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A cheeseburger, please: Tonsillectomy technique speeds return to normal diet, reduces pain

Less than four hours after her tonsillectomy, Madison Boehm had a request.

A cheeseburger, please.

The 3-year-old’s mother, Lisa, was amazed. After all, it took her other child, Nick, 7, a day or two to want solid food because of soreness that lingered after his tonsillectomy.

Like the vast majority of the nearly 300,000 children who have tonsillectomies in the United States every year, Nick had both of his tonsils completely removed via a technique known as an extracapsular tonsillectomy (ET).

Madison, however, had an intracapsular tonsillectomy (IT) – a technique championed at CHOC in which 95 percent of the tonsils are removed, preserving the “capsule,” and thus protecting the muscle underneath.

The result: less risk of bleeding after surgery, vastly decreased pain after surgery, and a rapid return to normal diet.

Madison underwent an intracapsular tonsillectomy at age 3 and quickly resumed her regular diet.

Dr. Kevin Huoh, a pediatric otolaryngologist, brought the technique to CHOC when he started there in September 2013 after learning it during his fellowship at Stanford University Medical Center. So, too, did fellow pediatric otolaryngologist Dr. Nguyen Pham, who joined CHOC around the time Huoh did.

Since then, more than 1,000 children have undergone intracapsular tonsillectomies at CHOC, with the rate of tonsillar regrowth – the most cited concern for not performing ITs – remaining extremely low, Dr. Huoh says. In addition, the rate of post-tonsillectomy bleeding, the most feared post-operative complication, is pretty much zero, much lower than with traditional extracapsular tonsillectomy.

Now, in a recently published research paper in Laryngoscope, the foremost publication for otolaryngologists (also known as ENTs – for ear, nose, and throat – practitioners), Huoh predicts there will be a “paradigm shift” over the next five to seven years.

He believes ITs will become the standard surgical technique for removing tonsils in children either for snoring and sleep disordered breathing or for chronic/recurrent tonsillitis.

And CHOC, Dr. Huoh notes, was among the first pediatric hospitals in the country to adopt ITs as the standard technique.

“The reasons (most other ENTs) are not doing ITs are probably psychosocial,” Dr. Huoh says. “They’re not exposed to it. They’ve been doing tonsillectomies the same way for forever and they have a lack of exposure to this new procedure. Simply, they are set in their old ways.

“But this procedure is very, very favorable. It’s very easily learned, and it really works.”

Dr. Kevin Huoh brought the intracapsular tonsillectomy (IT) technique to CHOC in September 2013 and predicts IT will be the standard tonsillectomy technique in the U.S. in five to seven years.

Intracapsular tonsillectomies have steadily gained popularity in the United States and across the world since the procedure first was described in 2002.

But as Dr. Huoh notes in his paper, “Current Status and Future Trends: Pediatric Intracapsular Tonsillectomy in the United States,” co-written by Dr. Yarah Haidar and Dr. Brandyn Dunn, both of the UCI School of Medicine, only 20 percent of the 540 pediatric otolaryngologists who responded to a survey the three doctors sent perform intracapsular tonsillectomies.

That is certain to change in the coming years as the benefits of the technique become more widely recognized, Dr. Huoh says.

Dr. Huoh and other CHOC doctors mainly perform intracapsular tonsillectomies on children whose large tonsils cause obstructive sleep apnea.

Such was the case with Madison.

When she was 2, her parents noticed she snored a lot and woke up tired. She was sluggish and lethargic and took one or two three-hour naps per day.

“We went online and did some research, and sleep apnea popped up,” Lisa recalls.

Madison was diagnosed with having large tonsils and adenoids as well as obstructive sleep apnea, which made her a candidate for an intracapsular tonsillectomy.

Lisa says she and her husband, Cameron, researched the best hospital to take Madison to and they quickly settled on CHOC, where Dr. Pham diagnosed Madison as having large tonsils and adenoids as well as obstructive sleep apnea.

Madison had the surgery on Aug. 3, 2019.

“The doctors at CHOC were all dialed in, and I was holding her an hour after she went under,” Lisa recalls. “The recovery part is what was amazing. By the time we were home, she was totally out of the anesthesia fog and asking to eat.”

