happy that we did that. Now I have peace of mind. Now I know we need surgery." Or, I'm so glad that you helped me avoid unnecessary surgery. Almost no one have ever told me, wow, I can't believe you just did that to my child. That was—

Yeah, no, and I think that's helpful to hear this too, because a lot of times we've got kids who come away without an actual physical exam, not again from you, but from some places in the US. And so it's hard to know what to do next because, you know, we receive them back as therapists and Sometimes ENT may not be super communicative with us even, and we're like, well, we don't even know if it's safe to ask this child to nasal breathe and to work on getting their tongue up and work on their chewing patterns and all of these things that really rely on having the ability to nasal breathe. So very helpful. What should a parent expect after either an adenoidectomy or tonsillectomy or adenotonsillectomy? Adenoids, I've seen kids back in school like the next day. It seems like almost like a no, not as big of a deal surgery, whereas tonsils are It's a very painful recovery. 2 weeks sometimes, I've heard kids it takes to recover. Thoughts, shares around that?

Yeah, I'm gonna get to that in 1 second. I just wanna finish 1 thought from before, which I think is super helpful to your audience. If you have a kid who you can't fully assess what's going on with their nasal breathing and you think it's extremely important, after hearing this discussion, maybe you and your audience will actually help the process go more smoothly by talking to the parents and saying, the ENT doctor will need to probably take a look in the back of the nose. Now, that sounds scary, but I promise you it's not that big of a deal, and it can be super helpful. So I think parents already coming in knowing that may be an option helps so much the process go more smoothly. So that's my blessing to all of you out there, is to help us because the physical exam in a kid can be a little bit tricky, mainly with parents' anxiety. But now you know that it's not that big of a deal. So now back to your question, adenoidectomy. Let's talk about how we do it real quickly. We put the patient under general anesthesia. They get a small breathing tube right down the midline, and we open their mouth with a special set of retractors. Those retractors get suspended on a stand, So, the mouth is wide open, and the teeth are protected, and now you have a view of the back of the throat. So, we're essentially working at the top of the patient's head, and we're using, in the case of the adenoids, a mirror, actually, to look up and under the soft palate and up into the nasopharynx. So, for an adenoidectomy, we typically use different varieties of instruments, but it's essentially a hot knife, a cautery device. That will cut and coagulate blood vessels, and we essentially shave down the adenoids like a layer at a time until you can see the back of the nasal septum. You can see the eustachian tubes. You have a clear view, and you know that the nasal breathing, the airway, is now connected properly to the oropharynx and the lower airway. Okay, so the adenoids are not that vascular. They don't bleed that much. They don't have that many blood vessels as compared to the tonsils. So. The tonsils are very vascular. There are 5 main arterial blood sources in each tonsil and many veins as well. So Russian and Eastern European patients who say that when they were younger, the ENT doctor would just like cut the tonsils out with them awake and use some kind of solution to stop the bleeding and put some packs there. And then they were given a bucket to spit the blood into. We do not do that. Our techniques have changed quite a bit. We use these plasma knives and coagulating knives that will stop the bleeding as we remove the tonsil. And now there are some different techniques. Some of you may be hearing about intracapsular tonsillectomies. Those are tonsillectomies where we don't cut around the tonsil, we actually shave the tonsil down layer by layer, leaving a little, like, tissue. So there's less pain and less chance of bleeding. But because you typically get into the nerve fibers and the muscle and you stop all those blood vessels, that's where the pain comes in. And the recovery after a tonsillectomy can be a little bit brutal and painful. So with a tonsillectomy, I typically, in kids under the age of 10 or 11, I tell them it's going to be a 1-week recovery, and most kids bounce back About 7 days after the surgery and then can go back to school. It's a little bit of a different experience in teenagers and adults where the pain becomes just more real to them or more inescapable. They're less distracted. They're focusing more on the pain, and it's more of like a 10-day to 2-week recovery. But an adenoidectomy, I tell people they, they can send their kids to school about 2 days after the procedure, and there's a very low risk of bleeding.

