Dr. Michael Rothschild discusses dysphagia in children, standards for evaluation and management of some common causes. He speaks about nasal, oral, hypopharyngeal and neuromuscular sources of pediatric dysphasia and some ways to manage them. Additionally, Dr. Rothschild shares workups for the different sources.
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Our next speaker is uh doctor Mike Rothschild. Um Mike has been, he's, he's really been a pleasure to work with um when I first came to Mount Sinai and started throwing around bronchoscopes in the hospital and whatnot. I think he was one of the only people who didn't think I was completely nuts. Um So, uh I've learned a lot from him. Um I, I, I've learned a lot from him. He's been a wonderful, wonderful partner over the past 12 years. Uh He um uh gives a pretty dynamic lecture with a lot of really cool photos and videos. Um So I'm really looking forward to your talk. I probably have seen some of these slides in different iterations uh in any event. Uh Mike has been uh associated with Mount Sinai for what, 40 years? Um Something like that uh Having trained in Cincinnati as was, was um mentioned, I, I believe by Anthony and um uh has really been, uh he's held the ent group together uh for many, many decades. And uh I just, I, I feel it's a really real privilege to not only introduce him but have to, having had the opportunity to work with him over the past decade. Feeling is mutual. This guy is amazing. I love working with him and thank you very much for having me. Um, uh, I'm going to talk to you today about dysphasia and Children Emily. Thank you for the shout out about Cincinnati. Cincinnati has two awesome exports, pediatric otolaryngology and Skyline chili. Um, and I'm very happy to be representative of that. Um, I don't have any financial relationships, uh, to disclose and the educational objectives. I believe you probably already have. But I'm going to talk about dysphasia, Children, standard methods of evaluation and we're going to review the management of some common causes and then we'll have time for questions. Um, so as I said, my name is Mike Rothschild. I'm a pediatric otolaryngologist. Um, I have, I see patients in New Jersey and Englewood and the upper East side of Manhattan and once a month in Williamsburg. Um, I have a much, much more interesting talk, but if you want to cancel the rest of the things, no, just the dysphasia talk. Ok. Uh, anyway, so of course, I'm going to talk about the anatomy of air breathing animals to start the talk. There are seven classes of vertebrates and four of them breathe air. That's mammals, birds, reptiles and amphibians, and what those four classes have is they all have an upper aerodigestive tract and we'll see why this is relevant in a minute. Uh, upper area, digester tract is basically some sharing of the Luminal space between the air and food passage. It's a very simple concept. Now, the problem is the pathways cross for some reason, some weird design flaw, the trachea is ventral to the esophagus, but the nasal airway is dorsal to the mouth. So you get a crossing of where the, the blue is where the air goes through and the red is where the food goes through. And for some reason, they share the same space. So the evolutionary challenge for any air breathing animal is this, how do you keep the arrow and the digestive parts separate? So if you get air entering the trachea, it's not a big deal that gives you, that's aerophagia. You get bloating. Anything other than air entering the airway is a problem that's aspiration. And that's, of course, as we've seen potentially lethal, it can lead to acute airway obstruction, chronic respiratory failure, sepsis, drowning, bleeding, you don't want stuff other than air in your, in your airway. So the evolutionary challenge is, well, how do you prevent aspiration? So there are a couple of different strategies that different um animal groups have tried. This is the simple strategy. The snake said, well, let's just put the airway way up front. So that way you see the trachea there very easy bronchoscopy, right? Um And it lets you eat things while you're breathing and, and you know, it has some downsides, but that's one way of preventing aspiration. Um, strategy number two, which a lot of mammals use and we're going to see is relevant later is simple. Well, let's just get, let's make that upper arrow digestive track that crossed area as small as possible. If we just move the airway up and stick it in the back of the nose, well, then there won't be as much shared space. And so, you know, a lot of mammals do that. You see dogs do that, horses do that. It's called an intra larynx. And the problem with this is, you know, it's great in terms of that. But, um, the problem is is if your nose gets blocked, you'll have a hard time breathing. Um, because you don't realize like horses can't pant, you know, dogs can pant that's breathing through your mouth. Horses can't breathe through their mouths and we'll see why that's relevant in a minute. Dolphins. Very similar thing that the equivalent of the nose is the blowhole. The larynx is actually called a goose beak larynx. It's plugged right up. You, you can't separate it, at least dogs can potentially separate that space so they can pant. Um, really, uh, dolphins