Episode 139: An ENTs Approach To Disordered Sleep & Airway Across The Lifespan with Chris Tran, MD

Hi and welcome to episode 139 of the Untethered podcast. Today we have Dr. Chris Tran joining us. Dr. Tran is a Southern California native who has a degree in psychology from usc, a medical degree from Ahari Medical College in Nashville, and completed ENT residency at lsu. He is board certified by the American Board of Otolaryngology, Head and neck surgery. Dr. Tran lives in Houston, Texas and has a comprehensive ENT practice with particular interests in breathing related surgery and in office procedures. He enjoys collaborating with local healthcare providers to optimize patient outcomes and has a strong passion for educating and empowering students and patients. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm Hi. I'm a certified orofacial myologist, feeding specialist 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, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Well Chris, thank you so much for joining me today.

Thank you for having me.

I'm really excited. It's not often that we get an ENT on the podcast and an ENT who thinks similarly. So I'm really excited to hear about your experience and maybe if you could start with telling us about your journey into the sleep and airway management space. Can you share a little bit about that with us?

Yeah. Yeah. So I am a board Certified ent. I have practice in Webster, Texas, which is a suburb of Houston. My clinical focuses are airway optimization for sleep, apnea and breathing, sinonasal surgery, functional frenioplasty and tethered oral tissues management and office based procedures and techniques. I treat pediatric and adult patients and I really try to espouse a collaborative care model as part of my treatment. And all that kind of developed as I kind of went down the rabbit hole of tethered oral tissues. So just as a kind of introduction to how that happened for me, I know there's a lot of stigma out there about how ents do not focus on these things or are not knowledgeable about these things, but I started out that way too, so I had excellent ENT training I studied at LSU Health Sciences center in New Orleans and great ENT training there that well prepared me for all aspects of practice. However, just like traditional ENT training, we didn't really learn much about tongue ties. And so it just so happens that in my practice we actually have a pediatrician's office right above our clinic. And so sometimes they would send down babies for tongue tie evaluations. And at the beginning, when I was starting to practice, you know, when you initially start practice, your schedule is pretty light, so I would be able to see them right, like, pretty immediately. So I practiced what I was taught and just, you know, doing simple tongue clippings with some scissors and setting patients on their way. But because my schedule was light, I decided, you know what, let me just follow up with some of these patients. Even though, you know, traditionally we were never really encouraged to follow up with these patients after doing a clipping. And so I ended up bringing some back. And to my chagrin, they were not improving as I would expect they would. And I just never knew, like, and I would never have known if I didn't ask them to come back. And so, yeah, so that's when I found, when I realized, like, I was missing something. So actually to stand on the shoulders of giants, I looked up, I did Google search, right? Like, okay, what am I missing? Right? And I stumbled across one of his lectures. And after I listened to this lecture, I think it was like an hour long lecture, my mind was blown. I was just flabbergasted because I didn't realize that what I was doing was not up to the standard of care that I would have wanted, that I want for my patients. So. So that's what led me down the rabbit hole. And I started to do more research and took some courses, the Breathe course and took Richard Baxter's course. Both of those courses, phenomenal. And I think what really helped me really incorporate this into my practice pretty seamlessly was that, you know, I had such good ENT training in at lsu. I was very comfortable with the anatomy already. I just didn't think about the functional side of it and what I was doing when I was releasing. Right. But after taking those courses and kind of opening my eyes to that, it was actually, it fits in very nicely with the rest of the. My ENT knowledge. Right? Yeah. It's crazy how you sometimes you have all this knowledge, but you just were missing one piece of puzzle, but you didn't know that piece of the puzzle was missing. And then now that that piece is there a lot of other Things in ENT also make more sense. So that's kind of what led me down to that.

I love that. And everybody has such interesting stories of how they kind of stumbled into this space of, you know, myo and tots and airway and in the way that we look at it from this perspective. And it was similar for me. Like I was practicing as a speech pathologist. I knew what I knew from school and from what my, you know, my patients and then took a MYO course and I was like, oh, my child is tongue tied and has a lip tie. And that's why breastfeeding was painful for 13 months. But I was turned away by two Ents and lactation consultant and a pediatrician. And you know, and it, you know, and I love that you said that you went back and had these, you had the patients come back because there's always people joke about it. Not that it's funny, but they're all like, you know, well, if people actually, you know, had the patients come back and ask them, like, did some quality control and check ins to see, like, did it function improve, we might actually see that no. If we're just, you know, doing too far of any anterior clipping, function maybe improve for a couple weeks with infant feeding or, you know, and then parents kind of report like it was status quo again. And so I think it's really cool that you had that opportunity to bring people back and then kind of go, hey, something's up here, like, how do we change this? And, and I think that speaks volumes too, because I think some providers would kind of go like, oh, you know what, this doesn't work and use that as a reason to like, not even entertain the whole tongue tied conversation. And instead you said, hold on, how do we make this better for these patients? So I just like, for my mom heart and my therapy heart over here, where I see these parents struggle with these infants, I'm like, oh, how do we create more of you? Can we clone you 10 times over?

