Featured pediatric expert
Kevin Huoh, MD
As a highly-regarded pediatric otolaryngologist, Dr. Kevin Huoh specializes in congenital and acquired head and neck tumors, vascular malformations, surgical therapy of sleep apnea, endoscopic airway management, and otologic surgery. After having been born with a large neck mass, Dr. Huoh had multiple surgeries as a child by pediatric otolaryngologists. This personal experience has motivated Dr. Huoh to pursue a career dedicated to the comprehensive and compassionate care of children with head and neck disorders.
Transcription
Melanie Cole (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children’s Health of Orange County. Together, we can keep kids happy and healthy. I’m Melanie Cole. And joining me today is Dr. Kevin Huoh. He’s the Chair in the Department of Surgery and a pediatric otolaryngologist with Children’s Health of Orange County, and he’s here to speak to us today about pediatric tonsillectomy, what parents need to know about this procedure that they are still doing. Dr. Huoh, thank you so much for joining us as we get into this fascinating topic.
Dr. Kevin Huoh: Thank you, Melanie, for having me.
Melanie Cole (Host): Well, thank you. And I’d like you to start with the function of the tonsils, what are they, what do they do. And give us a little background on the evolution of removing them in the first place.
Dr. Kevin Huoh: Sure. So, the tonsils are a couple of paired organs in the back of the throat, and their main function throughout evolutionary history is to serve as part of your natural immune system. And so, they defend the body against germs that they may encounter, that come into your mouth. And historically, they were always removed because of many infections or they got too big. And there have been historical documents of tonsil removal as early as in the Roman Empire where they used to remove tonsils using their fingernails. So, it’s a very, very ancient process of removing the tonsils.
Melanie Cole (Host): I read that during my research that this date’s back very long ago, so for a while. And I told you off the air when I was younger, a lot of kids got their tonsils removed and their adenoids as well. Usually, it was kind of done at the same time. Then, it seemed to have tapered off a little. Did it taper off a little? And why do children sometimes need their tonsils removed these days? We used to do it for recurrent strep. But now, what’s going on in that world?
Dr. Kevin Huoh: So throughout history, the main indication to remove tonsils was usually infections. So if we got too many strep infections or too many sore throats. We went to the doctor, doctor said, “Hey, you know what? You need to have your tonsils out.” And that was really the prevailing theory, even when I was growing. But nowadays, with modern antibiotics and catching things a little sooner, actually removing tonsils for recurrent throat infections is relatively rare. And what we remove tonsils mostly for now is for sleep apnea or for snoring. And so when those tonsils respond to the various infections that a child may get, sometimes they get really, really big, very enlarged and they can cause trouble with breathing while kids are sleeping. And so overwhelmingly, I would say over 90% of the tonsillectomies that I perform at Children’s Hospital of Orange County are for sleep apnea or airway obstruction.
Melanie Cole (Host): So, what does that mean then? How do tonsils get involved in sleep apnea or airway obstruction? Tell us a little bit about how they’re involved in that.
Dr. Kevin Huoh: When kids go to sleep, all their muscles in their throat relax. And so, the airway passage becomes more narrow naturally while you’re sleeping, and so you can hear snoring. Even adults will have snoring because all their muscles in their throat are relaxed. If the tonsils are too big, they limit the amount of space that a child has for air to pass while the child is sleeping. And it’s more common in children than adults having big tonsils because children face more infections, more viral infections, more bacterial infections, but naturally their tonsils would enlarge during these infections. In addition, children have smaller airways. Just by nature, their head, their neck hasn’t grown to a fully adult size. And so, those big tonsils pose more of an issue while kids are sleeping than if they were in an adult.
Melanie Cole (Host): Yes, by nature of their anatomy. That was a good explanation. So, tell us a little bit about sleep apnea in kids. Are there symptoms parents would notice? Are we the ones hearing it? Do they notice it themselves? Tell us how we would know.
Dr. Kevin Huoh: The most common way this comes to our attention is when parents either sleep with their kid on vacation or they’re still co-sleeping with their child and they notice that their kid is snoring louder than an adult. And during the sleep, not only are they snoring, but they notice pauses or gasps for air while they’re sleeping.
And I noticed in my own son, a few years ago, my son would crawl into our bed naturally at night and I would hear him struggling to breathe and snore, and those are the cardinal hallmarks of what parents should be aware of as symptoms of sleep apnea. Also, the kids who have sleep apnea or trouble breathing while they’re sleeping may seem extra tired during the day. They may have a hard time waking up. And also conversely, some kids who don’t sleep well and have sleep apnea are hyperactive during the day. There has also been an association between attention deficit hyperactivity disorder and sleep apnea as well. And so, you know, when your kid is tired, oftentimes they’re not laying down on the ground, but they’re instead bouncing off the walls, and that’s when you know your child needs a nap. So, those are some of the signs during the day that your child may have sleep apnea. Another symptom that we commonly see is that some kids have a hard time being potty trained at night, and sleep apnea can cause some of those symptoms as well.