can't do that and I have, well, I won't get into that. But what's the advantage of that? Well, one advantage is if you got your larynx and you're plugged up into your nose and separated, that protects against aspiration. And, you know, if you imagine a dolphin swimming fast through the water and scooping up a bunch of fish. Um, you really want to keep those 22 tracks separate. Um, and then the second advantage and this will come up in pediatrics is they can simultaneously drink and breathe for a prolonged period of time. So they're breathing through their noses, drinking through the mouths. They don't have to stop and take a breath to, um, to breathe when they're drinking for a long time. And so this is the human strategy number three, because we don't have those other things where we plug the no arrow back into the noses. We're just going to have evolve this complex swallowing mechanisms with vocal cords and cough reflexes that all my colleagues are, are going to talk to you about to keep you from aspirating. So the human upper air digestive tract in adults has a couple of features that are important. The tongue is partially in the pharynx. The larynx is far from the skull base. It's lower down. There's a large supra laryngeal pharynx that space that's shared by the air and food passengers. Now, what's the advantage of this? Well, some people say this is where language comes from having that distensible space. Um lets you actually modulate sounds coming from the vocal cords. Uh and uh that may be the, the rudimentary um uh mechanism that allows speech to develop, but also you can breathe a lot better because you can breathe through your mouth. You know, if you, if you think about a marathon runner, you can move a lot more air through your mouth than you can through your nose. The downside sleep apnea, reflux and aspiration. So now let's look at modern adult humans and compare them to other upper e digestive tracts. Well, here is the human, the tongue is partially in the pharynx. The larynx is far from the skull base, it's lower down and there's a large supra, is this a and a large supra pharynx? Now compare that to the chimpanzee. You see those things are different. The, the larynx is much higher in the back and the tongue is all the way in the mouth. Ok. That's a nonhuman primate. Now, let's look at the um the uh archaeological uh re or the anthropological record. This is a, a proto human uh homos uh species, the neanderthals. Um You see also, similarly, you got the larynx is up higher, the tongue is further forward. So a lot of those things that you see in the chimpanzee you'll also see in the um prehuman species. And then finally relevant for this talk, infants, infants share a lot in terms of this design with the neanderthals and the chimpanzees in that their larynx is up higher. It's not really an intra larynx, but it's closer, the tongue is more forward and that gives them a lot of the same abilities that the zebras had in that. Um slide I showed you, they can, I think constantly while breathing for prolonged periods of time. Something that humans don't adult humans don't necessarily do. Here's a, here's another um drawing that kind of shows that a little better. You can see that shared space is sort of separated by the larynx being higher, the epiglottis poking up into, above the pallet into the back of the nasopharynx. So you make a separate passageway for food and uh air. Um Here again, this is a posterior view. You can see the distance between the uh top of the larynx and the back of the nasopharynx is much greater in the human adult. So, is that the price of speech, I'm not really sure, apparently there is controversy about that, but in any case, that's the um that's the situation. So the infant, as I said, has an anatomical arrangement similar to the lower mammals and the early hominids. It's more like an intra larynx. And as we said, there are pros of that, that continuous feeding while breathing, while feeding. But the cons is they are much more dependent on the nasal airway. And we'll see why that's relevant when we start talking about um dysphagia in Children. And, and again, I'm trying to look minimize the extent of this talk. So not to step on other people's talks. Most pediatric e and T dysphagia really talking about problems that present in infancy. There are a lot of issues. Um rising later childhood. I, I consider them more to be in the realm of pediatric G I, I'm not really talking about things like strep throat or acute dysphagia. It's a different thing. Um So I sort of broke the ent version of pediatric dysphagia into a few categories, nasal, oral, hyper pharyngeal, neuromuscular, and then everything that I'm going to let my G I colleagues talk about. Um, so nasal, let's talk about nasal dysphagia. Um And I I spend way too much time with chat GP T. But um so as this is what I said before, uh human infants are more dependent on the nasal airway. So one thing that really can cause um swallowing problems in small Children is anything that blocks the nose, neonatal rhinitis is the term that we give to babies have a relatively small nasal airway and a little bit of congestion is much more likely to impact their ability to feed than an adult because remember they're obligate nasal breathers for the first