It's so unfortunate because everything else that we do, like tonsillectomies, nasal surgery, septoplasty, everything has a follow up. Like you always see patients in follow up, but for some reason in the medical education, like, why does this not require follow up? It just doesn't make sense. But it's like if somebody taught me that the shape of a circle is actually called a square, I'll continue to call it a square until somebody makes me understand that that's actually not a square, it's actually a circle, right? So it's, it's, it definitely was eye opening. And, and that's one of the things that I was saying. Like, it actually makes sense. Right? It makes sense that we follow up just like every other surgery. But for some reason, you know, that has not been the traditional teaching.

Yeah. And then I. My question for you too on that whole follow up piece is obviously with a newborn, we don't always do a lot of pre op per se, older kids and adults. We do. But what about post? Are you a big proponent of teaching like active wound care? Because I know you're not suturing like a newborn. You know, what do you, what do you protocol in that?

Yeah, yeah. So generally how it happens in my, in my clinic is so I have like Tongue Tied Tuesday and Tongue Tied Thursday.

I have that on social media.

But I actually have those days are set aside for or tether oral tissues patients. And what we do is when patients know that that's what they're coming in for, we actually will send them videos to watch ahead of time. So it's kind of like a primer educationally, but also, especially for the infants, there's a stretch video so they can kind of have an idea of like what it looks like or what you're supposed to be doing for the stretches. And then my protocol for once they are getting the release. So I will typically do the release and then have them do a trial feed afterwards. And then we do some stretches or sometimes we'll do the stretches before we do the trial feed, depending. But I always go through the stretches with the parents before they leave. Because it's one thing to watch a video and it's another thing to actually have your fingers in there and then me tell you, like, no, you have to go deeper. Like, you have to go more or like be more firm, you know?

Yeah. I think a lot of parents are afraid they're gonna hurt the baby or they're like, this seems like cruel, like, what am I doing? And so I remember as a mom, when my second daughter was released at 5 days old by the oral surgeon I went to in Maryland, they did the same thing where like we fed and they said, okay, when you're done with the feedback, call us back in and we'll go over the stretches with you. And I mean, I was that therapist already at that point, so I kind of knew, but at the same time it was my own child. It's like you forget everything when it's your own kid. And so it was so nice to have someone there showing Me guiding me and me making sure like, okay, I can do this to everybody else's child by doing it right on my own. So I love that it's so key to go over it with the parents and make sure they feel confident before they leave the office.

Yeah, yeah, for sure. And then I also have the stretch video like on YouTube and I just will tell them to just refer back to it if they need a refresher or whatnot. I also. So as far, to answer your question though, as far as follow up, so I'll typically see patients at one week follow up and then depending on how things are going, I'll either see some patients weekly or like four week, like post op visit follow up. And then I kind of just base the follow ups depending on how things are going. But that's kind of a minimal follow up that I'll do is one week and four weeks. And then I also encourage them to have a lactation consultant on board for in between those periods. Right. That's where it's like totally helpful. And then we talk about body work and all those things. We have resources that we have recommendations for local providers.

I love it. You have the whole team going, we can talk more about that. So in terms of the team, are there specific ways that you communicate with team members or things that you're looking for? Whether it's lactation, a, you know, feeding specialists beyond lactation, like an SLP or OT or you know, myofunctional therapists for our older kids and adults, dental providers, are there certain things? And it was like kind of a loaded question. But I look at everybody as a team. So what is the approach there in terms of communicating with everybody and all being on the same page?

Yeah, so generally I try. So after I see patients, I'll try to get a copy of my note to any of the team members within a day or two. So I still fax notes. Some people who don't have fax, I'll email the notes. But I pretty explicitly say in the note like recommendation I recommended bodywork or I recommend like palate evaluation for lingual palatal space or recommendation, you know, if they didn't already have a lactation consultant. I recommend IVCLC establishment of care. Right. So I'd be pretty explicit in like that treatment section that this is what I like them to do. And I'll also put there like for example, you know, we want to do these things like before release or you know, whatever. I, I really encourage like open communication. So all of my like Team members, they all have my cell phone, my email. So we always like either text or email about patients if there's any issues or whatnot to kind of help to coordinate the care. Especially if there's, you know, there's some complex patients sometimes like, they need to do one thing first and then the next thing. And so just having all those lines open for whatever is the most convenient at the time for each provider is very helpful because then it also helps me to determine, like when I should do certain things or do I need to wait on releasing a tie for other things. So it's a little bit of work and I definitely have an assistant that helps me organize everything. But I think it's one of those things that will provide patients with optimal care.

Yeah, no, and I think like you said, it's work, but it's critical to the success of the case for a lot of the patients. So I highly appreciate that. It's something that I do with some of my team members. I recently moved to South Florida, but my practice is still mainly up north and my team is like operating up there. And so, you know, we have a really great network of providers across the dmv. And it's incredible when you have the ability to text or email the oral surgeon or the, you know, whoever the release provider might be. Plus, you know, they say, hey, is the kid ready? And, or what are we, you know, where are we at? And they won't release the patient unless the patient is truly ready. And I think that we need to have more of that going on. And you know, with teams across the United States. Well, really globally. But I'll focus on the US First. Yeah. Because a lot of these kids coming out who get released without proper pre op, you know, or post op plans in place, it's just, it's a lot of them head back for additional releases because we end up getting reattachment or, and. Or the child is highly dysfunctional. And then we have a really upset parent who is going like, my kid won't eat at all. Now what do I do? They weren't ready. This is not. This is not what a tongue tie for me.

