On this episode I welcome Jordan Glicksman Ear Nose and Throat Surgeon in private practice at Newton Wellesley Hospital and Lecturer part time at Harvard Medical School. We discuss the following:

• The basics of adenoids
• When they may need to be removed
• The purpose of tonsils
• Obstructive sleep apnea
• T&A procedures
• Recovery times
• Other options besides surgery

00;00;08;28 – 00;00;30;26

Dr. Mona

Welcome to this episode. I am so excited to welcome Doctor Jordan Glicksman. He is an ear, nose and throat surgeon in private practice at Newton Wellesley Hospital and a lecturer part time at Harvard Medical School, based in Massachusetts. And I’m so excited to talk to him all about tonsils and adenoids. Welcome, doctor Glicksman for joining us today. And thank you for joining us today.

 

00;00;31;03 – 00;00;32;03

Jordan Glicksman

Thanks for having me.

 

00;00;32;05 – 00;00;50;08

Dr. Mona

So we’re doing two episodes. We are doing one on Tonsils and Adenoids. And then I’m releasing another episode today with Doctor Glicksman on ear tubes. So make sure you listen to both of these episodes because you will get a lot of education about it. Thanks again for joining us. Now I want to talk about tonsils and adenoids first.

 

00;00;50;11 – 00;01;02;18

Dr. Mona

Some parents don’t know the purpose of an adenoid or tonsils. They don’t know where it is. But let’s just discuss basics about adenoids. So what are they? What are their purpose? Do they have a purpose? Tell me more about adenoids.

 

00;01;02;21 – 00;01;26;07

Jordan Glicksman

Sure. So the adenoids are a type of immune tissue in the throat, behind the nose. That part of the nose or that part of the throat, I should say. It’s called the nasopharynx. Because behind the nose, it sits in the midline in between where the station tubes open on either side. And it has an immune function where it traps and samples germs that may enter the mouth of the nose so your body can detect them before they enter into the body.

 

00;01;26;14 – 00;01;47;29

Jordan Glicksman

They produce immunoglobulins, which can help fight infections. And that’s that’s why we have them, is to, to some extent to protect us from infections. That being said, the adenoid tissue actually, tends to invert or disappear over time as children get older. And so they aren’t a absolutely critical part of our immune system, even though they might help a little bit.

 

00;01;48;05 – 00;01;59;20

Dr. Mona

And so we know that they have some benefit. But of course, we know that sometimes they need to come out. So what may be some instances that we have to tell ourselves, okay, let’s let’s see, we might need to get them out because the benefits may be there to remove them.

 

00;01;59;24 – 00;02;18;27

Jordan Glicksman

Yeah. So that’s a great question. The probably most common reason that we would take adenoids out in children is because they have a condition called obstructive sleep apnea, or possibly to a lesser extent, some other type of disturbed breathing at night where the adenoids are causing a blockage. And that’s definitely the most common reason that we would take them out.

 

00;02;18;29 – 00;02;31;18

Jordan Glicksman

There’s other less common, reasons such as recurrent infections, of the adenoids themselves, or in some cases. And this is becoming less common, for patients that are having problems with recurrent ear infection.

 

00;02;31;21 – 00;02;43;22

Dr. Mona

Great. I this is so helpful. And I think, like I said, because it’s not something that we can always visually, you know, parents can really see, right, meaning just from looking inside their mouth. And it’s not something that’s visible. Correct.

 

00;02;43;24 – 00;02;53;05

Jordan Glicksman

No. You can’t see it at all. Which is right. One of the challenges. You really need specialized equipment, or for a child to be sedated in the operating room in order to see it.

 

00;02;53;08 – 00;03;10;03

Dr. Mona

Right? And so it’s it is one of those things that do get removed, and we’ll get into, like, what? You know, the tonsils and adenoids being removed. But I’ve always, you know, talk to some families about this. Is there a possibility that you may need to remove the adenoids and then have to remove it again, like, for example, they grow back.

 

00;03;10;03 – 00;03;11;19

Dr. Mona

Is that a possibility?