So, Lisa got Madison a cheeseburger.

She never complained about her throat – just soreness on the top of her hand from the IV.

“She completely recovered in a couple of days,” Lisa says of Madison, who enjoys dancing and gymnastics. “From that first night after surgery, she has been sleeping normally, and I feel that her personality has come out a little more.”

Lisa says she has referred her friends who have kids with tonsillar problems to CHOC pediatric otolaryngologists.

“The doctors treat their patients like they are their own kids,” she says. “I had total confidence in them. They carefully explained everything that was needed, and I could always be in touch with them. They are second to none.”

Learn more about CHOC otolaryngology.

Why sports physicals are important – especially after a COVID-19 diagnosis

With league and school sports beginning to resume after a prolonged COVID-prompted off season, many young athletes are heading back to the field again.

Having a sports physical is an important step before getting back into the game – especially after a having COVID-19 symptoms or a diagnosis.

But what exactly is a sports physical and why are they needed? In this Q & A, Dr. Matthew Kornswiet, a sports medicine pediatrician in the CHOC Primary Care Network, answers these questions and more.

Coaches and parents should continue to follow safe return to sports guidelines from the Centers for Disease Control & Prevention and locally, the California Interscholastic Federation and California Department of Public Health.
Does having COVID-19 affect my child’s ability to play sports safely?

If your child had symptoms of or tested positive for COVID-19 at any point, it is important that they see their provider before returning to sports.

Research shows that sometimes after a COVID-19 infection, a patient has a small risk of developing myocarditis (inflammation of the heart) or multisystem inflammatory syndrome in children, also known as MIS-C, an inflammation of multiple areas of the body.

Even if your child had a sports physical recently, it is important that children have another physical exam after a COVID-19 infection before returning to sports.

In some cases, providers may recommend additional tests for your child’s heart or that they see a cardiologist, or heart doctor, for further evaluation. This is to ensure that children are safe to return to sports.

What is a sports physical and why are they important?

A sports physical helps determine whether it’s safe for a child to participate in a sports or athletics. They can also help uncover and treat health problems that might interfere with participation. The provider may also offer tips to help with training and injury prevention.

What should I expect at a sports physical?

A sports physical is divided into two halves: the medical history and the physical exam.

During the medical history portion, the provider will ask key questions about serious illnesses among family members; current or previous medical conditions, such as asthma, epilepsy or diabetes; past injuries; and more.

During the second half of the visit the provider will perform a physical exam. The physical exam will measure the athlete’s vital signs; check the athlete’s heart and lungs; evaluate strength and flexibility; vision; and more.

The provider will also ask questions about the athlete’s mental health, use of drugs, alcohol or dietary supplements, including steroids or other so-called “performance enhancers” and weight-loss supplements.

What happens after the physical?

When the exam is over, the provider will complete and sign a form indicating fitness to participate in the sport, if all is well. In some cases though, the provider may recommend a follow-up exam, additional tests, or specific treatment for medical problems.

Young athletes shouldn’t worry that additional follow-up care means being benched. A sports physical’s ultimate goal is to ensure athletes are safe while playing sports – not to stop them from playing.

Additional follow-up could be as simple as rechecking blood pressure in a few weeks. A referral to a specialist could ultimately help athletic performance, such as in the case of slight knee pain during running that an orthopedic or sports medicine specialist can demystify and treat.

If my child has a sports physical, do they still need a regular physical or well check?

It’s critical that patients of all ages undergo a regular physical every year, whether or not they also have a sports physical. Depending on when your child had their last physical, it can be done at the same visit as the sports physical.

While sports physicals focus on well-being as it relates to athletics, regular physicals are more comprehensive, addressing broader physical and mental health concerns, and helping to ensure patients are up-to-date on vaccinations.

Where can my child get a sports physical?

Families usually have many options for receiving sports physicals. Your child’s physician or a sports medicine physician can provide a sports physical exam.

Remember, your pediatrician knows your child’s medical history thoroughly, can make referrals if needed, and will play a critical role in any ongoing care plans – not to mention, is one of their biggest fans.