Yeah. And then there's always the once in a blue moon parent who will say, oh, yeah, myofunctional therapist said we're ready, but they actually were not.

That happens sometimes too.

Yeah. So especially for releases, like, I always have to have some kind of communication directly from the myofunctional therapist because there's been more than one time where it's Been. Oh, but they said we were ready, but they actually were not. So yeah, we love them dearly.

But sign off. Yeah. So what are your goals then? Like from a sleep and airway management standpoint? Because I know you've got all kinds of patients coming your way. What do you look for from a goal standpoint?

So for all of my sleep patients, I'm just going to say sleep because like airway is essentially sleep also. So there's the common term people talk about airway focused ENT or airway centric ent. I kind of like dislike that term because if you say that in general, like without being in a setting of like myo or like minded professionals. Right. All ents would say I'm airway focused. Like that's what we do. We operate in the airway, we manage the airway. So it always kind of rubs me a little bit in the wrong way. Like it makes. Just because. Because it's not really like discreet, it's not like clear. Because really all ents are. I don't have a replacement term though. But I don't know, maybe enlightened. No, I know, I don't know. I don't know.

We'll have to think of something that specifies. I mean, I think in dentistry it makes sense because dentists, people assume like they work in the mouth, right. So to say you're an airway centric dentist, where you also are looking at the airway is very different than saying airway centric or airway focused ent. And I've always joked and said, well, I mean, by default ents do airway. Like that is their job. So like, it almost seems like a double, like you're saying it twice. But you know, I think, you know, for anybody who is obviously not in the space, it's a different type of approach to airway. Maybe. I don't know, I don't know how to phrase it either. But yeah, no, I can appreciate that.

Yeah, yeah, yeah. But yeah. So to answer your question, so in regards to what I look for, so all of these patients get a full anatomic assessment. So assessment of. For all my patients, they get a full anatomic assessment. So ears, nose, throat. So the whole upper airway examination, we also have the ability to look with a camera in the throat. So like a flexible fiber optic camera to look like further in the back. So if you can't, you know, you can't see like lower down into the throat, like into the larynx, for example, the voice box. Right. If there's issues down there. So we can, if indicated, we can also look in the office, like with, with those tools. It sounds scary, but it's pretty quick and painless for patients. But yeah. So specifically focusing for sleep patients on nasal anatomy and oral anatomy, I do use the tr. Mr. Classifications. I don't like, do percentages or anything, but I just do like visually and then I describe like compensations that I see within the note. So if anybody looks at my note, they can see like, okay, this is what, you know, this is what he saw. And you know, along that same vein, I like for my referring providers and other team members to also kind of document what they see, you know, because everybody, you know, has a, you know, maybe there's some borderline cases, you know, you know, that that could be helpful to get other people's evaluations and compare. But, but yeah. So did I answer your question?

Yeah, yeah. No, I think like, when talking about the goals, I think it's, you kind of touched on how like we want to know about function and I think that's important. So, like I'm creating a MYO course right now and in my Feed the Peeds course course where I teach like feeding really to the birth of five crowd with my, my other team of providers that we teach, I teach on the tots and the myo stuff and I also teach the tr Mr. And I, we put that into our evaluation forms and you know, we, we do teach them how to get percentages because from our standpoint, sometimes insurance likes to see numbers. And I'm, you know, we're private pay, but for those who aren't, I try to give them as many numbers as we can. But I also go back and tell them and I teach them, I say, here's the other side systems out there for classifying tether dural tissues because you're going to hear people say them. However, I've never used them because, you know, class one on this is a stage four on that and it means nothing unless somebody knows that scale. So describe what you see. Talk about the insertion, talk about their restrictive, you know, tissue, talk about the function impairment and, you know, or if they're, if it's not impairing function, obviously we're not going to refer on, but for all intents and purposes, exactly what you said. You know, I love that there's been some research behind the trmr so we can at least look at it from that, you know, from that standpoint. Plus we look at the compensations because we know, well, if there's compensations, everything goes out the window. Like now we have no number because they're compensating. So it's not really valid. But I think that.

They'Re doing all these compensations, so it's functionally an issue.

Yeah, right, exactly. It's like the face is tense and they're raising the floor of the mouth and they're, you know. So, yeah, I think it's very important to describe what we see. And I've told everyone I think that's the most useful information across providers. Nobody cares what scale. They just really want to know what's the functional impact, if one exists. What are you seeing from your training in your eyes, so that we can all kind of come together as a team and put all of our visions together to figure out the best treatment plan for this patient. So I love that you have a very similar perspective on that.

Yeah, yeah, yeah. And I think also from a, from a functional standpoint, I really like. So all of my sleep patients and Thai patients get an additional survey before I see them. Because I don't want to, like, if I say stuff, I don't want to impact what they put on their survey. I want to get it before I talk to them, but they'll get either. So for infants, so I use like an adaptation of Dr. Baxter's survey. So the infant tongue tie survey, I've kind of adapted it to what I'd like to see my patients talk about. And then his tongue restriction questionnaire. So older kids and adults will get that one. And then the infants will get the infant tongue tie survey. So from a functional standpoint, that really helps me to see, like, what symptoms they have, even as a screening tool too. So I can, you know, kind of like say if they have certain things, like, I can, I can show them. Look, you're having a lot of these things. Look at the screening survey. You have all these check marks on here, right? Like, is there something that's potentially contributing factor to all of these things? Something in common? So sometimes that's, that's how sometimes. Because patients, often adults, they're incredulous. Right. Like, you tell them, you know, you have a tongue tie, and no one's ever told them that before in all their years of life.