 

00;03;11;22 – 00;03;29;16

Jordan Glicksman

Absolutely. Because it’s a difficult area to see. Sometimes we don’t get the whole adenoid, pad out. Usually not a problem. And probably most of the time we don’t get all of it out. But when you leave some behind, obviously there’s, a chance for it to grow back to a partial extent or even to a larger extent to where it causes a problem.

 

00;03;29;16 – 00;03;30;03

Jordan Glicksman

Again.

 

00;03;30;06 – 00;03;41;15

Dr. Mona

And we’ll get into more about the tonsil and adenoid surgery. I had some questions for, Jordan, but I want to switch gears and talk about tonsils. So we talked about the adenoids. But what are the purpose of the tonsils?

 

00;03;41;17 – 00;03;56;10

Jordan Glicksman

They’re very similar. Except that they’re just that a little bit of a different location. These you actually can see when you look inside the mouth, if they’re big enough, sometimes they’re really small, and you can’t see them so easily. But they’re basically the same thing. They’re lymph tissue that’s sitting in the back of the throat.

 

00;03;56;15 – 00;04;14;04

Jordan Glicksman

This time behind the oral cavity. There’s sitting between two pillars of soft tissue, which are muscles that form kind of the bed in which they sit. And it’s the same sort of, function with a trap and sample germs. Enter the mouth of the nose. And they also produce immunoglobulins, which can help fight infection.

 

00;04;14;06 – 00;04;19;12

Dr. Mona

And so similar question if you know they have these benefits, when do we say hey, we need to take these out.

 

00;04;19;15 – 00;04;35;08

Jordan Glicksman

So it’d be a similar thing. There’s probably more reasons to take out the tonsils than there would be to take out the adenoids. So it’s more common to, take out the tonsils alone than to ever take out the adenoids alone. The biggest reason, again, that we would take them out would be obstructive sleep apnea.

 

00;04;35;10 – 00;04;58;26

Jordan Glicksman

But also children, they get recurrent throat infections, particularly with strep throat. Also, there’s a condition called the peritoneal or abscess, which is a more severe infection of the throat. And if patients are getting more than one of them, that’s typically when we start to recommend it. And then there’s a lot of more rare conditions that, are very specialized and specific, on a case by case situation that we, we consider taking them out as well.

 

00;04;58;28 – 00;05;09;17

Dr. Mona

In terms of strep, are there current recommendations or guidelines that say, hey, if you get X amount of cases in a year or six months, then hey, this might be time to be referred to an EMT.

 

00;05;09;24 – 00;05;29;27

Jordan Glicksman

Yeah. So, you’re a pediatrician and I’m an ear nose and throat doctor, and our respective societies actually got together and put together guidelines. And the guidelines are seven and one year, five year for two years or three year for three years. But there’s exceptions that might make you more likely to take out the tonsils in a patient, even if they don’t meet these criteria.

 

00;05;29;27 – 00;05;43;00

Jordan Glicksman

For example, if someone in the family or even the patient themself have had some kind of rheumatoid disease, that is thought to be related to strep throat, like rheumatic fever, for example, which is one of the reasons we try to take these tonsils out to prevent a complication like that.

 

00;05;43;06 – 00;06;01;24

Dr. Mona

And you had mentioned that many times you’ll remove the tonsils, without the adenoids, but you’ll never really remove the adenoids. It’s rare to just have to remove the adenoids. A lot of times this procedure is done together, right? We call it a to tonsils and adenoids get removed at the same time. Is there a reason why we remove them together?

 

00;06;01;26 – 00;06;21;24

Jordan Glicksman

There is, in general, it’s because we’re typically doing this, for, sleep apnea or at least some level of disturbed breathing at night. That’s caused by obstruction. And so they both can be locations where, you could get some obstruction. I know that there are some researchers looking at whether or not you can get away with one and not the other.

 

00;06;21;26 – 00;06;38;06

Jordan Glicksman

The general thinking and the general reason why they both come out together, is to avoid a patient having to go under a second anesthetic. You know, better to do one surgery, than than two. If you have the choice and the complication risks don’t really go up that much by taking both at the same time.