Beating COVID-19 and MISC-9: Matthew’s story

When 20-year-old Matthew came down with a mild case of COVID-19 before the holidays, he thought it had run its course. He didn’t expect to end up with MIS-C and in the hospital – much less, the one where his mom had worked for 15 years.

CHOC patient Matthew with his mother, Tiffani, a longtime CHOC employee.

Matthew’s mom, Tiffani, was a clinical dietitian at CHOC at Mission Hospital for most of that tenure before recently transitioning into a program manager role with The Sharon Disney Lund Medical Intelligence and Innovation Institute (MI3). Having spent many years working at patients’ bedside across many units at CHOC at Mission, Tiffani was already very familiar with CHOC’s practices, physicians and the environment of care, but when her son became critically ill, her role was solely that of a mom.

“When you are the parent of a sick child — whether he is 2 years old or 20 years old — you realize how truly dependent you are on the care team and must trust them to provide the solutions you can’t,” she says.

Positive for COVID-19

In December, Matthew tested positive for COVID-19. He had mild symptoms and quarantined for two weeks, spending Christmas apart from his family. Matthew got a negative COVID test in early January, and later tested positive for antibodies. He thought his illness was behind him and was making plans to donate convalescent plasma to help others fighting COVID.

The day after his antibody test, Matthew came down with a high fever. When that was followed by the quick onset and rapid progression of nausea and gastrointestinal symptoms, he headed for a local urgent care, which resulted in negative rapid flu and COVID tests.

A few days later he felt worse, so Tiffani took him to a local emergency department where he received fluids and a work-up. He was discharged, but Tiffani’s intuition and clinical background made her suspicious something else was going on. Dr. Antonio Arrieta, CHOC’s medical director of infectious disease, and Dr. Jacqueline Winkelmann, a pediatric hospitalist, were consulted.

They were concerned that Matthew’s lab work and symptoms – which included inflammation – might be indicative of Multisystem Inflammatory Syndrome in Children, or MIS-C. At their instruction, Tiffani brought Matthew immediately to the Julia and George Argyros Emergency Department at CHOC Hospital.

“From the minute we arrived in the emergency department at CHOC, things were completely different. I was allowed to stay with Matthew. The limited visitor policy in effect due to COVID still allows for one parent to be at the child’s bedside in most cases,” Tiffani says. “At the previous emergency department we visited, which was an adult facility, I had to drop him off at the curb and hope for the best, and that he would be able to advocate for himself despite feeling so sick.”

MIS-C diagnosis

By this point, it had been nearly a month since Matthew’s original COVID diagnosis. Once at CHOC, Matthew was admitted and quickly diagnosed with MIS-C.

“The original emergency department we went to didn’t suspect MIS-C at all because of Matthew’s age,” Tiffani says. “He is 20, and typically MIS-C affects younger kids, but CHOC was on high alert because of the increasing cases in the community. They saw beyond the typical case presentation and evaluated his labs and clinical status and found the rare case immediately.  I am so grateful we were able to receive Matthew’s care at CHOC.”

Finding answers and a treatment plan at CHOC

MIS-C can affect young adults up to age 21. It causes inflammation in blood vessels throughout the body due to a storm of reactions by the immune system. MIS-C is a relatively new syndrome that generally appears in people who have recovered from COVID-19.

A care team comprised of more than a dozen doctors from seven specialties, plus dozens of nurses, cared for Matthew in what would end up being a weeklong stay at CHOC. Those specialties included infectious disease, rheumatology, hematology, intensivists, hospitalists and cardiology. His pediatrician, Dr. Eric Ball, part of CHOC’s Primary Care Network, was updated and consulted as well.

Pharmacists at CHOC ensured that Matthew received the IVIG that he needed. High dose IVIG, or intravenous immunoglobulin, helps the body modulate inflammation . Matthew also received anticoagulants to reduce the risk of blood clot formation.

“We felt very calm and secure about the plan. Every specialty that was consulted was an active participant in Matthew’s plan of care,” Tiffani recalls. “The first night was really hard for us because Matthew’s blood pressure wasn’t stable, but we knew the care team was in close contact with the pediatric intensive care unit and would transfer Matthew there if he needed a higher level of care.”