Telling me that. Why has no one else ever told me that?

Yeah, yeah. But then you can point to it and say, look, you have all these symptoms that we, we see in patients who have this. So I think it's helpful both as a information gathering tool, but also as a patient Education tool.

Yes, I love that. I created this pediatric feeding screening tool, mostly for SLPs and OTs. And we have a milestone chart in it. And the way that we created the milestone chart from birth to 36 months, as oral motor skills should develop, really, we are able to draw a line across or kind of cross out what they don't have yet. So then we can sit with a patient, a parent, and say, hey, look, this is where the child currently is at. This is where we want them to be. And again, I think I love any type of educational tool that's visual that a parent can, you know, either walk, take home with them and kind of go like, sit down and absorb. Okay, this is what Dr. Tran told us. This is. You know, I think that's so powerful because, I mean, we know patients remember maybe a third of what we tell them, and it's always so overwhelming. Even if they came for that reason, I feel like they leave kind of like, okay, I kind of got my answer, but I'm feeling completely overwhelmed as to what to do next, even though I was told where to go next, like, holy cow, it's happening. So, yeah, I think that I love these kinds of tools because I think they really improve patient care and understanding of why we're recommending what we're recommending. So kudos to you. I love that. And then on the tongue tied topic, I actually had a question that came up recently in a discussion. So what are. And I'm curious to know your opinion as an ENT on this. So kids with ear infections, do you feel that children who have ear infections, knowing that obviously Eustachian tube changes over the early years of life, do you feel a posterior tongue tie can be directly impacted or can it a lack of, like, the tongue in the palate, for example, lightly suctioned to the palate, can that contribute to. I don't want to say cause, but can it contribute to eustachian tube dysfunction and otitis media? And.

That'S something I've spoken to some people about too, about how much an effect that can have. I don't think it's. I don't think for many people it would be a direct effect because as far as, like, Eustachian tube. So having the posterior tongue approximate the palate, push the palate up and then release kind of is like a pump for the Eustachian tube, right? So you could see how it could help to, you know, like, just in general, when you swallow, you clear the Eustachian tube, right? Like, because of the pumping mechanism. So theoretically, I mean, if you could. If you ensure that you have better posterior tongue mobility, you could have a better pump. If you have really poor posterior tongue mobility, then your tongue can't come up there and it can't pump it as well. But can you pump it with other things? Like, you know, some people are able to. To pop their ears without moving their tongue. Right? Like, you can. You can. You can flex the muscle in your palate and pop your ear. So there. There could be other ways. I don't think it's going to be a direct. A direct causation or anything like that, but I do feel like it's at least a tool that people use to pop their ears, that if you have impaired mobility, that's one less tool that you can use to pop your ears.

That's helpful.

Yeah.

I've seen, like, this discussion go, like, both directions, and of course, in the world, and, you know, Google, it's like, yeah, what. What's accurate? What's not so accurate? I'm over here creating this myo course, and I spent, like, I don't know, seven hours just, like, teaching, reviewing the anatomy to create my, you know, two and a half hour presentation to go over like, hey, this is the. These are the muscles, and then here are the bones that are directly related to the orofacial complex. And what we're doing. And, you know, I'm like, you know, there's the levator palatini muscle, which obviously is connected to what we're talking about. And so that's where I was like, I mean, if there's dysfunction there, I can see that. I don't know. I mean, obviously, maybe it can contribute. I wouldn't say it's a direct cause, but I'm not an ent, so I prefer.

But I will tell you, I will tell you that there are kids that we release tongue ties and they still get ear infections later. Right? And they still end up needing tubes later because there's so many other factors. And I would say the most salient factor is exposure, like daycare and like, social exposures, because no matter what you do to optimize anatomy, if you're just getting that exposure and you're getting sick, you're just gonna get it, right? So, you know, I think there are other. Definitely other things. Unfortunately, curing tongue ties do not cure all things.

We tell everybody, we're like, that is one piece of the puzzle.

Yeah, yeah.

One of many pieces of the puzzle. Yeah. No, thank you. I appreciate your perspective on that. So in terms of the whole, like, you know, polarization and discussion around tongue ties tether, oral tissues, like we just said, obviously it's one piece of the puzzle. Do you have any other thoughts to share with us or any interesting experiences surrounding tongue ties that you'd be willing to share either from patient experiences or anything to that effect?