six weeks of life. A little bit of congestion goes a long way. So, you know, there are all kinds of things we do to help people optimize a child's nasal airway. We're talking an anatomically normal child's nasal airway. Um The other reason why this is relevant in the same amount of mucosal edema in a child is going to result in a much greater cross sectional uh reduction of the uh greater reduction in the cross sectional area of the airway. Um just because of simple math. So that's why this is not so much of an adult thing, little nasal congestion, an adult is an annoyance in a child that can really threaten their ability to feed. And now I'm going to talk about a few ent things that aren't just common nasal congestion in normal babies, um bilateral coan atresia. Now, this is one of the few neonatal surgical emergencies in ent these kids cannot feed at all. Some of them if they're sick, if they have um multisystem anomalies or syndromic. Um These kids end up with a tracheotomy and you don't even fix these for a while. Uh but they often present especially the partial ones or unilateral ones with difficulties feeding and dysphagia. Um you can have piriform aperture stenosis. This is a narrowing of the front part of the nose. This is something also tends not to be as dramatic as the coin atresia patients. Um But o oftentimes we'll do early surgery just to drill that down and open it up and improve feeding. Um nuc A, this is a term called nasal obstruction without coal atresia or mid nasal stenosis. These are actually more common, you think be very careful about being aggressive with these. The surgical results are terrible. They usually get better with time. I use intranasal Ciprodex actually off label works very well to open up the nasal airway and help with feeding and nursing Um And if you are getting imaging, this is just a brief plug. One of my um concerns is that people tend to get a lot of scans in small babies and uh babies are much more um sensitive radiation sensitive in terms of long term malignancy risks. Um There's a whole think G uh image gently campaign. There's a lot of times you can substitute things like MRI or sonograms for CT scans in these Children with nasal congenital nasal anomalies. Um So as I said, they are obligate nasal breathers for the first six weeks of life. And the main thing you're gonna track in deciding whether these kids need intervention, surgical intervention is weight gain. So, I mean, it's a easy thing to ask if a kid is gaining weight. Well, no matter how congested their nose is, no matter kind of what weird, you know, laryngeal, uh abnormal reflexes, they have chances are they're going to be ok if they're gaining weight well, and they have a stable airway at baseline. In other words, episodic choking and stuff is less likely to be a structural problem and they can usually grow well. So those are, those are nasal, um causes of pediatric dysphagia, um oral causes, um oral ties. I mean, again, I, I don't know how off topic this was, but I was asked to speak about pediatric dysphagia. This is probably the most pediatric dysphagia patients. I see there is a lot of nonsense out there about this and there is not a lot of good data about oral ties causing pediatric feeding problems. So now I will say that neonatal lingual for anatomy and I do and a fair number of these seems to help, even if it's not an impressive tie, the called posterior um uh tongue tie. We'll talk about later in selected cases. In selected cases, the the people, the moms who get the best benefit from, those are the ones with nipple pain, um or slow nursing or a lot of Aage is sometimes it's a dramatic improvement. Um And then this label, the the lip tie that's really just for a diastema, the gap between the teeth. There's, there's very little evidence that that has any impact on feeding. There is very little evidence that there are speech benefits to early um uh free uh free for me. Um I do not recommend it and kids who are not having to, who are feeding well or gaining weight just because of the appearance. Um And uh there's these other ties, the cheek ties. Um There's a whole racket there, a lot of parents get caught up in the quest for a diagnosis they want to know. Does he have a tongue tie or not? I mean, you know, we don't have this problem with, you know, pancreatic cancer. Um It, it's a diagnosis. So they'll go from the pediatricians, the ent doctor, the speech therapist, the lactation consultants and they want to know does he have it or not? And it's just the wrong question. Remember a lingual frenulum is a normal structure. OK. Everybody has one and there is some variability in how prominent that web is and there's grading scales and people like grading scales. Oh, I had a grade three. I had a grade four. It's like adenoid sides. People try to impress you or they had 90% adenoid obstruction. I mean, it, it's silly stuff. It's marketing restriction of the tongue motion actually doesn't even come from that web that you see. It comes from the facial band in the floor of the mouth. That's the posterior tongue tie. And the example to give here is you see a sailboat mast and all the strength is in the mast. The thing that you see is the sail. So the posterior band. So when somebody, you look at a kid and they're not feeding