Since MIS-C can cause inflammation in the heart and with his very low blood pressures, Matthew was ultimately transferred to CHOC’s cardiovascular intensive care unit. He began receiving high-dose IV steroids and monoclonal antibodies under the care of Dr. Andrew Shulman, a CHOC rheumatologist, in order to further reduce inflammation.

Part of the care team

The early days of Matthew’s stay at CHOC are a blur to him, but he does remember doctors involving him in his care plan when he felt well enough for those conversations.

“I remember Dr. Arrieta telling me about the medicine and treatment I would receive. He said they have other tools in their toolbox, but he hoped they didn’t have to use them,” Matthew says. “I’m older than some of their typical patients, and I appreciated that they respected me as an adult. All my doctors had a great bedside manner. Every single doctor made sure I knew what was going on, and that was important to me.”

Despite her history as a longtime CHOC employee, Tiffani knew the high level of care her son received wasn’t simply because she was part of the CHOC family.

“Everyone at CHOC receives this level of care. We didn’t get special treatment because I work here,” Tiffani says. “In clinical settings we cannot always guarantee results, but the team strives to get the best outcome, using their collective skills, and everyone goes above and beyond.”

Tiffani did feel, however, that she had a big team rooting for her and Matthew behind the scenes.

“My colleagues from 15 years at CHOC checked in on us all the time, both virtually and physically on the unit,” Tiffani recalls. “Their support meant the world to me.”

Turning a corner

Matthew started to turn the corner almost as quickly as he got sick.

“It was miraculous,” Tiffani recalls.

Once Matthew started to feel better and more lucid, one of the first things he told his mom was how much he appreciated that everyone at CHOC cared so much about him getting better.

“Even though he had been so sick, he remembered that the person who cleaned his room knew his name, and the food service worker delivering his meals said she hoped he enjoyed his food and that it would make him stronger,” Tiffani recalls.

Matthew started connecting with his clinicians as well. As an electrical engineering student, Matthew was interested in the inner workings of the electrical circuits in his EKG – or electrocardiogram, which records the electrical signals from the heart to check for various heart conditions. The technician who performed Matthew’s EKGs would explain everything she was doing and how the machine worked. They also discussed how to improve the technology and what future devices might look like.

Although Matthew is still committed to becoming an electrical engineer someday, he took a special interest in healthcare after his experience as a patient. Even though he doesn’t want to become a clinician, he does see how he can contribute to advancing pediatric medicine with his coding and engineering skills. He has applied for CHOC’s MI3 Summer Internship Program, and hopes to work with Dr. Anthony Chang, CHOC’s chief intelligence and innovation officer, on data science and innovation projects.

A special gift from his care team

As Matthew continued to get better, and closer to going home from the hospital, his care team wanted to send him home with something to remember his journey and be a symbol of their continued support.

Matthew holds a heart pillow signed by the team at the CHOC Heart Institute.

It’s a tradition for heart patients at CHOC to receive a red heart-shaped CHOC Heart Institute pillow, signed by all their caregivers, when they finally go home.

“This gift is not only endearing to the patient, but symbolic to the parent,” Tiffani says, “These caregivers are tattooed on our hearts for their heroic efforts to save our kids.”

While Matthew’s care team closely monitored his status and lab reports as indicators of when he would be able to go home, his mom was noticing signs he was feeling better, too.

“I was encouraged when I saw the whites of his eyes again, as they had been pink before when he was really sick,” Tiffani says. “And when I took a photo of him and could see his cheekbones that was significant because it meant the medicine was removing the puffiness and inflammation from his body.”

A journey for both patient and Mom

While this health journey was Matthew’s, it affected his mom as well.

Matthew and Tiffani stand outside the doors of CHOC’s hospital in Orange.

“As a CHOC employee, I’ve long admired the talented doctors, nurses and other clinicians for the excellent care they provide. I am humbled to call them my colleagues,” Tiffani says. “As a parent, I am so thankful we have such a wonderful children’s hospital to care for kids in our community – whether they be 20 days, 20 months or in our case, 20 years old.”