 

00;06;38;08 – 00;06;54;11

Dr. Mona

And the reason why I wanted you on the podcast is it’s just so great to get, you know, surgical specialties on because parents, obviously, when they go to ents and they find out the, their child may need this, you know, they’re talking with their, child’s doctor about the potential of this. They have a lot of questions and they’re confused.

 

00;06;54;14 – 00;07;07;26

Dr. Mona

I know you’re just one ENT, but can you just describe basically what the recovery looks like? What parents can kind of expect? I’m sure they’ll get that guidance from their own HEA and T, but generally the follow up that’s kind of entails with this procedure.

 

00;07;08;02 – 00;07;26;08

Jordan Glicksman

Yeah. So, that’s a great question. The kids are very, very good recovers when it comes to, to adenoid surgery. You know, you and I, I know, I know that we both look, really young, but we’re we’re a little older. And when you are older, it’s because we’ve had more infections over our lifetime. We think, there’s more scarring that forms.

 

00;07;26;08 – 00;07;49;01

Jordan Glicksman

And so, as I mentioned before, the tonsils sit in between two muscles, soft tissue, pillars that are formed by muscle. And when we take the tonsils out, there’s more likelihood that there’s been more scar tissue. We think, to cause injury to the muscles, deep to the tonsil itself. And so in you and I, it might be a week or two or maybe even longer a, a pain that we’re not very happy.

 

00;07;49;06 – 00;08;08;00

Jordan Glicksman

I in general, I find that children within a couple of days are almost back to their normal baseline self. I do ask my patients, and I think most do, most of my colleagues do as well to not, eat raw foods like potato chips and that sort of thing. But generally with a soft diet and the the kids love this.

 

00;08;08;02 – 00;08;25;08

Jordan Glicksman

They’re eating ice cream and putting, all those fun things for a week. They tend to do really well. And in general, I don’t prescribe narcotics to children, after a tonsil surgery or an Android surgery because they just don’t need it. They tend to be fine with just Tylenol. And there’s a little bit of controversy around Advil.

 

00;08;25;11 – 00;08;31;02

Jordan Glicksman

Generally, I’ve not had major problems with it in terms of bleeding risk, but, basically town on Advil seems to cut it for children.

 

00;08;31;08 – 00;08;44;14

Dr. Mona

Oh. That’s great. Yeah. I mean, just obviously keeping them hydrated, like you said. And comfortable. And in terms of the actual procedure, we don’t have to get into too much of the nitty gritty, but it’s in an O.R. setting, and usually we’re using anesthesia, obviously. Right.

 

00;08;44;16 – 00;09;05;13

Jordan Glicksman

Oh, yeah. Absolutely. Yeah. There are probably parts of the world where they don’t use anesthetic, and that would be. That’s really cruel. And not something that I would ever want to put a child through when they’re awake. But, yeah, the patient typically comes in with their parents to the operating room, at least at our hospital. I think at most hospitals across the country now, we tend to be very, family centric when we treat kids.

 

00;09;05;19 – 00;09;34;07

Jordan Glicksman

Parents have concerns. The kid will typically be very nervous. It might be the first time they undergo surgery so that parents and the children will come back together in most cases, and then the child be put to sleep using, an anesthetic, that is inhalational, very similar to laughing gas. And just and then once the child asleep, then we put in the ID, typically, and then, the surgery begins after we do our typical time outs and, those safety protocols that we have in place to make sure that we do, everything as safe as possible.

 

00;09;34;09 – 00;09;53;25

Jordan Glicksman

The surgery itself, involves basically, it’s only a couple of minutes, and we, we use, when I do it, I use electric cautery. But there’s a bunch of different tools that you can use to take the tonsil out. And we make sure there’s not any significant bleeding. And then the patient’s awoken, brought to the recovery room, and once they’re awake enough, they’re returned to their loving care.

 

00;09;54;01 – 00;10;03;29

Dr. Mona

Awesome. And I’ve, you know, in residency, I obviously, I’m I’m a general pediatrician, but in residency, I’ve scrubbed into these these procedures and observed them. How long do they typically take?