well and the mom is having a lot of nipple pain and you look and well, there's not much of a web there. But if you put your finger and feel that band, those kids actually do very well. Whereas you get kids who have these terrible looking bands and the kids are feeding fine because they don't have as much tethering. Um Everybody see this article very good article if you haven't seen it. Um I mean, there really is a lot of less than forthright people out there doing this. Um So yeah, and again, like most procedures you don't always do it. You don't never do it, but you have to find selected uh patients who benefit from it and not do it on everybody and not let feature creep. Oh, we're going to cut this dye and the cheek dye and the diet and make your kid feel better. And there, there's a lot of, you're just like the funeral industry. They are dealing with um consumers who are in a very tense emotional state and are very willing to latch on to anything that somebody latch on. No pun intended. Anything that that somebody says is, is, is helpful. Um It's very important to be the voice of reason and talk people off the ledge. A lot of new parents, especially first time parents are very panicked about this stuff. Um Other sources, uh cleft lip and palate um big problem with um feeding. Uh and again, uh talking about interdisciplinary teams, we, we, we do this kind of stuff as an interdisciplinary manner. Um These kids have a problem creating a suction seal. Um So they, they usually the strategy here until you can do the lip repair around age two or three months of these special nipples and bottles. There are feeding operators that people sometimes use to help make a better seal positioning and you know, frequent burping to address the aerophagia. Um and lip repair done fairly early. Kids do very well, with a, with a good team approach. Um, occasionally you see these, you see like masses intraoral masses, these are epulis, they've seen teratoma. Um These, you know, typically they're not that complex, they just need to be excised again, one of the few procedures you do in the neonatal period. Um Some of these are small and can just be observed until they could gain some weight, but something like this kind of needs to come out for them to feed. Um And then you'll see weird stuff. You be with weed in. There are other types of macroglossia. Some downs patients have a lot of feeding problems. I mean, that's really beyond the scope of, of normal um pediatric E and T management. Many of these kids aren't amenable to surgical um treatment or if they are, it's not until much later. You can see this child with BAC and has tracheotomy and while tongue reduction is sometimes done, it's, it's, it's rarely done acutely in small Children to, to get them feeding. Um Granules see those occasionally and they can cause dysphasia, granular being an obstruction of the salivary um drainage system. And you'll often have a fairly sizable mass in the floor of the mouth and a small child. And these can either be just marsupialized opened up or actually removed. Um and then uh Mireia retrognathia. Um these, these kids often have terrible. These are a syndrome a kid here you can see with um golden hearts. Um They, they can often um have tremendous again, another trache patient, tremendous breathing problems and feeding problems. And there's some good work on Peter Taub at Mount Sinai. Um the plastic surgery, uh surgeon who runs the cleft and craniofacial team, there was a lot of, a lot of work with early mandibular distraction. A lot of times you can avoid a tracheotomy and really get them, them feeding better. So it's, it's quite surprising at what you can do with that. Um And then hypo pharyngeal stuff, OK. Um Laryngomalacia, Laryngo Malaysia is sort of like tongue ties. It's one of those things that every baby has to some degree. And the question is, is how bad is it? And again, the thing you watch for is weight gain kids who gain weight well, do well. Um and this is what Laryngo Latia looks like. You, you know it on the right, is the adult larynx on the left is the neonatal larynx where you really get that collapse in of the slot. Um uh soft tissues that furled omega shaped epiglottis. And these often coexist with reflux, um reflux tends to cause swelling of the uh the, the inter retinoid mucosa. And so that that'll flop in just like that anterior uh plot tissue is flopping in. Um So they're often seen in the same patient. They're both incredibly common diseases of childhood and, and most of these kids, you just tell them to wait and you tell, you, tell the parents, yeah, your baby squeaks. Yeah. Tell parents you can tell all the busy bodies are asking what's wrong with their baby that they're OK. They may take up to a year for the noise to go away. But the noise isn't really the problem. And then, you know, probably one or 2% of kids, they're just not gaining weight. And so you do this, which is a super glottal plasty and all you do is it's very simple procedure. You just, you just snip those little bands that are holding the larynx together and it sort of pops open and uh it's, I'm impressed just like Reno toy. This is one of those things that you don't do on everybody but the people who need it need it and, and it, it, it really markedly improves feeding. This