Awesome. Very helpful. When you talk about them being like shaved down, right, to the point of no longer obstructing the airway, but leaving some tissue intact versus like complete removal, right? That also allows for the opportunity for that tissue to grow back in the future, right? Or talk to me about that because I've had kids where it supposedly has grown back because they only partially shaved them down. And so that just tells me, well, we never got to the root of, never addressed the reason why they were enlarged in the first place. But love to hear like your thoughts on that.

Yeah. The root cause of adenotonsillar hypertrophy is a little bit tricky to put your finger on. They're part of a system of the, our upper airway immune system called the Waldeyer's ring. It encapsulates the adenoids in the back of the nose and the tonsils in the back of the oropharynx. And, you know, in some you could hypothesize why they're enlarged, but ultimately there's a very strong genetic component. And there's maybe an environmental component, but it really hasn't been parsed out well how we can adapt that environmental component to no longer happen, for example. But when we remove the adenoids and tonsils because they're enlarged, I think if you're taking away over 90% of the tissue bulk, they really— it's extremely rare for them to grow back. In cases where they've quote unquote grown back, I think they were probably incompletely removed to begin with. There's maybe the ability to grow back to 20% of what they were before. So I think in those cases that you've heard, the surgeon maybe was not appropriately aggressive, right? We always say you don't want to be too aggressive. You don't want to be too wimpy. You want to be appropriately aggressive for the procedure in front of you. It's extremely rare, actually, when done properly to grow. Awesome.

Thank you. That's very helpful, actually. So my next thought and question sort of around this topic too is, you know, we do have kids who continue to mouth breathe afterwards after they've had maybe tonsils and/or adenoids out. Any thoughts behind why that continues to happen?

That's time to see a myofunctional therapist. So there may be some maladaptive behaviors that children acquired during the period where they were so obstructed and they just learned to keep their mouth open. They have a hard time managing the velopharynx and closing off their upper airway, vice versa. And I think there's a learn— there's a relearning component to nasal breathing that In an adult, you can easily cue them to put their tongue on the roof of their mouth or think intently on the sound of their airflow at the tip of their nose and the kind of breathwork techniques that you just can't do in a child. So they'll oftentimes default back to their original operating system and just have their mouth hanging low and It just gives them a sense of comfort, you know. And then you have obviously tonal issues that you're certainly more an expert in than I am. But once we've taken the obstructive aspect out of the equation, we have to think outside the box, and that is an incredible time to collaborate.

Yeah, well, that's music to my ears. I love to hear that because it's, you know, pediatric feeding and/or myofunctional therapist. A lot of us have been taught that, you know, mouth breathing is a habit. Well, yes, it becomes habitual, but it's a habit for a reason. It's not just a habit in and of itself, right? And so there's an actual reason for the mouth breathing. So I love that, you know, you've kind of highlighted that here because we know that chronic mouth breathing obviously impacts sleep quality and feeding and oral posture and facial development over time. And anything else you want to add to that, especially with like the sleep disorder breathing side of things? I think it's a really good window for a lot of parents and therapists to see into, you know, there's something greater going on here if you do visualize mouth breathing to start.

One thing I'll say on that is that sometimes people get too concentrated on tonsils and adenoids. Tonsils and adenoids are components of the airway and of nasal obstruction, but we've got to think about the anterior or opening of the nose. You know, some kids have very narrow nasal passage or very stenotic nostrils and what we call the internal nasal valve. There can be enlargement of the inferior turbinates, the natural air filters we have in our nose, inflammatory considerations such as allergic rhinitis, chronic sinus infections. And then we also need to think about the actual morphology of the maxilla and the velopharynx. We see sometimes kids who have very, like, cobblestone mucosa, as we say, the lining in the back of the nose that can secrete a lot of liquid and also can just kind of crowd. And then that's— this is a big reason to consider a nasal endoscopy in someone where it's just not adding up. We have to think about the entire tube from top to bottom, not just tonsils and adenoids, and then we throw our hands up and it should have worked. We have to Dig deeper. And that's where collaborating and visualizing are actually so important.