Yeah, I think what makes it so polarizing besides the fact that medical education doesn't truly cover it in most instances? I think the other part of it that is really polarizing is the myofascial part. Right. So where we start to kind of drift into saying that, you know, constipation can improve and like sciatica can improve. Right. And just by releasing the tongue. Right. And yeah, we see those things happen. But when you tell somebody who's not like in the know that, that these are, this is happening, they kind of are. They kind of think you're, you're crazy. Right. So, but I think, I think that's what's the most polarizing thing is because people don't understand, like, you know, the fascia connection and whatnot. But even with the fascia connection, like, you don't see those things improve in everybody. Right. So there's still a lot that is not known or as far as the way I put it is, I ideally would like to predict what things are going to improve when I do a surgery. And with releasing ties, I can't always do that. Like, there are certain things I can predict, but there are some really surprising things that happen that like in one, in one patient, like, it's robustly changed, for example, like neck strain. Right. The most common things I see in adults with tongue ties are neck strain and grinding or bruxism. Right. In some patients, like, they'll never have to see a chiropractor again. Right. But in some patients, like, it improved, but maybe not that much. Right. So I hate not being able to predict things because as the surgeon, that's what you want to do. But when it comes to ties, I think that's the other polarizing point is there are so many effects that people will have that when you just talk to people, they don't believe you.

Yeah. Well, and I think it's interesting too, because there's a major divide, like in the speech world even, and you know, where people feel like, oh, like, I know there are some adults who have gone and gotten. They've gone and had their release done, but they didn't do the proper pre op and post ops. Now they're adamant that like ties don't, releases don't work. This is ridiculous. Why are we sending these, you know, if they're not breastfeeding, why are we sending these children for releases? And then you have the other side of it where we're going. Like you're saying, well, we don't know the full extent of what improvements we're going to see, but we generally know we're going to see some type of improvement. And if this child is functionally, you know, suffering like they really, whether they're feeding or they're asleep or even for some kids. I had a 13 year old who had been in 11 years of speech with seven speech therapists. Nobody had ever done an oral motor eval on him. Nobody had ever looked under his tongue. The mom was like, you're the first person to ever go in his mouth. His score was at the level of a two year old from a speech standpoint on the speech, standardized speech test. And when he had his functional frenuloplasty and we worked together for six months, he left and he could finally speak normally. And I mean, for a teenage boy that's huge. I mean there's a, there's a social emotional impact beyond just the speech factor. And so, you know, I think that people are so dismissive, but we forget we're working with humans with real emotions. And while they might be in preschool right now, a lot of these kids, like they're going to grow up to be children who are embarrassed by their teeth impinging on their lower lip if they have a malocclusion, if they're going to be embarrassed about their lisp at the age of 10 and 11 when people start to make fun of them and sometimes that happens earlier. There's a much further reaching impact on some of these kids. And so obviously it's a full team approach. It's not a tongue tie release and everything is magically fixed, which I think people would love. And some people think that's why it doesn't work because everyone just goes for release. Oh, it didn't work. Well, like you said, in some patients we do see some spontaneous recovery for certain symptoms. But for a lot of patients we need that full team approach to rehabilitate neuromuscular re education. We got to train the tongue where to exist in the mouth. We got to work on the entire body because it's been compensating for so long and everything is just in misalignment. For me, I was that adult, you know, case where I had what Was it orthodontic? Why can't I think of the word? Huh?

Relapse.

Yeah. Thank you. Relapse. The word is not coming to me this morning. Orthodontic relapse. Right. I had the orthodontic relapse. Like I had rpe, I had braces. Then I had upper and lower permanent lingual bars that I made them take off at 30 because I was like, why haven't they fallen out like you said they would 10 years ago? And then my teeth started to shift. I was like, what's going on? And so then I went into adult expansion, followed by Invisalign. And you know, and I'm not done yet. I need to have a turbinate reduction. Like I'm, I'm a work in progress. But it's one of those things where, you know, I appreciate the process because it's not just a one and done. It's now that I'm an adult, this is a much bigger puzzle to figure out and like different pieces to maneuver as I go through it with the kids, like or arguably an early intervention. My daughter, we expanded her with an ALF upper and lower at age 4 and she had a tongue tied release at 24 months. And she's now like redoing myo after expansion. But much easier of an approach to deal with her at 4 and 5 than me in my 30s. So I'm like, we can just back it up people and really start to believe in this early intervention and looking at function. We can treat adults too, obviously, and very successfully, but we need a lot more the older that we get. And there's a lot more cooks in the kitchen. I feel like with really making it hold full body at this point for me at least.

So it's a lot more complex.

It surely is. Yeah. Yeah. So what about like sleep and tonsils and adenoids? Do you see a lot of kiddos that. Do you refer for sleep studies? Like, what is your practice look like in that arena with, with young pediatricians?

So I'm sure there'll be a lot of like controversy over this. But I, I typically, I typically don't recommend a sleep study until we address things that. So the way I describe it is, okay, if you're bringing your child to me, usually you know that there's a sleep problem. Like you know that they have apneas or their mouth breathing or they're gasping and so you know that there's a breathing issue during sleep. The advantage of getting a sleep study up front is if you think that they're going to tolerate a CPAP to treat, to bypass those obstructions before we do something about the anatomy. Right. Most kids aren't going to do that. Like maybe some, you know, if they're desperate enough, like they'll, they'll do it. Right. But also like cpap, even though it's touted to be like, oh, the gold standard, right? Yeah, sure, it's the gold standard. You're bypassing all obstructions. But you know, you think about putting this mask on your face and compressing it down. Right. And you know, you're a kid growing, right. And you're, you're restricting your, the physical like pressures. Right. So there could be some skeletal or anatomic, you know, limitations that arise from that. So it's not always like CPAP isn't always the answer for everybody. So my thing is if you know that there are certain issues, like if those tonsils are grade four out of four tonsils, right. You know, you're going to have to get those out. Might as well get those out first. And if you have any persistent things, then you can always get a sleep study after. But also depending on what the rest of your anatomy is. Right. So one of the most quoted ENT studies for tonsillectomy, adenotonsillectomy and sleep quotes about 85% cure rate in kids with adenoto selectomy.