A week after Matthew was admitted to the hospital, he was well enough to go home. Since MIS-C is a new condition, little is known about its potential long-term effects. Matthew will remain in the care of CHOC cardiology, infectious disease and rheumatology, plus undergo regular lab work to monitor his health.

Matthew also decided to join a research study led by Dr. Arrieta, which is looking at MISC-C and its long-term effects.

“I kind of look at it as I just overcame this new disease and joining the research study isn’t a lot of trouble for me. So, if I can help the doctors help other people, then of course I’ll do it,” Matthew says.

These days, Matthew is feeling a lot better. He is improving every day and working to get his strength back but is avoiding exercise at the advice of his cardiologists.

Tiffani is back at work, with a renewed sense of appreciation for CHOC.

“I love working at CHOC, but because it is a clinical setting, I don’t get to take my kids to work with me and show them what I do,” she says. “I have often told them about how special the team is. They have seen me go back to work late at night to help a family or answer a doctor’s call on the weekend. So, when Matthew got sick, I needed my work family to show up for me, and they did. Now the whole family understands why those of us that work at CHOC, do what we do —because every family deserves this type of care. We didn’t receive special care because I work at CHOC, we received special care because of CHOC.”

COVID-19 safety sticker doodle art delights CHOC patients

It’s a busy Friday morning on CHOC’s Orange campus, and a steady stream of staff, young patients and their parents make their way to a COVID-19 screening station.

After answering questions about COVID-19 symptoms and possible exposures and have body temperatures 100.4 degrees or lower, patients and their guardians who clear screening are asked to place a small round sticker on their upper body before they head to their appointments.

The stickers are a different color every day, and they tell others that their wearers have no COVID-19 symptoms or exposure. This screening process is one of a host of processes and procedures in place to ensure CHOC’s facilities are safe for patients, families, staff and physicians.

These other safety measures include daily health screenings for staff; masking and increased personal protective equipment when necessary; physical distancing practices; enhanced cleaning practices; and COVID-19 vaccination for staff and providers.

Health screenings are conducted by members of the CHOC team, and during slower stretches of their shifts, many of the screeners have taken to adding kid-friendly doodles to the small circular stickers worn by patients and families.

Balloon hearts. Bear paw prints. Lollipops. Dinosaurs. Whales. Popsicles. Elephants.

The list goes on.

An example of the doodle art decorating screening stickers at CHOC

And while far from professional renderings and just a small gesture, the drawings cheer up young patients who sometimes might feel scared about visiting the doctor.

“I really love the dinosaur sticker!” one girl declared before heading to her appointment.

Madison McCracken, an EMT and emergency department tech, has been a CHOC screener for two months.

“We are defenders of childhood,” Madison says. “While going to the doctors might be scary, drawing on little dots is one way we can defend childhood and have fun.”

Winnie Le, a clinical nurse and supervisor of the screening program, oversees the 50 to 75 screeners who sign up for shifts in six-week schedules and are stationed at a handful of locations throughout the Orange hospital campus.

“I’m glad to see that screeners are getting creative with their skills,” Winnie says.

Spruced-up stickers line a table at a screening station, where staff, patients and families are checked for COVID-19 symptoms and exposure.

Chloe Parise has been serving as a screener for nearly six months.

“Drawing on the stickers is important to me because even drawing something as simple as a smiley face can brighten someone’s day,” she says. “I didn’t realize how much of an impact it was making until some coworkers were telling me how excited the kids were about the stickers.

“It may not seem like it at first, but a drawing on a sticker can help focus on the positive side of things, and parents can forget the stressful reason their child is at the doctor’s for just a second and smile at the pizza doodle that someone made.”

When Chloe first started drawing on stickers, she noticed patients chose a sticker with a doodle over a blank one every time.

“So, I started drawing smiley faces, muffins and tacos because those were things I loved to draw on my homework when I was in high school,” she says.

“The next week, they wanted me to do it again, and people were commenting on how much they loved them. A security guard at CHOC gifted me some colored pens he wasn’t using not long after that, and I’ve been doing my best to draw on every sticker I can ever since.”

