Innovations in Pediatric Voice and Sleep Care

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm joined by my colleague Dr. Swathi Appachi, a pediatric otolaryngologist-head and neck surgeon, who is Director of our Pediatric Voice Center. Dr. Appachi, welcome to Head and Neck Innovations.

Swathi Appachi: Thanks for having me.

Paul Bryson: Well, it's great to have you on the podcast. I think this is your first appearance, so please, let's start by having you share some background on yourself for our listeners, where you're from, where you trained, and how you came back to Cleveland Clinic.

Swathi Appachi: I actually grew up in Bedford, Ohio, so not that far away at all. Then went to college at Duke University, came back to Cleveland for med school, which I did at the Lerner College of Medicine. I did residency here at the Cleveland Clinic and then did a pediatric otolaryngology fellowship at Texas Children's, and then came back to be staff here at the Cleveland Clinic.

Paul Bryson: Well, it's great to have you back. I was just really pleased that we could recruit you back and it's great to have you and to see your career continuing to take off, and I think we'll get into it, but you also have a leadership role in the residency program too.

Swathi Appachi: Yes, and I'm thrilled to be a part of that just like you. I like watching everybody grow and see their careers grow, so that's been fun.

Paul Bryson: I'd also like to make a plug for our Catalyst Grant program, and the listener may not be aware, but our philanthropy group here at the Cleveland Clinic has a catalyst grant program that is very competitive, but really offers very meaningful, impactful dollars for program and research development. And Dr. Appachi’s Pediatric Voice Center program was the recipient of this, and it's been a really important springboard as she grows this program, and it really was a catalyst for starting this process here. So I wanted to make sure we highlighted that before we got into a number of topics on the podcast, first on pediatric voice care, and then we're going to learn more about some new innovations in pediatric sleep apnea and upper airway management.

For those who don't know, the Pediatric Voice Center here at Cleveland Clinic Children's is a multidisciplinary clinic with expertise and experts in pediatric otolaryngology, pediatric laryngology, speech language pathology, and it’s uniquely focused on voice disorders in children and young adults. Can you talk a little bit more about the clinic, some of the techniques and just sort of your vision for this program?

Swathi Appachi: One of my favorite things during residency, along with pediatric otolaryngology, I loved being on the laryngology service and rotation, as you know. And so ultimately when I decided to go into pediatric laryngology, laryngology was still very much a passion of mine. So while I was down at Texas Children's for Fellowship, I did some work with Dr. Julina Ongkasuwan and was really excited about the idea of building a pediatric voice center here at the Cleveland Clinic because we did not yet have one. And so that was one of my goals when I came here. And the Catalyst Grant, as you mentioned, really did help us kind of get some of the capital needed, the scopes and get some things that we could use to help the children feel more at ease, and then also some funds to help jumpstart research as well. So I think there's a lot the incidence of hoarseness or dysphonia in children, it is not small.

I think a lot of parents let it go because it's not life, or health limiting I should say, but these kids can be perceived as sometimes even less intelligent than their peers or children or their teachers may not understand what they're saying, and so they kind of might be academically ostracized as well as socially. And so we wanted to have a place where kids that do have dysphonia could be seen and we could delve deeper into what's going on with their voice and potentially help them as well. We built this program with buy-in from you, Dr. Will Tierney, Dr. Rebecca Nelson from Laryngology, and then also initially we had Emily Laurash from speech-language pathology, and now we have Bethany Beckham, and we also have somebody from Child Life present with us for every clinic visit. So we offer this clinic currently once a month, and it's kind of a referral process.

People who are referred from either pediatrician's offices, the greater network of speech and language pathologists within the Cleveland Clinic, and then also the other pediatric otolaryngologists. If the children show up in their office first, they then refer them on to us. And so the biggest thing we have to try to do is to get a look at their voice box with flexible laryngoscopy or a videoscopy is really what we're hoping to get. And so that's where a Child Life specialist really comes in. We even have a puppet to show the children what happens when we put a camera in their nose. And so with all of those techniques, we try our very best to help the children be as at ease as possible while we do this exam, and then we go over the exam with the parents and the next steps that we could potentially do for them.

Paul Bryson: Yeah, it's really great, but it does require some additional considerations. You mentioned Child Life, and maybe the listener isn't entirely sure what that is, but could you maybe just share with the listener a little bit about the critical role that those colleagues play? You mentioned the puppet and the model that helps with, I'm hoping to make the process of endoscopy just a little bit easier for our smaller patients.