 

00;10;04;02 – 00;10;18;10

Jordan Glicksman

Not very long. Typically. Usually they’re going to sleep. And waking up part takes longer than the actual surgery itself. Obviously we don’t try to rush, but typically we’re looking at less than five minutes, maybe ten minutes, tops, to get this done, under routine circumstances.

 

00;10;18;13 – 00;10;32;07

Dr. Mona

In some ways, I think that’s great to hear for parents, I hope. When I scrubbed in, I actually didn’t, you know, how would I have known unless I scrubbed in? And so I scrubbed in and I was like, wow, this is amazing. And you all are obviously very well trained and know how to do this. So it was just so great to see.

 

00;10;32;07 – 00;10;50;23

Dr. Mona

And like you said, the recovery is, you know, fluids, cold items. People often ask, who do I follow up with my pediatrician or the specialist? As general pediatricians, we always say follow up with the specialist. Of course, if your specialist is not available, which they should be, you can always come to us. But sometimes I get patients coming in, you know, post-op.

 

00;10;50;25 – 00;10;57;21

Dr. Mona

They forget that they can call their surgeon. So definitely talk to the surgeon because they’re going to follow up with you if you have any concerns.

 

00;10;57;23 – 00;11;18;27

Jordan Glicksman

Yeah. If I’m operating on someone and I think I just do whatever research and I know is like this, we take, you know, great pride in our work and also, ownership over our patients. And until, you know, the problem’s completely resolved, we want to be part of that, 100%, and make sure that, the recovery is as soon as it can possibly be, and that the family and the child are happy.

 

00;11;19;00 – 00;11;41;15

Jordan Glicksman

Well, as happy as they can be, given that they just had a surgery and, you know. Yeah, from our perspective, we typically follow up, at least in my practice, and about a month, so they’ve had a full chance to heal and recover, and we it’s mostly just a meet and greet and saying hello. And typically the parents are really happy because not only is the kid not stopping the breathing at night, they’re also not snoring, which obviously, can be distressing to the parents as well.

 

00;11;41;15 – 00;11;58;24

Dr. Mona

And I’m sure there are many different situations with various cases, but sometimes is it that you’re monitoring the patient before deciding to do surgery? Are there just more instances that say, hey, surgery is probably the best option? How does that kind of look like for you in terms of deciding, hey, we need to go to the O.R. now, or this is something that we’re going to monitor.

 

00;11;59;00 – 00;12;28;12

Jordan Glicksman

I’m so glad you asked that, because we kind of did just jump to surgery. There are definitely medical, options, as well, in part I it depends on how severe it seems to be. And severity often involves how much it’s affecting the child’s quality of life and their ability to do well at school. But in some cases, yeah, simply treating them with a needle steroid spray like Flonase, which, fortunately is not absorbed to a large extent by the body and is delivered in a high concentration where it needs to be, but not enough to the rest of the body to cause major complications.

 

00;12;28;12 – 00;12;48;06

Jordan Glicksman

And the vast majority of cases, something as simple as that can really go a long way, to making the child better. And sometimes just the child growing can allow them to, outgrow the problem. Now that that, of course, is specific to, sleep apnea and the sleep concerns. But that would be, one of the ways that we try and avoid surgery in our patients.

 

00;12;48;08 – 00;12;54;10

Jordan Glicksman

If that’s what the parents, would like us to do. And if we agree that’s in the best interest of the child. Absolutely.

 

00;12;54;13 – 00;13;10;29

Dr. Mona

Yeah. I’m glad we talked about that. And I think parents, again, parents are often concerned when the word surgery comes up. Right. They think, of course, and I understand that, you know, they want to know if there’s other options. Is this what’s the best situation? And like I said, I’m just so glad we’re talking about this because there are other options before then.

 

00;13;10;29 – 00;13;29;22

Dr. Mona

Even as general pediatricians, sometimes we talk about all the things you’re mentioning, right. Let’s do some nasal steroid sprays. And then of course we say, hey, go talk to the EMT. We just think it’s nice to start that process. It does not mean you immediately need to get the surgery, but it’s just important to start that conversation, like you said, to get a better quality of life for that child.