Right.

Well, we're at the other 15%. Right. There's a lot, there's other papers that talk about like palate expansion and skeletal surgery like after failed adenotonsillectomy. Right. I don't think that there's a paper specifically on tongue ties after adenotonsillectomy, specifically like just that. But I do find, I do feel like, because I will see kids after having adenotonsillectomies and they still have sleep issues. Right. I feel like a lot of those patients are tongue tied patients. And whether or not they need like skeletal orthodactic surgery, I do feel like a large portion of them didn't really need that. They just needed the tongue tie released. That would be a really interesting study. I wouldn't be able to do it, but that would be a good study for people to do.

I mean, that's fascinating too. I feel like there's so much interesting information coming out too now on who was it? I have to think of the name. I just put it in my course, but it's not officially published yet. But there was, I think it was a case study study where they observed like a 43% reduction in tonsil size with skeletal expansion as well. And so I was, you know, I. I'm sure that this is also probably not every case, and it's going to depend on so many variables. But I saw this with my daughter, and I posted it in a group once, and I was told to take it down because there's no evidence to support that this could have possibly happened. I'm like, no, I came to the group because she's had this ALF appliance in her mouth for three months, and she's had chronically enlarged tonsils, like three, three plus that look infected. But she doesn't mouth breathe, so the ENT wouldn't take them out. Not that I wanted to put her under surgery, but I was like, I'm a little concerned that her airway is a bit constricted. And so she went into the appliance with. That wasn't my intention because I, you know, in my brain, I was never taught that that could be a possibility. And I'm like, her tonsils are like, oh, size one. They went from like a three plus to a one in three months. It's cold and flu season. It's cold. Cold in the D.C. metro area. This is November. Like, has anybody seen anything like this? Like, what are. Like, what's going on? And I was like, I know it can also fluctuate throughout childhood. So there. There could be that, but we had changed absolutely nothing else. No medications, no food, no, like, no. Nothing else. Right. So I'm like, I would expect during cold and flu season and cold air that maybe they would have remained the same size. I wouldn't expect them to shrink. So, like, could this be the appliance and people like, yeah, I'm seeing some of that, too. And, you know, and before that, I had patients come to me and go, like, well, we're going to not do the tonsillectomy. We're going to do a growth appliance first. And I was like, yeah, that's not going to work. I mean, I can't really say that, but I really don't think there's any merit to that. And then I sat with my own child and I was like, oh, maybe there is something when we gain more airway space and we don't have as much turbulent air coming in, because I think she was maybe breathing more at night and that decreased as well. Possibly. But anyways, I don't know. I don't know. I have no idea on this topic. But have you seen or heard of or had any discussion around this.

So I feel, I mean, there's always going to be like case, essentially case reports or whatnot. I don't ever tell patients, like, you know, you should do this and let's see if your tonsils decrease in size. But I mean, from a physiologic standpoint or pathophysiologic standpoint. So the turbulent, turbulent airflow causing tissue edema. Right. Like, so we see this all the time with the uvula. Right. People who snore, the uvulus is flapping around and it causes it to really enlarge. And then if you decrease their snoring a lot of times that you feel will get small again. Right? Well, you could have, when it was large, you could have gone and cut it. But like, you fix the snoring another way and now it's small again. Right. So who's to say that can't happen with the tonsils too, if the tissue is kind of rubbing around and flapping around with the snoring and whatnot. But then also like with the mouth breathing thing, you know, constantly exposing it to antigens, like airborne antigens, and maybe, maybe that's playing the role. I don't know. I don't have a scientific answer. But I mean, when we think about like pathophysiology, you know, and edema in the airway or swelling in the airway, like turbulent flow could cause tissue edema. So who's to say that that can't happen for the tonsils?

Yeah, it's a very interesting topic. So I guess my other question for you is, I know that it's really hard to find ents who look at this, the airway from the standpoint that you do and a couple other of the big names like in the industry that, you know, with really trying to appreciate from a myofunctional standpoint. Like, how do we help the patient sitting in front of us if they're coming back with, oh, they have no allergies, but we know there's inflammation. We can't expect them to nasal breathe currently because they do have some enlarged either tonsils and, or adenoids, but nobody's willing to remove them. They haven't even offered a plan of action. They've kind of just turned the patient away. Do you have any recommendations for how to find ents that are more, you know, who are trained in this space, if you will?

Yeah, it's. It's tough because there's not really like.

There'S not like a directory now it's.

Like directory or anything. So yeah, I don't have a good answer for you on that.

Yeah, that's kind of what we were up against.

But yeah, I think, but I think a good start are all of these online communities that people are participating in that essentially are becoming a directory of sorts for like minded professionals. So I think those are, those are good ways to start.

Thank you.