Melanie Cole (Host): Wow. This is so interesting to revisit this as something that, you know, we heard about or had when we were kids and now we’re parents. So, this is so interesting to me, Dr. Huoh. There are different procedures for removing tonsils. Can you tell us a little bit about those? And give us sort of a brief overview about how you might make the distinction or how you might make that decision about which one that you’re going to do.
Dr. Kevin Huoh: The decision to remove tonsils is usually based on a history of sleep apnea. So if a parent comes in and says their child snores and has witnessed pauses or gasping for air while they’re sleeping. And then, you look in their throat and their tonsils are big, we can move directly onward to scheduling surgery to remove the tonsils and usually the adenoids as well. Sometimes for certain cases, we’ll order a sleep study to verify that the child indeed is having sleep apnea. The process of removing the tonsils and adenoids is all done through the mouth. So, there’s no cuts or incisions on the face or in the neck. It’s all done through the mouth, actually. And there’s a variety of ways to take tonsils out. You can use cold instrumentation as we say or a knife or scissors, or you can use electricity or radiofrequency ablation. So, there’s a lot of different technologies that have come about for taking tonsils out.
Melanie Cole (Host): Now, tell us a little bit about the recovery process. And then, I’d like you to touch on that recovery because I remember, you know, the ice cream and the popsicles and all of that sort of thing. So, what are we doing for them these days?
Dr. Kevin Huoh: So, recovery from tonsillectomy can be quite variable. At CHOC, the procedure that we do most commonly is something called an intracapsular tonsillectomy. So, this is a little bit of a newer operation that has come into vogue in the last 20 years or so, and it’s actually extremely common in Europe and becoming more common in the United States. When we don’t remove the entire tonsil, we remove about 90% to 95% of the tonsil to leave a little bit of the tonsil behind. The benefit of this operation versus the traditional tonsillectomy is that there’s a lot less risk of bleeding after surgery. So, traditionally after tonsillectomy, there’s always a risk of 3% to 5% of having bleeding up to a week after surgery. Whereas with the intracapsular operation, the risk of bleeding is actually less than 1%. And at our institution, closer to half a percent chance.
But to touch on the recovery piece of it, intracapsular tonsillectomy is also less painful than a traditional tonsillectomy. So, our patients return to a regular diet almost immediately after surgery. My son was eating mac and cheese that night after surgery. We just told parents to avoid any sharp food for a week or so. Now, if you have the traditional operation, there’s quite a bit more discomfort involved. And we usually tell parents to stick with the ice cream and yogurt for a week or so. And kids will then take pain medication, usually Tylenol and Motrin, for a few days after surgery.
Melanie Cole (Host): Wow. Well, Dr. Huoh, you’ve given us such great information. This was so educational. Can you wrap it up for us? Speak to parents with your best advice if they think their child suffers from sleep apnea or if they have other concerns. What would you like them to know about pediatric tonsillectomies and the evolution of this really interesting procedure?
Dr. Kevin Huoh: Great. Thanks, Melanie. So, pediatric tonsillectomy remains one of the most common surgeries that we perform on children in the United States. Nearly 300,000 children under undergo tonsillectomy every year. And usually, the most common reason is for sleep apnea. And so if you feel like your child has a hard time sleeping, has maybe different energy during the day, they’re too tired or too hyper and you hear snoring, I would definitely bring that up with your pediatrician. And it may be something that you want to see an ENT surgeon or a otolaryngologist for to see if a tonsillectomy may be the right choice for your child. And once you make that decision, just know that there are more than one way to take out the tonsil. And one way that’s becoming more popular, I would say, is intracapsilar tonsillectomy. So, be sure to ask your ENT doctor about that. It has advantage of being less painful and the recovery time is often better and there’s a less risk of bleeding after surgery as well. So, those are kind of the highlights that I would like to point out.
Melanie Cole (Host): Thank you so much, Dr. Huoh, for joining us and sharing your incredible expertise with us today. For more information on tonsillectomies or for more pediatric health and wellness tips, please visit choc.org. Thanks for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children’s Health of Orange County. Together, we can keep kids happy and healthy. Please remember to share on your social channels as we’re all learning from the experts at CHOC together. I’m Melanie Cole.
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Learn more about CHOC’s otolaryngology program
At CHOC, our pediatric otolaryngologists provide comprehensive care for children of all ages – from newborns to teens – with conditions of the ears, nose, throat (ENT).