 

00;13;29;22 – 00;13;46;20

Dr. Mona

I think there is a fear of surgeries in general. I find that that happens a lot. And I I’m also low intervention, low surgery if we don’t have to. But in so many cases, I mean, let’s be you’re I know, I know, you do this every day. It really helps the child. And if it helps the child, that’s what we want, right?

 

00;13;46;20 – 00;13;57;20

Dr. Mona

We want to try most conservative. But at the end of the day, sometimes it’s what’s really going to help them. And it’ll make them sleep better at night, figuratively and literally. And then also the parents. So I agree with that.

 

00;13;57;23 – 00;14;20;05

Jordan Glicksman

Yeah, I agree with you completely. And I joke, sometimes with my patients and their families. And I say even though this is a minor surgery for me, I recognize that this isn’t a minor surgery for you. The only minor surgery my patients perspective or a family’s perspective is surgery on someone else or not their family. You know, even though even a five, ten minute operation, has the potential for complications.

 

00;14;20;05 – 00;14;39;19

Jordan Glicksman

Fortunately, in this case, it’s very safe. And thousands and thousands are done across the country, each day without problems. But at the same time, it is something that we, we take very seriously, even if for me, it’s a you know, a typical day at work, definitely not a typical day in the life of our patients. So, it’s definitely something we take very seriously.

 

00;14;39;24 – 00;14;46;21

Dr. Mona

Yeah, I can tell. And I can tell you have a passion for it. And it is so great to talk to you. What would be your final message for everyone listening today?

 

00;14;46;24 – 00;15;05;27

Jordan Glicksman

Well, I think that if, if you’ve got concerns about, your child with respect to adeno chancellor disease, be it your child snoring and having behavioral issues, related to potentially not getting enough sleep or they’re getting a lot of throat infections, like you said, I think it is important to talk to your pediatrician about it and if appropriate, not to be seen by a specialist.

 

00;15;05;29 – 00;15;21;06

Jordan Glicksman

You know, even if you come in and it turns out that the child doesn’t need surgery, no one’s gonna be upset. We’d rather see, you know, ten children that, don’t have a problem. Then, you know, be in a situation where we miss one, that we can really help. So, you know, it doesn’t mean you’re going to go see a surgeon that you need surgery.

 

00;15;21;08 – 00;15;32;05

Jordan Glicksman

We’re here to support you with medical and surgical. And even if it’s just observation, we’re here to be part of this by your experience. And make sure that your child has the best possible outcome, and maximizing their potential and their health.

 

00;15;32;10 – 00;15;50;25

Dr. Mona

Yeah. And it’s a team effort. Like you said, it does not necessarily mean surgery is the answer, but it’s just something that you all are trained every day in this area. This is what you do day in and day out. You know, tonsils, you know, adenoids. You know, you’re just we’re going to talk about later. So I want the experts of the expert to weigh in on my patient.

 

00;15;50;25 – 00;16;15;03

Dr. Mona

So I love when I can, you know, find a great EMT to work with me, work with my patients. And again, thank you so much for coming on. Jordan Bookman. He is at Newton Wellesley Hospital and he actually and his wife also follow me on my Instagram account. So that’s how I found him to. Come on, make sure you listen to the other episode today about ear tubes, because you’re going to get some education on that procedure as well.

 

00;16;15;03 – 00;16;18;06

Dr. Mona

And when that’s indicated, thanks again, Jordan, for joining us.

 

00;16;18;08 – 00;16;19;26

Jordan Glicksman

And thanks for having me. It’s a pleasure.

 

00;16;20;01 – 00;16;35;23

Dr. Mona

Thank you for tuning in for this week’s episode. As always, please leave a review. Share this episode with a friend. Share it on your social media. Make sure to follow me at PedsDocTalk on Instagram and subscribe to my YouTube channel, PedsDocTalkk TV. We’ll talk to you soon.