Absolutely. So that kind of pops a question into my head. So I had, in April 2022, I had a septoplasty, nasal turbinate reduction, and a nasal swell body reduction. I had never heard of swell bodies before, but everything was inflamed. Is there an age, even in pediatrics, where you would consider reducing turbinates or even moving towards a septoplasty or fixing the septum, a certain point of growth that you have to wait for before that's considered?

Excellent question. So inferior turbinate reduction, I routinely do in kids age 2 and above when I see that the turbinates are hypertrophic and blocking and a component to the airway obstruction. So it's a very safe procedure. We typically just use a probe that goes inside the turbinate. This is done under general anesthesia as well. And the probe has a cautery function that will essentially shrink the turbinates. And then we manually move the bone slightly inside the nose, making more space for the airflow in the nose. So I don't have a limit when it comes to a turbinate reduction. But with a septoplasty, the septum, the bottom portion of— this is the bone, and then you have the cartilage on top. The bone is a component of our overall facial growth structure. So, there's a growth plate there that, if disrupted, can impede your skeletal cranial growth. So, we typically will not do this until adolescents have passed puberty. So, I typically wait for head size before considering a septoplasty. However, a turbinate reduction, or let's call it a minor septoplasty that does not involve aggressive tissue removal, can be done in younger patients, very special circumstances. So for example, a few years ago, I had an early teenage boxer and he had gotten his face punched and his septum had a fracture in it so bad that it was blocking his nasal passage. So, you know, he was suffering, his quality of life was reduced as a result of his bad nasal breathing, and his father was a fighter too. And I just kind of explained to them that I think we need to deal with this. So I would say we did a gentle septoplasty on him, and that would be one that didn't disrupt the growth plate, but got him to a much better place of function. But that's the exception to the rule.

Yeah, no, it's helpful to learn about that because I didn't realize that my septum was kind of turned sideways almost in the back posterior portion, was blocking almost the entire left side of my nasal cavity. Had no clue because it's not, it wasn't super visible. So that was a fun learning.

How's your breathing now?

Oh, it's great. I can breathe butt through.

Oh, great.

I also have an appliance in my mouth too to do more expansion. And we did split the suture, Marpy.

Oh, wow.

Oh yeah. So it was actually last August that we did that. I had like all your traditional expansion and braces as a kid. I had permanent retainers that I have. When I asked the dentist to take the permanent retainers out, I think I was 30. 'Cause he told me they would fall off by the time I was 20 and they didn't. Immediately started to shift. And I definitely had, you know, the midfacial region was more retracted than it should be. And what I started to notice was like maxilla, the left side was actually turned in a little bit, like the bone itself.

Really?

Starting to wake up, like there were a couple days I woke up a year ago and I would go, oh no, I can't open my jaw. Like too painful. Don't know what that is. And I had never had TMJ issues before that. Anyways, Koval, who is an orthodontist in Boca, Is doing like more traditional expansion with my kids and not traditional, but airway guided expanders. And so I had watched her do Marpey on a number of other people and I finally was like, okay, let's try this. So she did piezocorticotomy down the center, split the suture all the way up to the front 8 millimeters and let that split on its own because of the nerve that's there. And yeah, I mean, I will tell you that immediately massive improvement, no jaw issues.

Wow.

My jaw moves much straighter up and down now. We're in the stage of it's just in there holding and I'm— now we're kind of shifting teeth with her clear aligner system. But what also was very interesting was after my nasal surgery, I developed a chronic postnasal drip and that immediately went away when she split the suture. And now it's like—

Really?

There sometimes, but not as frequently. And I honestly think it has to do like if I'm sitting in like a recycled situation, like I'm in the car or I'm on a plane or something, I feel like it kicks in. So it could also be triggered by certain allergens or certain environments. I don't know. Fascinating. I can't really put my finger on like exactly why and when it happens aside from that.

Yeah. Kudos to you that you didn't just accept the changes that were occurring and you made a big girl decision to do all that. And now you're receiving the benefit. And the chronic postnasal drip can be a tricky one. Pretty effective treatment algorithm for that. If it continues to be a problem, please reach out to me.