Yeah, unfortunately, I don't have, I don't.

Know, I was like, I don't know if you have any secret, you know, secrets up your sleeve you can throw at us, but it's okay. And that's pretty much what we do too. I have my MYO membership, which is a community of myofunctional therapists and there's, you know, some dentists and we do, everyone constantly is coming in there and going like, hey, who do you know here? Hey, who do you know here? And it's great that we have the ability to do that here and some of the other groups online because I think without that, like it's just patients are going untreated and it's really, I'm a big connector. I have a lot of parents who also message me and I encourage them to on Instagram and I say, DM me, I will help you find somebody in your area and if not, you know, an ENT or a dentist, I'll find a feeding therapist or a myofunctional therapist who may know, you know, go to them first and then they may be able to connect you with the team if necessary. So it's, it's so critical, I think that we help these patients because they have nowhere to turn to. And I know as providers, we're over here kind of going like we're trying to figure that out too. So. Yeah, yeah, go ahead.

Sorry. I do think it's one of those things that because the results are so robust, like there's so much benefit that people are getting from treating these things in this manner. It's only a matter of time before it happens where it's no longer like airway centric or airway focused ents that you're looking for. It's just part of the ENT curriculum. Right. But it just has to get there. It just has to get there.

Exactly. And I guess my last question for you too then on that sort of similar topic is when you have a child, I actually love that you don't make them go for a sleep study. I think that it's kind of traumatic for some kids to have to go to a center and or parents trying to do the home sleep test. Depending on what it is a kid has to wear, whether it's on their hand or their face, which I think they're invaluable. But at the same time, we know what we see and we know what may be necessary. So I've always been told that sometimes it's an insurance thing. Sometimes insurance might require like a sleep study to cover certain procedures. I don't know. That's just kind of hearsay.

But there is some truth to that. But there are other, there are other ways to, like, for example, like, you don't have to have sleep apnea. You could have like sleep disorder breathing. Right. As the diagnosis. Right. So. But there are some things like that insurance does unfortunately, tie your hands a little bit.

Yeah.

But so far I think for most things it's not terrible.

That's good. And so like when these kids come to you and they're sitting in front of you with like, you know, maybe mid level enlarged tonsils and you're like, I don't know that we necessarily need to take them out yet. Do you have, do you treat with like nasal sprays or medication or any. Anything first? Or do you typically go for the procedure or like, what's your protocol? I know there's obviously various factors, but.

Yeah, yeah, yeah. So obviously the other factors have to have to be playing a role. If we're just talking about isolated tonsillar hypertrophy in the absence of like allergies, in the absence of maybe any other symptom, I would say do nothing. If they have borderline tonsillar hypertrophy with sleep symptoms and they don't have any nasal symptoms, no allergies or anything, usually there's something else. Now what I would say is, and depending on the age too, because some patients, depending on the age, you can get a more functional evaluation physical exam wise, but you can like say if there are sleep issues, but the only thing you find there's no tongue tie, you know, there's no oral restrictions, but maybe just borderline tonsillar hypertrophy. I would say why not do myofunctional therapy? Right. Especially if you're not sure functionally how they're using their tongue. Because the studies do show that you can get a decrease in the hi with just myofunctional therapy. And so I do find that a lot of kids don't have great tongue positioning and whatnot. And so it's pretty. I would say it's less common to have sleep symptoms and just have borderline tonsillar hypertrophy. And that's it. Usually there's something else going on, but, like, say, for this kind of hypothetical situation, I would still just do myofunctional therapy. Right. Because the study shows that kind of improvement, like pretty robust improvement. Right. 50% in kids, 62% in adults. Right. And you don't lose anything because you're not operating. You're not, you're not structurally altering any anatomy, but you're just optimizing function. And if that does it, well, like you talked about with improved airflow with ALF on your daughter, maybe if you have improved airflow, maybe less mouth breathing through myofunctional therapy, maybe those tonsils will decrease in size. Right. I'm not gonna tell patients, like, that's what I'm, you know, before. But my goal point. Right. But say if for that hypothetical situation, right. I'm not going to be really aggressive with removing tonsils if they're not enlarged significantly. I mean, it's a pretty, it's a pretty big surgery to recover from. And even though it's like one of the quote unquote, like bread and butter procedures of ents, it's like one of the most high, one of the more high risk and like lower reward surgeries. Obviously, it could potentially be high reward, Right. If the, if the tonsils are huge, like, it's going to be high reward.

Both. Like, do you ever remove just adenoids, even if the tonsils are enlarged? Do you typically do both or is it again, just kind of depending on functional impairment?

So, yeah, so that's, that's also a controversial subject. And I think in ENT also, whether you can just remove adenoids for sleep disorder, breathing versus tonsils and adenoids. For me, what would justify removing adenoids alone and not tonsils? Or one, if the tonsils are small, but two, if you're having symptoms from the adenoids being enlarged, recurrent ear infections, like persistent rhinorrhea, like, because it's so blocking in the back that it can't go down, it just goes out. I think those are factors that I look at to see if I will just offer adenoidectomy alone without tonsils. So every patient is kind of different. I kind of use everything that's going on to make that determination. But the other thing is also age dependent factors, because if they're really young, doing a tonsillectomy is. Is a huge deal, especially in the really young ones. So I try not to unless it's like really prominent.