Swathi Appachi: Child Life, they're wonderful. They are everywhere within the children's hospital and specifically I think of them as an advocate just for the child. They're there only for the child to advocate for them to explain to them in layman's or childlike terms what's going to be happening, how they're going to help them through it, and then they help facilitate whatever's going to be happening. So on the inpatient side, that could be before surgery, kind of talking them through what's going to happen in the office visit, if there's a procedure going to happen, talking them through that, or even just if they're really scared of the physician or the doctor or the ear exam. Sometimes we've had Child Life come up and just sort of again, help the child by giving them distraction techniques like little stress balls or toys or bubbles, just something to get their mind off what's going to happen. And sometimes they're helping the child focus on something other than what's going on while I'm getting the history from the parents too. So they're really critical. And then they show them with a puppet, this is where the camera goes, it goes in through your nose and they stand there. They help sometimes hold an iPad or they give the child something to play with in their hands and they help the endoscopy part of the exam go as smoothly as we can hope for.

Paul Bryson: That's great. Thank you for that. As the center's up and running, what's on the horizon as far as maybe new research or management strategies or surgical procedures for pediatric voice disorders?

Swathi Appachi: So a lot of what we see is pediatric voice nodules, which isn't necessarily an operative, something we can fix operatively. And also a lot of the mainstay of treatment is voice therapy. And so we're sort of trying to follow these children longitudinally every time they come to clinic, getting their own outcomes reported to us after treatment. And we're hoping to see, just observe them over time, what helps them. At what point do we consider surgery if we ever get to that point? Sometimes we do, and you just cannot understand the child and they're having real troubles. But we've had some successes with voice therapy and we've had a couple surgical successes as well. So we're hoping to follow these children along longitudinally.

And then I think the other really exciting area is sort of a very specific subset of children with voice disorders. We have an excellent cardiac surgery program here, but sometimes with cardiac surgery then in these kids with their anatomy and just everything that they go through, they can have issues with vocal fold movement, which in turn leads to kind of a horse or a breathy voice or even sometimes swallowing. So we're trying to follow these children as well, both on the inpatient side where we are hoping to use what other centers have also started using laryngeal ultrasound to actually use ultrasound technology to see if the vocal folds are moving, because sometimes the endoscopy can be challenging in infants or young kids if they're really upset, you sometimes can't even see the vocal folds well. So this would be a non-invasive way to really examine their vocal folds. And so we're partnering with the ICU to get this kind of up and running in the kids who have invasive cardiac procedures, especially the ones that can put the vocal folds at risk just by nature of the anatomy and the surgery itself, and then following those children over time.

And again, just sort of observing when does it come back, if it's going to come back, because sometimes function does return. And then what we're really hoping do is to build a pediatric or mirror innervation procedure and service here as well for the children whose function might not ever come back to help their vocal cords move and trying to reinnervate so that we can at least lend some tone and improve their voice and swallowing. We're also trying to inject those children earlier than maybe we used to in the past with something temporary to kind of bulk up that vocal fold while they're waiting for function to return or maybe not, but something to help them with speech and swallowing in the interim. And I think we're here trying to do that younger than we've thought about doing it in the past because the studies do show that that is helpful.

Paul Bryson: Yeah, it's very exciting. Being able to intervene in a meaningful way and maybe even a less invasive way that you describe, and then to have that option for renovation is really exciting. I feel like everything that I've read on the adult side is that the kids sometimes do even better than the adults with this surgery.

Swathi Appachi: They do. They do. I think that speaks to the neuroplasticity still at this age.

Paul Bryson: Well, I wanted to change gears a little bit and just talk about a related area of the pediatric upper airway. And earlier this year, Cleveland Clinic, as you know, began offering hypoglossal nerve stimulation implants to pediatric Trisomy 21 children. It's a unique offering in our area of the United States. And we've spoken previously with our surgical sleep and snoring experts about the Inspire® implant. But can you share the impetus of this technology to this patient population and what if the outcomes looked like so far?

Swathi Appachi: So children with Trisomy 21 are very predisposed to obstructive sleep apnea just by nature of the disease process itself. So they sometimes have lower tone. Their tongues are bigger than children without Trisomy 21. They have kind of flattened and setback midface, so that sort of pushes everything back. And so they have a lot of risk factors for obstructive sleep apnea. The first line treatment in children with obstructive sleep apnea, surgical treatment is taking out tonsils and adenoids, and that's still very much the first line treatment for children with Trisomy 21. However, even after tonsillectomy and adenoidectomy, these kids can still have residual sleep apnea and it can even still be severe sleep apnea. So a CPAP is the next best offering, but it's hard enough for adults to wear CPAP, let alone teenagers who maybe don't always understand why they have to wear this mask. And so they may be even more resistant to CPAP as a treatment for their sleep apnea.