All right, I might have to come see you then because it's not 100%. I always believe that there's always a cure. There's always a way to fix an underlying issue. So I'm like, I don't take no for an answer, and I'm like, we got to get to the bottom of this. So there's something we can do, then I'm all for it. I think that also just goes to like that team approach too, is like. Talking to different providers. And one of the biggest things that I have found is just from like learning from other providers that I either collaborate with or other courses I've taken, or at one point we had like a myofocused kind of meeting that I would host at my house back when I lived in Maryland. And this was like pre-COVID. And to sit around a table, right, with all different medical providers and hear everybody's take on the same case, right, everything from oral surgeon to ENT to you know, hygienists, speech pathologists, myofeeding, PT, OT, osteopath, like it was just vision therapists. It was very interesting to hear everybody's different viewpoint on the exact same images and case sitting in front of you. And I just think it speaks so beautifully to like when you can collaborate with other medical professionals and learn from each other. Like we all see things, the same thing, but through a different lens. And it all really works beautifully together when we have the opportunity. I know time doesn't always allow it.

Right.

We have the opportunity to actually do things like that.

That's like a high maintenance patient's dream. That you're gonna talk to all 12 of my medical professionals about my case, right? Yeah, of course. I'm gonna call each one of them individually.

This, in this case though, this was a pediatric case, but it was like the, one of the most severe cases that we had ever, you know, worked with. And so that's why we did bring that particular case to the table to be like, this is a good one for study club. Like, let's talk about this case. Obviously that's not how everything happens and not everybody needs all those eyes on a case necessarily all the time. Yeah, no, I know that you collaborate to, Melissa loves you. And so I know you refer to SLP for feeding or swallowing concerns or myo, all the things. And we're always so appreciative of that.

Yeah, I think it's really important to not, especially in patients and families who are looking for answers, and we don't have all the answers. There's so many things that we can't explain or we hit dead ends where I've done everything that I medically and surgically can do to help optimize your case. Now, We have to work on behavior and function and improving tone. So I think it's really important to refer early on, not necessarily at the end of the road, and especially when we have tricky cases. And it's actually been refreshing over the last few years. I've been getting a lot of calls from orthodontists and dentists and, you know, myofunctional feeding specialists To get involved in these patient cases. And I really enjoy it and I welcome it. I know different people be more old school and they just wanna like do their thing and stay in their lane. But I think that most of the, let's call it the younger generation, we understand multidisciplinary is usually better.

Absolutely. We, and we super appreciate that. I know that you mentioned like it would be helpful if like we think a kid is gonna be potentially scoped, right? How we can basically have that conversation to prep the parent, right? So hopefully their nervous system is a little bit more, you know, calm, and the kid then can be calm when that does happen. Is there— are there other things that would be helpful for you as an ENT to have a referring provider like an SLP, OT, myo, feeding, whatever, either send you information-wise, or is there a way you prefer people communicate with you in those types of, you know, collaborative situations?

That's a really good question. I think it's definitely like physician The physician really depends on the personality. So for me, I love a text message, had a heads up about a patient, especially when the parents come in with some kind of loaded idea or some, like they're on a mission to, I want you, like, I don't think my child has big tonsils and adenoids and I don't surgery and I'm here for a second opinion. And they'll come in with these preconceived notions. of what's going on, many of them rightfully so, but they're like looking for you to validate their initial thought. Then you're already like on your heels. So I love a good prep text. Hey, I've seen this patient, we've been working with them for 3 months now. We've really hit a speed bump. We think that there's potentially some nasal obstruction. Maybe you'd think that a nasal endoscopy is a good idea. So it kind of like puts me on a mission and I don't need to start from scratch. So I'm very busy. I typically work 5 days a week from 7:30 in the morning if I'm doing surgery all the way to 6:00 PM. And I'm just like nonstop. So I, and I see a high volume of patients in private practice. So for me, if I already have an idea of like what's going on in a case and we can frame it properly when I'm entering the room, it's so helpful. And I think most people probably feel that way too.