I have two questions from my group that I would love to ask if you have a couple more minutes. We good? Okay. So one question is how the removal of tonsils and adenoids impacts our overall health, like, from an immune standpoint. Do you have any thoughts on that?

Yeah. So I know there's, like, a study that everybody quotes about increased risk of, like, upper respiratory infections and things like that for people who've had their tonsils and adenoids taken out. The problem with that study is it's an associative study. It's not ideologic. Right. So it's like saying it's kind of like the study on PPIs causing all these different osteoporosis and things like that. Right. Like PPIs. Like, generally. Generally speaking, older people take PPIs. Older people are also more likely to have osteoporosis. Right. So same thing for, like, adenotoxillectomy and, like, upper respiratory infections. People who are having upper respiratory infections also tend to be people who are more likely to have inflammation of the tonsils and adenoids, which will then need to be removed. So I don't think it's a causative thing there. Now, specifically for, like, immune function, I would say, okay, there's definitely some immune function with those tissues. Exposure to antigens will induce, like, immune system response. Right. And these. The way I describe it to patients is kind of like these areas that the adenoids and the tonsils, they're like lymphatic tissue. So they're just like all the lymph nodes in your neck. Like, when you get sick and you get these lymph node swellings in your neck, these are essentially the same as that. Now, they have a special quality of being exposed to the outside air, so you can get exposure to those different antigens. But as far as, like, lymphatic drainage, there will be other pathways that things can drain, not just those. I don't think we know for certain how much an effect that it can have. And for that reason, like, I definitely wouldn't recommend just having a low threshold to take them out on everybody. I think it's appropriate to take them out when they're causing functional issues, obstruction and whatnot. Right. But I wouldn't have a low threshold for that reason is we don't know how much of an effect it's having. And I don't know if we'll ever be able to do a study like that. Right. Like, there's. That would be a really hard study to do, but, yeah. Yeah. So, I mean, thinking pathophysiologically, sure. I'm sure that there's some immune system effect, but risks and benefits, right?

Yeah.

Also, having bad sleep is going to have a poor immune system effect.

Absolutely. Yep. Okay. And then the last question is, how does someone determine if a tongue tie release will negatively impact the airway space? Is there some sort of diagnostic indicator? And I think this kind of goes. This begs the question of. All right, if we have these individuals, obviously, who've had their tongue on the floor of their mouth their whole life, they have not been. Their tongue's not been up in the palate, they sleep on their back. Now the tongue is released. Is there. I know we've had certain cases where release providers have said, I'm actually concerned that releasing this tongue will cause a greater sleep issue because their tongue will now more easily fall back in the back of the throat just based on the symptoms of that patient. So is there a scale, an indicator, anything you look for to determine safety measures in terms of releasing a tie in sleep cases?

Yeah. So what I would say is the big question. There is space. Right. So if there's space, we're assuming that these patients are getting like, myofunctional therapy. Of course, right now, with myofunctional therapy and with exercising the tongue, giving it better tone and everything like that, it's not going to just flop to the back like a dead fish. Right. So doing the pre work is going to be critical to make that happen. But if you don't have enough space, then it has nowhere to go. So that's where you would have. The issue is there's not enough space in the palette for it to go or whatnot. So that's where it's really important to collaborate with your dental providers, like, from an ENT perspective, because we, we're not really comfortable with, like, palate and dental interventions. Like, I know about those things because out of necessity, like, I kind of have to know about these different tools that, that you'll have to do this. But I. If you told me, like, should this, if you asked me, should this patient get like rapid palatal expansion or an appliance, like, I want to say no, you go talk to your airway focused dentist or your orthodontist about that. But that's where the collaboration comes into play, because I have to rely on my dental colleagues to make that final determination for me. What I look for is, is there a lot of overflow of the tongue during lingual palatal suction? If there's a lot of overflow of the tongue onto the maxillary dentition, then that's a bad sign. That's not going to go scalloping right on the edges of the tongue. That's a sign that it's pushing against the teeth, whether that's from a thrust of the tongue or whatnot. But that's why I like to look at it on lingual palatal suction and see how much overflow there is.

No, that's. That's great. Thank you. I know from a myo standpoint, that'll make people very happy. They'll kind of go like, what can we look at? And we do. We obviously do look for scalloping. We look at palatal overflow. We look at all this in our myofunctional evaluation. So you're speaking our language. I love how we brought that full circle, though, because, you know, I do the same where it's like, I've had to become familiar with dentition. I've had to become familiar with all of these different appliances to a certain extent. But I always love saying, I don't move teeth for a living. That's out of scope. I work with the soft tissue, so you're going to have to go talk to, you know, the dentist or the ortho about that. But I think that that really brings it, like I said, full circle to why it's so important to have the entire team working together, because it is typically more complex. Like, most patients are not just a straightforward one provider type of case. You know, we rarely see something like that. So, you know, I appreciate that. So thank you. Is there anything that you want to share with us that we didn't cover today? I know we talked about a ton.

I don't think so.

We covered it all well. Awesome. Thank you so much for joining me, Chris. I know we're welcoming you into the Mayo membership in January to come chat with us then, and I look forward to that as well.

Yeah, me too. Sounds good.

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