is rarely an airway thing. I mean, you know, even though it's strider, their airways are safe and there's really very few people who are threatened by uh with airway obst, with luring Malaysia, they tend to be Children with neurological problems. Luring of Malaysia in older patients is often people with neurological uh disorders and hypotonia and they will often end up with a tracheotomy anyway. But we're talking about just normal kids with, with um routine luring of Malaysia. There we go. Let's see. That's the resident doing that side and uh I can always clean it up a little bit for the Yeah. And you see, now it's just, it's just larger and lets spring up and then there are all variants on this thing. You can do things where you adhese the, uh, epiglottis to the back of the tongue and so forth. But that's really simple. Reflux. I'm not going to spend a lot of time on Reflux. We got people who know a lot more about Reflux than I do. But this is also a thing that can contribute to this page sort of in one way like uh I just described, um because we're in back arching, delayed feeds. Um And again, uh for treating reflux, uh we address the RF age, a lot of these kids swallow a lot of gas which makes the reflux worse. I have a whole handout about positioning and, and avoiding laying them down flat right after feeding. Um I don't know if this is, um this is a tip I got from one of my colleagues at chop but using alkaline water uh when you're mixing formula, I mean, I don't know if that helps at all, but I've been, there's not much of a downside to it and it helps older kids. So I've been, I've been offering that as a, as a possible solution for bottle fed babies or babies who are, are formula. Um Laryngeal Cleft, this is a rare thing. This is the one thing that I always put it as a disclaimer in my notes is I cannot rule this out in the office. And this is more like, not so much the uh in terms of swallowing problem, but more likely um frequent aspiration, choking, coughing. I mean, the huge laryngeal clefts, it's not subtle. I mean, those kids are surgical emergency but a type one laryngeal cleft where there's just a little divit between the retinoids that kid may present years later. Yeah, he's always coughing. He's got a lot of pneumonia or not really sure why. And until you actually go under anesthesia and feel that thing and that's again where the triple scope comes in handy, you can't really rule it out. Um And then just to finish up uh neuromuscular stuff. Um these are mostly premature infants or the kids who have congenital muscular dystrophy, various neuropathies or myopathies, cerebral palsy. Um uh The, the common concern here is aspiration. I mean, as I was saying before, our human strategy for preventing aspiration relies on this whole system. The vocal cords have not or did not evolve for speech, the vocal, that's a side benefit, the vocal cords evolved to protect the airway. Um So if a lot of that is deranged, either from paralysis or just general sensory um issues, um you see, in geriatric uh population, you see a lot of stroke, patients will have aspiration because of loss of sensation with kids. It's more likely impairments of those normal uh protective reflexes. Um and there are all things you can do that, thickening feeds, um, feeding therapy. Some Children, you just can't feed orally safely because of the risk of aspiration. They get A G two. And then in terms of, um, in terms of uh of working this up, there's, there's sort of two ways of doing this. One is the modified bearing swallow and the other is the functional endoscopic evaluation of swallowing, uh modified barrel seas. Uh So what we're doing is we're looking for aspiration, we're looking for penetration and we're looking to see if the cough triggers. Um One thing I learned, um when researching this talk is if you Google M BS and fees, you get a lot of stuff about fees for purchase of mortgage, mortgage backed securities. But that has just, if you're Googling, that has nothing to do with this. Um So just comparing these to the modified barium swallow, um, it shows the oral phase and it shows below the cry pharynges, which is something that the feast doesn't do. Um It's not as uncomfortable. Um And you're less relying on cooper operation of the patient. It's also less operator dependent. Um It can be hard to get somebody who's good at doing a fees study, but the, the fees has the advantage of there's no radiation. Um, there's a lot easier in terms of scheduling logistics. It's, it's technically hard to get the speech therapist and the parent and the kid and the radiologist all in the same place together and you can do it in the bedside. Like I said, a lot of these are um ice NICU patients and uh it's nice not to have to transport them to a special suite. And what's also good is you can look in as close to the modified bar and swallow where you're just seeing, you know, the, the contrast material, you can try different real foods by staining them and you can see if you're aspirating normal secretions and you can always record it and look at it later. Uh And then after that, I see, uh I'm just timing it perfectly right beyond the cryo fringes. And here's my gastroenterology colleague, all these rings and slings nicolas and eoe and so forth. That's you. Thank you.