And I think that's really good for people to hear because, you know, pro grad school and in programs like grad school, we were writing 17-page reports, which is ridiculous. But in our programs, we really try to teach people like, if you're writing a report for insurance and it's lengthy, that's fine. But when you're referring to a medical provider that you're hoping will pay attention to what you have to say, you need to give them a small list of bullet points as to why you're referring this patient, what you're hoping the outcome to be, or what, you know, what your concerns are yourself. And so I think that just kind of also reiterates like method in which somebody actually does that, whether it be a text or an email or a, you know, keep it brief.

Yeah, keep it brief and keep, and keep it like concise. So if it's message communicating to the physician, yeah, but also if the parents are coming with the last note, which was, would be super helpful. I'm really just looking at the assessment and plan, right? I'm looking at like your final take before you was You know, feeding issues, low tone, previously had this surgery done, concerned that this may be the problem, referred to ENT for visualization or something like that.

Yeah. Amazing. Speaking about like feeding difficulties and airway dysfunction, can we talk about that for a minute? 'Cause I'm curious.

Absolutely.

You know, you mentioned at the beginning of the episode, for example, and I've worked with some of those babies and they are very challenging to feed and very stressful for families. I know some children will prioritize, right, breathing over everything else. And we always say airway first. Breathing is going to take, you know, the first seat to anything, and everything else will then compensate or follow. So you're working or receiving children who have these issues?

Yeah. I mean, I will say that I do not do complex pediatric airway cases. I did not complete a pediatric ENT fellowship dedicated to that. So oftentimes when I'm seeing cases like that, I'm sort of assessing them and triaging them, and I will refer them to someone at one of the academic or large pediatric hospitals for day-to-day management. But I think it's important to understand, you know, like I'm trying to exactly think about a 12-month-old baby of a speech pathologist who was having, and it was almost like the, the mom knew too much. She was almost like too well-informed. Mm-hmm. So she came in with some interesting ideas. This was a kid who was a little bit low tone. He was having severe obstructive apneic episodes at night. At the visit with me, I could hear very loud stertor. Mouth was wide open, drooling, and I could only imagine how poor the breathing was at night when he was supine. And he had actually seen a pediatric ENT. At one of the hospitals who did on the kid, and they found that he had like not just severe sleep apnea, like one of the worst sleep apnea scores I've ever seen. And they had recommended at the children's hospital a they said that there was likely some laryngomalacia, and that they recommended a laryngoplasty, laser laryngoplasty to remove part of the very floppy epiglottis, and to do a TNA on the kid. And the mom. Was asking me, "Why don't we just take out the adenoids and see what happens?" Okay, you know, I was basically like, "We're so past this point with your child that he's in the danger zone." And this is that kind of case where you want to apply my kid is normal principles and just needs the normal regular treatment pathway, which is the tonsils and the adenoids. But this is a special circumstance, so you have to recognize when it is a special circumstance. Refer to the pediatric ENTs, and in this case, I was reaffirming the pediatric ENT's plan, which was we need to deal with the underlying issue here, which is that obstructive omega-shaped epiglottis causing the laryngomalacia and the floppy tissues in addition to the TNA. But this is something that needs to be done at a tertiary care hospital because this is a severe case.

Yeah. Yeah. No, that's very helpful to hear, to understand, to know. And there's a lot of people who will default to, oh, it might be LM, laryngomalacia. Like maybe we gotta rule that out. And I've worked with a couple of these that have— Right.

Again, scope exam.

Yeah.

You know, we could do an in-office scope on that kid and maybe uncomfortable for a few seconds, but I can visualize the larynx most of the time and come up with a diagnosis.

Yeah, and then refer if you need to, right? So that's helpful. Amazing. Okay, I want to go back really quickly because we spent a lot of time on tonsils and adenoids, which I think people are going to absolutely love, but the chronic ear infections, right?

Yeah.

We talked about that a little bit. I've seen it firsthand, especially earlier in my career before I really dove into the feed feeding side, but a lot of kids with delayed speech and language because they just weren't hearing because of how full their middle ears were and they were chronically full and sometimes they can, they go for PE tubes. And so is there a, I don't know, I know there's always the rule and then there's real life and how we actually treat each case, but what is sort of the ideal situation for a child to need to, you know, have the PE tubes put in to help with drainage of middle ears?