Other examples of sticker art at CHOC

Chloe’s screening co-worker was Davina Lance, a health information nurse who has been at CHOC for 31 years.

Davina says she loves working as a screener because she doesn’t see patients much during her regular duties, which mostly involve her performing triage over the phone.

“I used to get a little fix seeing the kids in the hospital hallways, but COVID has changed all of that,” Davina says. “So, I love being a screener.”

Davina bought a set of colored gel pens and keeps her designs simple.

“Believe me, I’m no artist,” she says with a laugh. “But when I’m going through the screening questions with a parent, the child is looking at which sticker he or she wants to choose. It happens every time.”

Davina draws doodles appropriate to the season or day. She went to town during the holiday season, and on the first day of March 2021, she drew bunny faces because spring and Easter are around the corner.

“It was also windy today,” Davina says. “So I drew kites.”

Learn more about what to expect when visiting CHOC’s campus and offices during COVID-19.

Celebrate National Nutrition Month: Personalize your plate

By Sabrina Chen, CHOC dietetic technician, registered

MyPlate has been widely used to give a visual representation of how much we should eat of each food group. It’s important to jazz up our diets and personalize our plates to our lifestyles, personal tastes and goals. Each year, the Academy of Nutrition and Dietetics celebrates National Nutrition Month. This year’s focus is on personalizing your plate. Take this month as a time to reflect on your personal goals to reach a healthy lifestyle.

Food is a wonderful way to bring people together and showcase different foods of various backgrounds and cultures. Don’t be afraid to try different cuisines you are unfamiliar with — you never know what your new favorite meal might be! You can also experiment with different ways of cooking to switch up the flavor or even save time.

Implementing healthy nutrition habits doesn’t have to be boring or repetitive. Try incorporating a new vegetable every week or switching up your protein from animal sources to non-animal sources such as tofu or lentils. Plan your meals ahead of time with a variety of nutritious foods every day.

Here are a few ideas that might help you personalize your plate and incorporate new-to-you foods:

  • Whole grains: Chapatti, tortillas, buckwheat noodles, wild rice
  • Vegetables: Bok choy, napa cabbage, okra, daikon radish
  • Fruits: Kumquats, papaya, Korean pears, dates
  • Dairy: Fortified soy milk, low fat cottage cheese, fresh cheeses
  • Proteins: Fish, adzuki beans, tofu, lentils
  • Healthy fats: sesame seeds, macadamia nuts, walnuts and avocado oils.

“There is no one-size-fits-all approach to nutrition and health” as said by the Academy of Nutrition and Dietetics. The recommended serving size of each food group can vary depending on various factors like age, gender and activity level. What works for other people, may not work for you. You can receive personal nutrition advice from a registered dietitian or dietetic technician, who can also provide tips on following a healthy diet.

To help get you started on diversifying the food on your plate, here is a delicious recipe for Japanese-inspired sesame soba noodles.

Japanese-inspired sesame soba noodles

Ingredients

Sesame dressing

  • ¼ cup rice vinegar
  • 2 tablespoons tamari, more for serving
  • ½ teaspoon toasted sesame oil
  • 1 teaspoon grated ginger
  • 1 garlic clove, grated
  • ½ teaspoon honey

Soba noodles

  • 6 ounces soba noodles
  • Sesame oil, for drizzling
  • 2 avocados, sliced
  • Squeezes of lemon
  • 2 cups blanched snap peas
  • ¼ cup edamame
  • 1 watermelon radish or 2 red radishes, very thinly sliced
  • 1/4 cup fresh mint leaves
  • Sesame seeds

Instructions

  1. Make the dressing: In a small bowl, combine the vinegar, tamari, sesame oil, ginger, garlic and honey. Set aside.
  2. Bring an unsalted pot of water to a boil and cook the soba noodles according to package directions. Drain and rinse well in cold water. This helps to remove starches that cause clumping. Toss the noodles with the dressing and divide into two to four bowls. Squeeze fresh lemon juice onto the avocado slices and add to the bowls along with the snap peas, edamame, radish, mint, and sprinkle with sesame seeds. Drizzle with more tamari or sesame oil, if desired.