And we do know that in kids sleep apnea can really decrease learning, can increase behavioral problems, and so as well as also the downstream cardiac and pulmonary effects that exist for adults as well. And so Inspire®, and the hypoglossal nerve stimulator has now been FDA approved for treating sleep apnea in Trisomy 21 patients who are older than the age 13 or older, and then also have severe sleep apnea, somewhere between 10 to 50 events an hour, and then are unable to wear CPAP and that population. We are working with the sleep medicine program, Dr. [Brandon] Hopkins and I, along with Dr. Vaishal Shah and Dr. Brian Chen from Sleep Medicine are taking this program and moving it forward. And so far we have already implanted three children. The first one has had their device turned on and by all accounts is doing well with it and the family is happy and they're seeing a difference in their child. So that's very exciting to see. And so I think we're hoping to really push this forward, really get more patients to come here so that we can do this procedure for them and overall improve their sleep and their quality of life.

Paul Bryson: Yeah, that's very exciting. As you see some of these early successes in this specific pediatric patient population, do you foresee this being expanded to other children in the pediatric who may have upper airway difficulties?

Swathi Appachi: I do. I do. I think that there's quite a few children that could benefit from this, not just the Trisomy 21 population. There's definitely a subset of patients that we all have as pediatric otolaryngologists. We've done tonsillectomy-adenoidectomy in some, we've even done a base of tongue reduction. They still have sleep apnea in the severe range, and it is affecting their quality of life. And so especially for maybe even the older teenagers, once they've stopped growing and all of that, this could be something that we could really offer. And also other maybe syndromic children who have, again, the anatomy or the underlying tone issues that could predispose on to having residual sleep apnea for tonsils, adenoids come out. I think all of these children could benefit from the hypoglossal nerve stimulator.

Paul Bryson: Yeah, that's very exciting. It'll be interesting to see how that evolution, how it progresses in the pediatric population as some of the technology also changes and target groups change in our adult groups too.

Swathi Appachi: Yeah.

Paul Bryson: Well, I wanted the third prong of conversation I wanted to have with you is that we may have some listeners who are earlier in their career who may be researching or interviewing with residency programs, maybe there's some medical students that are listening, and you're now one of the associate program directors of our Otolaryngology-Head and Neck Surgery Residency Program. Can you share with the listener your role in the program, goals for our residents, and why medical students might consider matching with us or trying to match with us?

Swathi Appachi: Yes. I'm very excited to be one of the associate program directors, along with Dr. Mamie Higgins, and then our Program Director is Dr. Kyra Osborne. And along with what we do as a team, which is to interview prospective residents for our program and also day-to-day runnings of the residency, my specific role is to build a didactics program, so to work with those who are facilitating grand rounds and also guest speakers and leadership talks and professionalism talks, but also just the nuts and bolts of otolaryngology and head and neck surgery. So having our faculty come and speak with our residents. And so making sure that we have different topics, but that we cover the breadth and depth of otolaryngology. We're also really excited. There's a new otolaryngology core curriculum, and so we're having the residents lead didactics too for an hour and teach each other. And I think that there's something really powerful about having your chief resident teach you something or your senior resident teach you something.

So we're definitely pushing that forward this year as well. And I am particularly excited to “A” be back here as faculty, but then to “B” be back here in this role because I love this program so much, I think it really prepared me surgically. And that's obviously one of the goals that we want to continue forward is to train incredibly gifted surgeons and to also train them to be able to push the field forward, whether that be surgically or with research, but to give them the tools for that. And so I think that we want to train residents who go out and change the field and are strong leaders and strong surgeons. And so we're very excited for that. And I think that we have such great faculty here who truly believe in that goal as well. And that is why anybody should consider interviewing here, matching with us, coming here for the wave rotation, because I think we all truly care about the residents.That's one of the reasons I came back as well. And I think we care about their education, and I think that we have such breadth. Every single subspecialty here is represented by at least three or four physicians here who are all wanting to train residents.

Paul Bryson: Well, thank you. The program's lucky to have you and to have you back. I think you have a unique perspective of being a medical student here as well, and also a resident. So I think it's going to be great to see the program grow with yours, Dr. Higgins’, Dr. Osborne's leadership. So yeah. Thank you.

Well, I think we've reached the end. Any other take home messages for our listeners? You eloquently described the goals and the vision of the residency program. Any other final comments on the voice center or the upper airway program in the pediatric group?

Swathi Appachi: Yeah, we are trying to build both. So to get the message out there, I guess we want this to be the place to receive pediatric care of otolaryngology problems, so anybody with voice disorders, anybody with obstructive sleep apnea, we want to see and we want to help them. We want to help children achieve their full potential, so we're very excited to move that forward.

Paul Bryson: Well, for more information on Pediatric Otolaryngology Services at Cleveland Clinic, please visit ClevelandClinic.org/PediatricENT. That's ClevelandClinic.org/PediatricENT. And to speak with a specialist or submit a referral, please call 216.444.8500. That's 216.444.8500.

Dr. Appachi, thanks for joining Head and Neck Innovations.

Swathi Appachi: Thank you so much for having me.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.