Yeah, so you're talking to a second-generation ENT. My dad's an ear specialist, so this is like my wheelhouse and a big passion of mine. Is making sure that everyone who should be hearing can be hearing. And, you know, we rely on a few different, like, checkpoints during the process to know that they're hearing well. One is that newborn hearing test that people— that babies have when they're born, and then pediatric checkups and parental reports. So, you know, if that second checkpoint is not such a tight checkpoint, we do see a lot of kids who end up Having fluid retained in the middle ear, infections that go unnoticed as just kind of like a cranky, fussy kid. You know, a lot of times when, actually, let me frame it like this. There are 2 main reasons why we have to drain liquid from the middle ears. One would be recurrent infection. That's kind of like your 3-5-7 rule where 7 or more infections in a 1-year period, over a 2-year period per year, and 3 per year for 3 years. Which I think is almost like the guidelines should be even a little bit tighter. Essentially, recurrent that are not going away, requiring multiple courses of antibiotic. The other reason why would be trapped fluid, which may not be infected fluid, just trapped fluid in the middle ear that's been there for 3 months or greater. So sometimes we look in pediatric ears and we just see fluid without the redness and the swelling and the pus, but If you would put your head into an aquarium and I said a few words to you, I don't think you'd really understand me too well. So that's kind of what's going on with those chronic effusion cases. I like in circumstances like this when pediatricians refer early and when therapists refer early when they think that there is any kind of speech concern can't just be explained by pronunciation and/or cognitive function. Specifically in my office, we have microscopes in all of the exam rooms, and with a microscope. You get an amazing view of the tympanic membrane of the middle ear, and it's much better than those like otoscopes that you just don't get such a great view. So I think we have to worry about the kids that fall through the cracks. You know, the helicopter mom who's taking her kid every single week and is not going to miss an ear infection, they're going to be okay. Mom's on top of it, but it's really kids maybe in the public school system or just kind of Actually, I shouldn't single out any school system, but the kids that fall through the crack and they can't necessarily tell you that they're not hearing well because they've been so maladapted for so long. That's where I think early referral. I love to tell parents, I just looked in your kid's ears. There's no infection. There's no effusion. They don't need tubes. Everything is okay. Right? So that's my passion is just send them to who can get a proper exam, do an audiogram, a tympanogram, and let's be absolutely sure. If not, let's talk about how we need to intervene.

Amazing. Amazing. Yeah, I know. And I remember back to preschool where I feel like every year the kids were getting those exams. It was a Jewish preschool up north, but still it was like they were getting those exams every year. So their little sheet would come home and the tympanogram was done on site and they were like bringing the machinery around with them.

Yeah, that's ideal.

It was amazing. It was amazing. And I'm like, now I don't think they've had that done in a while. But anyways, I would, I feel like I would know if my kids were not hearing. But also being—

I think you would—

like, you can hear it change in their voice, you know, when you're this heightened in your skills. But yeah, so last question I have for you: airway-focused orthodontics or palate expansion, right? And kind of that coming into the picture. And my thought process here is because I know too much, right? I'm one of those moms. Started both my kids into expansion at age 4, and older one who's almost 11, when she started, we were still living up north. She had a slow and ALF appliance put in, functional wire. And what was really crazy, I mean, we did a CBCT before and after, and I think the most telling thing about it was that her nasal airway and her sinuses were so full, you could barely see her septum on the imaging. You could really— there was— and I have it, like, I can even send it to you. It's wild.

I'd love to see it. Yeah, I'd love to see it.

And then afterwards, after— and I will say her tonsils were large and angry. She was constantly getting sick. And all of a sudden, 3 months into the appliance, she wasn't getting sick and it was cold and flu season, right? And then COVID happened the next year and that was a whole nother story. But when it came out a year later at age 5 and then January of that, so that was like August 2020, and then January 2021, we redid the CBCT and everything was open and beautiful.

Whoa.

You could see her septum and her turbinates and her sinus cavities. And I teach and I use this image to show people like, this is what sometimes it looks like and this is what it should look like, right? So if you're ever looking at imaging from any of your patients, you have an idea of what you're looking for and when you should be referring because this kid came breathe. So I don't know, it was wild. I don't know if you ever see that or if you ever refer for like orthodontics or anything to help with that midfacial region growth. And, you know, I know it's all interconnected, but did you have any thoughts around the airway-focused ortho expansion?

