Innovations in Pediatric Voice and Sleep Care (podcast)

Children with voice disorders may face challenges in being understood by their peers and teachers, which can lead to social isolation and lowered self-esteem. Unfortunately, because voice disorders do not typically directly impact health, families may not be referred or seek care. However, effective pediatric voice care — early diagnosis and treatment of voice disorders — can help prevent long-term damage, improve outcomes and help children achieve their full potential in terms of vocal health and overall well-being.

In a recent Head and Neck Innovations podcast episode, Swathi Appachi, MD, explains how the specialized care provided by multidisciplinary clinics, such as the Pediatric Voice Center at Cleveland Clinic Children's, ensures that children receive comprehensive evaluation and tailored interventions.

“I think a lot of parents let voice disorders like dysphonia go because it's not health limiting,” says Dr. Appachi. “But these kids can be perceived as sometimes less intelligent than their peers or children or their teachers may not understand what they're saying, and so they might be academically or socially ostracized. With the Pediatric Voice Center, we wanted to have a place where kids with dysphonia could be seen, we could delve deeper into what's going on with their voice, and potentially help them as well.”

The episode also covers:

• The creation of the Pediatric Voice Center
• Effective therapies for treating pediatric voice nodules
• Treating vocal disorders after cardiac surgery
• The latest innovations in pediatric voice and sleep care, including hypoglossal nerve stimulation for sleep apnea in children with Trisomy 21
• Updates on the Otolaryngology-Head and Neck Surgery Residency Program, of which Dr. Swathi serves as Associate Program Director

Click the podcast player above to listen to the episode now, or read on for a short, edited excerpt. Check out more Head and Neck Innovations episodes at clevelandclinic.org/podcasts/head-and-neck-innovations or wherever you get your podcasts.

Excerpt from the podcast

Podcast host Paul Bryson, MD, MBA: I want to change gears a little bit and just talk about a related area of the pediatric upper airway. 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.

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, MD: So children with Trisomy 21 are very predisposed to obstructive sleep apnea just by nature of the disease process itself. They sometimes have a 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. 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. 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. So they may be even more resistant to CPAP as a treatment for their sleep apnea.

We 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. 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, also have severe sleep apnea, somewhere between 10 to 50 events an hour, and are unable to wear CPAP.

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. 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.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 improve their sleep and their quality of life.

Dr. Bryson: 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?

Dr. Appachi: I do. I do. I think that there are quite a few children that could benefit from this, not just the Trisomy 21 population. There's 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, but they still have sleep apnea in the severe range, and it is affecting their quality of life. So especially for the older teenagers, once they've stopped growing, this could be something that we could really offer.

Same with 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.

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