I have kind of been on the other end of it where the orthodontists typically have exhausted their ability to help a kid, or they think that a kid would not be a candidate, and then they'll send them to me. But it's really refreshing to hear this because I think that there's gotta be an algorithm for myself and my colleagues for noticing maxillary facial deficits and room for improvement in order to widen the horizontal size of the nasal airway. And we always think about like tissue inflammation and enlarged turbinates and allergies and things like that. But we really don't have the training that to teach us about expansion and how it can change the maxillary airway. So I think I'm starting to learn more about this by talking to people and hearing it from someone as qualified as you. And maybe that would be a good area for me to really dig into so that I know which kids would benefit from it.

Yeah. Yeah. I mean, there's a great ortho I mentioned that we're going to here in Boca, so I can definitely share her information cuz she teaches and is doing a ton of research on all of her cases and she's doing like the therapy with me and expansion with the kids. And I do think there's a big difference, traditional orthodontists, how most orthodontists learn things in school. And then a lot of the orthos who are now going for that, and it sounds silly to say airway-focused because I think everything is kind of airway-focused, right? But they call it that airway-centric or airway-focused orthodontics, which—

Yeah.

Kind of adds on a whole nother layer to what they're doing. And a lot of discussion around we need to grow the palate on 3 planes, not We don't want to just do the rapid palatal horizontal expansion, but we want to bring the palate down. We want to grow the face forward, which was so opposite of what a lot of orthos were taught in school, where a lot of them were retracting the lower jaw to meet the retracted upper jaw. And no, now we're all going like, no, grow the face forward to open the airway, right? It goes back to a lot of the things that I teach too, where people say, well, the kid's sucking their thumb, or they were using a paci. I took the paci away. Now they're sucking their thumb. I can't take that away. It's serving a biological need right now. It's actually typically advancing their lower jaw, I think, and opening up their airway to make it easier for them to breathe. So I'm—

Oh, really? Well, I never heard that.

I'm a big proponent of you cannot take away something like that or teach them not to suck their thumb until you've guaranteed their nasal airway is clear and that they can breathe. And then if the habit is still there and the tongue is up in the palate, then we can work on getting the thumb out because there's no need for a thumb. If we can breathe through our nose and our tongue is on our palate, the tongue is then serving its purpose, right? So it's been very— I was taught, get the thumb out, then do myo. Get the thumb out, then focus on therapy. And after working with so many kids, I was like, why are some of these kids who've never addressed getting the thumb out just— they're just stopping? They don't seem to have a need for it anymore. Oh, because we addressed the underlying issue and now their tongue is up on the roof of their mouth and they also have a patent nasal airway. What do you know? Like, cool.

That's fascinating.

Yeah. So anyways, I know we could talk about this all day long, but share with us where everybody can find you. We'll definitely link your website and your social below the episode, but go ahead and let us know.

Yeah, of course. So I have 2 offices. One, my office is in Hollywood, my primary office where I'm at 4 days a week. One day a week I'm down by Coconut Grove. You can, so you can find me on Google Maps in either office. I'm on Instagram as @arielgrobmanmd. I often post videos and try to show some fun stuff in the operating room and Also pictures of my kids and vacations too. And I am on, and I have a website now. Anyone who wants any kind of consulting or other outside of just patient care, it's drgrobman.com. And I'm sure if anyone hits up Hallie, you can get my cell phone number or email, but Instagram is usually the easiest way to just DM me and we can chat.

Amazing. Well, we'll make sure your Instagram, website, all that fun stuff is connected to the episode. And thank you so much for your time.

Of course, it's my pleasure.

Quick disclaimer, all information, content, and material of this podcast are the opinions of the speakers and serves as informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider. Thanks for listening to this podcast. If you found value in this episode and want to hear more of these myotats, airway, and feeding-related episodes, be sure to leave a review on Apple podcast and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @halliebulkin on Instagram to get all the latest updates.